Factors associated with postcesarean blood transfusion: a case control study.

OBJECTIVE: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD. METHODS: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio. RESULTS: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001). CONCLUSIONS: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.

Gestational diabetes and long-term risk for dyslipidemia: a population-based historical cohort study.

OBJECTIVES: To assess the course of lipid levels over time in postpartum women according to gestational diabetes status, taking into account potential confounders, such as comorbid conditions and body weight. METHODS: The data for the present analysis were collected from a 2.3 million member integrated care provider in Israel. Included were all female members aged 15-50 years who performed a 50 g glucose challenge test (GCT) between March 1995 and May 2009. We collected all follow-up lipid consecration tests performed from date of delivery following the GCT (index date) until April 2017. Data analysis was performed for each lipid component individually (triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C)) and the effects of the several risk factors (history of gestational diabetes mellitus (GDM), age at delivery, obesity status and smoking status) were investigated using general linear model taking into account potential confounders. RESULTS: A total of 160 527 women (6.1 million person-years of actual follow-up) were eligible for the analysis, including 10 234 women with GDM (6.4% of the entire cohort). During the study follow-up period, a total of 2.1 million lipid tests were performed. When adjusting for follow-up time, age at index date, body mass index status, and smoking status, GDM was associated with a 1.8-fold risk (95% CI 1.73 to 1.88) for dyslipidemia defined by TG, 1.45-fold risk (95% CI 1.38 to 1.52) for dyslipidemia defined by LDL-C, and 1.44-fold risk (95% CI 1.39 to 1.50) for dyslipidemia defined by HDL-C. DISCUSSION: The results of this retrospective cohort analysis indicate that gestational diabetes confers added risk for developing hyperlipidemia post partum, particularly dyslipidemia defined by TG, as compared with women with normal glucose tolerance.

Reproductive health counseling, attitudes, and practices: a cross-sectional survey among bariatric surgeons.

BACKGROUND: Women of childbearing age constitute a substantial proportion of patients who undergo weight loss procedures. However, little is known regarding family planning knowledge, attitudes, and practices among bariatric surgeons. OBJECTIVES: We explored the reproductive health and contraceptive practices among bariatric surgeons. SETTING: A national society of bariatric surgeons. METHODS: A cross-sectional study. Anonymous surveys were sent to all members of the Israeli Society for Metabolic and Bariatric Surgery. RESULTS: The Israeli Society for Metabolic and Bariatric Surgery survey elicited a response rate of 96% (n = 48). Most (89.6%, n = 43) considered female reproductive health perioperative counseling very important, and the majority of respondents (66.7%, n = 32) felt comfortable discussing these issues. Nevertheless, only 54.2% (n = 25) reported routinely having family planning and pregnancy conversations with their patients. There was a general awareness that women should delay conception after surgery; however, only a minority of bariatric surgeons consistently either recommended the use of contraception after surgery (39.6%, n = 19) or referred patients for contraceptive advice (25.0%, n = 12). Most (81.3%, n = 39) practitioners reported not having accurate knowledge of contraception and felt that collaboration with other bariatric healthcare providers would provide patients with optimal reproductive-health counseling. CONCLUSIONS: Bariatric surgeons acknowledged the importance of reproductive healthcare and the need to delay conception among women undergoing bariatric surgery. However, they inconsistently addressed family planning and contraceptive issues and reported lack of accurate knowledge in this regard. This highlights the need for multidisciplinary collaboration between bariatric healthcare providers to improve reproductive and contraceptive care in these patients.

Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study.

