Placental vascular lesions differ between male and female fetuses in early-onset preeclampsia.

PURPOSE: A growing body of evidence accumulate pointing to sex-specific differences in placental adaptation to pregnancy complications. We aimed to study if there is a difference in placental histopathology lesions, between female and male fetuses in pregnancies complicated with preeclampsia. METHODS: The medical files of all patients with preeclampsia, were reviewed. Placental lesions were classified to lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. Comparison was performed between the male and the female groups. RESULTS: The study included 441 preeclamptic patients. Women in the male preeclampsia group (n = 225) had higher rate of chronic hypertension (p = 0.05) and diabetes mellitus (p < 0.005), while women in the female preeclampsia group (n = 216) had higher rate of thrombophilia. There were no between groups differences in neonatal outcome or placental histopathology lesions. The early preeclampsia cohort included 91 patients. Placentas from the female early preeclampsia group (n = 44) had more vascular changes related to MVM lesions (decidual arteriopathy), as compared to the male early preeclampsia group (n = 47), 50% vs. 25%, p = 0.01. CONCLUSIONS: Higher rate of placental MVM lesions in the female as compared to male group correspond with sex-specific difference of placental pathophysiological adaptation, in early preeclampsia.

Placental disorders of pregnancy in subsequent IVF pregnancies - a sibling cohort.

RESEARCH QUESTION: To assess whether the incidence of placental disorders of pregnancy decreases with increasing parity in repeat IVF pregnancies, in the same way as natural pregnancies. DESIGN: This was a retrospective cohort of deliveries between November 2008 and January 2020, in a single university-affiliated medical centre. The study included women with only IVF-attained singleton pregnancies (no natural conception) with at least two deliveries, and compared the obstetric and perinatal outcomes between first, second and third deliveries. Each woman served as her own control. The primary outcome was the incidence of placental-related disorders of pregnancy, defined as small for gestational age (SGA) neonates and/or pre-eclampsia. RESULTS: A total of 307 first deliveries, 307 second deliveries and 49 third deliveries by the same women were compared. A trend for a decreased rate of pre-eclampsia was noted with increased parity (P = 0.06) and a significant decrease in the rate of SGA: 11.7% for first delivery, 7.8% for second delivery and 2.0% for third (P = 0.04). This difference in SGA incidence was maintained in a matched sub-analysis of the 49 women with three deliveries (P = 0.04), and after adjustment for fresh/frozen embryo transfer (P = 0.03). Although SGA and pre-eclampsia were generally more common in IVF than natural pregnancies, their decrease with increasing parity mimicked that in natural pregnancies. CONCLUSION: IVF pregnancies are associated with an increased risk of placental disorders of pregnancy. However, they exhibit a decrease in incidence with increasing parity.

The effectiveness of McCall culdoplasty following vaginal hysterectomy in advanced stages of uterine prolapse.

INTRODUCTION AND HYPOTHESIS: Following vaginal hysterectomy (VH), fixation of the vaginal vault is needed to prevent post-operative recurrence/exacerbation of vault prolapse. The effectiveness of McCall culdoplasty in cases of advanced prolapse is unclear. We aimed to compare the effectiveness of McCall culdoplasty following VH in patients with mild versus advanced stages of uterine prolapse. METHODS: In this retrospective study, the Pelvic Floor Distress Inventory (PFDI-20) was utilized to compare the subjective results of vaginal hysterectomy plus McCall culdoplasty between women with mild uterine prolapse stage 2 (mild prolapse group) and advanced uterine prolapse stages 3-4 (advanced prolapse group). The primary outcome, the subjective awareness of prolapse, was analyzed as well as all other aspects of PFDI-20. A sample size of 130 was calculated. RESULTS: The mild prolapse group consisted of 26 (19.3%) patients and the advanced prolapse group consisted of 109 (80.7%) patients. There were no differences between the groups in demographic and clinical characteristics. The rates of concomitant prolapse and incontinence surgeries, performed at the time of VH and post-operative complications. were the same between groups. The mean follow-up was more than 5 years in both groups. Awareness of prolapse was similar between the groups (11.5% in the mild prolapse group and 5.5% in the advanced prolapse group, p = 0.374). There was no significant correlation between the stage of apical prolapse before surgery and awareness of prolapse after the surgery (r = 0.0132, p = 0.879). All aspects of the PFDI-20 questionnaire were similar in the two groups. CONCLUSION: McCall culdoplasty was found to have an equal subjective effectiveness following VH in both mild and advanced stages of uterine prolapse.

