The impact of cerclage placement on gestational length in women with premature cervical shortening.

OBJECTIVES: Cervical insufficiency (CI) is a condition consistent with painless cervical dilatation that can lead to preterm delivery. Cervical cerclage is a procedure in which cervical suture is performed for preventing preterm labor in several indications. Late emergency cerclage is technically more challenging compared to elective cerclage, performed earlier during pregnancy, prior to cervical changes. Pregnancy outcomes with emergency cerclage were found to be improved in previous reports, but there is still inconclusive data. To assess the effectiveness and safety of emergency cerclage vs. conservative management with progesterone and/or bed resting, in preventing preterm birth and improving neonatal outcomes in women with clinically evident cervical insufficiency. METHODS: This is a retrospective cohort study conducted on all women diagnosed with cervical insufficiency between the 16th and 24th gestational week who met the inclusion criteria, from January 2012 to December 2018. Obstetric and neonatal outcomes: time from diagnosis to delivery, duration of pregnancy, birth weight and Apgar score, were compared between women who underwent cerclage and those who treated conservatively. RESULTS: Twenty eight women underwent emergency cerclage (cerclage group) and 194 managed with a conservative therapy, progesterone and/or bed rest (control group). Time from diagnosis to delivery 13 weeks vs. 8 weeks and birth weight 2,418 g vs. 1914 g were significantly higher in the first cohort. Average pregnancy duration was three weeks longer in the cerclage group, but that was not significant. No complications occurred in the cerclage group and no difference in mode of delivery were found. CONCLUSIONS: Emergency cerclage is an effective and safe procedure in preventing preterm birth and prolongation of pregnancy, in women with cervical insufficiency in the late second trimester.

Isolated Fallopian Tube Torsion: An Underdiagnosed Entity with Debatable Management.

STUDY OBJECTIVE: To study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management. DESIGN: Retrospective cohort study from October 2017 through October 2020. SETTING: Tertiary care hospital. PATIENTS: All patients with surgically confirmed adnexal torsion or IFTT during the study period. INTERVENTIONS: All of the patients underwent gynecological examination, imaging, and laparoscopy. MEASUREMENTS AND MAIN RESULTS: During this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination. CONCLUSION: IFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.

Correction to: Once episiotomy, always episiotomy?

The original article can be found online.

Once episiotomy, always episiotomy?

OBJECTIVE: To investigate the association between episiotomy and perineal damage in the subsequent delivery. STUDY DESIGN: A retrospective cohort study was conducted, comparing outcome of subsequent singleton deliveries of women with and without episiotomy in their first (index) delivery. Deliveries occurred between the years 1991-2015 in a tertiary medical center. Traumatic vaginal tears, multiple pregnancies, and cesarean deliveries (CD) in the index pregnancy were excluded from the analysis. Multiple logistic regression models were used to control for confounders. RESULTS: During the study period, 43,066 women met the inclusion criteria; of them, 50.4% (n = 21,711) had subsequent delivery after episiotomy and 49.6% (n = 21,355) had subsequent delivery without episiotomy in the index pregnancy. Patients with episiotomy in the index birth higher rates of subsequent episiotomy (17.5 vs. 3.1%; P < 0.001; OR 1.9; 95% CI). In addition, the rates of the first and second degree perineal tears as well as the third and fourth degree perineal tears were significantly higher in patients following episiotomy (33.6 vs. 17.8%; P < 0.001, and 0.2 vs. 0.1%; P = 0.002, respectively). Nevertheless, there was no significant difference at the rates of CD and instrumental deliveries, between the groups. While adjusting for maternal age, ethnicity, birth weight, and vacuum delivery-the previous episiotomy was noted as an independent risk factor for recurrent episiotomy in the subsequent delivery (adjusted OR 6.7; 95% CI 6.2-7.3, P < 0.001). The results remained significant for term (adjusted OR 6.8; 95% CI 6.2-7.4, P < 0.001) as well as preterm deliveries (adjusted OR 4.5; 95% CI 3.3-6.3, P < 0.001) in two different models. CONCLUSION: Episiotomy is an independent risk factor for recurrent episiotomy in the subsequent delivery.

Early onset preeclampsia and cerebral palsy: a double hit model?

