The benefit of active management in true knot of the umbilical cord: a retrospective study.

PURPOSE: To compare perinatal outcomes between active and routine management in true knot of the umbilical cord (TKUC). METHODS: A retrospective study of singletons born beyond 22 6/7 weeks with TKUC. Active management included weekly fetal heart rate monitoring(FHRM) ≥ 30 weeks and labor induction at 36-37 weeks. Outcomes in active and routine management were compared, including composite asphyxia-related adverse outcome, fetal death, labor induction, Cesarean section (CS) or Instrumental delivery due to non-reassuring fetal heart rate (NRFHR), Apgar5 score < 7, cord Ph < 7, neonatal intensive care unit (NICU) admission and more. RESULTS: The Active (n = 59) and Routine (n = 1091) Management groups demonstrated similar rates of composite asphyxia-related adverse outcome (16.9% vs 16.8%, p = 0.97). Active Management resulted in higher rates of labor induction < 37 weeks (22% vs 1.7%, p < 0.001), CS (37.3% vs 19.2%, p = 0.003) and NICU admissions (13.6% vs 3%, p < 0.001). Fetal death occurred exclusively in the Routine Management group (1.8% vs 0%, p = 0.6). CONCLUSION: Compared with routine management, weekly FHRM and labor induction between 36 and 37 weeks in TKUC do not appear to reduce neonatal asphyxia. In its current form, active management is associated with higher rates of CS, induced prematurity and NICU admissions. Labor induction before 37 weeks should be avoided.

Role of Gynecological Ultrasound in Evaluation of Pelvic Urologic Pathologies.

BACKGROUND: Advances in examination techniques have improved routine assessment of non-gynecological structures in the pelvis. OBJECTIVES: To describe the sonographic features of incidental urological abnormalities found during gynecological transvaginal ultrasound. METHODS: A retrospective descriptive analysis of patients who underwent gynecological ultrasound and were diagnosed with urologic findings was performed. The sonographic features of the findings including size, echogenicity, and vascularity were examined. RESULTS: Gynecological ultrasound diagnosed urological findings in nine women. Two had primary neoplasms of the urinary bladder, one had metastases to the urinary bladder, one had polyps in the distal ureters, four presented with calculus in the distal ureters (one of them was 19 weeks pregnant), and one showed diverticulum of the urethra. At presentation five women (56%) had urinary complaints. Two patients (22%) with abdominal pain with distal ureteral calculi had normal transabdominal ultrasound targeted to the urinary system prior to the gynecological sonography. CONCLUSIONS: Transvaginal ultrasound is useful in the diagnosis of urological abnormalities, mainly in the urinary bladder and the distal ureters. We suggest adding transvaginal assessment for female patients with urinary complains in whom transabdominal ultrasound of urinary system was unremarkable.

The perils of true knot of the umbilical cord: antepartum, intrapartum and postpartum complications and clinical implications.

BACKGROUND: True knot of the umbilical cord (TKUC) is found in 0.3-2.1% of pregnancies and is associated with an increased risk of adverse perinatal outcomes. METHODS: A retrospective cohort study including all singleton pregnancies delivered from 2011 to 2019 was performed. Diagnosis of TKUC was made postnatally, immediately after delivery of the baby. Comparison was made between pregnancies with and without TKUC regarding maternal, fetal and neonatal adverse outcome. RESULTS: Overall, 867/85,541 (1%) pregnancies were diagnosed with TKUC. Maternal age, BMI, gravidity and parity were significantly higher in pregnancies with TKUC as well as higher rate of induction of labor, meconium-stained amniotic fluid, and delivery prior to 37 weeks. The rate of cesarean deliveries due to non-reassuring-fetal monitor was significantly higher in pregnancies with TKUC. Overall, there were 2.5% IUFD in pregnancies with TKUC vs. 1% in pregnancies without TKUC (p < 0.001). Importantly, the rate of IUFD prior to 37 weeks of gestation was not significantly higher in the group with TKUC, however, the rate of IUFD after 37 weeks of gestation was 10 folds higher in fetuses with TKUC, 0.9% vs. 0.08% (p < 0.001). Significantly, more neonates with TKUC needed phototherapy or suffered from hypoglycemia. There were no differences in the 5 min Apgar scores, admission to the NICU and number of days of hospitalization. CONCLUSION: Pregnancies complicated with TKUC are associated with a tenfold higher risk of IUFD beyond 37 weeks of gestation. To the results of this study suggest that it would be prudent to induce labor around 37 weeks of gestation in pregnancies with prenatal diagnosis of TKUC. It may be warranted to use continuous fetal monitoring during labor and delivery in those cases were antenatal diagnosis of TKUC is made.