Should the interval between doses of antenatal corticosteroids be shortened in certain cases? Factors predicting preterm delivery < 48 h from presentation.

PURPOSE: Treatment with antenatal corticosteroids (ACS) to women at risk for preterm birth (PTB) is associated with a reduction in adverse neonatal outcomes. Obstetricians occasionally shorten the interval between the doses of steroids if delivery is predicted to occur before ACS are fully administered. In this study, we aimed to investigate predicting factors to identify patients that will deliver prematurely, less than 48 h from presentation. METHODS: The computerized medical files of all PTBs (< 34 weeks) were reviewed. Maternal demographics, pregnancy and delivery characteristics were compared between PTB that occurred < 48 h vs. > 48 h from triage presentation. RESULTS: In total, 494 PTB cases were included: 302 women in the study group (PTB < 48 h) and 192 women in the control group (PTB > 48 h). No significant differences were found in demographic characteristics between the groups. At presentation, the study group had higher rates of uterine contractions (p < 0.001) and cervical length < 25 mm (p < 0.001) as well as a higher rate of non-reassuring fetal (NRFHR) monitor (p < 0.001). In contrast, the control group presented with higher rates of preeclampsia (p = 0.003) and preterm premature rupture of membranes (p = 0.038). In multivariable analysis, all of the above factors remained significant after controlling for background confounders. CONCLUSIONS: Various factors at presentation can predict delivery < 48 h. These factors can be used to predict patients to whom the ACS interval should be shortened. Future prospective studies should investigate the effect of this shortening on neonatal outcomes.

Reproductive outcome after early pregnancy loss treated with misoprostol versus surgical aspiration.

RESEARCH QUESTION: Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration. DESIGN: A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention. RESULTS: Baseline characteristics were comparable between women who received misoprostol (n = 163) and women who underwent surgical aspiration (n = 122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; P = 0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; P = 0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; P = 0.16), 12 months (78.5% versus 78.7%, respectively; P = 0.97) and 24 months (92.0% versus 91.8%, respectively; P = 0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; P = 0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; P = 0.81) and birthweight (3295 versus 3161 g, respectively; P = 0.07). CONCLUSIONS: Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction.

Placental-related disorders of pregnancy and IVF: does placental histological examination explain the excess risk?

RESEARCH QUESTION: What are the clinical characteristics of pregnancies complicated by fetal growth restriction (FGR) and preeclampsia in patients who have undergone IVF, and what is the correlation between these complications and histopathological placental findings in such pregnancies. DESIGN: A retrospective cohort of patients who had delivered their babies at our institution who had been diagnosed with preeclampsia, whose babies had been diagnosed with FGR, or both. Deliveries in which the placenta was sent for histopathological examination were included. Computerized files and pathological reports were reviewed, and maternal, obstetric, neonatal outcomes and placental histopathological reports were compared between pregnancies conceived by IVF and controls. Placental lesions were classified according to the Amsterdam criteria. RESULTS: Between December 2008 and December 2018, the placentas of 1114 singleton babies who had received a diagnosis of FGR, whose mothers had received a diagnosis of preeclampisa, or both, were examined. A total of 105 patients conceived with IVF and 1009 were conceived spontaneously. The IVF group was older, of lower parity and had a higher rate of diabetes and chronic hypertension. Deliveries occurred at an earlier gestational age, although birth weight was not significantly different between the groups. The rate of neonatal adverse composite outcome among IVF deliveries was significantly lower (59.0% versus 76.7%; P < 0.001). On placental examination, placental weight, maternal and fetal vascular malperfusion lesions were similar between the groups, whereas villitis of unknown etiology was significantly more common among the IVF group (16.2% versus 8.3%; P = 0.007). CONCLUSION: Neonatal outcome is relatively favourable in IVF patients with placental-related diseases. Placental chronic villitis is more common in IVF patients, pointing to an additive immunological cause.

Are women with cervical incompetence at a higher risk of experiencing urinary and pelvic organ prolapse symptoms?

