Improved neonatal outcomes in pregnancies with coexisting gestational diabetes and preeclampsia in normal birthweight neonates- insights from a retrospective cohort study.

INTRODUCTION: We aimed to assess neonatal and maternal outcomes in appropriate-for-gestational-weight (AGA) neonates of mothers with both gestational diabetes mellitus (GDM) and preeclampsia (PET). METHODS: Medical records of women diagnosed with GDM or PET were reviewed. Women with AGA neonates were divided into three groups- GDM, PET, and GDM + PET and maternal neonatal and placental outcomes were compared. The primary outcome was a composite of adverse neonatal outcomes, including intensive care unit admission (NICU), neurological morbidity, hypoglycemia, ventilation, respiratory distress syndrome (RDS), phototherapy, sepsis, blood transfusion, and neonatal death. Post-hoc analysis was performed to determine between-group significance. RESULTS: Composite adverse neonatal outcomes are significantly lower in women with multiple morbidities compared to women with confined PET (p = 0.015), and a similar trend is observed when comparing neonatal outcomes between women with GDM to those with GDM + PET, yet these results are underpowered (18.9 % vs. 12.8 % respectively, p = 0.243). Placentas of women with GDM + PET were larger, with a lower rate of placentas below the 10th percentile as compared to placentas of women with isolated PET (p < 0.001), but with similar rates of MVM lesions. DISCUSSION: While maternal and placental outcomes in patients of the GDM + PET group resemble the characteristics of the PET group, surprisingly, the neonatal outcomes in this group are significantly better compared to isolated morbidities. The paradoxical benefit attributed to the coexistence of GDM + PET may be explained by a balance of the opposing trends characterizing these morbidities-the reduced blood and nutrient supply characterizing PET vs. chronic overflow and abundance typical of GDM. CLINICAL TRIAL REGISTRATION: approval of local ethics committee WOMC-19-0152.

The Effect of Preemptive Local Infiltration on Postoperative Pain After Vaginal Hysterectomy: A Retrospective Study.

STUDY OBJECTIVE: To investigate the effect of preemptive infiltration on postoperative pain and the use of analgesics after vaginal hysterectomy (VH). DESIGN: A retrospective study. SETTING: An urogynecology unit in a tertiary medical center. PATIENTS: A total of 120 patients who had undergone VH. INTERVENTIONS: The study group contained 60 patients who participated in a former randomized control study, in which preemptive local infiltration of bupivacaine (n = 30) or sodium chloride 0.9% (n = 30) was performed. The control group included 60 consecutive patients who underwent a VH, for whom no local infiltration was performed. MEASUREMENTS AND MAIN RESULTS: Postoperative pain at rest was assessed using the 10 cm visual analog scale at 3, 8, and 24 hours after surgery. The levels of pain, as well as the use of analgesics, postoperatively, were compared between the groups. The mean surgery length in the infiltration group was shorter (86.4±29 vs 118.6±30, p <.001) and the rate of posterior colporrhaphy was lower (73.1% vs 91.3%, p = .010) than the control group. There were no differences in levels of pain at all points of time. However, the infiltration group required a lower morphine dose in the recovery unit (3.7 ± 2.3 mg vs 5.3 ± 2.4 mg, p <.001) and less use of analgesia (all kinds) 24 hours after surgery (54.2% vs 79.6%, p <.001) compared with the control group. On multivariant analysis, preemptive infiltration was found to be independently inversely associated with the dose of morphine used in recovery, as well as analgesics used 24 hours after surgery. CONCLUSION: Preemptive local infiltration of either bupivacaine or sodium chloride 0.9% reduced the use of morphine in the recovery unit, as well as the use of analgesics 24 hours after VH, compared with no infiltration at all.

The effect of preemptive local anesthesia on postoperative pain following vaginal hysterectomy: A randomized controlled trial.

