Risk factors for relaparotomy after a cesarean delivery: a case-control study.

BACKGROUND: Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center. METHODS: A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders. RESULTS: During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h. CONCLUSION: We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience.

PURPOSE: To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy. METHODS: A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture. RESULTS: During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01). CONCLUSION: Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Correlation of Meconium-Stained Amniotic Fluid and Adverse Pregnancy Outcomes between 37 to 39 and 40 to 42 Weeks of Gestational Age.

OBJECTIVE: We aimed at assessing the association between meconium-stained amniotic fluid (MSAF) and adverse maternal and neonatal outcomes in early-term versus late-term pregnancies. STUDY DESIGN: Early-term pregnancies (37-39 weeks of gestation) presented with MSAF were compared with late-term (40-42 weeks of gestation) pregnancies with MSAF. The groups were compared with respect to background characteristics, maternal outcomes, and neonatal outcomes. The composite neonatal outcome was the primary outcome of the study, and secondary outcomes included maternal and neonatal outcomes. RESULTS: The early-term group comprised 239 women, compared with 362 women in the late-term group. The primary outcome did not differ between groups. We found a higher prevalence of gestational diabetes (8.37 vs. 3%, p < 0.05), a shorter second stage of labor (45.61 ± 54.67 vs. 65.82 ± 62.99 minutes, p < 0.05), and a longer hospital stay (2.84 ± 2.21 vs. 2.53 ± 1.26 days, p < 0.05) in the early-term group. Other maternal and neonatal characteristics and outcomes were not significantly different between the two groups. CONCLUSION: In term pregnancies complicated by MSAF, adverse neonatal and maternal delivery outcomes are equivalent, regardless of gestational age, and therefore, any term pregnancy complicated by MSAF should be considered high risk and managed appropriately. KEY POINTS: · In term pregnancies complicated by MSAF, adverse neonatal and maternal delivery outcomes are equivalent, regardless of gestational age.. · Any term pregnancy complicated by MSAF should be considered high risk and managed appropriately.. · Deliveries presented with MSAF are typically considered to be high risk and require close fetal surveillance by a certified team with resuscitation skills.. · Our study may help to reduce the need for a close fetal surveillance and delivery interventions if MSAF is not identified as a risk factor for adverse outcomes in late-term pregnancies..

Hospital antenatal admissions for threatened preterm labor: how long should we be "observing"?

PURPOSE: We sought to describe temporal trends in hospital admissions for threatened preterm labor (TPTL) and to examine hospital admission duration among women delivered or discharged undelivered. METHODS: We carried out a cohort study on all TPTL admissions among pregnancies with a live singleton fetus and intact membranes between 1999 and 2015 using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. ICD-9 codes were used to identify women with TPTL. Duration of antenatal admission length of stay was calculated in days following admission to hospital until delivery ("Delivery Admission") or undelivered discharge ("Observation Admission"). Analyses included evaluating trends of birth admissions over total admissions, identifying predictors of delivery using logistic regression, and measuring risk for delivery with increasing duration of antepartum hospitalization. RESULTS: Of 15,335,288 pregnancy admissions, 1,089,987 admissions were for TPTL, with 61.8% being 'Delivery Admissions". During the 16-year study period, overall rates of TPTL admissions declined with a rising proportion of admissions being "Delivery Admissions". "Delivery Admissions" were more common among patients who were older, non-Caucasian, obese, or who had placental abruption. "Observation Admissions" were more common among admissions for antepartum hemorrhage or antepartum spotting. Among all "Delivery Admissions" for TPTL, 89% had delivered within 2 days, 7% delivered within 3-6 days, and 5% delivered beyond 6 days. CONCLUSION: Overall admissions for TPTL declined over the study period with increasing proportions being "Delivery Admissions". Protocols taking into consideration declining risk of preterm birth among patients undelivered after 2 days may be helpful in reducing unnecessary prolonged observation admissions.

Isolated fetal echogenic bowel and iron-rich mineral water supplement: a case series and review of the literature.