Antenatal Detection of True Knot in the Umbilical Cord - How Accurate Can We Be?

BACKGROUND: Umbilical cord knot (UCK) is associated with increased risk of fetal death, but is usually diagnosed only after delivery. Our objective was to examine the accuracy of prenatal ultrasound in the diagnosis of UCK and the outcomes of these pregnancies. METHODS: A prospective study was performed on 56 patients in which UCK was suspected during a routine level-II anatomical scan (study group). Data included demographics, pregnancy outcome, and short-term neonatal follow-up. The control group included pregnant women with normal pregnancy without UCK in a 4:1 ratio matched for gestational age at delivery. RESULTS: True knot was observed postnatally in 54 out of 56 fetuses (detection rate of 96.4 %). Gestational age at diagnosis of UCK was 22.1 ±â€Š3.1 weeks. The female to male ratio was 1:1 in both groups. Maternal age and parity were significantly higher in pregnancies with UCK compared to controls. The mean gestational age at delivery was 37.1 weeks of gestation in the UCK group. There was no difference in the birthweight percentile. 47 patients (87 %) underwent induction of labor. There were no differences in the rate of cesarean section or Apgar scores. No neonate with UCK needed ventilation. None suffered from seizures and none needed brain imaging. There were no cases of fetal or neonatal death in the pregnancies with UCK. CONCLUSION: There is a high detection rate of UCK during targeted scan of the umbilical cord performed during the level-II anatomical scan. Careful pregnancy follow-up and early term delivery may result in excellent obstetrical outcomes.

Dynamic esophageal patency assessment: an effective method for prenatally diagnosing esophageal atresia.

BACKGROUND: Esophageal atresia is a major anomaly with a low prenatal detection rate. We propose a sonographic method termed dynamic esophageal patency assessment. OBJECTIVE: This study aimed to assess the feasibility and performance of the dynamic esophageal patency assessment in a high-risk population. STUDY DESIGN: A prospective study was conducted in a single tertiary fetal ultrasound unit for 12 months. The study group included pregnant women referred for a targeted scan because of one or more of the following: (1) polyhydramnios; (2) small or absent stomach; (3) vertebral, anal atresia, cardiac, tracheoesophageal fistula, renal, and limb abnormalities; (4) first-degree relative with esophageal atresia; and (5) genetic mutation associated with esophageal atresia. In addition to dynamic esophageal patency assessment, a comprehensive anomaly scan was carried out. The fetal esophagus was observed during swallowing. Cases that demonstrated uninterrupted fluid propagation through the esophagus were classified as normal. Cases that demonstrated interrupted fluid propagation, with the formation of a pouch, were classified as abnormal. Cases with unclear visualization of the esophagus or cases that failed to demonstrate either fluid propagation or a pouch were classified as undetermined. Dynamic esophageal patency assessment results were compared with postnatal findings, considered "gold standard." Test performance indices and intra- and interobserver agreements were calculated. RESULTS: For 12 months, 130 patients were recruited, and 132 fetuses were scanned. The median gestational age (interquartile range) at the time of scan was 31.4 weeks (29.0-35.3). Of 132 fetuses enrolled, 123 (93.2%) were normal, 8 (6%) were abnormal, and 1 (0.8%) was undetermined. Excluded from test performance analysis were 3 cases that were terminated without postmortem autopsy (1 was abnormal and 2 were normal), and a fourth case was excluded as it was classified as undetermined. The detection rate of esophageal atresia was 100%, with no false-positive or false-negative case. Sensitivity, specificity, and positive and negative predictive values of the dynamic esophageal patency assessment were 100%. The Kappa coefficient was 1 for both inter- and intraobserver agreements (P<.0001). The median time (interquartile range) required to complete the dynamic esophageal patency assessment was 6.00 minutes (3.00-13.25). CONCLUSION: The dynamic esophageal patency assessment is a feasible and highly effective method of ascertaining an intact esophagus and detecting esophageal atresia in suspected cases.

