Trial of labor after cesarean in women in their second delivery - labor characteristics and postpartum factors which influence a patient's choice.

INTRODUCTION: We aimed to assess trial of labor rates in patients in their second pregnancy following a cesarean delivery (CD), and asses the correlation to delivery and postpartum characteristics of their primary delivery. MATERIALS AND METHODS: This was a retrospective cohort of deliveries at our institution between 2009 and 2016. Files of patients with one past CD and a subsequent second delivery were reviewed. Included were patients with a favorable past indication for CD - malpresentation, nonreassuring fetal heart rate, multiple gestation, or placenta previa/abruption. Cases in which a TOLAC was undertaken were compared to those who did not undergo a TOLAC regarding maternal, obstetric, and neonatal outcomes. RESULTS: Five hundred and thirty-six deliveries matched the inclusion criteria, in which 269 patients attempted a TOLAC (TOLAC group) and 267 patients did not (no TOLAC group). Patient demographics at the time of primary CD were similar, but the rate of preterm deliveries was higher among the no TOLAC group. In their second delivery, patients who attempted a TOLAC were younger, had a lower body mass index, had a lower rate of assisted reproduction, and has less pregnancy-related complications (diabetes, hypertensive disorders). CONCLUSIONS: In patients with a first CD, a history of preterm delivery negatively correlated with a TOLAC, while patient age, body mass index and gestational comorbidities negatively affected TOLAC rates in subsequent delivery.

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.

Complications of the third stage of labor in in vitro fertilization pregnancies: an additional expression of abnormal placentation?

OBJECTIVE: To assess the correlation between in vitro fertilization (IVF) and complications of the third stage of labor. DESIGN: Retrospective cohort of vaginal deliveries from November 2008 to January 2020. Maternal and obstetric outcomes of singleton deliveries were compared between IVF and non-IVF pregnancies. SETTING: University hospital. PATIENT(S): Women with live singleton vaginal deliveries at >24 weeks of gestation. INTERVENTION(S): In vitro fertilization-attained pregnancies (compared with spontaneous ones). MAIN OUTCOME MEASURE(S): Complications of the third stage of labor, defined as manual placental removal (either entire removal due to nonseparation or exploration of the uterine cavity due to suspected retained products of conception). RESULT(S): Overall, 1,264 IVF pregnancies and 34,166 non-IVF pregnancies were included. Deliveries in the IVF group were characterized by an older maternal age, lower parity, higher rate of diabetes and hypertensive disorders, higher rate of placental abnormalities, earlier gestational age, higher rate of labor induction, chorioamnionitis, and instrumental delivery. Complications of the third stage of labor occurred in 5.9% of IVF deliveries and in 2.8% of controls, and blood transfusion was more prevalent in IVF deliveries. The rate of complications of the third stage were higher in both fresh and frozen transfer cycles as compared with spontaneous pregnancies (5.8%, 8.8%, and 2.8%, respectively), although no difference was noted between fresh and frozen transfers. In vitro fertilization was associated independently with complications of the third stage of labor after adjustment for potential confounders. CONCLUSION(S): In vitro fertilization is associated independently with an increased risk of complications of the third stage of labor.

Obstetric and perinatal outcomes of in vitro fertilization and natural pregnancies in the same mother.

OBJECTIVE: To compare obstetric and perinatal outcomes between pregnancies conceived using in vitro fertilization (IVF) and natural pregnancies of the same women. DESIGN: This was a case-control study of deliveries between November 2008 and January 2020 in which each IVF pregnancy was matched to a natural pregnancy of the same woman (1:1 ratio). SETTING: University hospital. PATIENT(S): We included women with consecutive live singleton deliveries (>24 weeks of gestation) at the Edith Wolfson Medical Center. We excluded IVF pregnancies attained using egg donation. INTERVENTION(S): In vitro fertilization-attained pregnancies (as compared with natural ones). MAIN OUTCOME MEASURE(S): Primary outcome: preterm birth (PTB). SECONDARY OUTCOMES: small for gestational age (SGA) neonates and pregnancy-induced hypertension (PIH; gestational hypertension or pre-eclampsia). RESULT(S): A total of 544 IVF pregnancies were matched to 544 natural pregnancies, each in the same woman. In 292 women (53.7%), the natural pregnancy preceded the IVF pregnancy. Maternal age was significantly higher in IVF deliveries. Gestational age at delivery and the rates of PTB, PIH, instrumental delivery, cesarean delivery, and SGA neonates were comparable between IVF and natural pregnancies. Birth weight was slightly lower in IVF pregnancies. On multivariate analysis, IVF was not independently associated with PTB, SGA, or PIH after adjustment for confounders. CONCLUSION(S): When compared in a cohort of the same women, natural and IVF-attained pregnancies did not differ with regard to obstetric and perinatal outcomes.

Clinical Characteristics of Women with Isolated Fallopian Tube Torsion Compared with Adnexal Torsion.

BACKGROUND: Isolated fallopian tube torsion (IFTT) is a rare gynecological entity and its diagnosis is challenging. OBJECTIVES: To compare clinical characteristics, sonographic findings, surgical management, and outcomes of women with surgically verified IFTT compared to those diagnosed with adnexal torsion. METHODS: A retrospective case-control study in a university hospital was conducted. Thirty-four women with surgically verified IFTT between March 1991 and June 2017 were compared to 333 women diagnosed with adnexal torsion within the same time period. RESULTS: Both groups presented primarily with abdominal pain, which lasted longer prior to admission among the IFTT group (46.8 ± 39.0 vs. 30.0 ± 39.4 hours, P < 0.001). Higher rates of abdominal tenderness with or without peritoneal signs were found in the adnexal torsion group (90.3% vs. 70.6%, P < 0.001). Sonographic findings were similar; however, an increased rate of hydrosalpinx was found among the IFTT group (5.9% vs. 0.0%, P = 0.008). Suspected adnexal torsion was the main surgical indication in only 61.8% of IFTT cases compared with 79.0% in the adnexal torsion group (P = 0.02). Salpingectomy with or without cystectomy was more commonly performed in the IFTT group (35.3% vs. 1.5%, P < 0.001). The leading pathological findings among the IFTT group were hydrosalpinx and paraovarian cysts. CONCLUSIONS: The clinical signs and symptoms of IFTT and adnexal torsion are similar. Although sonographic imaging demonstrating a paraovarian cyst or hydrosalpinx may be helpful in diagnosing IFTT, it is rarely done preoperatively.