BACKGROUND: Reproductive-aged women constitute a substantial proportion of patients who undergo weight loss procedures. While the risk of gallstone disease after such procedures has been addressed extensively, the impact of pregnancy on gallstone disease after bariatric procedures has not been reported. OBJECTIVES: To explore the effects of pregnancy on cholecystectomy rates after laparoscopic sleeve gastrectomy (LSG). SETTING: A university hospital. METHODS: A cross-sectional cohort study of reproductive aged women (18-45 yr) who underwent LSG. The association between pregnancy and cholecystectomy was evaluated with Cox regression analysis. RESULTS: Of 1056 women of childbearing age who underwent LSG during 2006-2017, 128 (12.1%) subsequently experienced a pregnancy. Median follow-up durations were 3.9 and 4.9 years for women who did and did not conceive, respectively (P < .001). The median time from procedure to conception was 509 (374-1031) days. Overall, 117 (11.1%) women underwent cholecystectomy after LSG. The rate of cholecystectomy among those who conceived was higher than among those who did not (18.8% versus 10.0%, P = .005). In an unadjusted analysis, pregnancy was associated with an increased risk of cholecystectomy (hazard ratio [95% confidence interval]: 3.97 [2.58, 6.09], P < .0001). The association between pregnancy and cholecystectomy persisted after controlling for confounding factors (hazard ratio [95% confidence interval]: 3.82 [2.47, 5.92], P < .0001). Among those who experienced pregnancy, lower gestational weight gain was the only factor found to be associated with cholecystectomy after surgery (P = .05). CONCLUSIONS: Pregnancy is associated with a 4-fold increased risk of cholecystectomy after LSG. Thus, the desire for future pregnancy should be considered before LSG.

Twin pregnancy outcomes after metabolic and bariatric surgery.

BACKGROUND: The effect of bariatric surgery (BS) on twin pregnancy outcomes is unclear. OBJECTIVES: We examined associations of BS with maternal and perinatal outcomes among women with twin gestation. SETTING: A university hospital. METHODS: A retrospective case-control study of twin deliveries during 2006 through 2017. The study group comprised all women with twin pregnancy who had undergone BS and delivered during the study period. A control group was established by matching preoperative body mass index, age, parity, and delivery year. RESULTS: Data from 66 women with twin gestation were analyzed, 22 postBS and 44 matched control parturients. Compared with the control group, the study group had lower rates of gestational diabetes (9.1% versus 36.4%, P = .02) and gestational hypertensive disorders (0% versus 25.0%, P = .01); hemoglobin levels were lower at both early pregnancy (median 12.3 versus 13.4 g/dL, P < .001) and after delivery (9.3 versus 10.5 g/dL, P < .001). Median neonatal birthweights and the proportion of small-for-gestational-age infants were comparable between the groups. The degree of birth weight discordance between the twins was higher (17.2% versus 8.8%, P < .001) in the control group. CONCLUSIONS: In this study involving twin gestations, pregnancy outcomes were more positive among women who had undergone BS; as noted by reduced prevalences of gestational diabetes and gestational hypertensive disorders as well as a lesser degree of birth weight discordance. Nevertheless, BS was associated with lower hemoglobin levels during pregnancy and the postpartum period. Future studies are warranted to confirm our findings and evaluate the long-term outcomes of newborns of postBS mothers.

Maternal nutritional status and related pregnancy outcomes following bariatric surgery: A systematic review.

Up to 80% of patients who undergo bariatric surgery are women of childbearing age. Coupled with improved fertility in women with obesity after bariatric surgery, pregnancy postbariatric surgery has become increasingly more common. Although numerous studies have evaluated associations of bariatric surgery with pregnancy outcomes, the effect of maternal nutritional status on maternal and perinatal outcomes is not well established. We used Medline and Embase databases and a manual search of references for articles published until June 2018 to conduct a systematic review on nutritional status after bariatric surgery and its association with maternal and perinatal outcomes. Of the 306 initially identified articles, 27 met the study inclusion criteria, comprising 2056 women with pregnancies after bariatric surgery. Deficiencies were reported in maternal concentrations of vitamins A, B1, B6, B12, C, D, K, iron, calcium, selenium, and phosphorous. The only adverse events documented for these deficiencies encountered during pregnancy were anemia (vitamin B12, iron), night blindness (vitamin A), and urinary tract infections (vitamin A, D). This systematic review suggests that various micronutrient deficiencies are common among pregnant postbariatric surgery patients. Nevertheless, despite the concern that these deficiencies could adversely affect pregnancy outcomes (e.g., lower neonatal birth weight), evidence of such is lacking. Further prospective studies are warranted to confirm our findings and better delineate the optimal supplementation regimen during pregnancy after bariatric surgery.

