Decision-to-delivery interval and neonatal outcomes in intrapartum umbilical cord prolapse.

BACKGROUND: Rapid delivery is important in cases of umbilical cord prolapse to prevent hypoxic injury to the fetus/neonate. However, the optimal decision-to-delivery interval remains controversial. OBJECTIVE: The aim of the study was to investigate the association between the decision-to-delivery interval in women with umbilical cord prolapse, stratified by fetal heart rate pattern at diagnosis, and neonatal outcome. STUDY DESIGN: The database of a tertiary medical center was retrospectively searched for all cases of intrapartum cord prolapse between 2008 and 2021. The cohort was divided into three groups according to findings on the fetal heart tracing at diagnosis: 1) bradycardia; 2) decelerations without bradycardia; and 3) reassuring heart rate. The primary outcome measure was fetal acidosis. The correlation between cord blood indices and decision-to-delivery interval was analyzed using Spearman's rank correlation coefficient. RESULTS: Of the total 103,917 deliveries performed during the study period, 130 (0.13%) were complicated by intrapartum umbilical cord prolapse. Division by fetal heart tracing yielded 22 women (16.92%) in group 1, 41 (31.53%) in group 2, and 67 (51.53%) in group 3. The median decision-to-delivery interval was 11.0 min (IQR 9.0-15.0); the interval was more than 20 min in 4 cases. The median cord arterial blood pH was 7.28 (IQR 7.24-7.32); pH was less than 7.2 in 4 neonates. There was no correlation of cord arterial pH with decision-to-delivery interval (Spearman's Ρ = - 0.113; Ρ = 0.368) or with fetal heart rate pattern (Spearman's Ρ = .425; Ρ = .079, Ρ = - .205; Ρ = .336, Ρ = - .324; Ρ = .122 for groups 1-3, respectively). CONCLUSION: Intrapartum umbilical cord prolapse is a relatively rare obstetric emergency with an overall favorable neonatal outcome if managed in a timely manner, regardless of the immediately preceding fetal heart rate. In a clinical setting which includes a high obstetric volume and a rapid, protocol-based, response, there is apparently no significant correlation between decision-to-delivery interval and cord arterial cord pH.

Trend and risk Factors for Severe Peripartum Maternal morbidity - a population-based Cohort Study.

OBJECTIVES: While the rates of maternal mortality in developed countries have remained low in recent years, rates of severe maternal morbidity (SMM) are still increasing in high income countries. As a result, SMM is currently used as a measure of maternity care level. The aim of this study was to investigate the prevalence and risk factors of SMM surrounding childbirth. METHODS: A nested case-control study was performed between the years 2013-2018. SMM was defined as peripartum hospitalization involving intensive care unit (ICU). A comparison was conducted between parturient with SMM to those without, randomly matched for delivery mode and date of birth in a 1:1 ratio. Multivariable logistic regression models were used to evaluate the independent association between SMM and different maternal and pregnancy characteristics. RESULTS: During the study period, 96,017 live births took place, of which 144 (1.5 per 1,000 live births-0.15%) involved SMM with ICU admissions. Parturient with SMM were more likely to have a history of 2 or more pregnancy losses (18.2% vs. 8.3%, p = 0.004), deliver preterm (48.9% vs. 8.8%, p < 0.001), and suffer from placenta previa (11.9% vs. 1.5%, p < 0.001), and/or placenta accreta (9.7% vs. 1.5%, p = 0.003). Several significant and independent risk factors for SMM were noted in the multivariable regression models: preterm delivery, history of ≥ 2 pregnancy losses, grand-multiparity, Jewish ethnicity, and abnormal placentation (previa or accreta). CONCLUSIONS FOR PRACTICE: SMM rates in our cohort were lower than reported in developed countries. An independent association exists between peripartum maternal ICU admissions and several demographic and clinical risk factors, including preterm birth and abnormal placentation.

Boosting maternal and neonatal humoral immunity following SARS-CoV-2 infection using a single messenger RNA vaccine dose.

