Placenta previa in in vitro fertilization and unassisted pregnancies-is there a difference in perinatal outcomes and placental histology?

INTRODUCTION: In-vitro-fertilization (IVF) is an independent risk factor for placenta previa (PP). Our aim was to study this link by comparing the clinical characteristics and placental histology of pregnancies complicated by PP in IVF versus unassisted pregnancies. METHODS: A retrospective-cohort study of deliveries with PP between 2008 and 2021. Placental histology, obstetric and neonatal outcomes were compared between IVF and unassisted pregnancies. Included, were singleton deliveries complicated by PP at gestational weeks (GA) >24. RESULTS: A total of 182 pregnancies were included - 23 IVF pregnancies (IVF group) and 159 unassisted pregnancies (Control group). The control group was characterized by higher gravidity (p = .007) and parity (p < .001) and a trend of more past cesarean deliveries, whereas the IVF group- by a higher rate of nulliparity (p < .001) and diabetes mellitus (p = .04). The control group was characterized by a higher rate of placental weight below the 10th percentile (47.8 versus 13.9%, p = .001) and by a trend of a lower overall placental weight. No differences were noted in maternal and fetal vascular lesions. DISCUSSION: While PP in non-assisted pregnancies is probably associated with previous CDs, in IVF it is more "sporadic," and may complicate any index pregnancy. A lower placental weight was more prevalent in the control group, supporting the concept that pregnancies complicated by PP following IVF can be attributed to initial abnormal location of placentation, rather than an underlying pathological uterine segment of implantation. Nevertheless, IVF and unassisted pregnancies entail similar perinatal outcomes in cases of PP.

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.

Placental Lesions and Pregnancy Outcome in Anterior as Compared to Posterior Placenta Previa.

The uterine location of placenta previa (PP), anterior vs. posterior has an impact on pregnancy outcome. We aimed to study maternal and neonatal outcome and placental histopathology lesions in anterior vs. posterior PP. The medical records and histopathology reports of all singleton cesarean deliveries (CD) performed due to PP, from 24 to 41 weeks, between 12.2008 and 10.2018, were reviewed. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM, FVM), maternal and fetal inflammatory responses (MIR, FIR). Gestational age (GA) at delivery was similar between the anterior PP (n = 67) and posterior PP (n = 105) groups. As compared to the posterior PP group, the anterior PP group had higher rate of previous CD (p < 0.001), placental accreta spectrum (p = 0.04), lower neonatal Hb at birth (p = 0.03), higher rate of neonatal blood transfusion (p = 0.007) and prolonged maternal hospitalization (p = 0.02). Placentas from the anterior PP group had lower weights (p = 0.035), with increased rate of MVM lesions (p = 0.017). The anterior PP location is associated with increased adverse maternal and neonatal outcome, lower placental weights and increased rate of malperfusion lesions. Abnormal placentation in the scarred uterine wall probably has an impact on placental function.

The impact of mode of delivery on neonatal outcome in preterm births.

INTRODUCTION: To evaluate the impact of mode of delivery on the outcome of neonates born before 34 weeks of gestation. MATERIAL AND METHODS: This is a retrospective cohort study of all singleton live neonates born between 24.1 and 34.0 weeks of gestation at our institute between January 2009 and July 2017. Maternal and pregnancy characteristics, as well as the neonatal outcome, were compared between vaginal delivery (VD) and cesarean delivery (CD). RESULTS: Of 475 preterm births, 223 (46.9%) were delivered vaginally and 252 (53.1%) were delivered by CD. Women who delivered vaginally were younger, (29.6 ± 6 versus 31.2 ± 6 years, p = .003), had lower rate of hypertensive disorders (9.9 versus 36.1%, p < .001), and diabetes mellitus (0.4 versus 4.4%, p = .006), and had higher rate of drug abuse (4.9 versus 1.6%, p = .006), as compared to those who delivered by CD. Neonates who were born by VD had higher birth weight (1716 ± 595 versus 1443 ± 507, p < .001) and a lower rate of Small for gestational age (7.2 versus 19.4%, p < .001) than those who were born by CD. Although VD neonates had higher Apgar score, as compared with CD, the neonatal composite outcome was similar between the two modes of deliveries. These findings were consistent in subgroups analysis according to gestational age (GA). By logistic regression analysis, only the administration of betamethasone up to 1 week prior to delivery (aOR = 0.59, 95% CI 0.38-0.92, p = .001) and GA at delivery (aOR = 0.74 95% CI 0.64-0.84, p = .004) were found to be independently protective against composite neonatal outcome. CONCLUSIONS: It seems that neonatal outcome is not affected by the mode of delivery.