OBJECTIVE: We aimed to study the effect of preemptive local anesthetic without adrenaline on postoperative pain following vaginal hysterectomy and concomitant trans obturator tape (TOT). STUDY DESIGN: This was a double-blinded, randomized, controlled trial. Women who undergone elective vaginal hysterectomy were included. Solutions of either Bupivacaine-Hydrochloride 0.5%, or Sodium-Chloride 0.9% as a placebo, were prepared prior to surgery, according to randomization. The chosen solution was injected before incision, in a circumferential manner, to the cervix. The amount of fluid administered was 10 ml. When colporrhaphy was also performed, an additional 5 ml of solution were injected in the midline of the vaginal wall prior to each incision line. We conformed to the CONSORT recommendations. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. We estimated that the intervention would cause a 25% reduction in the primary outcome. The required total sample size was calculated to be 30 patients women for each group. We used ANOVA for continuous variables and the Chi-square or Fisher exact tests for categorical variables. RESULTS: A total of 30 women were included in each group. The level of postoperative pain, as assessed by VAS, was not significantly different between the groups, in all points of time. In addition, there was no difference between the groups in opioid based analgesics during recovery, nor in postoperative analgesic use. CONCLUSION: Preemptive local anesthesia was not shown to be efficient in reducing postoperative pain after vaginal hysterectomy and TOT.

Placental histology of acute versus continuous meconium exposure - Association with obstetric and neonatal outcomes.

OBJECTIVE: We aimed to compare obstetric and neonatal outcomes of deliveries complicated by meconium stained amniotic fluid (MSAF), according to placental histology of continuous vs. acute meconium associated changes. METHODS: This was a retrospective cohort study of singleton deliveries complicated by MSAF at a single university-affiliated medical center during 2008-2018. Obstetric and neonatal outcomes were compared between cases with placental acute vs. continuous meconium exposure associated changes (columnar epithelial changes and meconium-laden macrophages, respectively). Regression analysis was used to identify independent associations with adverse neonatal outcomes. RESULTS: The medical records of 294 deliveries at our institution were reviewed, along with medical records of the neonates and the histopathological reports of their placentas. Ninety-two cases were classified as an acute placental reaction to meconium (acute exposure group) and 200 as continuous placental exposure (continuous exposure group). Patient demographics did not differ between groups. Placentas from the continuous exposure to meconium were associated with a higher rate of placental weight <10th percentile (p = 0.03) while the acute exposure group was associated with a shorter time between rupture of membranes and delivery (p = 0.02). and higher rates of non-reassuring fetal heart rate in labor (p = 0.003), and of adverse neonatal outcome (p = 0.02). In multivariable analysis adverse neonatal outcome was associated with acute histologic exposure to meconium independent of background confounders (aOR = 1.51, 95% CI 1.12-3.67). CONCLUSIONS: Acute histological changes of MSAF were independently associated with adverse neonatal outcomes as compared to continuous histologic MSAF.

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 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.

When is the right time to remove staples after an elective cesarean delivery?: a randomized control trial.

Objective: To determine if there are differences in scar healing and cosmetic outcome between early and late metal staples removal after cesarean delivery.Study design: Randomized controlled trial, in which patients undergoing a scheduled nonemergent cesarean delivery were randomly assigned to early staples removal versus late staples removal. Outcome assessors were blinded to group allocation. Scars were evaluated 8 weeks after cesarean delivery. Primary outcome measures were Patient and Observer Scar Assessment Scale (POSAS) scores. Secondary outcome measures included surgical site infection, wound disruption, hematoma, or seroma.Results: During the study period, 104 patients were randomized. There were no between-group differences in maternal demographics. Both groups had similar indications for cesarean delivery and similar rate of previous one or more cesarean delivery. Patient and Observer Scar Assessment Scale were similar for patients (p = .932) and for physician observer (p = .529). No significant differences were demonstrated between the groups in the rate of surgical site infection or wound disruption.Conclusions: Removal of stainless steel staples on postoperative 4 versus postoperative 8 after cesarean delivery showed similar outcome without significant effect on incision healing. Therefore, timing of removal staples after cesarean delivery could be performed based on patients and surgeon preference.

