Risk factors for uterine incision extension during cesarean delivery.

BACKGROUND: Unintentional extension of uterine incision is a known complication during cesarean delivery estimated to occur in 4-8% of cesarean deliveries. The aim of this study was to examine risk factors associated with unintentional uterine incision extension and to assess which of them are independent risk factors for this condition. STUDY DESIGN: We conducted a retrospective cohort study at a large public university tertiary referral center between 2003 and 2017. Included were women who underwent cesarean delivery during this time period. Demographic, medical, obstetrical and surgical data were collected. The primary outcome was the presence of uterine incision extension during cesarean delivery. Secondary outcomes included detection of risk factors associated with uterine incision extension. A multivariate analysis was additionally performed to identify general and labor related risk factors for unintentional extension of uterine incision among patients that underwent cesarean delivery during second stage of labor. RESULTS: During the study period, 25,879 cesarean deliveries performed in our medical center were assessed. Out of them, 731 (2.8%) cases of unintended uterine incision extension were identified. Women in this group had high rates of full cervical dilatation and increased maternal hemorrhage. Assessment of incision extension direction revealed that two-thirds of extensions were lateral, mostly unilateral. Median size of the extension was 2.7 ± 1.2 cm.Independent parameters associated with unintended uterine incision extension included nulliparity, vertex presentation, epidural anesthesia and cesarean section indication. Further analysis including cesarean deliveries performed during the second stage of labor revealed 397 (15.3%) cesarean deliveries in which incision extension was noted and 2205 (84.7%) cesarean deliveries without incision extension. Following multivariate analysis performed in women who underwent cesarean delivery during second stage of labor, two independent parameters associated with unintended uterine incision extension remained significant - past cesarean delivery and failed vacuum attempt. CONCLUSIONS: Vacuum extraction attempt and previous cesarean delivery are independent risk factors for uterine incision extension in women undergoing cesarean delivery during the second stage of labor. We also showed the majority of these extensions to be lateral.

Factors associated with postcesarean blood transfusion: a case control study.

OBJECTIVE: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD. METHODS: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio. RESULTS: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001). CONCLUSIONS: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.

Chronic hypoxia in pregnant mice impairs the placental and fetal vascular response to acute hypercapnia in BOLD-MRI hemodynamic response imaging.

INTRODUCTION: Brief hypercapnic challenge causes acute placental hypoperfusion with fetal brain sparing on BOLD-MRI. We hypothesize that this non-invasive imaging strategy can distinguish between normal pregnancy and chronic placental hypoperfusion (using the maternal hypoxia model). METHODS: Eighteen pregnant female ICR mice were randomized to three groups: normoxia, late-onset hypoxia (12%O2;E13.5-17.5) and early-onset hypoxia (12%O2;E10.5-17.5). On E17.5, animals were imaged in a 4.7-T Bruker-Biospec MRI scanner. Fast coronal True-FISP was performed to identify organs of interest (placenta and fetal heart, liver and brain). BOLD-MRI was performed at baseline and during a 4-min hypercapnic challenge (5%CO2). %-change in placental and fetal signal was analyzed from T2*-weighted gradient echo MR images. Following MRI, fetuses and placentas were harvested, weighed and immuno-stained. RESULTS: In normoxic mice, hypercapnia caused reduction in BOLD-MRI signal in placenta (-44% ± 7%; p < 0.0001), fetal liver (-32% ± 7%; p < 0.0001) and fetal heart (-54% ± 12%; p < 0.002), with relative fetal brain sparing (-12% ± 5%; p < 0.0001). These changes were markedly attenuated in both hypoxia groups. Baseline fetal brain/placenta SI ratio was highest in normoxic mice (1.14 ± 0.017) and reduced with increasing duration of hypoxia (late-onset hypoxia: 1.00 ± 0.026; early-onset hypoxia: 0.91 ± 0.016; p = 0.02). Both hypoxic groups exhibited fetal growth restriction with prominent placental glycogen-containing cells, particularly in early-onset hypoxia. There was increased fetal neuro- and intestinal-apoptosis in early-onset hypoxia only. CONCLUSIONS: BOLD-MRI with brief hypercapnic challenge distinguished between normoxia and both hypoxia groups, while fetal neuroapoptosis was only observed after early-onset hypoxia. This suggests that BOLD-MRI with hypercapnic challenge can identify chronic fetal asphyxia before the onset of irreversible brain injury.