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTs), in addition to cervical incompetence, have a multifactorial etiology. Connective tissue disorders are common risk factors in both entities. The objective of this study was to compare long-term urinary and pelvic organ prolapse-related symptoms in patients who experienced cervical incompetence and those who did not. METHODS: In this historical prospective cohort, analysis of cervical incompetence cases from one medical center between 2006 and 2009 were compared with a matched control group. All cases included a minimum 7-year follow-up. Symptoms of urinary and prolapse-related complaints during follow-up were evaluated based on the Pelvic Floor Distress Inventory-20 questionnaire. RESULTS: The study group comprised 37 women who experienced cervical incompetence matched to 34 consecutive controls. There was no difference between the groups in demographic or obstetric characteristics, except for a higher cesarean section rate and earlier deliveries among women with cervical incompetence. On assessment of patient's symptoms, during follow-up, the average Pelvic Organ Prolapse Distress Inventory-6 score was significantly higher in patients who experienced cervical incompetence than in controls (15.0 ± 26.1 vs 1.7 ± 7.1 respectively, p = 0.034). Urinary complaints, as reflected by the Urinary Distress Inventory-6 index, were also more common in women with cervical incompetence (17.9 ± 19.1 vs 3.9 ± 7.3 p = 0.027). CONCLUSIONS: Women with a history of cervical incompetence experienced a higher rate of pelvic organ prolapse and urinary symptoms compared with women who had no cervical insufficiency.

Protracted postpartum urinary retention-a long-term problem or a transient condition?

INTRODUCTION AND HYPOTHESIS: Protracted postpartum urinary retention (P-PUR) is a rare puerperal complication of overt urinary retention that proceeds beyond the 3rd postpartum day. Long-term consequences of P-PUR are poorly reported. The objective of the study was to compare the long-term outcome of patients with P-PUR with a matched control group, using a validated pelvic floor distress questionnaire. METHODS: All medical files of women diagnosed with P-PUR between 2005 and 2016 were reviewed. The control group was comprised of women who had a consecutive birth, matched in a 1:2 ratio, by maternal age, parity, neonatal birth weight, analgesia, and route of delivery. All women were evaluated for long-term symptoms of urinary or fecal incontinence and pelvic-organ-prolapse-related complaints by a telephone interview, at least 1 year following their delivery, using the Pelvic Floor Distress Inventory-Short Form (PFDI-20) questionnaire. RESULTS: During the study period, there were 27 cases of P-PUR out of 52,662 deliveries (0.051%). There were no differences between the study group (n = 27) and controls (n = 54) in age, BMI (kg/m2), parity, birth weight, route of delivery, and rate of episiotomy. The majority of patients in both groups opted for epidural analgesia. Second stage of labor was longer in the study group than in controls, 134.1 ± 74.6 min vs. 73.4 ± 71.6 min, respectively, p < 0.001. The scores of the PFDI-20, UDI-6, and POPDI-6 did not differ between the groups. However, the study group had minimally elevated scores on the CARDI-8 scale (1.0 ± 2.6 vs. 0.0 ± 0.0, p = 0.012). CONCLUSIONS: P-PUR is a rare postpartum complication, yet this disturbing condition has negligible if any clinical impact on long-term urogynecologic disorders. These findings carry a reassuring message to both patients and their health care providers.

Characteristics and trends of sexual assaults in Israel - A large cohort study of 3941 victims.