Early versus delayed follow-up after misoprostol treatment for early pregnancy loss.

RESEARCH QUESTION: Does extending the follow-up after misoprostol treatment for early pregnancy loss increase the success rate? DESIGN: Patients who had experienced early pregnancy loss (<12 weeks) and were treated with misoprostol in a single university-affiliated medical centre were prospectively followed before and after the implementation of a new treatment protocol extending the follow-up from 1 to 2 weeks. All patients received misoprostol 800 µg vaginally on day 1 and a second dose, when needed, on day 4 or 8. Patients underwent surgical aspiration after 1 week in the early follow-up group (n = 84) or 2 weeks in the delayed follow-up group (n = 85) if complete expulsion was not achieved (defined as endometrial thickness ≤15 mm and absence of gestational sac on transvaginal sonography). The primary outcome was treatment success, defined as no need for surgical aspiration. RESULTS: Women in the delayed follow-up group had a higher rate of successful treatment compared with women in the early follow-up group (88.2% versus 76.2%, respectively; P = 0.040), and a lower rate of second dose administration (32.9% versus 51.2%, respectively; P = 0.016). The incidence of non-expulsion of the gestational sac was also lower in the delayed follow-up group (1.2% versus 10.7%; P = 0.009). Treatment acceptability did not differ between the study groups. CONCLUSION: In women with early pregnancy loss treated with misoprostol, extending the follow-up protocol from 1 to 2 weeks resulted in an increase in treatment success.

The Impact of Salpingectomy on Anti-Mullerian Hormone Levels and Ovarian Response of In Vitro Fertilization Patients.

BACKGROUND: Laparoscopic salpingectomy is strongly related to successful in vitro fertilization (IVF) treatments. OBJECTIVES: To compare the ovarian reserve, including anti-mullerian hormone (AMH) levels, in patients who underwent salpingectomy before IVF to IVF patients who had not been salpingectomized. METHODS: In this retrospective study, medical records of women who were treated by the IVF unit at our institute were reviewed. We retrieved demographic data, surgical details, and data regarding the ovarian reserve. Details of 35 patients who were treated by IVF after salpingectomy were compared to 70 IVF patients with no history of salpingectomy treatment. Nine women underwent IVF treatment before and after having salpingectomy, and their details were included in both groups. RESULTS: The levels of AMH, follicular stimulating hormone (FSH), estradiol, and progesterone were not significantly different in the groups. The antral follicular count (AFC), number of oocytes retrieved, amount of gonadotropin administered for ovarian stimulation, and number of embryos transferred (ET) were also not significantly different. CONCLUSIONS: Salpingectomy does not seem to affect ovarian reserve in IVF patients.

Risk factors for nonreassuring fetal heart rate tracings after artificial rupture of membranes in spontaneous labor.

BACKGROUND: We aimed to characterize factors associated with nonreassuring fetal heart (FHR) tracings after artificial rupture of membranes (AROM), during the active phase of labor. METHODS: Delivery charts of patients who presented in spontaneous labor, at term, between 2015 and 2016 were reviewed. We identified cases in which AROM was performed during the active stage of labor. We compared deliveries with a normal FHR and those who developed nonreassuring FHR. Nonreassuring FHR was defined as fetal tracing that necessitated intrauterine resuscitation, which included: oxytocin withheld, amnioinfusion, or immediate instrumental or cesarean birth. RESULTS: Of 664 deliveries, nonreassuring FHR occurred in 141 (21.2%) and normal FHR in 523 (78.7%). Both groups were notable for similar maternal characteristics and a similar gestational age. Epidural block was significantly more common in the nonreassuring FHR group (P < .001), as was meconium during delivery (P = .01). Deliveries in the nonreassuring FHR group were characterized by significantly lower Bishop scores at AROM. Mean birthweight was significantly lower in the nonreassuring FHR group (3201 ± 418 vs 3342 ± 376 g, P < .001), yet, neonatal outcome did not differ between the groups. In a multivariate logistic regression model, nulliparity, AROM at a station lower than -2, and increased birthweight were all significantly associated with a decreased rate of nonreassuring FHR, while prolonged duration from AROM to delivery and oxytocin augmentation significantly increased the risk for nonreassuring FHR. DISCUSSION: Nonreassuring FHR after AROM during delivery is associated with parity, fetal station at AROM, birthweight, and oxytocin augmentation.