BACKGROUND: Post-COVID-19 vaccine boosting is a potent tool in the ongoing pandemic. Relevant data regarding this approach during pregnancy are lacking, which affects vaccination policy guidance, public acceptance, and vaccine uptake during pregnancy. We aimed to investigate the dynamics of anti-SARS-CoV-2 antibody levels following SARS-CoV-2 infection during pregnancy and to characterize the effect of a single postinfection vaccine booster dose on the anti-SARS-CoV-2 antibody levels in parturients in comparison with the levels in naïve vaccinated and convalescent, nonboosted parturients. STUDY DESIGN: Serum samples prospectively collected from parturients and umbilical cords at delivery at our university-affiliated urban medical center in Jerusalem, Israel, from May to October 2021, were selected and analyzed in a case-control manner. Study groups comprised the following participants: a consecutive sample of parturients with a polymerase chain reaction-confirmed history of COVID-19 during any stage of pregnancy; and comparison groups selected according to time of exposure comprising (1) convalescent, nonboosted parturients with polymerase chain reaction-confirmed COVID-19; (2) convalescent parturients with polymerase chain reaction-confirmed COVID-19 who received a single booster dose of the BNT162b2 messenger RNA vaccine; and (3) infection-naïve, fully vaccinated parturients who received 2 doses of the BNT162b2 messenger RNA vaccine. Outcomes that were determined included maternal and umbilical cord blood anti-SARS-CoV-2 antibody levels detected at delivery, the reported side effects, and pregnancy outcomes. RESULTS: A total of 228 parturients aged 18 to 45 years were included. Of those, samples from 64 were studied to characterize the titer dynamics following COVID-19 at all stages of pregnancy. The boosting effect was determined by comparing (1) convalescent (n=54), (2) boosted convalescent (n=60), and (3) naïve, fully vaccinated (n=114) parturients. Anti-SARS-CoV-2 antibody levels detected on delivery showed a gradual and significant decline over time from infection to delivery (r=0.4371; P=.0003). Of the gravidae infected during the first trimester, 34.6% (9/26) tested negative at delivery, compared with 9.1% (3/33) of those infected during the second trimester (P=.023). Significantly higher anti-SARS-CoV-2 antibody levels were observed among boosted convalescent than among nonboosted convalescent (17.6-fold; P<.001) and naïve vaccinated parturients (3.2-fold; P<.001). Similar patterns were observed in umbilical cord blood. Side effects in convalescent gravidae resembled those in previous reports of mild symptoms following COVID-19 vaccination during pregnancy. CONCLUSION: Postinfection maternal humoral immunity wanes during pregnancy, leading to low or undetectable protective titers for a marked proportion of patients. A single boosting dose of the BNT162b2 messenger RNA vaccine induced a robust increase in protective titers for both the mother and newborn with moderate reported side effects.

Maternal Blood Angiogenic Factors and the Prediction of Critical Adverse Perinatal Outcomes Among Small-for-Gestational-Age Pregnancies.

OBJECTIVE: Our objective was to determine whether maternal blood angiogenic factors in suspected-small-for-gestational-age (sSGA) fetuses can predict critical adverse perinatal outcomes (CAPO) and improve risk assessment. METHODS: Women with singleton pregnancies diagnosed with sSGA, between 24 and 356/7 weeks' gestation, were included. Clinical and sonographic comprehensive evaluations were performed at enrolment. Plasma angiogenic factors, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF), were obtained at diagnosis. In parallel, three attending maternal-fetal-medicine specialists predicted the risk (1-5 scale) of these pregnancies to develop CAPO, based on the clinical presentation. CAPOs were defined as prolonged neonatal intensive care unit hospitalization, fetal or neonatal death, and major neonatal morbidity. Statistical analysis included sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic (ROC) curve analyses. RESULTS: Of the 79 cases included, 32 were complicated by CAPO (40.5%). In SGA fetuses with CAPO, the sFlt-1/PlGF ratio was higher (p < 0.001) and PlGF was lower (p < 0.001) as compared with uncomplicated pregnancies. The areas under the ROC curves for specialists were 0.913, 0.824, and 0.811 and for PlGF and sFlt-1/PlGF ratio 0.926 and 0.900, respectively. CAPO was more common in pregnancies with absent end-diastolic flow or reversed end-diastolic flow (AEDF or REDF) in the umbilical artery upon enrolment (91.6%). Yet, 65.6% of cases involving CAPO occurred in patients without AEDF or REDF, and 66.6% of these cases were not identified by one or more of the experts. The sFlt-1/PlGF ratio identified 92.9% of the experts' errors in this group and 100% of the errors in cases with AEDF or REDF. CONCLUSIONS: Among sSGA pregnancies prior to 36 weeks' gestation, angiogenic factors testing can identify most cases later complicated with CAPO. Our data demonstrate for the first time that these markers can reduce clinician judgment errors. Incorporation of these measures into decision-making algorithms could potentially improve management, outcomes, and even health care costs. KEY POINTS: · Angiogenic factors at diagnosis of sSGA can be used to predict CAPO.. · The sFlt-1/PlGF ratio can flag sSGA pregnancies at increased risk.. · The sFlt-1/PlGF ratio at admission of sSGA adds to clinical assessment..