Natural iron-rich mineral water (IRMW) is a supplement with a higher iron bioavailability than oral iron supplement tablets. Five (4%) of 116 women who consumed IRMW starting from 16 weeks of gestation were diagnosed as having isolated foetal echogenic bowel at a single community maternity clinic between 2012 and 2015. The workup of all the women was otherwise negative. Four women taking IRMW were re-checked after discontinuation of the supplement and had a normal-appearing foetal bowel. Our observations suggest that isolated echogenic bowel may be related to the consumption of IRMW, possibly due to the high absorption of iron, leading to the coating of the internal wall of the foetal bowel and subsequent appearance of an echogenic bowel. Although this finding appears free of harmful ramifications, its possible sonographic effects on the appearance of the foetal bowel should be considered in light of the increasing popularity of IRMW use.IMPACT STATEMENTWhat is already known on this subject? IRMW is a highly absorbed iron supplement. The differential diagnosis for foetal echogenic bowel is broad and requires thorough investigation. Iron is secreted through the maternal blood to the amniotic fluid, which is swallowed by the foetus, reaching its bowel.What do the results of this study add? IRMW consumption is a possible aetiology of an isolated foetal echogenic bowel in the second half of pregnancy, conveying no risk of foetal morbidity or mortality.What are the implications of these findings for clinical practice and/or further research? In light of the increasing popularity of IRMW, we believe that it is important to increase the level of awareness of the possible effects of its intake on the sonographic appearance of the foetal bowel.

Obstetrical outcomes of ART pregnancies in patients with male factor infertility.

PURPOSE: Pregnancies conceived by in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are associated with an increased incidence of obstetrical and neonatal complications. With the growing rate of male factor infertility, which is unique by not involving the maternal milieu, we aimed to assess whether obstetrical outcomes differed between IVF/ICSI pregnancies due to male factor infertility and those not due to male factor infertility. METHODS: A retrospective cohort study of women receiving IVF/ICSI treatments at a single hospital over a five-year period was involved in the study. Inclusion criteria were women with a viable pregnancy that delivered at the same hospital. Pregnancies were divided into male factor only related and non-male factor-related infertility. The groups were compared for several maternal and neonatal complications. RESULTS: In total, 225 patients met the study criteria, with 94 and 131 pregnancies belonging to the male factor and non-male factor groups, respectively. Demographic and clinical characteristics were comparable, except for younger maternal age and higher incidence of twin pregnancies in the male factor group. A sub-analysis for singleton pregnancies revealed a less likelihood of cesarean delivery, preterm birth, and male gender offspring in the male factor group (p < 0.05). These differences were not observed in the sub-analysis for twin pregnancies. Other outcome measures were similar in both groups, both for singleton and twin pregnancies. CONCLUSION: Singleton IVF pregnancies due to male factor infertility are associated with a reduced incidence of some adverse outcomes, likely due to lack of underlying maternal medical conditions or laboratory conditions related to ICSI. Our findings require validation by further studies on larger samples.

Efficacy of a second external cephalic version (ECV) after a successful first external cephalic version with subsequent spontaneous reinversion to breech presentation: a retrospective cohort study.

OBJECTIVE: Determining the efficacy of performance of a second external cephalic version (ECV) following successful first ECV with subsequent spontaneous reinversion to breech presentation in reducing the rate of cesarean delivery (CD). METHODS: Data were reviewed on healthy women with fetuses in breech presentation who underwent a first ECV after 36 weeks. Routine ultrasound study was performed at 39-week gestation, and a repeat ECV procedure was performed if the fetus had reverted to non-cephalic presentation. Obstetrical outcome measures were compared between women who underwent one successful ECV between 36- and 41-week gestation in which the fetus remained in cephalic presentation until labor and those who underwent a successful first ECV after which the fetus returned to breech and a second ECV was performed. The primary outcome was the rate of secondary CD during vaginal delivery in cephalic presentation; rate of successful second ECV was the secondary outcome. RESULTS: Overall 250 women underwent one ECV attempt of which 169 (67%) were successful. Of them 28 reverted to breech presentation, all women underwent two attempts of which 21 (76%) were successful. A second successful ECV attempt was associated with a 33% incidence of a CD vs. 2.8% after one successful ECV in which the fetus remained in cephalic presentation. CONCLUSION: A second ECV after a successful first ECV with subsequent spontaneous reversion to breech presentation can be expected to be successful in 76% of cases but lead to CD in 33% of cases. Our findings can be used to support patient counseling and decision-making before second ECV attempt.