Pharmacomechanical catheter thrombolysis for pregnancy-related proximal deep venous thrombosis: prevention of post-thrombotic syndrome.

OBJECTIVE: The efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) in preventing post thrombotic syndrome (PTS) for pregnancy related deep vein thrombosis (DVT) is unknown. STUDY DESIGN: An observational cross section study of women with pregnancy related proximal (femoral/iliofemoral) DVT who underwent PCDT followed by anticoagulation (study group), and women who were treated with anticoagulation alone (control group). Women were evaluated for PTS using the Villalta scale (primary outcome) and VEINES-QOL/Sym questionnaires. RESULTS: Eleven women with iliofemoral DVT underwent PCDT, two during their first trimester and nine postpartum; 18 women were treated with anticoagulation only. There were no significant differences in age, number of previous pregnancies, and duration of anticoagulation or thrombophilia between the groups. The time between DVT diagnosis and study inclusion was longer in the study group [median 50.5 (range 16-120) months] compared to the control group [median 27 (range 11-64) months], p = .4. None of the women in the PCDT group developed PTS, compared to six (33.3%, p = .03) in the control group, four of whom developed severe PTS. One patient in each group developed recurrent DVT, and one patient in the study group developed a calf hematoma. A reduced frequency of lower extremity symptoms was observed in the PCDT group (VEINES-Sym questionnaire), but no differences in quality of life (VEINES-QOL questionnaire) were reported. CONCLUSION: This study suggests that PCDT may reduce the incidence of PTS in women with pregnancy related proximal DVT.Bullet pointsDVT involving the iliofemoral veins and development of post thrombotic syndrome is frequent among pregnant or postpartum womenStudies of pharmacomechanical catheter-directed thrombolysis (PCDT) for deep vein thrombosis did not include pregnant or postpartum womenIn our observational cross section study women who underwent PCDT (mainly in the postpartum period) had reduced frequency of post-thrombotic syndrome compared to women who received anticoagulation onlyLarger studies are required to confirm the use of PCDT for prevention of PTS in this population.

Missed opportunities for optimal antenatal corticosteroid timing in medically indicated preterm births.

OBJECTIVE: Although delivery timing is physician dictated in indicated preterm births, suboptimal antenatal corticosteroids (ACS) administration occurs in most cases. We aimed to characterize the patterns of use of ACS in indicated preterm births and identify missed opportunities of optimal ACS administration. METHODS: We reviewed the records of women who received ACS and were delivered due to maternal or fetal indications at 24-34 weeks of gestation during 2015-2017 at a university hospital. Optimal ACS timing was defined as delivery ≥24 h ≤7 d from the previous ACS course. RESULTS: Overall, 188 pregnancies were included. The median gestational age at delivery was 32 weeks. Considering only the initial ACS course, the rate of optimal timing was 32.4%. Of 105 (55.8%) women eligible (delivery >7 d since the initial ACS course), only a third (n = 38) received a rescue ACS course. Among women who did not receive rescue ACS course despite their eligibility (n = 67), the decision-to-delivery was ≥3 h in 36 (53.7%), and ≥24 h in 20 (29.9%), representing 19.1 and 10.6% of the entire cohort, respectively. The urgency of the decision to deliver (i.e. in the upcoming 24 h and later) and allowing a trial of labor, were both positively associated with decision-to-delivery interval ≥3 h and ≥24 h. The rate of delivery within any optimal window (either initial or rescue course) was 40.4%, with gestational hypertensive disorders (OR [95% CI]: 2.40 (1.23, 4.72), p = .01) and decision to deliver made at first hospitalization (OR [95% CI]: 2.27 (1.04, 4.76), p = .04) as independent positive predictors of optimal ACS timing. The rate of composite adverse neonatal outcome was significantly lower in those with optimal ACS administration as compared to those with suboptimal timing (32.9 versus 50.9%, OR [95% CI]: 0.47 (0.26, 0.87), p = .02). CONCLUSIONS: Suboptimal ACS administration occurred in most indicated preterm births. Underutilization of rescue ACS course and a substantial rate of missed opportunities for optimal ACS administration were identified as potentially modifiable contributors to improve ACS timing.