Neurodevelopmental outcome of children born with an isolated atretic cephalocele.

PURPOSE: The existing data on the neurodevelopmental outcome of children born with an isolated atretic cephalocele (IAC) are scant. We aimed to expand upon these data by describing our experience with affected children, as well as assist parents and clinicians in deciding how to proceed when an IAC is diagnosed prenatally. METHODS: A follow-up study was conducted on nine children who were born with an IAC. Evaluations were performed by pediatric neurologists and child development specialists. Developmental outcomes were based on a global development evaluation that assessed gross and fine motor skills, receptive and expressive language levels, activities of daily living, communication skills, and social domains. Adaptive skills were estimated by the Adaptive Behavior Assessment System, Second Edition. RESULTS: None of the nine children (median age 4 years and 6 months) had abnormal findings on neurological examination. Six children had age-appropriate developmental milestones, two had a mild motor delay, and one had mild expressive language delay (catchup was achieved by all of the latter three by ~ 3.5 years of age). The mean general adaptive composite score was 105 ± 11.7 (normal = 100). None of the children had behavioral, social, or communication problems. CONCLUSIONS: Children diagnosed with an IAC with/without a falcine sinus and devoid of coexisting intracranial abnormalities seem to have a normal neurodevelopmental outcome. Continuation of pregnancy may be recommended when an IAC is detected prenatally, and reassurance if detected postnatally.

Multicystic Dysplastic Kidney: Prenatal Compensatory Renal Growth Pattern.

OBJECTIVES: To assess the prenatal growth pattern of the normal kidney contralateral to a multicystic dysplastic kidney (MCDK). METHODS: A retrospective study was conducted in a single referral center over 4 years. Cases diagnosed prenatally as MCDK and confirmed postnatally constituted the study group. For creation of nomograms, only isolated cases of MCDK were included. RESULTS: Sixty-one fetuses had a diagnosis of an MCDK during the study period. After exclusion of cases with associated malformations, 47 fetuses remained, providing 94 measurements for creation of nomograms. The growth pattern of the normal kidney contralateral to an MCDK was linear throughout gestation (percentile = 20.01 + 1.5 gestational age; linear R2  = 0.753; r = 0.868) and was significantly higher during the third trimester (29-38 weeks' gestation) compared to the second trimester (22-28 weeks' gestation; P < .001). A comparison of the growth pattern of the normal kidney contralateral to the MCDK to the growth pattern of a solitary kidney revealed a significant higher compensatory trend during the third trimester (P < .0001). The mean kidney lengths at 22 and 38 weeks' gestation correlated with the 52nd and 88th and with the 84th and 90th percentiles for the normal kidney contralateral to the MCDK and a solitary kidney, respectively. CONCLUSIONS: According to our study, the normal kidney contralateral to an MCDK has a unique growth pattern during intrauterine life, with dominant growth during the third trimester. The exact mechanism for this pattern, in comparison to early renal hypertrophy shown in solitary kidneys, is currently not clear. These data provide relevant information for the multidisciplinary prenatal counseling of future parents regarding the future renal outcome.

Relaparotomy post-cesarean delivery: characteristics and risk factors.