Retrievable inferior vena cava filter utilization in obstetric patients.

Objectives: The objective of this study is to evaluate patterns of use and outcomes of retrievable inferior vena cava filters (rIVCF) in obstetric patients. Methods: A single center review of consecutive patients who underwent rIVCF placement during pregnancy/postpartum in 2005-2016. A pooled analysis of the relevant cases in the English literature was conducted. Results: The current cohort comprised 24 women, median age 27 [interquartile range 24-30] years. Among 10 filters placed during pregnancy, the most common indication (n = 4) was the need to withhold anticoagulation therapy before delivery, in the presence of acute thrombosis. In the postpartum period, most filters (64%, 9/14) were an adjunct to catheter-directed thrombolytic therapy. Inferior vena cava filters (IVCF)-related complications occurred in seven (29.2%). Retrieval was attempted in 21 patients (87.5%), and was technically successful in 19 (90.5%), for an overall removal rate of 79.1%. Pooled analysis of the literature (n = 98) showed comparable rates for filter removal and complications (81.6%, p = .78 and 24.2%, p = .60, respectively). Suprarenal placement (p = .12) and elective cesarean section (p = .19) did not reduce overall complication and retrieval rates. The estimated radiation dose among pregnant patients who underwent rIVCF placement without adjunct catheter directed thrombolysis (CDT) (mean 695 Gy cm2) was significantly lower than the radiation dose used in postpartum patients (1863 Gy cm2) or in pregnant patients in whom adjunct CDT was utilized (4059 Gy cm2) (p = .001 for both comparisons). Conclusions: Frequent rIVCF-related complications, radiation exposure, and removal failure call for their cautious utilization in obstetric patients. The role of suprarenal placement and elective cesarean section to improve outcomes has yet to be established.

The effect of surgery-to-conception interval on pregnancy outcomes after sleeve gastrectomy.

BACKGROUND: The optimal timing of pregnancy after bariatric surgery has not been established, with data limited regarding laparoscopic sleeve gastrectomy (LSG), currently the most common bariatric operation performed. OBJECTIVES: We explored associations of the surgery-to-conception interval with pregnancy outcomes after LSG. SETTING: A university hospital. METHODS: We assessed pregnancy outcomes in relation to the surgery-to-conception interval for all women who underwent LSG and delivered during 2006 to 2018. RESULTS: Of 154 patients, 67 (43.5%) conceived within the first 18 months postoperatively (early-pregnancy group), whereas 87 (56.5%) conceived later (late-pregnancy group). The median surgery-to-conception interval was 390 (interquartile range 247-459) days in the early-pregnancy group and 1104 (8527-1548) days in the late-pregnancy group. Compared with the early-pregnancy group, the late-pregnancy group had higher gestational weight gain (median 11 versus 8 kg, P < .001) and lower hemoglobin levels in early pregnancy (12.3 versus 12.6 g/dL, P = .03) and after delivery (10.0 versus 10.4 g/dL, P = .02). Other maternal and perinatal outcomes were similar between the groups, including the proportion of small-for-gestational-age infants (11.9% versus 14.9%, P = .64) for those who conceived within or later than 18 months after surgery. Similar rates of small-for-gestational-age infants were found between those who conceived within or ≥12 months after surgery (P = 1.0). CONCLUSIONS: Timing of pregnancy after LSG was found not to be associated with pregnancy outcomes. Together with documentations of a similar safety profile of pregnancy occurring earlier or later in the postoperative course, these data should reassure women who do not wish to delay conception after surgery.

The long-term effect of pregnancy on weight loss after sleeve gastrectomy.