Anti-RhD antibody therapy modulates human natural killer cell function.

Anti-RhD antibodies are widely used in clinical practice to prevent immunization against RhD, principally in hemolytic disease of the fetus and newborn. Intriguingly, this disease is induced by production of the very same antibodies when an RhD negative woman is pregnant with an RhD positive fetus. Despite over five decades of use, the mechanism of this treatment is, surprisingly, still unclear. Here we show that anti-RhD antibodies induce human natural killer (NK) cell degranulation. Mechanistically, we demonstrate that NK cell degranulation is mediated by binding of the Fc segment of anti-RhD antibodies to CD16, the main Fcγ receptor expressed on NK cells. We found that this CD16 activation is dependent upon glycosylation of the anti-RhD antibodies. Furthermore, we show that anti-RhD antibodies induce NK cell degranulation in vivo in patients who receive this treatment prophylactically. Finally, we demonstrate that the anti-RhD drug KamRho enhances the killing of dendritic cells. We suggest that this killing leads to reduced activation of adaptive immunity and may therefore affect the production of anti-RhD antibodies.

Immune-Mediated Fetal Complete Atrioventricular Block: Can Dexamethasone Therapy Revert the Process?

BACKGROUND: Fetal complete atrioventricular block (CAVB) is usually autoimmune mediated. The risk of developing CAVB is 2% to 3% in anti-Ro/SS-A seropositive pregnancies and it increases 10 times after previous CAVB in siblings. Despite being a rare complication, CAVB carries a 20% mortality rate and substantial morbidity, as about 65% of newborns will eventually need life-long pacing. Once found, fetal CAVB is almost always irreversible, despite aggressive immunotherapy. This poor outcome prompted some research groups to address this situation. All groups followed anti-Ro/SS-A seropositive pregnancies on a weekly basis during the second trimester of pregnancy and tried to detect first degree atrioventricular block (AVB) using accurate echocardiographic tools, assuming they may characterize the initiation of the immune damage to the A-V conduction system, at which point the process might still be reversible. Some of the groups treated fetuses with first degree AVB with maternal oral fluorinated steroids. We summarized the results of all groups, including our group. We describe a case of a fetus that developed CAVB 6 days after normal sinus rhythm (NSR), who under aggressive dexamethasone therapy gradually reverted to NSR. This fetus had a previous sibling with CAVB. We assumed the immune damage to the conduction system in this small group of fetuses with a previous CAVB sibling may have occurred more quickly than usual. We therefore recommend a twice-weekly follow-up with these fetuses.

Recurrence risk of preterm birth in a subsequent singleton pregnancy after a spontaneous preterm triplet delivery.

OBJECTIVE: History of prior preterm birth (PTB) represents one of the strongest risk factors for recurrent PTB. Nevertheless, whether the occurrence of PTB in multifetal gestation is associated with increased risk of PTB in subsequent pregnancies remains unclear. We aimed to determine the recurrence risk of PTB in a subsequent singleton pregnancy after a previous spontaneous preterm triplet delivery. STUDY DESIGN: A retrospective matched case-control study. The study group comprised all women with spontaneous preterm trichorionic triplet delivery who had a subsequent singleton pregnancy during 2006-2017 at two university hospitals. A control group of women with spontaneous preterm dichorionic twin delivery and a subsequent singleton pregnancy, was established by matching, four-to-one, according to maternal age, parity, gestational age at delivery, and delivery year. RESULTS: Data from 170 women were analyzed, 34 with preterm triplet delivery and 136 matched control women with preterm twin delivery. Gestational age at the subsequent singleton delivery was higher in those with preterm triplet delivery than in those with preterm twin delivery (median 39 vs 38 weeks, P = 0.02). Women with prior triplet PTB had a significantly lower rate of recurrent PTB as compared with women with prior twin PTB (5.9 % vs. 25.0 %; OR [95 % CI]: 0.19 (0.04, 0.82), P = 0.02) with lower proportions of low-birth weight infants (<2500 g) (0 % vs. 11.8 %, P = 0.04). CONCLUSIONS: The risk of recurrent PTB following spontaneous PTB in triplet pregnancy was low compared to preterm twin delivery. These data provide reassurance for those who experienced preterm triplet delivery and suggest the need for further studies to understand the mechanisms contributing to PTB in multifetal pregnancies.