INTRODUCTION: To improve care for victims of sexual assault, specialized assault centers have been developed globally, providing medical, psychological and legal care in one place. Our assault center serves a large population in the center of Israel. In 2010, we initiated a program aimed to prevent assaults among minors and to encourage early referral of victims to the center. The goal of the current study was to assess the impact of this program by comparing the characteristics of sexual assaults before and after the program's initiation. MATERIAL AND METHODS: We conducted a historic cohort study of all victims of sexual assaults who were treated in our center between October 2000 and November 2017. A comparison was performed between victims treated before and after January 2010 (early vs. late study period), when the prevention program was initiated. The program mainly included lectures in middle and high schools, and workshops for police investigators. RESULTS: Overall, 3941 victims of sexual assault were treated in our center during the study period. Most victims were females (90.5%). Mean age was 23.0 ± 11.0 years. Most victims were single (93.1%), and approximately half knew their perpetrator before the assault. Compared with the early study period, in the late study period we observed a decrease in the rate of minor victims (31.9% vs. 24.7%, respectively, P < .001) and an increase in the rate of victims who arrived to the center within 3 days of the assault (P = .001). However, we observed higher rates of multiple-perpetrator assaults (16.7% vs. 21.9%, respectively, P < .001), alcohol use (29.2% vs. 40.1%, respectively, P < .001), and drug use (7.2% vs. 9.0%, respectively, P = .04). Moreover, in the late study period, fewer victims were willing to press charges (79.5% vs. 64.4%, respectively, P < .001). CONCLUSION: Our prevention program might have contributed to reducing the rate of sexual assaults among minors and shortened the time interval between the assault and victim's arrival to the center. Nonetheless, more efforts should be taken to reduce the involvement of alcohol and drugs in sexual assaults and to encourage victims to press charges.

The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study.

BACKGROUND: The association between the number of vaginal examinations (VEs) performed during labor and the risk of infection is unclear. The literature regarding this issue is not consensual, and the available studies are relatively small. Therefore, we aimed to study the association between the number of VEs during labor, and maternal febrile morbidity, in a very large cohort. METHODS: This is a retrospective cohort study. All women who delivered vaginally ≥37 weeks, at our institute, between 2008 and 2017 were included. Patients who underwent cesarean delivery or who were treated with prophylactic antibiotics, or had a fever ≥38.0 °C prior to the first VE were excluded. Cases of intrauterine fetal death, known malformations, or missing data were excluded as well. The cohort was divided according to the number of VEs performed: up to 4 VEs (n = 9716), 5-6 VEs (n = 4624), 7-8 VEs (n = 2999), and 9 or more VEs (n = 4844). The rates of intrapartum febrile morbidity (intrapartum fever and chorioamnionitis), postpartum febrile morbidity (postpartum fever and endometritis), and peripartum febrile morbidity (any of the mentioned complications) were compared. RESULTS: Overall, 22,183 women were included in the study. On multivariate analysis, we found that performing 5 VEs or more during labor was independently associated with intrapartum febrile morbidity (5-6 VEs: aOR = 1.83, 95% CI (1.29-2.61), 7-8 VEs: aOR = 2.65 95% CI (1.87-3.76), 9 or more VEs aOR = 3.47 95% CI (2.44-4.92)), postpartum febrile morbidity (5-6 VEs: aOR = 1.29, 95% CI (1.09-1.86), 7-8 VEs: aOR = 1.94 95% CI (1.33-2.83), 9 or more VEs aOR = 1.91 95% CI (1.28-2.82)), and peripartum morbidity (5-6 VEs: aOR = 1.48, 95% CI (1.15-1.91), 7-8 VEs: aOR = 2.15 95% CI (1.66-2.78), 9 or more VEs: aOR = 2.57 95% CI (1.97-3.34)). CONCLUSION: The number of VEs performed during labor is directly correlated with febrile morbidity. Performing five or more VEs during labor is independently associated with febrile morbidity; For intrapartum and peripartum febrile morbidity the risk rises as more VEs are performed.

Enhancing patient mobility following cesarean-delivery - the efficacy of an improved postpartum protocol assessed with pedometers.

BACKGROUND: The incidence of thromboembolic complications is highest in the immediate postpartum period, especially following caesarean delivery (CD). Ambulation following CD is important in their prevention. We examined the effect of an educational protocol on patients' mobility following CD, with the use of digital step counters (pedometers). METHODS: Starting February 2018, we implemented an educational protocol at the maternity ward, which included nurses' tutoring and subsequent patients' education, regarding the importance of early ambulation. Following CD, ambulation was initiated 4 h following surgery (as compared to 6 h prior). Scheduled IV acetaminophen was administered at six-hour intervals for 48 h (as compared to only 24 h prior), while additional analgesics were given upon patient request. We compared maternal demographics, delivery and postpartum course between the pre-protocol group (n = 101) and the post-protocol group (n = 100). All patients were asked to wear pedometers for 48 h following the delivery to assess ambulation. RESULTS: Patients' demographics, surgical and post-partum course were non-significant between the groups, except for surgical length (48.5 ± 14.6 vs. 53.5 ± 15.3 min in the pre and post protocol groups, respectively, p = 0.02). The pre-protocol group was treated with more additional analgesics (p = 0.02). A higher number of steps was taken in the post-protocol group as compared to the pre-protocol group (4394 ± 2985 vs.3551 ± 2931, respectively p = 0.04). In a linear regression analysis in which the number of steps served as the dependent variable, this educational protocol was independently associated with a higher number of steps [coefficient 988 steps, 95% CI 137-1838, p = 0.02], as was smoking, after adjustment for surgical length, emergent surgery, maternal age and body mass index. CONCLUSION: An educational protocol which included earlier ambulation and regular interval pain control was associated with improved ambulation following CD.