BACKGROUND: Pregnancy outcomes after bariatric surgery have been addressed extensively; however, the impact of pregnancy on long-term outcomes after bariatric surgery has only been sparsely studied. OBJECTIVES: We explored the effects of pregnancy on weight loss outcomes after laparoscopic sleeve gastrectomy (LSG). SETTING: University hospital. METHODS: A cross-sectional case-control study. Eighty women who became pregnant after LSG were matched by preoperative body mass index, age, and follow-up duration to 80 post-LSG patients who did not conceive after surgery (control group). RESULTS: The median follow-up duration was 5.2 years for the study group and 5.3 years for the control group (P = .73). For the study group, the median time from surgery to conception was 508 (interquartile range 372-954) days and the median gestational weight gain was 9 (6-12) kg. Comparing the study with the control group, median percentage total weight loss was similar, 31% versus 30% (P = .77); as was percentage excess weight loss (EWL%) 72% versus 71% (P = .77). For the study group, a multivariable analysis showed EWL% at the end of follow-up to be directly correlated with the lowest EWL% achieved before pregnancy (ß = .78, P < .0001), and inversely correlated with time lapsed from surgery (ß = -.26, P < .0001); yet EWL% was not found to be associated with surgery-to-conception time interval, gestational weight gain, breastfeeding, co-morbidities, smoking, occupational status, physical activity, and dietary habits. CONCLUSIONS: Pregnancy after LSG does not affect long-term weight results. Coupled with the positive reports of improved pregnancy outcomes after bariatric surgery, these data should reassure women who wish to conceive after surgery.

Maternal and Perinatal Outcomes After Laparoscopic Sleeve Gastrectomy.

OBJECTIVE: To examine associations of laparoscopic sleeve gastrectomy with maternal and perinatal outcomes. METHODS: We conducted a retrospective case-control study of deliveries that occurred from 2006 to 2016 at two university hospitals. The study group comprised all women who had undergone laparoscopic sleeve gastrectomy and who delivered during the study period. If a woman had more than one pregnancy during the study period, data from only her first pregnancy were used. A control group was established by matching preoperative body mass index (BMI), age, parity, delivery history, and delivery year. RESULTS: Data from 238 women were analyzed, 119 post-laparoscopic sleeve gastrectomy and 119 matched control parturients. Among the post-laparoscopic sleeve gastrectomy patients, the median preoperative BMI was 41.7 (interquartile range 39.9-44.4) and the median postoperative BMI was 28.9 (26.6-32.0). Compared with the control group, the study group had lower rates of gestational diabetes mellitus (3.4% vs 17.6%, P=.001), large-for-gestational-age neonates (1.7% vs 19.3%, P=.001), and birth weight greater than 4,000 g (0.8% vs 7.6%, P=.02) but higher proportions of small-for-gestational-age (SGA) neonates (14.3% vs 4.2%, P=.01) and low-birth-weight neonates (12.6% vs 4.2%, P=.03). Rates of gestational hypertensive disorders and prematurity were comparable between the groups. For the study group, hemoglobin levels were lower in early pregnancy (median 12.6 vs 13.2 g/dL, P=.001) and after delivery (10.5 vs 10.8 g/dL, P=.002), and a higher proportion of patients were treated with intravenous iron supplementation during pregnancy (14.3% vs 0.8%, P=.001). Cesarean delivery rates during labor were lower in the study group (10.1% vs 20.2%, P=.04). CONCLUSION: Laparoscopic sleeve gastrectomy was associated with reduced rates of gestational diabetes mellitus, excessive fetal growth, and cesarean delivery and an increased rate of SGA and low-birth-weight neonates.

Hypoglycemia during oral glucose tolerance test among post-bariatric surgery pregnant patients: incidence and perinatal significance.