Gestational diabetes and long-term risk for dyslipidemia: a population-based historical cohort study.

OBJECTIVES: To assess the course of lipid levels over time in postpartum women according to gestational diabetes status, taking into account potential confounders, such as comorbid conditions and body weight. METHODS: The data for the present analysis were collected from a 2.3 million member integrated care provider in Israel. Included were all female members aged 15-50 years who performed a 50 g glucose challenge test (GCT) between March 1995 and May 2009. We collected all follow-up lipid consecration tests performed from date of delivery following the GCT (index date) until April 2017. Data analysis was performed for each lipid component individually (triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C)) and the effects of the several risk factors (history of gestational diabetes mellitus (GDM), age at delivery, obesity status and smoking status) were investigated using general linear model taking into account potential confounders. RESULTS: A total of 160 527 women (6.1 million person-years of actual follow-up) were eligible for the analysis, including 10 234 women with GDM (6.4% of the entire cohort). During the study follow-up period, a total of 2.1 million lipid tests were performed. When adjusting for follow-up time, age at index date, body mass index status, and smoking status, GDM was associated with a 1.8-fold risk (95% CI 1.73 to 1.88) for dyslipidemia defined by TG, 1.45-fold risk (95% CI 1.38 to 1.52) for dyslipidemia defined by LDL-C, and 1.44-fold risk (95% CI 1.39 to 1.50) for dyslipidemia defined by HDL-C. DISCUSSION: The results of this retrospective cohort analysis indicate that gestational diabetes confers added risk for developing hyperlipidemia post partum, particularly dyslipidemia defined by TG, as compared with women with normal glucose tolerance.

BOLD-MRI demonstrates acute placental and fetal organ hypoperfusion with fetal brain sparing in response to phenylephrine but not ephedrine.

INTRODUCTION: We previously reported blood oxygen level dependent MRI (BOLD-MRI) for monitoring placental and fetal hemodynamic changes in mice following maternal hypercapnia. Here we use BOLD-MRI to compare the placental and fetal hemodynamic effects of different maternal vasopressors in mice. METHODS: Pregnant ICR mice (n = 16; E17.5) anesthetized with pentobarbital (80 mg/kg i.p.) were placed supine in a 4.7-T Bruker Biospec MRI. Following baseline images, equipotential doses of ephedrine (10 mg/kg) or phenylephrine (10mcg/kg) were administered intravenously. Changes in placental and fetal signal were analyzed from T2*-weighted gradient echo MR images (TR/TE = 147/10 ms). Different regions of interest (placenta, fetal heart, fetal liver and fetal brain) were identified. Percentage change of BOLD-MRI signal intensity (SI) were presented as time curves. RESULTS: Ephedrine and phenylephrine elicited markedly different effects. Phenylephrine caused an approximate 50% reduction in placental, fetal heart and fetal liver BOLD-MRI-SI, but fetal brain BOLD-MRI-SI was unchanged (statistically different from placenta and other fetal organs; p < 0.001), and the fetal brain/liver BOLD-MRI-SI ratio was markedly increased versus baseline (p < 0.001). Following ephedrine, placental BOLD-MRI-SI increased 30% and fetal heart BOLD-MRI-SI was reduced 26%; other fetal organs were unchanged. Blood gases were unchanged. DISCUSSION: Phenylephrine induced BOLD-MRI-SI changes suggestive of placental and fetal hypoperfusion with brain sparing. Ephedrine induced BOLD-MRI-SI changes suggestive of increased cardiac output; we speculate that reduced fetal heart BOLD-MRI-SI may be due to increased fetal myocardial oxygen extraction or metabolic acidosis. The result demonstrates the potential of BOLD-MRI as a non-invasive hemodynamic tool for assessing pharmacodynamics effects in the placental and fetus.

Trial of labor after cesarean in older women who never delivered vaginally.