Maternal cardiovascular hemodynamics in normotensive versus preeclamptic pregnancies: a prospective longitudinal study using a noninvasive cardiac system (NICaS™).

BACKGROUND: Preeclampsia is among the most common medical complications of pregnancy. The clinical utility of invasive hemodynamic monitoring in preeclampsia (e.g., Swan-Ganz catheter) is controversial. Thoracic impedance cardiography (TIC) and Doppler echocardiography are noninvasive techniques but they both have important limitations. NICaS™ (NI Medical, PetachTikva, Israel) is a noninvasive cardiac system for determining cardiac output (CO) that utilizes regional impedance cardiography (RIC) by noninvasively measuring the impedance signal in the periphery. It outperformed any other impedance cardiographic technology and was twice as accurate as TIC. METHODS: We used the NICaS™ system to compare the hemodynamic parameters of women with severe preeclampsia (PET group, n = 17) to a cohort of healthy normotensive pregnant women with a singleton pregnancy at term (control group, n = 62) (1/2015-6/2015). Heart rate (HR), stroke volume (SV), CO, total peripheral resistance (TPR) and mean arterial pressure (MAP) were measured 15-30 min before CS initiation, immediately after administering spinal anesthesia, immediately after delivery of the fetus and placenta, at the abdominal fascia closure and within 24-36 and 48-72 h postpartum. RESULTS: The COs before and during the CS were significantly higher in the control group compared to the PET group (P < .05), but reached equivalent values within 24-36 h postpartum. CO peaked at delivery of the newborn and the placenta and started to decline afterwards in both groups. The MAP and TPR values were significantly higher in the PET group at all points of assessment except at 48-72 h postpartum when it was still significantly higher for MAP while the TPR only exhibited a higher trend but not statistically significant. The NICaS™ device noninvasively demonstrated low CO and high TPR profiles in the PET group compared to controls. CONCLUSIONS: The immediate postpartum period is accompanied by the most dramatic hemodynamic changes and fluid shifts, during which the parturient should be closely monitored. The NICaS™ device may help the clinician to customize the most optimal management for individual parturients. Our findings require validation by further studies on larger samples.

Uterine electrical activity, oxytocin and labor: translating electrical into mechanical.

PURPOSE: Uterine activity plays a crucial role in labor, especially when utero-tonic materials are administered. We aimed to determine the electrical responsiveness of the uterine musculature to labor augmentation with oxytocin using electrical uterine myography (EUM) technology, and to assess whether the kinetics of the EUM device may serve as a predictor for successful vaginal delivery. METHODS: EUM prospectively measured electrical uterine activity in women with singleton gestations at term (≥ 37 + 0 weeks) undergoing labor augmentation by oxytocin administration. The results were reported as the EUM index, which represented the mean electrical activity in 10-min intervals and measured in units of microwatt per second (mW/s). Measurements were performed at least 30 min before oxytocin initiation and until at least four contractions per 10 min were recorded by standard tocodynamometry. The delta EUM index was defined as the difference between the mean EUM index before and after the initiation of oxytocin. RESULTS: The mean EUM index increased significantly during oxytocin augmentation in all the parturients (P < 0.001). Mean and minimum (but not maximum) uterine electrical activity during oxytocin infusion correlated with the baseline uterine activity. The delta EUM index was not significantly affected by demographic or obstetric parameters. There was no correlation between the delta EUM index and time to delivery or the mean EUM index during oxytocin administration and time to delivery. CONCLUSIONS: Uterine electrical activity as evaluated by EUM is significantly intensified following oxytocin administration, regardless of obstetrical characteristics, and is correlated with the baseline uterine electrical activity prior to oxytocin infusion.