BACKGROUND: While hypoglycemia during an oral glucose tolerance test (OGTT) has been shown to occur in a considerable portion of nonpregnant post-bariatric surgery (BS) patients, its incidence among pregnant post-BS patients evaluated for gestational diabetes has only been sparsely studied. OBJECTIVES: We investigated OGTT results and pregnancy outcomes in pregnant women who underwent 3 types of bariatric procedures before pregnancy. SETTING: A university hospital. METHODS: From medical records, data were collected on glucose measurements during a 100-g, 3-hour OGTT, as well as maternal and fetal outcomes. RESULTS: Of 119 post-BS pregnant patients included in the study, 55 underwent laparoscopic sleeve gastrectomy, 34 laparoscopic adjustable gastric banding, and 30 laparoscopic Roux-en-Y gastric bypass surgery. Hypoglycemia (<55 mg/dL) was encountered in 59 (49.6%) patients during the OGTT. Among them, the nadir plasma glucose levels occurred 2 hours after glucose ingestion in 25 (42.4%) and after 3 hours in 34 (57.6%), with a median value of 47 (44-52) mg/dL. The risk of hypoglycemia was higher among women with prior laparoscopic Roux-en-Y gastric bypass surgery (83.3%) than among those with prior laparoscopic sleeve gastrectomy (54.5%; P = .009) or laparoscopic adjustable gastric banding (11.8%; P<.0001). Time from surgery to conception was significantly shorter among women with evidence of hypoglycemia during OGTT (median 711 versus 1246 days, P = .002). Compared with patients without evidence of hypoglycemia, patients who experienced hypoglycemia had lower rates of gestational diabetes (P = .03) but higher proportions of low birth weight (P = .01) and small for gestational age infants (P = .03). CONCLUSIONS: Because hypoglycemia is common during OGTT among post-BS parturients, other diagnostic methods should be considered in this setting. The association found between hypoglycemia and poor fetal growth warrants investigation as to whether interventions to prevent hypoglycemia will improve fetal outcome.

Nerve growth factor plays a role in the neurotherapeutic effect of a CD45+ pan-hematopoietic subpopulation derived from human umbilical cord blood in a traumatic brain injury model.

BACKGROUND AIMS: Human umbilical cord blood (HUCB) is an important source of stem cells for therapy of hematopoietic disorders and is a potential therapy for various neurological disorders, including traumatic brain injury (TBI). The expression of nerve growth factor (NGF) and its receptors TrkA, p75NTR and α9ß1 integrin on an HUCB CD45+ pan-hematopoietic subpopulation was investigated in the context of its neurotherapeutic potential after TBI. METHODS: NGF and its receptors were detected on CD45+ cells by reverse transcriptase polymerase chain reaction, flow cytometry analysis and confocal microscopy. CD45+ cells were stimulated by TBI brain extracts, and NGF levels were measured by enzyme-linked immunosorbent assay. TBI mice were divided into six groups for xenogeneic intravenous transplantation, 1 day post-trauma, with 1 × 106 CD45+ cells untreated or treated with the anti-NGF neutralizing antibody K252a, a TrkA antagonist; VLO5, an α9ß1 disintegrin; or negative (vehicle) and positive (NGF) controls. RESULTS: The HUCB CD45+ subpopulation constitutively expresses NGF and its receptors, mainly TrkA and p75NTR and minor levels of α9ß1. In vitro experiments provided evidence that trauma-related mediators from brain extracts of TBI mice induced release of NGF from HUCB CD45+ cell cultures. HUCB CD45+ cells induced a neurotherapeutic effect in TBI mice, abrogated by cell treatment with either anti-NGF antibody or K252a, but not VLO5. CONCLUSIONS: These findings strengthen the role of NGF and its TrkA receptor in the HUCB CD45+ subpopulation's neurotherapeutic effect. The presence of neurotrophin receptors in the HUCB CD45+ pan-hematopoietic subpopulation may explain the neuroprotective effect of cord blood in therapy of a variety of neurological disorders.

Human Umbilical Cord Blood CD45+ Pan-Hematopoietic Cells Induced a Neurotherapeutic Effect in Mice with Traumatic Brain Injury: Immunophenotyping, Comparison of Maternal and Neonatal Parameters, and Immunomodulation.