OBJECTIVE: Maternal age is an established determinant of successful trial of labor after cesarean (TOLAC). While an increasing proportion of parturients are aged 40 years and older, and previously underwent a cesarean section, little data regarding TOLAC success for this age group is available. This study assessed TOLAC success, and its associated characteristics, among women >40 years who never delivered vaginally. STUDY DESIGN: A retrospective case-control study of all women who never delivered vaginally aged ≥40 years with a history of previous cesarean delivery, who delivered at our hospital during 2006-2017. Maternal, neonatal, and delivery characteristics were compared between women with successful and unsuccessful TOLAC. RESULTS: Of 335 older women who never delivered vaginally with a history of one cesarean delivery, 61 (18.2 %) elected TOLAC (18.2 %); the median age was 41[40-42] years and the inter-delivery interval 34 [25-50] months. Overall, 38/61 (62.3 %) had a successful TOLAC. Women with successful TOLAC had a higher rate of a non-recurrent indication for cesarean delivery in their previous cesarean delivery (42.1 % vs. 13.0 %, P = 0.01), whereas dysfunctional labor at previous delivery was more common in the failed TOLAC group (47.8 % vs. 15.8 %, P = 0.007). Failed TOLAC was associated with the presence of gestational diabetes (13.0 % vs. 0 %, P = 0.02) and having a comorbidity (47.8 % vs. 21.0 %, P = 0.02). Induction of labor at TOLAC was more common in the failed TOLAC group (34.8 % vs. 2.6 %, P < 0.001). Birthweight was higher in the failed TOLAC group (3330 vs. 3107 g, P = 0.04), as well as the birthweight difference between deliveries (212 g vs. 82 g, P = 0.03). Neonatal and maternal outcomes were comparable between groups, except for longer length of stay (5 vs. 4 days, P = 0.04) in the failed TOLAC group. In a multivariable logistic regression analysis, only two factors were independently associated with TOLAC failure: previous cesarean delivery due to dysfunctional labor (OR [95 % CI]: 13.40 (1.29, 138.71), P = 0.03) and higher inter-delivery birthweight difference (OR [95 % CI]: 1.18 (1.11, 1.39), P = 0.02). CONCLUSIONS: TOLAC in older women who never delivered vaginally is associated with a moderate success rate. The indication for cesarean delivery at the first delivery and inter-delivery birthweight difference were identified as having strong predictive value for TOLAC outcome.

Risk factors associated with neonatal thrombocytopenia in pregnant women with immune thrombocytopenic purpura.

Objectives: To characterize the risk factors associated with neonatal thrombocytopenia among pregnant women with immune thrombocytopenic purpura (ITP).Methods: We reviewed the records of ITP patients who delivered during 2006-2016 at our medical center.Results: Of 253 pregnancies, median maternal age at diagnosis was 29 [25-33] years, 222 (87.7%) had previously-diagnosed ITP and 31 (12.3%) were diagnosed with new-onset ITP during pregnancy. Baseline characteristics were comparable between the groups except for a higher proportion of nulliparity among those with new-onset disease (p = .002). Maternal nadir platelet count was significantly lower among those with new-onset compared to previously diagnosed ITP (median 62 × 109/L versus 81 × 109/L, p = .005). Neonatal thrombocytopenia (<150 × 109/L) was encountered in 24 (9.5%) pregnancies and required treatment in 12 (50%) of them. Neonatal platelet count was directly correlated with maternal platelet count at delivery (r = 0.23, p = .01), with significantly lower maternal platelet count among those whose newborns experienced thrombocytopenia (p < .001). Neonatal thrombocytopenia followed a higher proportion of pregnancies of women with new-onset than previously diagnosed ITP (22.6 versus 7.7%, p = .02). In multivariate analysis, the presence of new-onset ITP (odds ratio [95% CI]: 4.88 (1.68, 14.16), p = .004) was the only independent predictor of the development of neonatal thrombocytopenia.Conclusion: Neonatal thrombocytopenia presented following almost one-tenth of pregnancies with ITP. New pregnancy-onset disease was the only prognostic marker for neonatal thrombocytopenia. This finding could contribute to risk stratification and individualized patient management.

The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study.