Trial of labor following one previous cesarean delivery: the effect of gestational age.

PURPOSE: To stratify maternal and neonatal outcomes of trials of labor after previous cesarean delivery (TOLAC) by gestational age. METHODS: Retrospective cohort study of all singleton pregnancies with one previous cesarean delivery in TOLAC at term between 2007 and 2014. We compared outcomes of delivery at an index gestational week, with outcomes of women who remained undelivered at this index gestational week (ongoing pregnancy). Odds ratios and 95% confidence intervals were adjusted for maternal age, previous vaginal delivery, induction of labor, epidural use, presence of meconium, and birth weight > 4000 g. RESULTS: Overall, 2849 women were eligible for analysis. Of those, 2584 (90.7%) had a successful TOLAC and 16 women (0.56%) had uterine rupture. Those rates did not differ significantly for any gestational age (GA) group. Following adjustment for possible confounders, GA was not found to be independently associated with adverse maternal or neonatal outcomes. CONCLUSION: Among women at term with a single previous cesarean delivery, GA at delivery was not found to be an independent risk factor for TOLAC success or uterine rupture. We suggest that GA by itself will not serve as an argument for or against TOLAC.

Maternal hemodynamics in late gestation and immediate postpartum in singletons vs. twin pregnancies.

PURPOSE: Differences in hemodynamic changes during a cesarean section (CS) between twin and singleton pregnancies are poorly defined. The Non-Invasive Cardiac System (NICaS) is an impedance device that measures cardiac output (CO) and its derivatives. We compared maternal cardiac parameters using NICaS™ in singleton and twins before and during delivery, as well at the early puerperium in healthy women undergoing CS at term. METHODS: This prospective longitudinal study included women with twin (n = 27) or singleton pregnancies (n = 62) whose hemodynamic parameters were assessed by NICaS before an elective CS, after spinal anesthesia, immediately after delivery, after fascia closure, and within 24-36 and 48-72 h postpartum. RESULTS: By 24-36 h postpartum, the mean arterial pressure and the total peripheral resistance equaled preoperative values in both groups. The CO increased throughout the CS and peaked immediately after delivery in the singleton group (P < 0.0001), after which it abruptly began to decline until reaching a nadir 24-36 h after delivery (P < 0.0001), while it remained steady throughout the CS and then dropped until 24-36 h after delivery in the twin group (P < 0.05). None of the studied parameters differed significantly between the groups for the 24-36 and 48-72 h postpartum measurements. CONCLUSIONS: Hemodynamic parameters immediately before, during and shortly after CS in singleton and twin pregnancies are equivalent. Further evaluations of the value of NICaS™ in assessing cardiovascular-related pregnancy complications are warranted.

Severe intrahepatic cholestasis of pregnancy is a risk factor for preeclampsia in singleton and twin pregnancies.

OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP) is known to be associated with fetal complications. It recently was suggested to be associated possibly with preeclampsia (PET) as well. The objective of this study was to investigate that possibility. STUDY DESIGN: The study group included 78 women (54 singleton and 24 twin pregnancies) who had been diagnosed with ICP based on clinical presentation, elevated liver enzymes, and elevated total bile acids (>10 µmol/L). Disease severity was based on total bile acids levels as being severe (>40 µmol/L), moderate (20-40 µmol/L), or mild (10-20 µmol/L). The course of disease was reviewed carefully in each case. The control groups were comprised of apparently healthy women with singleton (n = 200) and twin (n = 100) pregnancies that were drawn randomly from a computerized registry of all the deliveries in our institution during the study period. RESULTS: The total incidence of PET was significantly higher for the patients with ICP who had singleton and twin pregnancies compared with the control groups (singletons: 7.4% vs 1.5%; P < .05; twins: 33.3% vs 6.2%; P < .05, respectively). The incidence of severe PET was also significantly higher in both singleton (11-fold) and twin (8-fold) pregnancies compared with control subjects. Severe ICP, but not mild ICP, was a major risk factor for PET among women with either singleton or twin pregnancies. The timing of the initial presentation of ICP had no effect on PET incidence rates. Preeclampsia occurred usually 2-4 weeks after the diagnosis of ICP, and proteinuria preceded elevated blood pressure in all cases. Moreover, the total bile acid levels among 33 women who were diagnosed as having PET, but not ICP, were within normal range. CONCLUSION: ICP increases the incidence of PET; severe disease was a major risk factor for preeclampsia. Therefore, we strongly suggest including routine evaluation for preeclampsia in the treatment of women with moderate and severe ICP.