Fetal Growth Restriction in Hypertensive vs. Heavy Smoking Women-Placental Pathology, Ultrasound Findings, and Pregnancy Outcomes.

We compared placental pathology, ultrasonographic findings, and obstetric outcomes, in gestations complicated by fetal growth restriction (FGR) with either a background of hypertensive disorder or heavy tobacco cigarette smoking. The medical records and placental pathology reports of pregnancies complicated with FGR (birthweight < 10th percentile) between December 2008 and May 2018 from a single tertiary center were reviewed. Placental pathology, ultrasound findings, and pregnancy outcomes were compared between hypertensive patients (HTN) and heavy smokers (SMO). We included 213 pregnancies: 129 (60.6%) in the SMO group and 84 (39.4%) in the HTN group. The HTN group was characterized by a higher BMI (p = 0.01), higher rates of Cesarean deliveries (p = 0.006), and a lower gestational age at delivery (35.6 ± 3.8 vs. 37.5 ± 2.9 weeks, p < 0.001). The HTN group had higher rates of placental weights < 10th percentile (p = 0.04) and maternal vascular malperfusion lesions (p < 0.001), while the SMO group had higher rates of inflammatory lesions (p = 0.04). On ultrasound, the HTN group had a higher head/abdomen circumference ratio (p < 0.001) and more abnormal Doppler studies (< 0.001). Neonates in the HTN group had lower birthweights (p < 0.001) and higher rates of NICU admissions (p = 0.002) and adverse neonatal outcome (p = 0.006). On multivariable analysis, gestational age at delivery (aOR = 0.65, 95%CI 0.55-0.87), hypertensive disorders (aOR = 1.8, 95%CI = 1.21-4.81), placental MVM lesions (aOR = 1.23, 95%CI = 1.08-5.02), and the combination of HTN+MVM (aOR = 2.63, 95%CI 1.78-7.30) were independently associated with adverse neonatal outcome. Hypertension and smoking may lead to FGR in different pathways as the two groups significantly differed in maternal characteristics, placental pathology, ultrasound findings, and neonatal outcomes. A hypertensive disorder probably represents a more hostile maternal environment than smoking and these pregnancies would probably benefit from closes monitoring.

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.

Effect of Digital Step Counter Feedback on Mobility After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To assess the effect of a personalized repeated feedback approach using digital step counters (pedometers) on mobility after cesarean delivery in high-risk patients. METHODS: This was a randomized controlled trial at a tertiary university hospital. Patients who underwent cesarean delivery and were defined as high risk for thromboembolic events were asked to wear a pedometer around their wrists postpartum for 48 hours. Patients were randomized to the feedback group, which received personalized feedback by the research staff regarding their mobility at three set timepoints, or the control group, which received standard care. The number of steps taken by patients was compared between the groups and served as the primary outcome. Secondary outcomes included patient reported pain, physical and mental recovery, and overall satisfaction. Sample size was predetermined to detect a 25% between-group difference in the primary outcome. RESULTS: From December 2018 to July 2019, 215 patients were recruited, randomized and completed follow-up-108 in the feedback group and 107 in the control group. Patients' demographics and intrapartum course were similar between the groups. The number of steps taken was significantly higher in the feedback group compared with the control group: 5,918±3,116 vs 4,161±2,532 steps, P<.001. Pain scores were similar between the groups, as was analgesic consumption. Patients in the feedback group reported a significantly easier physical and mental postpartum recovery and were significantly more satisfied with their delivery experience. Postpartum complications did not differ between the groups. CONCLUSION: In high-risk patients after cesarean delivery, mobility was improved by using a personalized feedback approach. Enhanced mobility was not associated with a higher rate of complications or pain and was positively associated with patient satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03724760.