Human umbilical cord blood (HUCB) transplantation has become an alternative cell therapy for hematological and oncological malignancies in the clinic and is considered for neurological disorders. The heterogeneity in the content of the different stem and progenitor cells composing HUCB mononuclear cells (MNC) may influence their engraftment and neurotherapeutic effect. We hypothesized that CD45 pan-hematopoietic marker expression is heterogeneous in MNC, and therefore, CD45+ subpopulation enrichment for neurotherapy may provide a tool to overcome cellular variance in different HUCB units. We employed an immunomagnetic separation method to isolate and characterize HUCB CD45+ pan-hematopoietic subpopulation and to investigate whether the vaginal or cesarean deliveries influence their neurotherapeutic effect in a traumatic brain injury (TBI) mouse model. Adult C57BL/6J male mice were subjected to moderate TBI and intravenously xenotransplanted with 1 × 106 CD45+ cells derived from either vaginal or cesarean HUCB units. A large heterogeneity in the expression of CD45 marker in MNC, both in vaginal and cesarean HUCB units, was found, regardless of the number of live births. A higher expression of hematopoietic markers was found in the CD45+ subpopulation while low expressional levels of typical mesenchymal markers were detected. Neurotherapeutic effects, evaluated with an established neurological severity score and novel object recognition test, indicated improved functional motor and memory recovery and found independent of delivery type. Cytokine analysis in extracts of TBI brain cortices indicated an acute immunomodulatory effect by HUCB CD45+ subpopulation upon xenotransplantation. These results may provide insights to CD45 marker as a predictor of HUCB units' quality for neurotherapy in TBI.

Neurotherapeutic effect of cord blood derived CD45+ hematopoietic cells in mice after traumatic brain injury.

Treatment of traumatic brain injury (TBI) is still an unmet need. Cell therapy by human umbilical cord blood (HUCB) has shown promising results in animal models of TBI and is under evaluation in clinical trials. HUCB contains different cell populations but to date, only mesenchymal stem cells have been evaluated for therapy of TBI. Here we present the neurotherapeutic effect, as evaluated by neurological score, using a single dose of HUCB-derived mononuclear cells (MNCs) upon intravenous (IV) administration one day post-trauma in a mouse model of closed head injury (CHI). Delayed (eight days post-trauma) intracerebroventricular administration of MNCs showed improved neurobehavioral deficits thereby extending the therapeutic window for treating TBI. Further, we demonstrated for the first time that HUCB-derived pan-hematopoietic CD45 positive (CD45(+)) cells, isolated by magnetic sorting and characterized by expression of CD45 and CD11b markers (96-99%), improved the neurobehavioral deficits upon IV administration, which persisted for 35 days. The therapeutic effect was in a direct correlation to a reduction in the lesion volume and decreased by pre-treatment of the cells with anti-human-CD45 antibody. At the site of brain injury, 1.5-2 h after transplantation, HUCB-derived cells were identified by near infrared scanning and immunohistochemistry using anti-human-CD45 and anti-human-nuclei antibodies. Nerve growth factor and vascular endothelial growth factor levels were differentially expressed in both ipsilateral and contralateral brain hemispheres, thirty-five days after CHI, measured by enzyme-linked immunosorbent assay. These findings indicate the neurotherapeutic potential of HUCB-derived CD45(+) cell population in a mouse model of TBI and propose their use in the clinical setting of human TBI.

Parasellar meningiomas in pregnancy: surgical results and visual outcomes.