Objective: While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare supracervical versus total cesarean hysterectomy as a surgical option for abnormally invasive placenta.Methods: We carried out an 8-year retrospective case-control study. Six cases of a patient treated by total hysterectomy were matched and compared to 30 controls treated by supracervical hysterectomy. Matching of cases with controls was based on coexisting placenta previa, a number of previous cesarean sections, and age, with five controls per case. Cases and controls were comparable in placental invasion topography. We compared the operative approach in all histologically identified cases of abnormally invasive placenta.Results: Overall, 36 women with histologically proven abnormally invasive placenta were identified. Composite blood products morbidity was higher among total hysterectomy patients (p = .02). Freshly frozen plasma utilization was greater among total hysterectomy patients (p = .01). Median operative time (142 ± 48 versus 136 ± 58 minutes) and hospitalization time (8.9 ± 3.1 versus 7.3 ± 1.5 days) were comparable between those who underwent supracervical versus total hysterectomy (p > .05). No case of maternal or neonatal death was encountered.Conclusion: The favorable maternal and perinatal outcomes observed in our study, suggest that supracervical hysterectomy should be considered as the first-line approach in cases of abnormally invasive placenta managed operatively.

Neonatal subgaleal hemorrhage unrelated to assisted vaginal delivery: clinical course and outcomes.

PURPOSE: The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH METHODS: A retrospective cohort study was conducted. All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011-2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups. RESULTS: The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively. Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group. A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%, P = 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups. CONCLUSIONS: SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.

Subsequent Pregnancy Outcomes After Failed Vacuum-Assisted Delivery.

OBJECTIVE: To examine trial of labor after cesarean delivery (TOLAC) success rates and its associated factors among women with a previous failed vacuum-assisted vaginal delivery. METHODS: We conducted a retrospective cohort study. The study group comprised all women with a prior failed vacuum-assisted vaginal delivery who subsequently delivered from 2008 to 2017 at a university hospital. RESULTS: Overall, 166 women with prior history of failed vacuum-assisted vaginal delivery delivered during the study period, with a median interdelivery interval of 28 (21-36) months. Of them, 53 (32%) had an elective repeat cesarean delivery, and 113 (68%) had a TOLAC. Although there were small statistical differences in the predelivery characteristics of the two groups, there were not clinically significant differences. Of the 113 women who underwent TOLAC in the subsequent pregnancy, the overall success rate was 67%. Neonatal 1- and 5-minute Apgar scores were lower among neonates born to women who experienced a failed TOLAC attempt compared with those who underwent successful TOLAC: 1-minute Apgar score less than 7 (6 [16%] vs 2 [3%], odds ratio [OR] 7.16, 95% CI 1.36-37.45, P=.01), 5-minute Apgar score less than 8 (3 [8%] vs 0 [0%], OR 15.5, 95% CI 1.78-308.7, P=.03). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among women who underwent TOLAC. CONCLUSION: Trial of labor after cesarean delivery in women with a previous failed vacuum-assisted vaginal delivery appears to be associated with an acceptable success rate. These data should improve patient counseling and provide reassurance for those who wish to deliver vaginally after a previous failed vacuum-assisted vaginal delivery.

Reproductive health counseling, attitudes, and practices: a cross-sectional survey among bariatric surgeons.

BACKGROUND: Women of childbearing age constitute a substantial proportion of patients who undergo weight loss procedures. However, little is known regarding family planning knowledge, attitudes, and practices among bariatric surgeons. OBJECTIVES: We explored the reproductive health and contraceptive practices among bariatric surgeons. SETTING: A national society of bariatric surgeons. METHODS: A cross-sectional study. Anonymous surveys were sent to all members of the Israeli Society for Metabolic and Bariatric Surgery. RESULTS: The Israeli Society for Metabolic and Bariatric Surgery survey elicited a response rate of 96% (n = 48). Most (89.6%, n = 43) considered female reproductive health perioperative counseling very important, and the majority of respondents (66.7%, n = 32) felt comfortable discussing these issues. Nevertheless, only 54.2% (n = 25) reported routinely having family planning and pregnancy conversations with their patients. There was a general awareness that women should delay conception after surgery; however, only a minority of bariatric surgeons consistently either recommended the use of contraception after surgery (39.6%, n = 19) or referred patients for contraceptive advice (25.0%, n = 12). Most (81.3%, n = 39) practitioners reported not having accurate knowledge of contraception and felt that collaboration with other bariatric healthcare providers would provide patients with optimal reproductive-health counseling. CONCLUSIONS: Bariatric surgeons acknowledged the importance of reproductive healthcare and the need to delay conception among women undergoing bariatric surgery. However, they inconsistently addressed family planning and contraceptive issues and reported lack of accurate knowledge in this regard. This highlights the need for multidisciplinary collaboration between bariatric healthcare providers to improve reproductive and contraceptive care in these patients.

Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study.

BACKGROUND: Reproductive-aged women constitute a substantial proportion of patients who undergo weight loss procedures. While the risk of gallstone disease after such procedures has been addressed extensively, the impact of pregnancy on gallstone disease after bariatric procedures has not been reported. OBJECTIVES: To explore the effects of pregnancy on cholecystectomy rates after laparoscopic sleeve gastrectomy (LSG). SETTING: A university hospital. METHODS: A cross-sectional cohort study of reproductive aged women (18-45 yr) who underwent LSG. The association between pregnancy and cholecystectomy was evaluated with Cox regression analysis. RESULTS: Of 1056 women of childbearing age who underwent LSG during 2006-2017, 128 (12.1%) subsequently experienced a pregnancy. Median follow-up durations were 3.9 and 4.9 years for women who did and did not conceive, respectively (P < .001). The median time from procedure to conception was 509 (374-1031) days. Overall, 117 (11.1%) women underwent cholecystectomy after LSG. The rate of cholecystectomy among those who conceived was higher than among those who did not (18.8% versus 10.0%, P = .005). In an unadjusted analysis, pregnancy was associated with an increased risk of cholecystectomy (hazard ratio [95% confidence interval]: 3.97 [2.58, 6.09], P < .0001). The association between pregnancy and cholecystectomy persisted after controlling for confounding factors (hazard ratio [95% confidence interval]: 3.82 [2.47, 5.92], P < .0001). Among those who experienced pregnancy, lower gestational weight gain was the only factor found to be associated with cholecystectomy after surgery (P = .05). CONCLUSIONS: Pregnancy is associated with a 4-fold increased risk of cholecystectomy after LSG. Thus, the desire for future pregnancy should be considered before LSG.

The adrenal cortex: Physiology and diseases in human pregnancy.

Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.

Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction.

INTRODUCTION: Subgaleal hemorrhage (SGH) is a life-threatening neonatal condition that is strongly associated with vacuum assisted delivery (VAD). The factors associated with the development of SGH following VAD are not well-established. We aimed to evaluate the factors associated with the development of SGH following attempted VAD. MATERIAL AND METHODS: A retrospective case-control study of women who delivered at a tertiary university-affiliated medical center in Jerusalem, Israel, during 2009-2018. Cases comprised all parturients with singleton pregnancies for whom attempted VAD resulted in neonatal SGH. A control group of VAD attempts was established by matching one-to-one according to gestational age at delivery, parity and year of delivery. Fetal, intrapartum and vacuum procedure characteristics were compared between the groups. RESULTS: In all, 313 (89.5%) of the 350 attempted VAD were nulliparous. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birthweight in the SGH group. In multivariate logistic regression analysis, only six independent risk factors were significantly associated with the development of SGH: second-stage duration (for each 30-minute increase, adjusted odds ratio [OR] 1.13; 95% confidence intervals [CI] 1.04-1.25; P = .006), presence of meconium-stained amniotic fluid (adjusted OR 2.61; 95% CI 1.52-4.48; P = .001), presence of caput succedaneum (adjusted OR 1.79; 95% CI 1.11-2.88; P = .01), duration of VAD (for each 3-minute increase, adjusted OR 2.04; 95% CI 1.72, 2.38; P < .001), number of dislodgments (adjusted OR 2.38; 95% CI 1.66-3.44; P < .001), and fetal head station (adjusted OR 3.57; 95% CI 1.42-8.33; P = .006). Receiver operating characteristic curves showed that VAD duration of ≥15 minutes had a 96.7% sensitivity and 75.0% specificity in predicting SGH formation, with an area under the curve equal to .849. CONCLUSIONS: Vacuum duration, the number of dislodgments, the duration of second stage of delivery, fetal head station, the presence of caput succedaneum and the presence of meconium were found to be independently associated with SGH formation.