The effect of meconium thickness level on neonatal outcome.

BACKGROUND: Despite its prevalence and potential maternal and neonatal implications, the literature on the thickness levels of meconium stained amniotic fluid (MSAF) and its impact on neonatal outcomes is relatively outdated and relies on relatively small sample sizes. AIMS: To study if different thickness levels of MSAF correlate with adverse neonatal outcome. STUDY DESIGN: A retrospective cohort study. SUBJECTS: The medical records and neonatal charts of all women with a singleton pregnancy, who underwent a trial of labor, at 37 + 0/7 weeks or beyond, between 10/2008 and 7/2018 were reviewed. OUTCOME MEASURES: The cohort was divided according to the level of meconium reported during labor into four groups: Clear (C group), Light meconium (LM group), Intermediate meconium (IM group), and Heavy meconium (HM group). Composite neonatal outcome included at least one of the following: umbilical artery pH ≤ 7.1, sepsis, need for blood transfusion, need for phototherapy, respiratory distress syndrome, meconium aspiration syndrome, need for mechanical ventilation support, necrotizing enterocolitis, intraventricular hemorrhage, hypoxic ischemic encephalopathy, periventricular leukomalacia, seizures, hypoglycemia, hypothermia, and death. Continuous parameters were compared with Anova's test or Kruskal Wallis, and categorical variables by chi-square test or Fisher exact test, as appropriate. Multivariant logistic regression was performed in order to eliminate possible cofounders. RESULTS: Overall, 24,445 deliveries were reviewed (C-20,185, LM-1074, IM-2736, HM-450). Composite adverse neonatal outcome was more common with increasing thickness of MSAF. On multivariable analysis, IM and HM were independently associated with composite adverse neonatal outcome. CONCLUSION: The degree of meconium thickness independently correlates with composite adverse neonatal outcome.

Mobility following cesarean delivery: an observational study utilizing pedometers.

Introduction: Thromboembolic events are a leading cause of maternal death, and peak in the postpartum period. We aimed to assess immediate patient mobility following cesarean delivery (CD) with digital step counters (pedometers), and to characterize factors associated with reduced mobility.Materials and methods: This was a prospective observational study at the maternity unit of the Edith Wolfson Medical Center between June 2017 and February 2018. Patients who underwent a cesarean - primary and repeat, and emergent and nonemergent - were asked to wear pedometers for 48 h following cesarean. Comparison of maternal characteristics, surgical, and postpartum course was performed between three groups: high mobility patients (n = 33), intermediate mobility patients (n = 34), and low mobility patients (n = 34), according to the upper third of steps recorded, intermediate third, and the lower third, respectively.Results: The average number of steps taken during the first 48 h following delivery was 6974 ± 2582, 2724 ± 732, and 1056 ± 454 in the high, intermediate, and low mobility groups, respectively, p < .001. Patients' demographics, parity, intrapartum, and postpartum course were not found to be associated with patient mobility. However, smokers were found to walk an additional 1549 steps following CD as compared to nonsmokers.Conclusion: This study failed to identify risk factors for reduced mobility in the immediate postpartum period, but an increased mobility was noted in smokers, most probably related to the need to ambulate outside the maternity ward. The decision to treat patients following a cesarean with thromboprophlaxis will continue to be based on previously identified risk factors.