Placental histopathological lesions in correlation with neonatal outcome in preeclampsia with and without severe features.

OBJECTIVE: We aimed to compare pregnancy outcome and placental histopathology in women with preeclampsia (PE) with and without severe features. METHODS: The medical records and placental pathology reports of all pregnancies complicated by PE during 2008-2016, were reviewed. Results were compared between those with and without severe features (severe PE vs. mild PE groups), according to current ACOG guidelines. Placental lesions were classified to maternal/fetal vascular supply lesions, and maternal/fetal inflammatory responses. Small for gestational age (SGA) was defined as neonatal birth-weight ≤10th%. Composite adverse neonatal outcome was defined as one or more of the following: sepsis, transfusion, phototherapy, respiratory morbidity, cerebral morbidity, NEC, or death. RESULTS: The severe PE group (n = 284) was characterized by lower gestational age at delivery (p < 0.001), and higher rates of antenatal corticosteroid use (p = 0.003), and cesarean deliveries (p < 0.001) as compared to the mild PE group (n = 151). More placentas <10th% and more composite maternal vascular malperfusion (MVM) lesions were observed in the severe PE group as compared to the mild PE group (p < 0.001 for both). In multivariate analysis, composite placental MVM lesions were independently associated with severe PE (aOR = 1.75, 95%CI 1.4-4.9). Higher rates of SGA (p = 0.016), and composite adverse neonatal outcome (p = 0.002) characterized the severe PE group. In multivariate analysis, adverse neonatal outcome was independently associated with gestational age (aOR = 0.54, 95%CI 0.49-0.68), SGA (aOR = 1.75, 95%CI = 1.15-3.59), severe PE (aOR = 1.8, 95%CI = 1.13-3.54) and placental MVM lesions (aOR = 2.13, 95%CI = 1.05-4.39). CONCLUSION: More pronounced placental pathology and higher rate of adverse neonatal outcome characterize preeclampsia with severe features as compared with the milder form of the disease.

Serum cholinesterases are differentially regulated in normal and dystrophin-deficient mutant mice.

The cholinesterases, acetylcholinesterase (AChE), and butyrylcholinesterase (BChE) (pseudocholinesterase), are abundant in the nervous system and in other tissues. The role of AChE in terminating transmitter action in the peripheral and central nervous system is well understood. However, both knowledge of the function(s) of the cholinesterases in serum, and of their metabolic and endocrine regulation under normal and pathological conditions, is limited. This study investigates AChE and BChE in sera of dystrophin-deficient mdx mutant mice, an animal model for the human Duchenne muscular dystrophy (DMD) and in control healthy mice. The data show systematic and differential variations in the concentrations of both enzymes in the sera, and specific changes dictated by alteration of hormonal balance in both healthy and dystrophic mice. While AChE in mdx-sera is elevated, BChE is markedly diminished, resulting in an overall cholinesterase decrease compared to sera of healthy controls. The androgen testosterone (T) is a negative modulator of BChE, but not of AChE, in male mouse sera. T-removal elevated both BChE activity and the BChE/AChE ratio in mdx male sera to values resembling those in healthy control male mice. Mechanisms of regulation of the circulating cholinesterases and their impairment in the dystrophic mice are suggested, and clinical implications for diagnosis and treatment are considered.