Uterine rupture risk in a trial of labor after cesarean section with and without previous vaginal births.

PURPOSE: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for the trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. METHODS: A retrospective cohort study was conducted, including women who underwent TOLACs from 2003 to 2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥ 24 weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was a uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders. RESULTS: A total of 11,235 women were included, 6795 of which had a PVD. Women with PVD had significantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p < 0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p < 0.0001), were more likely to undergo labor induction (OR 1.56, p < 0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p < 0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22. CONCLUSION: PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients.

Normal labor curve in twin gestation.

BACKGROUND: Failure to progress is one of the leading indications for cesarean delivery in trials of labor in twin gestations. However, assessment of labor progression in twin labors is managed according to singleton labor curves. OBJECTIVE: This study aimed to establish a partogram for twin deliveries that reflects normal and abnormal labor progression and customized labor curves for different subgroups of twin labors. STUDY DESIGN: This was a multicenter, retrospective cohort analysis of twin deliveries that were recorded in 3 tertiary medical centers between 2003 and 2017. Eligible parturients were those with twin gestations at ≥34 weeks' gestation with cephalic presentation of the presenting twin and ≥2 cervical examinations during labor. Exclusion criteria were elective cesarean delivery without a trial of labor, major fetal anomalies, and fetal demise. The study group comprised twin gestations, whereas singleton gestations comprised the control group. Statistical analysis was performed using Python 3.7.3 and SPSS, version 27. Categorical variables were analyzed using chi-square tests. Student t test and Mann-Whitney U test were applied to analyze the differences in continuous variables, as appropriate. RESULTS: A total of 1375 twin deliveries and 142,659 singleton deliveries met the inclusion criteria. Duration of the active phase of labor was significantly longer in twin labors than in singleton labors in both nulliparous and multiparous parturients; the 95th percentile duration was 2 hours longer in nulliparous twin labors and >3.5 hours longer in multiparous twin labors than in singleton labors. The cervical dilation progression rate was significantly slower in twin deliveries than in singleton deliveries with a mean rate in twin deliveries of 1.89 cm/h (95th percentile, 0.51 cm/h) and a mean rate of 2.48 cm/h (95th percentile, 0.73 cm/h) in singleton deliveries (P<.001). In addition, epidural use further slowed labor progression in twin deliveries. The second stage of labor was also markedly longer in twin deliveries, both in nulliparous and multiparous women (95th percentile, 3.04 vs 2.83 hours, P=.002). CONCLUSION: Twin labors are characterized by a slower progression of the active phase and second stage of labor compared with singleton labors in nulliparous and multiparous parturients. Epidural analgesia further slows labor progression in twin labors. Implementation of these findings in clinical management might lower cesarean delivery rates among cases with protracted labor in twin gestations.

Transporting an Artificial Intelligence Model to Predict Emergency Cesarean Delivery: Overcoming Challenges Posed by Interfacility Variation.

Research using artificial intelligence (AI) in medicine is expected to significantly influence the practice of medicine and the delivery of health care in the near future. However, for successful deployment, the results must be transported across health care facilities. We present a cross-facilities application of an AI model that predicts the need for an emergency caesarean during birth. The transported model showed benefit; however, there can be challenges associated with interfacility variation in reporting practices.

Exposure to Meconium-Stained Amniotic Fluid and Long-Term Neurological-Related Hospitalizations throughout Childhood.