Is there a role for placental histopathology in predicting the recurrence of preterm birth?

PURPOSE: Spontaneous preterm birth (sPTB) is a major cause of neonatal morbidity and mortality with a relatively high rate to recurrence. Our aim was to study the role of placental histopathology in predicting recurrence of sPTB. METHODS: We conducted a retrospective cohort study. The medical records and placental pathologic reports of all women with sPTB (gestational age 230/7-366/7 weeks), during 2008-2015, were reviewed. Only women who had a subsequent delivery were included. Multiple pregnancies and women with known uterine anomalies were excluded. Placental histopathology lesions were classified into maternal and fetal vascular malperfusion lesions, acute maternal and fetal inflammatory responses lesions, and chronic inflammatory lesions. Placental lesions were compared between patients with and without recurrent sPTB on their subsequent pregnancies. RESULTS: Maternal characteristics, gestational age, birthweight, and the rate of preterm rupture of membrane at index delivery were similar between the recurrent sPTB (n = 72) and the non-recurrent sPTB (n = 167) groups. The incidence of placental vascular malperfusion lesions, or inflammatory lesions did not differ between the study groups. However, on multivariate logistic regression analysis, the presence of only acute inflammatory response lesions was associated with recurrence of early sPTB ( < 34 weeks) (adjusted OR 3.16; 95% CI 1.22-8.18). CONCLUSION: The presence of isolated placental acute maternal or fetal inflammatory response in index sPTB may be associated with recurrence of early sPTB.

Amniotic fluid transitioning from clear to meconium stained during labor-prevalence and association with adverse maternal and neonatal outcomes.

OBJECTIVE: The objective of this study is to compare pregnancy outcomes in deliveries complicated by primary meconium-stained amniotic fluid (MSAF, present at membrane rupture) and secondary MSAF (transitioned from clear to MSAF during labor). METHODS: The medical records and neonatal charts of all deliveries ≥ 370/7 weeks between October 2008 and July 2018 were reviewed. The primary outcome was composite adverse neonatal outcome that included early neonatal complications. RESULTS: Of 30,215 deliveries during the study period, 4302 (14.2 %) were included: 3845 (89.4%) in the primary MSAF group and 457 (10.6%) in the secondary MSAF group. The rate of the primary outcome was higher in the secondary MSAF group (p = 0.006). This association remained significant after controlling for background confounders. The secondary MSAF group had higher rate of cesarean deliveries (CDs) and assisted vaginal deliveries. There was a higher rate of composite adverse neonatal outcome when secondary MSAF was diagnosed < 3 vs. >3 h before delivery (p = 0.004). CONCLUSION: Secondary MSAF was associated with higher rates of adverse neonatal outcome, CDs, and assisted vaginal deliveries, compared with primary MSAF.

Bloody amniotic fluid during labor - Prevalence, and association with placental abruption, neonatal morbidity, and adverse pregnancy outcomes.

OBJECTIVE: To study the association between bloody amniotic fluid (BAF) during labor and adverse pregnancy outcomes. STUDY DESIGN: In the last 10 years we have implemented an institutional protocol that mandates obstetricians/midwives to report their subjective impression of the color of amniotic fluid (clear, meconium stained, bloody) during labor. The medical records, and neonatal charts of all singleton deliveries ≥ 370/7 weeks between 2008-2018 were reviewed. The cohort was divided into two groups: clear AF (Clear group) and BAF (BAF group). Cases with meconium stained AF were excluded. The primary outcome was a composite of the following complications: umbilical Ph ≤ 7.1, seizures, hypoxic-ischemic encephalopathy, intra-ventricular hemorrhage, periventricular leukomalacia, hypoglycemia, hypothermia, mechanical ventilation, meconium aspiration syndrome, RDS, NEC, phototherapy, sepsis, or transfusion. RESULTS: Overall, 21,300 deliveries were reviewed, 20,983 (98.5%) in the Clear group and 317 (1.5%) in the BAF group. The rate of the primary outcome did not differ between the BAF (2.2%) and the Clear (2.1%) groups. The rate of placental abruption (both clinically and hystopathologically) did not differ between the groups (3.2% vs. 1.9% and 1.6% vs. 0.6%, respectively). BAF was associated with higher rates of labor induction (p = 0.002), assisted vaginal deliveries (p = 0.04), cesarean deliveries (p = 0.03), and lower birth weights (p = 0.03). CONCLUSION: BAF observed in labor was not associated with composite adverse neonatal outcome, nor with placental abruption. BAF was associated with higher rates of labor induction, assisted vaginal deliveries, cesarean deliveries, and lower birth weights. These findings may assist obstetricians and neonatologists in the interpretation of BAF observed in labor.