PURPOSE: Relaparotomy following cesarean delivery (CD) is performed at a rate of 0.2-1% of CD. The objective of the present study was to identify risk factors for relaparotomy following CD, and to examine whether there is a difference in the risk of relaparotomy between CD performed during different hours of the day. METHODS: A retrospective study on all CD over 10 years compared pregnancies that underwent laparotomy within 1 week following CD to those that did not. RESULTS: Sixty-four patients underwent relaparotomy out of 24,239 CDs (0.26%). In univariate analysis, relaparotomy was significantly associated with pregnancies following assisted-reproductive-technologies odds ratio (OR) 95% confidence interval (CI) 3.15 (1.90-5.22), hypertensive disorders of pregnancy OR 3.05 (1.62-5.72), twin pregnancies OR 95% CI 3.78 (2.21-6.48), preterm deliveries OR 95% CI 2.44 (1.46-4.10), placenta previa OR 95% CI 6.41(2.55-16.09) and urgent CD 1.74 (1.06-2.86), especially during the second-stage of labor OR 95% CI 2.73 (1.34-5.54). The time of day of CD did not influence the rate of relaparotomy. In a multivariable-regression analysis, the adjusted odds ratio for relaparotomy was 10.24 in CD due to placenta previa, and 5.28 in CD performed at the second-stage of delivery. At relaparotomy, active bleeding was found in 50 patients (78.1%), nearly half received packed cells, 12.5% developed consumptive coagulopathy, and 17.2% needed hospitalization in the intensive care unit. 6.3% underwent a second relaparotomy, mainly due to bleeding. CONCLUSION: Placenta previa, and urgent CDs mainly those performed at the second stage of labor are risk factors for relaparotomy after CD.

Postpartum visits in the gynecological emergency room: How can we improve?

BACKGROUND: The attendance to the gynecological-emergency-room (GER) of women only a few weeks following previous discharge after birth comprises a medical as well as social problem. The objective of the study was to characterize the postpartum women that attended the GER, and depict the leading etiologies and risk-factors that lead them to attend the GER, and to examine correlations between their medical findings at discharge and the reasons for their attendance to the hospital. METHODS: All women that attended the GER between 01/01/2016 and 30/09/2016 during 6 weeks after birth were included. The variables assessed were: medical history, mode of birth, maternal complications of birth, diagnosis at the GER, treatment received and readmission. RESULTS: There were 446 visits of 413 women (5.6% of all deliveries). Most were generally healthy after their first normal vaginal birth with no complications during or following birth. 38.7% had a cesarean birth (p < 0.001). The most common causes of the visits were fever (30.3%), problems in episiotomy or surgical scar (26.6%) and abdominal pain (25.7%). Women with hypertensive disorders during birth had significantly more hypertensive problems in the GER. Diabetic women suffered statistically more from hypertensive disorder in the GER. 33.2% were examined and found healthy. Seventy-two women (1% of all deliveries) were hospitalized, most of them due to infection. Only 7.5% were referred to the GER due to bleeding. CONCLUSIONS: Postpartum women are at risk of morbidities, especially following cesarean sections and in women with hypertensive disorders of during pregnancy. Scheduled visits to high-risk women to attend outpatient clinic sooner are recommended.

Perinatal Outcome of Twin Pregnancies Complicated by Rupture of Membranes at 13-20 Weeks: Is Selective Termination an Appropriate Management Option?

OBJECTIVE: To evaluate the outcome of twin pregnancies that were complicated by rupture of membranes at 13-20 weeks of gestation and were managed by expectant management or by selective termination. METHODS: A retrospective cohort study of all bichorionic twin pregnancies that were referred to three fetal medicine units between 2001 and 2016, due to rupture of membranes of one sac at 13-20 weeks of gestation. Women without clinical signs of infection who opted for expectant management or selective termination were included. RESULTS: 20 patients met the inclusion criteria. 7 of them were managed expectantly and 13 underwent selective termination. In the expectant management group there was one case of fetal demise and two cases of neonatal death, resulting in a survival rate of 79 %. The median gestational age at delivery was 30 weeks. 3 neonates suffered from prematurity-related complications and 2 suffered from oligohydramnios-related orthopedic complications. Following selective termination the survival rate was 50 % (all fetuses that were not reduced), the median gestational age at delivery was 39 weeks, and the neonatal outcome was favorable. The maternal outcome was favorable in both groups. CONCLUSION: Selective termination in twin pregnancies complicated by rupture of membranes at 13-20 weeks has a favorable outcome and should be offered.