BACKGROUND: Cerebral palsy (CP) is a late sequel of pregnancy, and the role of preeclampsia is debatable. OBJECTIVE: The aims of this study were to determine the association between preeclampsia and cerebral palsy and to determine the risk factors for the development of cerebral palsy in these patients. STUDY DESIGN: A retrospective population-based cohort study was designed that included 229,192 singleton pregnancies. The study population was divided into 2 groups: (1) patients with preeclampsia (n = 9749) and (2) normotensive gestations (n = 219,443). Generalized Estimating Equation multiple logistic regression models were performed to study the associations among preeclampsia, small for gestational age, gestational age at delivery, and the risk factors for the development of cerebral palsy in neonates of women with preeclampsia. RESULTS: The rate of cerebral palsy was double in patients with preeclampsia than in the normotensive group (0.2% vs 0.1%; P = .015); early onset preeclampsia and small for gestational age were independent risk factors for the subsequent development of cerebral palsy (odds ratio, 8.639 [95% confidence interval, 4.269-17.480]; odds ratio, 2.737 [95% confidence interval, 1.937-3.868], respectively). A second model was conducted to determine the risk factors for the development of cerebral palsy in women with preeclampsia. Birth asphyxia, complications of prematurity, and neonatal infectious morbidity, but not small for gestational age or gestational age at delivery, were independent risk factors for the development of cerebral palsy. CONCLUSION: In a comparison with normal pregnant women, the rate of cerebral palsy is double among patients with preeclampsia, especially those with early-onset disease. Early-onset preeclampsia is an independent risk factor for cerebral palsy. Among women with preeclampsia, the presence of neonatal infectious morbidity, birth asphyxia, and complications of prematurity are independent risk factors for the development of cerebral palsy, which further supports the role of a multi-hit model in the pathogenesis of this syndrome.

Intrapartum cervical lacerations and their impact on future pregnancy outcome.

Objective: To investigate the significance of intrapartum cervical lacerations on subsequent pregnancies.Study design: A retrospective cohort analysis was conducted, comparing outcomes of subsequent singleton pregnancies, in women with and without a history of cervical lacerations in a previous delivery. Deliveries occurred between the years 1991-2014 at the Soroka University Medical Center. Multiple logistic regression models were constructed to control for clinically significant confounders.Results: During the study period 187,162 deliveries met the inclusion criteria. Of them, 429 (0.2%) occurred in women with a history of cervical lacerations in the previous pregnancy (study group). The study group exhibited significantly higher rates of recurrent cervical lacerations (21/429, 4.9% versus 275/187 162,0.1%, p value = .001), cerclage (13/429, 3% versus 260/187 162, 0.1% p value = .001), cervical incompetence (8/429, 1.9% versus 609/187 162, 0.3% p value = .001) cesarean delivery (CD) (97/429, 22.6% versus 26 280/187 162,14%, p value = .001), severe perineal tears (third or fourth degree; 2/429, 0.5%, versus 164/187 162, 0.1%, p value = .056) and blood transfusion (11/429, 2.6% versus 2448/187 162, 1.3%, p value = .022) as compared with the comparison group. Using a multivariable logistic regression model, history of cervical laceration in a previous pregnancy was found to be an independent risk factor for subsequent CD (OR 1.4, 95% CI 1.1-1.9), recurrent cervical laceration (OR 29.3, 95% CI 17.7-48.5), severe perineal lacerations (OR 11.7, 95% CI 5.1-27.2), and preterm delivery (OR 1.8, 95% CI 1.1-2.8) in the subsequent pregnancy.Conclusions: A history of intrapartum cervical laceration is an independent risk factor for recurrent cervical lacerations, CD, preterm delivery, and severe perineal lacerations in the subsequent pregnancy.

Colostrum of Preeclamptic Women Has a High Level of Polyphenols and Better Resistance to Oxidative Stress in Comparison to That of Healthy Women.

Preeclampsia is a common pregnancy complication. Abnormal development of the placenta is the prevailing cause theory of this complication. Women with preeclampsia suffer from acute oxidative stress and high lipid oxidation in plasma. The aim of this study was to compare levels of polyphenols and lipid peroxidation in colostrum of nursing mothers with and without preeclampsia. The study was conducted at the Department of Obstetrics and Gynecology at Soroka University Medical Center. The study group consisting of 18 women, who were diagnosed with preeclampsia, was compared to the control group: 22 healthy women. The total phenolic content in the colostrum was determined by using the Folin-Ciocalteu method. Lipid peroxidation was determined by measuring MDA, using the TBARS assay. Polyphenol concentrations were significantly higher (about 33%) in the colostrum of the study group compared with the control group (p = 0.00042). Lipid peroxidation levels (MDA) were significantly lower (about 20%) in the colostrum of the study group compared with the control group (p = 0.03). Negative correlation was found between MDA concentration and the polyphenol level (R = -0.41, p = 0.02). In conclusion, we showed in this study a potential compensation mechanism that protects the newborn of a mother with preeclampsia from the stress process experienced by its mother.