Reduced fetal movements at term in singleton low risk pregnancies-Is there an association with placental histopathological findings?

INTRODUCTION: Maternal perception of fetal movements has long been considered an indicator of fetal well-being. A sudden decrease in the number of fetal movements is suggestive of fetal compromise. We aimed to determine whether the maternal perception of reduced fetal movements (RFM) is associated with placental pathological lesions in a low-risk term population. MATERIAL AND METHODS: Our study was a case-control study that was performed in a single university center. Placental histopathology, maternal demographics, labor characteristics, and neonatal outcomes of term, singleton pregnancies with maternal perception of RFM during the 2 weeks prior to delivery were collected. To isolate the effect of RFM on placental pathology, we excluded cases complicated by preterm birth, hypertensive disorders, diabetes mellitus, small-for-gestational-age and congenital/genetic anomalies. We compared pregnancy outcomes and placental pathology between the RFM group and a control group matched for gestational age and mode of delivery. Placental lesions were classified according to the "Amsterdam" criteria. Composite adverse neonatal outcome was defined as one or more of the following: sepsis, transfusion, hypoglycemia, phototherapy, respiratory morbidity, cerebral morbidity, necrotizing enterocolitis and fetal/neonatal death. Multivariable regression analysis was performed to identify independent associations with adverse neonatal outcome. RESULTS: We included patients who gave birth from January 2008 until May 2019. The study group included 203 term pregnancies with RFM during the 2 weeks prior to delivery, which was matched with 203 controls. The RFM group was characterized by a higher rate of placental weight <10th percentile (22.6% vs. 3.9%, P < .001), a higher rate of maternal vascular malperfusion lesions (30.5% vs. 18.7%, P = .007) and lesions of maternal inflammatory response (43.3% vs. 29.5%, P = .005). At delivery, the RFM group had higher rates of cesarean delivery due to non-reassuring fetal heart rate monitoring (P = .01), 5-minute Apgar score ≤7 (P = .03), neonatal intensive care unit admissions (P < .001) and composite adverse neonatal outcomes (P = .007). Using multivariable analysis, RFM (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.1-4.8), and placental maternal vascular malperfusion lesions (aOR 1.2, 95% CI 1.0-2.9) were independently associated with adverse neonatal outcome. CONCLUSIONS: After excluding important placental-related morbidities, RFM was associated with a higher rate of placental weight <10th percentile and placental maternal vascular malperfusion lesions vs. controls. This study suggests a placental involvement in the association between RFM at term and adverse pregnancy outcomes.

Placental histopathology in IVF pregnancies resulting from the transfer of frozen-thawed embryos compared with fresh embryos.

PURPOSE: To study whether placentas of singleton pregnancies conceived after fresh embryo transfer (ET) contain more histopathological lesions compared with placentas of singleton pregnancies conceived after frozen-thawed embryo transfer (FET). METHODS: A prospective cohort study of placental histopathology in 131 women with singleton IVF pregnancies who delivered at a single medical center, between December 2017 and May 2019. The prevalence of different placental histopathology lesions was compared between women who conceived after fresh ET and FET. RESULTS: Women who conceived after fresh ET (n = 74) did not differ from women who conceived after FET (n = 57) with regard to maternal age, BMI, nulliparity, or infertility diagnosis. Gestational week at delivery was lower in pregnancies conceived after fresh ET (38.5 vs. 39.2 weeks, respectively, p = 0.04), and a trend for a lower birthweight following fresh ET was noted (3040 vs. 3216 g, respectively, p = 0.053). However, placental histopathology analysis from pregnancies conceived after fresh ET was comparable to pregnancies conceived after FET, with regard to the prevalence of maternal vascular malperfusion lesions (45.9% vs. 50.9%, respectively, p = 0.57), fetal vascular malperfusion lesions (17.6% vs. 21.1, p = 0.61), acute inflammatory response lesions (28.4% vs. 28.1%, respectively, p = 0.96), and chronic inflammatory response lesions (13.5% vs. 8.8%, respectively, p = 0.48). CONCLUSION: Placental histopathology did not differ between IVF pregnancies conceived after fresh and frozen ET. These results are reassuring for clinicians and patients who wish to pursue with transferring fresh embryos.