The association between indications for cesarean delivery and surgery time.

OBJECTIVE: We aimed to determine risk factors for prolonged surgery time of cesarean delivery (CD). METHODS: We conducted a retrospective cohort study in a single tertiary university-affiliated medical center (2011-2022). The study group consisted of all women who underwent CD that lasted >90 min (representing the 95th percentile of CD length in our cohort). Data were compared with CDs with an operation time of <90 min. Demographic, obstetric, and surgical characteristics, as well as indications for surgery and urgency (in labor vs. elective surgery), were compared. RESULTS: Overall, during the study period, 31 660 CDs were performed in our center. Of them, 1397 (4.4%) lasted >90 min. After applying a multivariate analysis, abnormal placentation (relative risk [RR] 1.5 [95% confidence interval (CI), 1.3-1.8]), previous uterine scar (RR, 2.15 [95% CI, 1.5-3.0]), general anesthesia (RR, 3.5 [95% CI, 2.9-4.4]) and preterm delivery (RR, 2.06 [95% CI, 1.78-2.4]) were found to be associated with prolonged surgical time. CD due to malpresentation (RR, 0.57 [95% CI, 0.46-0.7]), multiple gestations (RR, 0.72 [95% CI, 0.6-0.9]), and patient request (RR, 0.56 [95% CI, 0.38-0.84]) were found to be protective factors. CONCLUSION: The main risk factors associated with additional surgery time in CD are general anesthesia, abnormal placentation, previous uterine scar, and preterm delivery.

Is Grand Multiparity an Independent Risk Factor for Blood Transfusion?

The relation between grand multiparity and poor pregnancy outcome, especially postpartum hemorrhage and blood transfusion, has displayed inconsistent findings. Some studies have identified an increased maternal and neonatal morbidity, but the more recent literature is less clear about the risks. The objective of the study is to determine the association of grand multiparity with postpartum blood transfusion. We conducted a retrospective cohort study in a single tertiary university-affiliated medical center between 2011 and 2019. All women were categorized into one of three groups based on the number of previous deliveries: (a) nulliparous (no previous delivery), (b) multiparous (1-4 previous deliveries), and (c) grand multiparous (≥ 5 previous deliveries). We compared the demographic, clinical, and pregnancy outcomes of the study groups. The primary outcome was the need for red blood cell transfusion during the index admission. During the study period, there were 87,343 deliveries in our center. Among the study population, 36,777 (42.1%) were nulliparous, 49,072 (56.1%) were multipara, and 1494 (1.7%) were grand multiparous. Overall, 1602 women (1.8%) were treated with RBC transfusion. Cesarean delivery, macrosomia, preterm delivery, multiple gestations, antenatal anemia, thrombocytopenia, intrauterine fetal death (IUFD), and prolonged second or third stage of labor were more prevalent among women who were treated with RBC transfusion. After controlling for potential confounders, including maternal age, preterm delivery, IUFD, mode of delivery, and antenatal thrombocytopenia, grand multiparity was found to be an independent protective factor for RBC transfusion (RR = 0.2 (0.007-0.56). After controlling for cofounders, grand multiparity alone is not associated with postpartum blood transfusion.

Perinatal outcomes following uterine rupture during a trial of labor after cesarean: A 12-year single-center experience.