Urine protein-to-creatinine ratio: a point of care for the diagnosis of preeclampsia.

BACKGROUND: The aim of this study was to determine the correlation between the urine protein-creatinine ratio (UPCR) and the 24-hour urine protein excretion test (UPET), and to identify the optimal threshold values of UPCR for the diagnosis of preeclampsia and its severe form. METHODS: This prospective cohort study included 81 hypertensive pregnant patients who had a 24-h UPET and a UPCR tests. Two groups were created using a UPCR cut-off of 23.2 mg/mmol (40 negative UPCR, 41 positive UPCR). RESULTS: Forty-nine patients of were diagnosed with preeclampsia, and 23 of them had a severe disease. There was a significant correlation between UPCR and 24-h UPET. A cut-off UPCR value of 23.2 mg/mmol had an area under the curve (AUC) of 0.27, sensitivity of 89%, specificity 88%, positive predictive value 90%, a positive likelihood ratio (+LR) of 7.41 and a negative likelihood ratio (-LR) of 0.13 for the diagnosis of preeclampsia. UPCR value of 325 mg/mmol had an AUC of 0.841, and a sensitivity of 83%, specificity 81%, positive predictive value 81%, +LR of 4.4 and -LR of 0.2 for the diagnosis of severe preeclampsia. CONCLUSIONS: The UPCR test is highly correlated with the 24-h UPET. We propose a novel and sensitive cut-off for the diagnosis of preeclampsia by UPCR test. The UPCR test can be used for the identification of hypertensive patients with preeclampsia and severe disease.

Fetal heart rate monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis.

OBJECTIVE: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2. MATERIALS AND METHODS: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders. RESULTS: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis. CONCLUSION: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2.

Antioxidants and Polyphenols: Concentrations and Relation to Male Infertility and Treatment Success.

Oxidative stress is induced by reactive oxygen substances (ROS) that are known to affect male fertility. The aims of this study were to prospectively investigate and characterize total antioxidant and specifically polyphenols concentrations and their relations to sperm quality and fertility treatment success. During their infertility treatment, sixty-seven males were prospectively recruited to this study. After separation of the sperm from the semen sample, the semen fluid samples antioxidants and polyphenols concentrations were determined. Antioxidant concentration was significantly associated with sperm concentration and total motile count. Antioxidants concentration in the group of male with sperm concentration ≥ 15 × 10(6) was significantly higher than in the group of male with antioxidants concentration < 15 × 10(6) (830.3 ± 350 µM and 268.3 ± 220 µM, resp., p < 0.001). Polyphenols concentration did not differ between the groups of sperm concentration above and below 15 × 10(6) (178.7 ± 121 µM and 161.7 ± 61 µM, resp., p-NS). No difference was found between fertilization rates and antioxidants or polyphenols concentrations. This is the first study that reports on polyphenols concentration within semen fluid. More studies are needed in order to investigate polyphenols role in male fertility.

Induction of labor in twin gestation: lessons from a population based study.

INTRODUCTION: The route of delivery and the role of induction of labor in twin gestations are controversial. The aim of this study was to determine the efficacy of induction of labor in twin gestations. METHODS: This retrospective population based cohort study included 4605 twin gestations divided into following groups: 1) spontaneous parturition (n = 2937, 63.78%); 2) induction of labor (n = 653, 14.2%) and 3) elective cesarean delivery (n = 1015, 22.04%). RESULTS: The rate of vaginal delivery in the labor induction group was 81% (529/653). In comparison to the other study groups, induction of labor in twins was independently associated with a 77% reduction in the risk of cesarean delivery (OR 0.23; 95% CI 0.18-0.31) and a 78% reduction in the risk of postpartum death for the second twin (OR 0.22; 95% CI 0.05-0.94). The rate of nulliparity, term delivery and labor dystocia was higher in the induction of labor group (p < 0.001 in all comparisons). CONCLUSIONS: Our results suggest that induction of labor in twin gestation is successful and is independently associated with substantial reduction in the risk of cesarean delivery and postpartum death of the second twin.