Pregnancies Following Hysteroscopic Removal of Retained Products of Conception after Delivery Versus Abortion.

AIM: To compare clinical variables, sonographic findings and pregnancy outcomes following the hysteroscopic removal of retained products of conception (RPOC) after delivery and abortion. METHODS: This is a retrospective cohort of operative hysteroscopies performed between 2011 and 2015 for suspected RPOC, during which trophoblastic tissue was obtained. Patient demographics, clinical presentation, sonographic evaluation, subsequent infertility and pregnancy outcomes were compared between post-delivery (n = 85) and post-abortion (n = 93) cases. RESULTS: The main presenting symptom in both study groups was vaginal bleeding. On sonographic evaluation, maximal endometrial thickness was significantly higher in the post-delivery group, while irregularity and increased flow were more common in the post-abortion group. There was a similar rate of deliveries following hysteroscopy in both groups with 40% in the post-delivery group and 39.7% in the post-abortion group. Deliveries in the post-delivery group were characterized by a higher rate of abnormal placentation - 30.5% - including low lying placenta and placenta accreta. A significant rate of vaginal deliveries in both groups entailed manual removal of the placenta or exploration of the uterine cavity (23.5 and 10.5%, p = 0.20). CONCLUSION: Pregnancies following RPOC after delivery entail a higher rate of abnormal placentation.

Differences in knowledge, attitudes and behaviors of Israeli HIV-uninfected gay men in HIV-discordant vs. concordant steady relationships.

HIV-discordant gay male couples may play an important role in HIV-transmissions. This cross-sectional study compared the knowledge, attitudes and sexual behaviors of HIV-uninfected gay men, between those in HIV-discordant and those in HIV-concordant steady relationships. Anonymous questionnaires were distributed electronically in designated gay-related internet sites and in AIDS-clinics in 2015. The dependent variable was defined as a steady relationship of an HIV-uninfected man with an HIV-infected partner. Risky sexual behavior was defined as unprotected anal intercourse (UAI) with a sex partner whose HIV-status was either positive or unknown. Of 2,319 responders, 460 (20%) were HIV-uninfected gay men in steady relationships, of whom 72 were in HIV-discordant relationships and 388 were in HIV-concordant relationships. Those in HIV-discordant relationships presented better established knowledge regarding HIV-transmission, more lenient attitudes regarding UAI, and reported being involved in riskier sexual behavior, both within and outside their steady relationship compared to men in HIV-concordant relationships. UAI was performed by 48% of the HIV-discordant couples and was associated with the use of sero-positioning strategy and with achieving undetectable viral-load. These findings reflect the complexity of constant use of condoms during long-term sero-discordant relationships. Targeted interventions for HIV-prevention in HIV-discordant couples should be employed for balancing the partners' desire for intimacy and sexual pleasure in the relationship, while reducing the risk for acquiring HIV. ABBREVIATIONS: ART: Antiretroviral therapy; PEP: Post exposure prophylaxis; PrEP: Pre exposure prophylaxis; STI: Sexually transmitted infections; UAI: Unprotected anal intercourse.