OBJECTIVE: To determine perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term. METHODS: A retrospective single-center study examining perinatal outcomes in women with term singleton pregnancies with one prior CD, who underwent a trial of labor after cesarean (TOLAC) and were diagnosed with uterine rupture, between 2011 and 2022. The primary outcome was a composite maternal outcome, and the secondary outcome was a composite neonatal outcome. Additionally, we compared perinatal outcomes between patients receiving oxytocin during labor with those who did not. RESULTS: Overall, 6873 women attempted a TOLAC, and 116 were diagnosed with uterine rupture. Among them, 63 (54.3%) met the inclusion criteria, and 18 (28%) had the maternal composite outcome, with no cases of maternal death. Sixteen cases (25.4%) had the composite neonatal outcome, with one case (1.6%) of perinatal death. No differences were noted between women receiving oxytocin and those not receiving oxytocin in the rates of maternal composite (35.7% vs 26.5%, P = 0.502, respectively) or neonatal composite outcomes (21.4% vs 26.5%, P = 0.699). CONCLUSION: Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for the mother and neonate, though possibly more favorable than previously described. Oxytocin use does not affect these risks.

Maternal hypothyroidism and its effect on placental histopathology in singleton live births resulting from in vitro fertilization treatment.

We aimed to examine the impact of maternal hypothyroidism on placental pathology and perinatal outcomes in singleton live births resulting from IVF, using medical records of IVF births between 2009 and 2017 at a tertiary hospital. The primary outcomes included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. Secondary outcomes included foetal, maternal, perinatal, and delivery complications. There were 1,057 live births, of which 103 (9.7%) and 954 (90.3%) were in the study and control groups, respectively. Patients in the study group were more likely to have diabetes mellitus, polycystic ovarian syndrome, gestational diabetes mellitus, and non-reassuring foetal heart rate (NRFHR) tracing during delivery. After adjustment for potential confounding factors, hypothyroidism was significantly associated with the bilobed placenta (aOR 4.1; 95% CI 1.2-14.3), retroplacental haematoma (aOR 2.4; 95% CI 1.2-4.9), decidual arteriopathy (aOR 2.0; 95% CI 1.2-4.1) and subchorionic thrombi (aOR 2.4; 95% CI 1.3-5.0). Additionally, there was a statistically significant relationship with NRFHR tracing. The incidence of acute chorioamnionitis and severe foetal inflammatory response was higher in the study group. In conclusion, the placental histopathology patterns of singleton IVF live births show that maternal hypothyroidism has a significant impact on adverse perinatal outcomes.

The association between increased subjective sensation of fetal movements and pregnancy outcome-a prospective cohort and a retrospective comparative analysis.

OBJECTIVE: To determine pregnancy outcomes in women with subjective sensation of increased fetal movements (IFM). METHODS: A prospective cohort study of women after 20 weeks of gestation who were referred with subjective sensation of IFM (April 2018-April 2019) for assessment. Pregnancy outcome was compared to pregnancies with a normal sensation of fetal movements all through pregnancy who underwent obstetrical assessment at term (37-41 weeks of gestation) matched by maternal age and pre-pregnancy BMI in a 1:2 ratio. RESULTS: Overall, out of 28,028 women referred to the maternity ward during the study period, 153 (0.54%) presented due to subjective sensation of IFM. The latter mainly occurred during the 3rd trimester (89.5%). Primiparity was significantly more prevalent in the study group (75.5% vs. 51.5%, p = .002). The study group had increased rates of operative vaginal deliveries and cesarean section (CS) due to non-reassuring fetal heart rate (15.1% vs. 8.7%, p = .048). Multivariate regression analysis showed that IFM was not associated with NRFHR affecting the mode of delivery (OR 1.1, CI 0.55 - 2.19), opposed to other variables such as primiparity (OR 11.08, CI 3.21-38.28) and induction of labor (OR 2.46, CI 1.18-5.15). There were no differences in the rates of meconium-stained amniotic fluid, 5 min Apgar score, birth weight, or rates of large/small for gestational-age newborns. CONCLUSION: Subjective sensation of IFM is not associated with adverse pregnancy outcomes.

Characteristics and outcomes among pregnant women with end-stage renal disease on hemodialysis.