OBJECTIVE: This study aimed to investigate the possible impact of meconium-stained amniotic fluid (MSAF) on the occurrence of neurological-related hospitalizations throughout childhood and adolescence. STUDY DESIGN: In this population-based cohort analysis, all singleton deliveries occurring between 1991 and 2014 at the Soroka University Medical center were included and the long-term neurological-related hospitalizations were compared between children with and without MSAF during their delivery. A Kaplan-Meier survival analysis was constructed for the evaluation of cumulative hospitalization rate due to neurological morbidity over the 18 years of follow-up, and a Cox proportional hazards model was used to study the independent association between MSAF and childhood neurological morbidity while controlling for potential confounders. RESULTS: During the study period, 243,725 deliveries met the inclusion criteria; 35,897 of the cohort (15%) constituted the exposed group (MSAF), while the rest of the cohort (n = 207,828) constituted the unexposed group (no MSAF). A total of 7,543 hospitalizations due to neurological-related morbidity were documented with a rate of 3.2% (1,152) in children exposed to MSAF as compared with 3.1% (6,391) in the unexposed group (OR 1.1, 95% confidence interval 0.9-1.1, p = 0.149). The survival curve showed a comparable cumulative hospitalization rate in the MSAF-exposed group compared with the unexposed group (log rank p = 0.349). The Cox analysis, controlled for gestational diabetes and hypertension, gestational and maternal ages, demonstrated MSAF exposure not to be an independent risk factor for neurological-related hospitalizations during childhood (adjusted hazard ratio = 1.03, 0.96-1.09). CONCLUSION: Fetal exposure to MSAF, at any gestational age, does not appear to be an independent risk factor for later neurological-related hospitalizations throughout childhood and adolescence. KEY POINTS: · MSAF is associated with several short-term complications such as low Apgar scores.. · The long-term implications of MSAF exposure are yet to be clearly defined.. · Fetal exposure to MSAF is not a risk factor for neurological morbidity throughout childhood..

Isolated Single Umbilical Artery as a Risk Factor for Urinary Tract Infections in Childhood.

OBJECTIVE: This study aimed to determine whether isolated single umbilical artery (iSUA), even absent identifiable genitourinary (GU) abnormalities, increases the risk of GU infection during childhood. STUDY DESIGN: Retrospective population-based comparison of fetuses with iSUA versus normal three-vessel cords. Fetuses with growth restriction, prematurity, multiple gestations, and anatomical or chromosomal anomalies were excluded. The primary outcome was hospital-associated GU infection during the first 18 years of life. Kaplan-Meier's survival curves were used to assess cumulative risk; Cox's multivariable models were used to adjust for confounders. RESULTS: Among 227,599 term singleton deliveries, children with iSUA (n = 729) had a higher incidence (1.8 vs. 0.6%, p < 0.001) and cumulative incidence (log-rank test, p < 0.001) of hospital-associated GU infection. The Cox's models confirmed these findings (hazard ratio: >2.82, confidence interval: 1.63-4.87 in composite models). CONCLUSION: iSUA represents an independent risk factor for GU infection. Urinary tract imaging may be warranted.

#metoo? The association between sexual violence history and parturients' gynecological health and mental well-being.

PURPOSE: Sexual violence is a global health problem. We aimed to evaluate the association between self-reported history of sexual violence and parturients' health behaviors, focusing on routine gynecological care, and mental well-being. METHODS: This was a retrospective questionnaire-based study, including mothers of newborns delivered at the "Soroka" University Medical Center (SUMC). Participants were asked to complete three validated questionnaires, including: screening for sexual violence history (SES), post-traumatic stress disorder (PDS) and post-partum depression (EPDS). Additionally, a demographic, pregnancy and gynecological history data questionnaire was completed, and medical record summarized. Multiple analyses were performed, comparing background and outcome variables across the different SES severity levels. Multivariable regression models were constructed, while adjusting for confounding variables. RESULTS: The study included 210 women. Of them, 26.3% (n = 57) reported unwanted sexual encounter, 23% (n = 50) reported coercion, 1.8% (n = 4) assault and attempted rape, and 1.4% (n = 3) reported rape. A significant association was found between sexual violence history and neglected gynecological care, positive EPDS screening, and reporting experiencing sexual trauma. Several multivariable regression models were constructed, to assess independent associations between sexual violence history and gynecological health-care characteristics, as well as EPDS score. Sexual violence history was found to be independently and significantly associated with a negative relationship with the gynecologist, avoidance of gynecological care, sub-optimal routine gynecological follow-up, and seeking a gynecologist for acute symptoms (adjusted OR = 0.356; 95% CI 0.169-0.749, adjusted OR = 0.369; 95% CI 0.170-0.804, adjusted OR = 2.255; 95% CI 1.187-4.283, and adjusted OR = 2.113; 95% CI 1.085-4.111, respectively), as well as with the risk of post-partum depression (adjusted OR = 4.46; 95% CI 2.03-9.81). All models adjusted for maternal age and ethnicity. CONCLUSION: Sexual violence history is extremely common among post-partum women. It is independently associated with post-partum depression, neglected gynecological care, a negative relationship with the gynecologist, and with reporting of experiencing sexual trauma. Identifying populations at risk and taking active measures, may reduce distress and improve emotional well-being and family function.