Are there gender-specific differences in pregnancy outcome and placental abnormalities of pregnancies complicated with small for gestational age?

INTRODUCTION: Adaptations to pathological intrauterine environment might differ in relation to fetal gender. We aimed to study sex-specific differences in placental pathology of pregnancies complicated by small for gestational age (SGA). METHODS: The medical records and placental histology reports of all neonates with a birth-weight ≤ 10th percentile, born between 24 and 42 weeks of gestation, during 2010-2018, were reviewed. Composite neonatal outcome was defined as one or more of early following complications: neonatal sepsis, blood transfusion, phototherapy, respiratory morbidity, cerebral morbidity, necrotizing enterocolitis, or death. Results were compared between the male and female groups of neonates. Placental lesions were classified into maternal and fetal vascular malperfusion (MVM and FVM) lesions, maternal and fetal inflammatory responses (MIR and FIR), and villitis of unknown etiology (VUE). RESULTS: The male SGA group (n = 380) and the female SGA group (n = 363) did not differ in regard to maternal age, BMI, smoking, associated pregnancy complications, gestational age, and mode of delivery. Neonates in the SGA male group had increased birth-weight and increased respiratory morbidity as compared to the female SGA group (p = 0.007, p = 0.005, respectively). There was no between-group differences in the rate of placental lesions. By multivariate logistic regression analysis, male gender (aOR 1.55, 95% CI 1.05-2.30, p = 0.025), FIR (aOR 4.83, 95% CI 1.07-13.66, p = 0.003), and VUE (aOR 1.89, 95% CI 1.03-3.47, p = 0.04), were found to be independently associated with adverse composite neonatal outcome. DISCUSSION: Male gender as well as placental FIR and VUE are independently associated with adverse neonatal outcome in SGA neonates.

Placental pathology in pregnancies complicated by fetal growth restriction: recurrence vs. new onset.

OBJECTIVE: In an attempt to shed new light on the pathogenesis of fetal growth restriction (FGR), we aimed to study pregnancy characteristics, neonatal outcomes, and placental histopathological lesions of FGR pregnancies in two different subgroups: when developed after appropriate for gestational age (AGA) pregnancy and when developed after previous pregnancy with FGR. STUDY DESIGN: Pregnancy and placental reports of all singleton pregnancies complicated by FGR (defined as actual birthweight below the 10th percentile according to local birthweight nomograms) between 2008 and 2018 were reviewed. Included were only cases with previous delivery. Maternal background, neonatal outcomes, and placental histopathology were compared between FGR that occurred after FGR (recurrent FGR group) and FGR that occurred after an AGA pregnancy (FGR after AGA group). Placental lesions were classified according to the current "Amsterdam" criteria. Continuous variables were compared using the Student's t test or the Mann-Whitney test as appropriate. Categorical variables were compared using Chi-square or Fisher's exact test as appropriate. RESULTS: A total of 334 FGR cases with a previous delivery were included in the study. Of them, 111 cases constituted the recurrent FGR group and 223 constituted the FGR after AGA group. The recurrent FGR group was characterized by higher rates of maternal diabetes during pregnancy and hypertensive diseases (9% versus 2.7%, p = 0.01 and 19.8% versus 11.6%, p = 0.04). The FGR after AGA group was characterized by a higher rate of fetal vascular malperfusion (FVM) lesions (29.6% versus 18.0%, p = 0.02), and by lower mean birthweight (1842 ± 424.9 versus 1977.4 ± 412.2, p = 0.005), as compared to the recurrent FGR group. CONCLUSION: Recurrent FGR was associated with maternal background morbidities during pregnancy which represents a chronic repeated insult, while "new" FGR cases (those followed an AGA pregnancy) were characterized by a higher rate of FVM lesions and lower birthweight which probably represent an "accident" in placentation. These findings may suggest that different mechanisms of placental dysfunction exist in the two subgroups of FGR.