Placenta accreta is an independent risk factor for late pre-term birth and perinatal mortality.

OBJECTIVE: This study is aimed to identify the risk factors for the development of placenta accreta (PA) and characterize its effect on maternal and perinatal outcomes. STUDY DESIGN: This population-based retrospective cohort study included all deliveries at our medical center during the study period. Those with placenta accreta (n = 551) comprised the study group, while the rest of the deliveries (n = 239 089) served as a comparison group. RESULTS: The prevalence of placenta accerta is 0.2%. Women with this complication had higher rates of ≥2 previous CS (p < 0.001), recurrent abortions (p = 0.03), and previous placenta accreta [p < 0.001]. The rates of placenta previa and peripartum hemorrhage necessitating blood transfusion were higher in women with placenta accreta than in the comparison group. PTB before 34 and 37 weeks of gestation was more common among women with placenta accreta (p < 0.01), as was the rate of perinatal mortality (p < 0.001). Placenta accreta was an independent risk factor for perinatal mortality (adj. OR 8.2; 95% CI 6.4-10.4, p < 0.001) and late PTB (adj. OR 1.4; 95% CI 1.1-1.7, p = 0.002). CONCLUSION: Placenta accreta is an independent risk factor for late PTB and perinatal mortality.

A prior placenta accreta is an independent risk factor for post-partum hemorrhage in subsequent gestations.

OBJECTIVE: The rate of placenta accreta, a life threatening condition, is constantly increasing, mainly due to the rise in the rates of cesarean sections. This study is aimed to determine the effect of a history of placenta accreta on subsequent pregnancies. STUDY DESIGN: A population based retrospective cohort study was designed, including all women who delivered at our medical center during the study period. The study population was divided into two groups including pregnancies with: (1) a history of placenta accreta (n=514); and (2) control group without placenta accreta (n=239,126). RESULTS: (1) A history of placenta accreta is an independent risk factor for postpartum hemorrhage (adjusted OR 4.1, 95% CI 1.5-11.5) as were placenta accreta (adjusted OR 22.0, 95% CI 14.0-36.0) and placenta previa (adjusted OR 7.6, 95% CI 4.4-13.2) in the current pregnancy, and a prior cesarean section (adjusted OR 1.7, 95% CI 1.3-2.2); (2) in addition, placenta accreta in a previous pregnancy is associated with a reduced rate of mild preeclampsia in future pregnancies (1.8% vs. 3.4%, RR 0.51, 95% CI 0.26-0.98); (3) however, in spite of the higher rate of neonatal deaths in the study group, a history of placenta accreta was not an independent risk factor for total perinatal mortality (adjusted OR 1.0, 95% CI 0.5-1.9) after adjusting for confounders. CONCLUSION: A history of placenta accreta is an independent risk factor for postpartum hemorrhage. This should be taken into account in order to ensure a safety pregnancy and delivery of these patients.

Postpartum uterine artery Doppler velocimetry among patients following a delivery complicated with preeclampsia.

OBJECTIVE: To evaluate postpartum uterine artery (UtA) velocimetry in patients following severe preeclampsia (PET) as compared with normotensive controls. STUDY DESIGN: Postpartum UtA velocimetry was obtained prospectively during the early postpartum period. The right and left UtA pulsatility index (PI) was measured and the presence of an early diastolic notch was noted. For categorical variables, the χ2 test or Fisher exact was used as appropriate and for continuous variables the t-test was used. The p value <0.05 was considered statistically significant. RESULTS: Thirty-one patients following severe PET and 52 normotensive controls were included in the study. Following severe PET, higher rates of intrauterine growth restriction, cesarean delivery, preterm delivery and accordingly lower neonatal birth weight were noted. Postpartum UtA velocimetry measurements were performed on average 51.2 h after delivery (range 8-169). Right and left UtA PI was comparable between patients following severe PET and controls. The presence of unilateral and bilateral early diastolic notches were significantly higher in patients following severe PET. CONCLUSIONS: The pathophysiology of uterine involution and the physiologic return of the uterine arteries to the non-pregnant state may be different following severe PET.