Vaginal delivery in SARS-CoV-2-infected pregnant women in Israel: a multicenter prospective analysis.

KEY MESSAGE: Among SARS-CoV-2-infected mothers, vaginal delivery rates were high and associated with favorable outcomes with no cases of neonatal COVID-19. PURPOSE: To investigate the mode of delivery and its impact on immediate neonatal outcome in SARS-CoV-2-infected women. METHODS: A prospective study following pregnant women diagnosed with COVID-19 who delivered between March 15th and July 4th in seven university affiliated hospitals in Israel. RESULTS: A total of 52 women with a confirmed diagnosis of COVID-19 delivered in the participating centers during the study period. The median gestational age at the time of delivery was 38 weeks, with 16 (30.8%) cases complicated by spontaneous preterm birth. Forty-three women (82.7%) underwent a trial of labor. The remaining 9 women underwent pre-labor cesarean delivery mostly due to obstetric indications, whereas one woman with a critical COVID-19 course underwent urgent cesarean delivery due to maternal deterioration. Among those who underwent a trial of labor (n = 43), 39 (90.7%) delivered vaginally, whereas 4 (9.3%) cases resulted in cesarean delivery. Neonatal RT-PCR nasopharyngeal swabs tested negative in all cases, and none of the infants developed pneumonia. No maternal and neonatal deaths were encountered. CONCLUSIONS: In this prospective study among SARS-CoV-2-infected mothers, vaginal delivery rates were high and associated with favorable outcomes with no cases of neonatal COVID-19. Our findings underscore that delivery management among SARS-CoV-2-infected mothers should be based on obstetric indications and may potentially reduce the high rates of cesarean delivery previously reported in this setting.

Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18 years of follow-up.

Since introduced, the Apgar score has remained the most widespread predictor for neonatal morbidity and mortality. We aimed to investigate the association between low 5-min Apgar score and long-term infectious pediatric morbidity. A population-based cohort analysis was performed comparing total and specific subtypes of infectious morbidity leading to hospitalization among term newborns with normal (≥ 7) and low (< 7) 5-min Apgar scores, born between 1999 and 2014 at a single tertiary regional hospital. Infectious morbidity included hospitalizations involving a pre-defined set of infection-related ICD-9 codes. A Kaplan-Meier survival curve was constructed to compare cumulative infectious morbidity incidence and a Cox proportional hazards model to adjust for confounders. The long-term analysis of 223,335 children (excluding perinatal death cases) yielded 585 (0.3%) infants with low 5-min Apgar scores. The rate of infection-related hospitalizations was 9.8% and 12.4% among newborns with normal and low 5-min Apgar scores, respectively (p = 0.06). Adjusting for maternal age, gestational age, hypertension, diabetes, cesarean delivery, and fertility treatments, the association proved to be statistically significant (adjusted HR = 1.28; 95% CI 1.01-1.61).Conclusion: Term infants with low 5-min Apgar scores may be at an increased risk for long-term pediatric infectious morbidity.What is Known:• Though not meant to be a prognostic tool for long-term morbidity, studies assessing the correlation between low Apgar score and long-term outcomes were and are being performed, reporting significant associations with many outcomes-such as cerebral palsy (CP), ophthalmic disorders, GI disorders, and several types of malignancies.• Yet, an association between low Apgar scores and future health remains a matter of controversy.What is New:• Our work shows that a low 5-min Apgar score is independently associated with long-term pediatric infection-related hospitalizations among term singleton newborns.