Reduced fetal movements at term, low-risk pregnancies: is it associated with adverse pregnancy outcomes? Ten years of experience from a single tertiary center.

OBJECTIVE: We aimed to assess the outcomes of low-risk pregnancies complicated by isolated reduced fetal movements (RFM) at term. STUDY DESIGN: The study population were patients at term, with singleton, low-risk, pregnancies who presented to our obstetric-triage and delivered during the subsequent 2 weeks. The study group included patients with an isolated complaint of RFM (RFM group). The control group included patients without history of RFM (control group). The pregnancy, delivery, and neonatal outcomes were compared between the groups. Severe and mild composites of adverse neonatal outcomes were defined. Multivariate regression analyses were performed to identify independent association with adverse neonatal outcomes. RESULTS: Among the 13,338 pregnant women, 2762 (20.7%) were included in the RFM group and 10,576 (79.3%) in the control group. The RFM group had higher rates of nulliparity (p < 0.001), and smoking (p < 0.001). At admission, the RFM group had higher rates of IUFD (p < 0.001). The RFM group had higher rates of Cesarean delivery due to non-reassuring fetal monitor (p < 0.001), and mild adverse neonatal outcomes (p = 0.001). RFM was associated with mild adverse outcome independent of background confounders (aOR = 1.4, 95% CI 1.2-2.6, p < 0.001). CONCLUSION: Patients presented with isolated RFM at term had higher rates of IUFD at presentation and significant adverse outcomes at delivery.

Characteristics and prognosis of borderline ovarian tumors in pre and postmenopausal patients.

OBJECTIVE: To compare patient characteristics, imaging results, surgical management and prognosis of borderline ovarian tumors (BOT) between pre and postmenopausal patients. MATERIALS AND METHODS: A retrospective cohort of all cases of histologically verified BOT between 1990-2018, comparing presentation, imaging, surgical procedures and recurrence. Patients were included in the postmenopausal group if they reported 12 months of amenorrhea with or without menopausal symptoms. RESULTS: During this 28 year study period, 66 operations were performed in which BOT was confirmed. Postmenopausal patients were 37-89 years old and premenopausal patients 18-50 years old, with an average age of 63.9 ± 13.4 and 36.2 ± 8.4 years, respectively (p < 0.001). The majority of patients in both groups were diagnosed due to abdominal pain, followed by incidental diagnosis on routine ultrasound. Imaging and CA-125 levels upon presentation were similar. Almost sixty percent of postmenopausal and 26.3% of premenopausal patients underwent laparotomy (p = 0.01), while those who underwent laparoscopy were 35.7% and 60.5%, respectively (p = 0.03). Most postmenopausal patients underwent bilateral salpingo-oophorectomy (BSO), whereas premenopausal surgeries involved cystectomy. Nearly all study patients were diagnosed in stage one. Malignant transformation occurred in 7.1% of postmenopausal patients. No malignant transformation was found in premenopausal patients. CONCLUSION: BOT's present similarly in pre and postmenopausal patients. Postmenopausal patients undergo more extensive surgery, and are diagnosed in early stage disease. Despite a tendency for a more conservative approach in premenopausal patients, prognosis is similar in both groups.

Is advanced maternal age associated with placental vascular malperfusion? A prospective study from a single tertiary center.