BACKGROUND: Rapid visual deterioration may occur as the result of the quick growth of parasellar meningiomas in the high-hormone/increased fluid retention milieu of pregnancy; however, surgery before delivery entails increased maternal-fetal risk. We present our experience in the management of parasellar meningiomas that compress the optic apparatus during pregnancy, with a focus on decisions regarding the timing of surgery. METHODS: Serial visual examinations and other clinical data for 11 women presenting from 2002 to 2012 with visual deterioration during pregnancy or delivery as the result of parasellar meningiomas involving the optic apparatus were reviewed. Indications for surgery during pregnancy included severely compromised vision, rapid visual deterioration, and early-to-midstage pregnancy with the potential for significant tumor growth and visual decrease before delivery. All patients underwent surgery with the use of skull base techniques via pterional craniotomy. An advanced extradural-intradural (i.e., Dolenc) approach, with modifications, was used in seven. RESULTS: All women achieved a Glasgow Outcome Score of 5 at discharge with no new neurologic deficits; all children are developing normally at a mean 4.5 years of age (range, 1-9.5 years). Surgery during pregnancy was recommended for six women: four operated at gestational weeks 20-23 had excellent postoperative visual recovery; two who delayed surgery until after delivery have permanent unilateral blindness. Among five others operated after delivery, four had good visual recovery and one has pronounced but correctable deficits. Three of five women diagnosed at gestational weeks 32-35 experienced spontaneous visual improvement after delivery, before surgery. CONCLUSIONS: We recommend that surgery be offered to patients during pregnancy when a delay may result in severe permanent visual impairment.

Relationship between nulliparity and preeclampsia may be explained by altered circulating soluble fms-like tyrosine kinase 1.

OBJECTIVE: To test the hypothesis that the risk of preeclampsia in nulliparous women may be due to an anti-angiogenic state. METHODS: Maternal serum samples obtained in the third trimester from nulliparous (n = 86) and multiparous (n = 165) singleton uncomplicated pregnancies were analyzed for levels of angiogenic factors - soluble fms like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) by enzyme-linked immunosorbent assay (ELISA). RESULTS: For nulliparous and multiparous pregnancies, serum sFlt1 levels were 12 732 ± 832 and 10 162 ± 666 (p = 0.020), serum PlGF levels were 215 ± 15 and 249 ± 14 (p = 0.093) (all reported as mean SD in pg/ml) and mean ratios of sFlt1/PlGF were 93 ± 12 and 62 ± 5 (p = 0.023), respectively. Adjustment for maternal age and fetal birth weight did not alter the results. CONCLUSIONS: Nulliparous pregnancies had higher circulating sFlt1 levels and sFlt1/PlGF ratios than multiparous pregnancies, suggesting an association with an angiogenic imbalance. Taken together with the pathogenic role of anti-angiogenic factors in preeclampsia, our data may be one explanation for the epidemiological observation that nulliparity is a risk factor for the development of preeclampsia.

Israeli medical students' perceptions of six key medical specialties.

BACKGROUND: Choosing a medical specialty requires medical students to match their interests and social-cultural situations with their perceptions of the various specialties. OBJECTIVES: Examine Israeli 6th-year medical students' perceptions of six key specialties: pediatrics, orthopedic surgery, anesthesiology, obstetrics/gynecology, general surgery and family medicine. METHODS: Questionnaires distributed to 355 6th-year students from three successive classes (2008-2010) of 6th-year students at the Hebrew University - Hadassah School of Medicine, Jerusalem, Israel and the 2010 class of the Ben Gurion University School of Medicine, Be'er Sheva, Israel. RESULTS: Responses were obtained from 234 students, for a response rate of 66%. Pediatrics and obstetrics/gynecology were the specialties most often under positive career consideration by individual students. Anesthesiology and general surgery were least often under positive career consideration and were viewed as being in a workforce crisis. Pediatrics and family medicine, found to be especially popular among women, were perceived by 58% and 78% of respondents, respectively, as providing reasonable ratios of lifestyle to income. None of the students thought the same about general surgery and only 28% thought so about anesthesiology. Pediatrics and obstetrics/gynecology were reported to afford a controllable lifestyle by 63% and 8%, respectively, With respect to positive career considerations and lifestyle perceptions, there were no differences between the opinions of men and women students. Differences between genders arose in responses to queries of whether a specialty was interesting and challenging. Women were more likely than men to perceive pediatrics and family medicine as interesting and challenging while men were more likely to think that general and orthopedic surgery are interesting and challenging. CONCLUSIONS: Knowing the medical students' perceptions of the various specialties should help in understanding the maldistribution of physicians among the various specialties. Such data can also be an important input into the efforts of the healthcare leadership to promote a specialty distribution that matches the population's evolving needs.