Pelvic floor disorders following different delivery modes-a population-based cohort analysis.

INTRODUCTION AND HYPOTHESIS: Identifying protective factors against pelvic floor disorders (PFDs) is important. We investigated whether cesarean delivery (CD) at the indication of abnormal second stage of labor (ASSL) has the same protective effect against future PFDs. METHODS: This population-based cohort study included deliveries occurring from 1991-2017 in a tertiary medical center. Women were grouped by their delivery mode: patients with vaginal deliveries (VD) only; those with CD only, excluding second-stage indications; and those with CD due to ASSL. The outcome measure, PFDs and related repair diagnoses, included any recorded hospitalization involving a pre-defined set of ICD-9 codes. A Kaplan-Meier survival curve compared cumulative PFD morbidity in the different groups, and a Cox proportional hazards model controlled for confounders. RESULTS: A total of 106,003 patients met the inclusion criteria; 86.7% (n = 91,856) experienced VD only, 11.7% (n = 12,359) underwent CD only and 1.7% (n = 1788) had at least one CD due to ASSL. PFD-related hospitalization incidence was 0.7% (n = 719) for the entire cohort. While a significantly higher PFD-related hospitalization rate was recorded in the VD group (0.7%) compared with the ASSL CD group (0.3%) and the non-ASSL CD group (0.5%, p < 0.001), after controlling for potential confounders, an independent and protective association was noted between CD and later PFDs only in parturients who did not experience ASSL (aHR 0.679, 95% CI 0.51-0.90, p = 0.006). CONCLUSIONS: CDs may be protective against later PFD development only if performed prior to the second stage of labor.

Grandmultiparity, maternal age, and the risk for uterine rupture-A multicenter cohort study.

INTRODUCTION: Uterine rupture is a critical complication causing fetal and maternal morbidity and mortality. Data are conflicting regarding whether grandmultiparity (parity ≥ 6) is a risk factor. This multicenter cohort study aimed to determine whether grandmultiparity (parity ≥ 6) poses a risk for uterine rupture in women with no previous cesarean delivery. MATERIAL AND METHODS: A multicenter retrospective study of deliveries that occurred between the years 2003 and 2015 in three tertiary medical centers. Deliveries of grandmultiparous women were compared with those of multiparous women (parity 2-5). Women with previous cesarean deliveries were excluded. Multivariable regression modeling was applied to control for possible confounders. RESULTS: A total of 388 784 deliveries of multiparous women with unscarred uteri were recorded during the study period, including 53 965 deliveries of grandmultiparous women and 334 819 deliveries of multiparous women. Grandmultiparous women were significantly older (33.9 ± 5 vs 27.3 ± 5 years; P < 0.0001). Fourteen cases of uterine rupture were recorded in the grandmultiparae group (1 per 3855 labors) vs 41 in the multiparae group (1 per 8166 labors) (odds ratio [OR] 2.07, 95% confidence interval [95% CI] 1.13-3.81; P = 0.030). However, in a multivariable model controlling for maternal age, the association between grandmultiparity and uterine rupture lost its significance (adjusted OR 1.26, 95% CI 0.66-2.41; P = 0.491), and maternal age emerged as an independent predictor of uterine rupture (adjusted OR 1.08, 95% CI 1.04-1.13; P < 0.0001). Additionally, the risk for uterine rupture was elevated in a linear fashion, concomitant with age. CONCLUSIONS: Maternal age is a risk factor for uterine rupture. Grandmultiparity does not increase the risk beyond that associated with maternal age.

Maternal Hypothyroidism during Pregnancy and the Risk for Infectious Morbidity of the Offspring.