PURPOSE: Pregnancy at advanced maternal age (AMA) has become more common. There has been concern regarding the adverse effect deferring pregnancy might have on pregnancy outcomes. We aimed to prospectively study the effect of AMA on placental pathology. METHODS: A prospective case-control study was performed in a single university center. Placental histopathology, maternal demographics, labor characteristics, and neonatal outcomes of pregnancies with AMA were collected and compared to matched controls. We defined AMA as maternal age > 35 years at delivery. In attempt to isolate the effect of maternal age, we excluded cases complicated by preterm birth, hypertensive disorders, diabetes mellitus, small for gestational age, and congenital/genetic anomalies. RESULTS: The study group included 110 AMA patients that were matched with controls. The groups did not differ in maternal demographics, but the AMA group had a higher rate of assisted reproductive technologies (ART) as compared to the control group (p < 0.001). Placentas in the AMA group were characterized by a higher rate of maternal vascular lesions (MVM) (39.1% vs. 24.5%, p = 0.003), but not fetal vascular malperfusion lesions (p = 0.576). In multivariable analysis maternal age was associated with placental MVM lesions independent of all other maternal demographics (aOR 1.18 95% CI 1.06-3.17). Neonatal outcomes did not significantly differ between the groups. CONCLUSIONS: After excluding all background morbidities-AMA was associated with a higher rate of placental MVM lesions vs. controls. These findings suggest an independent effect of AMA on placental function. Large prospective trials are needed to study the clinical importance of these findings.

The association between the number of vaginal examinations during labor and perineal trauma: a retrospective cohort study.

PURPOSE: To study the association between the number of vaginal examinations (VEs) performed during labor and subsequent severe perineal trauma. METHODS: This is a retrospective cohort study. We included all women admitted to the delivery ward between 2008 and 2017, in active labor. Exclusion criteria included preterm deliveries (< 37 weeks), Cesarean deliveries and episiotomy during delivery. The primary outcome, severe perineal trauma, was defined as perineal tears grades 3-4. The cohort was divided into 4 groups, based on the number of VEs performed during labor: Group 1-up to two VEs (n = 4588), Group 2-three to four VEs (n = 5815), Group 3-five to six VEs (n = 4687), and Group 4-seven or more VEs (n = 7297). RESULTS: Overall, 22,387 women were included in the study. The rate of severe perineal trauma in groups 1, 2, 3 and 4 was 0.4%, 0.1%, 0.8%, and 0.4%, respectively (p < 0.001). Performing five or more VEs during labor was associated with a higher risk of severe perineal trauma (0.26% vs. 0.53%, p < 0.01), as compared to four VEs or less. Using a logistic regression model, we found that performing five or more VEs during labor (aOR = 1.72 CI 95% (1.21-2.47), p < 0.001) or performing an instrumental delivery (aOR = 2.65 CI 95% (1.72-4.07), p < 0.001) were directly associated with the risk for severe perineal trauma. Applying epidural anesthesia showed an inverse association with severe perineal trauma (aOR = 0.54 CI 95% (0.38-0.77), p < 0.001). CONCLUSION: Performing five or more VEs during active labor is associated with an increased risk for severe perineal trauma.

[THE EDITH WOLFSON CENTER FOR VICTIMS OF SEXUAL ASSAULT - LESSONS FROM 17 YEARS OF EXPERIENCE].

INTRODUCTION: The Center for Victims of Sexual Assault at Wolfson's Medical Center is the first of its kind in Israel. It was launched in 2000 by the Department of Obstetrics and Gynecology, and has since served over 4000 victims. The center provides care by a multidisciplinary team of gynecologists, social workers, forensic physicians, and police investigators, in a single place and with a supporting atmosphere. AIMS: To review the characteristics of female victims who were treated in the Center for Victims of Sexual Assault at Wolfson's Medical Center between 2000 and 2017. METHODS: This is a retrospective observational study. The data of all female victims who were treated in our center were retrieved from the medical files. The study was approved by the Institutional Review Board. RESULTS: During the study period, 3598 (90.5%) women and 376 (9.5%) men were treated in our center. The mean age of the female victims was 23.0 years, of whom 27.1% were minors. Most victims (69.8%) arrived at the center within 24 hours from the assault. The victim knew the perpetrator before the assault in half of the cases. About half of the assaults occurred on weekends. The victims reported a high rate of alcohol and drug use before the assault (36.2% and 8.1%, respectively), and this rate has increased over the years. Most victims (70.4%) filed a police report, though this rate has decreased over the years. DISCUSSION: The Center for Victims of Sexual Assault at Wolfson's Medical Center treats many victims each year. The challenges that we will face in the future are education against irresponsible use of alcohol and drugs, and efforts to increase the proportion of victims willing to report to the police.