PURPOSE: Pregnancy among women with end-stage renal disease (ESRD) has risen in frequency, which may be attributed to improvements in hemodialysis care. Our objective was to describe baseline characteristics and pregnancy outcomes among women with ESRD on hemodialysis. METHODS: Using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we created a cohort of women with ESRD on hemodialysis who gave birth between 2005 and 2015. We determined the proportion of adverse maternal and neonatal outcomes among this cohort. Then, we created a composite measure of vascular-mediated adverse pregnancy outcomes. Women who experienced at least one of either preeclampsia, intrauterine growth restriction, or intrauterine fetal death were categorized as having the composite measure. Then, multivariate regression models were used to estimate the associations between maternal baseline demographic and clinical characteristics and the composite measure. RESULTS: Among 8,765,973 deliveries between 2005 and 2015, 307 were to women with ESRD on hemodialysis. Over the study period, the incidence of pregnancies to women with ESRD increased from 0.47 to 5.76/100,000 births. An estimated 28% of pregnancies were complicated by preeclampsia, 8% by placental abruption, 58% delivered by cesarean, and in the postpartum, 28% required blood transfusions and 6% experienced sepsis. About 45% of babies were born preterm and 14% had IUGR. The composite measure of adverse events was not found to be associated with any baseline maternal characteristics. CONCLUSIONS: The frequency of pregnant women with ESRD on hemodialysis has risen, with adverse pregnancy complications for both mother and fetus. Transfer to high-risk centers is suggested for women with ESRD.

Mild thrombocytopenia and the risk for postpartum hemorrhage in twin pregnancies.

OBJECTIVE: We aimed to investigate the association of mild thrombocytopenia with postpartum hemorrhage (PPH) and blood transfusion among women with twin gestations. METHODS: A retrospective cohort study (Jan 2015 to May 2019) was performed. Women with twin pregnancies and pre-delivery mild thrombocytopenia were compared to those with normal platelet count. The primary outcome was the rate of PPH, defined as a composite of one or more of the following: (1) need for packed red blood cell transfusion; (2) postpartum hemoglobin decline of ≥3 g/dL; and (3) the use of postpartum uterotonics agents in addition to oxytocin. RESULTS: Of 1085 women who were included in final analysis, 315 (30.9%) had mild thrombocytopenia (and 770 (69.1%) served as controls. The rate of PPH was increased in the study group (14% vs. 9.4%, P = 0.03), as was the use of uterotonic agents (3.8% vs. 1.3%, respectively, P = 0.02). The rate of blood product transfusion and hemoglobin decline >3 g/dL was not significantly different between the groups. In multivariate logistic regression analysis, mild thrombocytopenia was associated with a higher risk for PPH (OR 1.55 [95% CI 1.02-2.35], P = 0.02). CONCLUSION: Mild thrombocytopenia in twin pregnancies is associated with an increased risk of interventions such as the use of uterotonic agents.

Low glucose at 3-hour 100 gram oral glucose tolerance test: implications for glucose control.

OBJECTIVE: To assess the clinical significance of a low 180-minute glucose value in a 100 g oral glucose tolerance test (OGTT) and a single high abnormal value. METHODS: A retrospective cohort study. The study group included women with 180-minute plasma glucose levels of ≤60 mg/dL and one abnormal value in the OGTT. The control group was comprised of women with one abnormal value in the OGTT and normal 180-minute glucose value. The primary outcome was glycemic control, defined as fasting blood glucose measurements > 90 mg/dL or post-prandial glucose values >140 mg/dL or 120 mg/dL (one-hour and two-hour post-prandial, respectively) in >30% of the measurements. Secondary outcomes were the rate of insulin treatment and the perinatal outcome consisting of birthweight, large-for-gestational-age, and polyhydramnios. RESULTS: Three hundred and one women were included, 143 in the study group and 158 in the control group. Pre-pregnancy BMI, first trimester fasting glucose levels, previous GDM, and familial diabetes were similar for both groups. Suboptimal glycemic control was more prevalent among the women in the study group (14% vs. 5.1%, respectively, p= .01). The need for insulin treatment was similar in both groups. CONCLUSIONS: Women with one abnormal value and a 180-minute hypoglycemia in the OGTT are at increased risk for suboptimal glycemic control.