OBJECTIVE: Animal studies indicate a possible intrauterine immunological imprinting in pregnancies complicated by hypothyroidism. We aimed to evaluate whether exposure to maternal hypothyroidism during pregnancy increases the risk of long-term infectious morbidity of the offspring. STUDY DESIGN: A retrospective cohort study compared the long-term risk of hospitalization associated with infectious morbidity in children exposed and unexposed in utero to maternal hypothyroidism. Outcome measures included infectious diagnoses obtained during any hospitalization of the offspring (up to the age of 18 years). RESULTS: The study included 224,950 deliveries. Of them, 1.1% (n = 2,481) were diagnosed with maternal hypothyroidism. Children exposed to maternal hypothyroidism had a significantly higher rate of hospitalizations related to infectious morbidity (13.2 vs. 11.2% for control; odds ratio: 1.2; 95% confidence interval: 1.08-1.36; p = 0.002). Specifically, incidences of ear, nose, and throat; respiratory; and ophthalmic infections were significantly higher among the exposed group. The Kaplan-Meier curve indicated that children exposed to maternal hypothyroidism had higher cumulative rates of long-term infectious morbidity. In the Cox proportional hazards model, maternal hypothyroidism remained independently associated with an increased risk of infectious morbidity in the offspring while adjusting for confounders. CONCLUSION: Maternal hypothyroidism during pregnancy is associated with significant pediatric infectious morbidity of the offspring.

Delivery mode and future infectious morbidity of the offspring: a sibling analysis.

PURPOSE: Cesarean delivery (CD) has been recently suggested to be associated with offspring's long-term health implications. We aimed to investigate the association between delivery mode and long-term infectious morbidity of the offspring while employing sibling matched analysis to maximize confounder control. METHODS: A retrospective population-based cohort study was performed, which included all sibling deliveries occurring between 1991 and 2014 at a regional tertiary medical center. Offsprings were followed up until the age of 18 years. The study included 13,516 individuals (6758 sibling pairs): the first born was via vaginal delivery and the second via CD. Each siblings pair was considered a matched set, with the aim to perform a within-family analysis. A Kaplan-Meier survival curve was used to compare the cumulative infectious morbidity incidence and a multivariable Cox survival hazards regression model to control for confounders. RESULTS: Crude rates of total infectious hospitalizations were found to be significantly higher in the CD group (OR 1.25; 95% CI 1.12-1.40). Specifically, bronchiolitis (OR 2.02, 95% CI 1.56-2.63), otitis (OR 1.52, 95% CI 1.21-1.9), and gastroenteritis (OR 1.41, 95% CI 1.05-1.9) were all found to be significantly more common in the CD group. The survival curve demonstrated significantly higher cumulative infection-related hospitalization rates in the CD group (log-rank p < 0.001). The Cox model, adjusted for several confounders, confirmed the significant association between CD and offspring's infection-related morbidity (adjusted HR 1.25; 95% CI 1.02-1.53). CONCLUSION: CD appears to be independently associated with later offspring infection-related morbidity, even while rigorously adjusting for confounders.

Prenatal exposure to isolated amniotic fluid disorders and the risk for long-term endocrine morbidity of the offspring.

BACKGROUND: Amniotic fluid abnormalities may be associated with adverse perinatal outcomes, some of which are endocrine related. OBJECTIVE: To evaluate whether in utero exposure to amniotic fluid abnormalities is associated with long-term endocrine morbidity in the offspring. STUDY DESIGN: In this cohort study, the incidence of long-term endocrine disorders was compared between singletons exposed and non-exposed to oligohydramnios or polyhydramnios. RESULTS: During the study period, 195 943 newborns were included in the study, of them 2.0% (n = 4072) and 2.9% (n = 5684) were exposed to oligohydramnios and polyhydramnios, respectively. Long-term endocrine morbidity was higher among children exposed to isolated amniotic fluid disorders, as was also noted in the Kaplan-Meier survival curve (log-rank test p < 0.001). Abnormal amniotic fluid volume was found to be independently associated with long-term endocrine morbidity of the offspring according to a Cox regression model controlled for clinically related confounders. CONCLUSION: In utero exposure to isolated amniotic fluid abnormalities is independently associated with long-term endocrine morbidity in the offspring.

Group B Streptococcus maternal colonization and respiratory infections in the offspring: lessons learned from an analysis of a population-based cohort with 18-year follow-up.

OBJECTIVE: Group B Streptococcus (GBS) early onset disease is a major cause for neonatal morbidity and mortality. We aimed to determine whether maternal GBS and the associated intrapartum antibiotic prophylaxis impacts pediatric long-term respiratory infectious morbidity. STUDY DESIGN: A population-based cohort study was conducted, during the years 1991-2013, comparing the incidence of hospitalizations due to common respiratory infections (RI) in offspring of mothers with and without GBS. Univariate analysis and a Cox proportional hazard model were used to estimate un-adjusted and adjusted hazard ratios for pediatric RI risk. RESULTS: During the study period, 173,757 term vaginal deliveries took place, of which 2.4% (4252) were diagnosed as GBS + gravidas. In univariate and multivariate analyses for the entire study period, RI risk was increased in exposed offspring. In a sensitivity analysis investigating study periods with different health policies, both GBS diagnosis rates and pediatric infectious respiratory morbidity rates increased over time, but with no independent association between the two. CONCLUSION: When analyzing large data sets spanning over long time periods, a special attention must be paid to account for healthcare trends, to avoid erroneous conclusions, as demonstrated here.

Long-Term Cardiovascular Morbidity in Children Born Following Fertility Treatment.

OBJECTIVE: To determine the risk of long-term cardiovascular disease (CVD) among children born following in vitro fertilization (IVF) and compared with spontaneous pregnancies. STUDY DESIGN: A population-based cohort study including all singleton deliveries occurring between 1991and 2014 at a tertiary medical center was performed. Hospitalizations up to the age of 18 years involving CVD were evaluated in children delivered following IVF, ovulation induction, and spontaneous pregnancies. CVD included valvular disorders, hypertension, arrhythmias, rheumatic disease, cardiomyopathy, ischemic heart disease, and heart failure. Kaplan-Meier survival curves were used to compare cumulative morbidity incidence, and a Cox regression model controlled for confounders. RESULTS: During the study period, 242 187 singleton deliveries met the inclusion criteria; 1.1% following IVF (n = 2603), and 0.7% following ovulation induction (n = 1721). Hospitalizations up to the age of 18 years involving CVD (n = 1503) were comparable in children delivered following IVF (0.6%), ovulation induction (0.7%), and spontaneous pregnancies (0.6%; P = .884). No significant difference in the cumulative incidence of CVD was noted between the groups (log rank P = .781). Controlling for maternal age, gestational age, birthweight, maternal diabetes, and hypertensive disorders in pregnancy, fertility treatment was not noted as a risk factor for long-term pediatric CVD (IVF adjusted hazard ratio 1.05, 95% CI 0.63-1.74, P = .86; ovulation induction adjusted hazard ratio 0.97, CI 95% 0.55-1.71, P = .92). CONCLUSIONS: Singletons conceived via fertility treatments do not appear to be at an increased risk of long-term pediatric CVD.

Placental abruption and long-term neurological hospitalisations in the offspring.

BACKGROUND: Placental abruption is a major determinant of maternal and perinatal morbidity and mortality, often related to asphyxia and preterm birth. However, the impact of abruption on the long-term morbidity of the offspring is less investigated. METHODS: We designed a hospital-based cohort study, in which the incidence of long-term neurology-related hospitalisations of offspring to women with and without placental abruption was assessed. All singleton deliveries between 1991 and 2014 were included in the study. Congenital anomalies, perinatal mortality, and multifetal pregnancies were excluded from the analyses. We compared cumulative morbidity incidence using Kaplan-Meier survival curves and estimated the risk for long-term neurological hospitalisations from Cox proportional hazards models after adjustment for putative including maternal age, parity, hypertensive disorders, pre-gestational and gestational diabetes, gender, ethnicity, and year of birth. RESULTS: Over the 22-year period, 2 202 269 person-years of follow-up, there were 217 910 deliveries of which 0.5% (n = 1003) were complicated with placental abruption. The median (interquartile range) follow-up of children in the abruption and non-abruption groups was 10.3 (4.6, 15.9) and 12.0 (6.3, 16.5) years, respectively. The cumulative incidence of total neurological hospitalisations was comparable between abruption (3.32 per 1000 person-years) and non-abruption (3.16 per 1000 person-years). Abruption was associated with increased rates of cerebral palsy (hazard ratio [HR] 6.71, 95% CI 3.32, 13.58) and developmental disorders (HR 3.36, 95% CI 1.38, 8.13), but not for total neurology-related hospitalisations (HR 1.08, 95% CI 0.78, 1.49). CONCLUSION: Placental abruption is associated with increased rate of cerebral palsy and developmental disorders in the offspring later in life. This study may define risk factors for childhood neuropsychiatric disorders, enabling early diagnosis and intervention in children with such disorders, and perhaps improving their prognosis.