Vaccination in twin pregnancies: comparison between immunization before conception and during pregnancy.

To evaluate the development of neutralizing Anti-Spike Protein IgG (Anti-S-IgG) during twin pregnancies before conception vs. during pregnancy. In this prospective study, three blood samples were collected from pregnant women and subjected to anti-S-IgG immunodiagnostics. The patient's medical records, including vaccination and PCR test results, were collected from the hospital's electronic database. Age-matched non-pregnant women were used as a control group. We enrolled 83 women with twin pregnancies. 49 women were vaccinated before conception, 21 women were vaccinated during pregnancy, and 13 were not vaccinated. Of the 13 women who weren't vaccinated, three became positive during pregnancy, and all three were severely ill. By contrast, in women who were vaccinated during or before pregnancy, COVID-19 infection during pregnancy caused only mild symptoms. A ten-fold lower level of neutralizing Anti-S-IgG in the 3rd trimester was observed in healthy women who were vaccinated before conception and remained healthy until discharge from the hospital after delivery 1605 (IQR: 763-2410) compared to the healthy women who were vaccinated during pregnancy 152 AU/mL (IQR: 54-360). This difference was higher among women who were infected by COVID-19 (as verified by a positive PCR test). The third-trimester level of neutralizing Ant-S-IgG in the infected group was 4770 AU/mL (4760-6100) in infected women vaccinated before conception compared to those vaccinated during pregnancy who had 70 AU/mL (IQR: 20-170) (p < 0.001). In women vaccinated at 13-16 weeks gestation, neutralizing Anti-S-IgG at 20-22 weeks went up to 372 AU/mL (IQR: 120-1598) but rapidly dropped to 112 AU/mL (IQR: 54-357) at 28-30 weeks, (p < 0.001), a faster decline than in women vaccinated at a median 22 weeks before conception. Being infected by COVID-19 before conception was linked to having low Anti-S-IgG levels during pregnancy, whereas being infected by COVID-19 during pregnancy led to a very high response in the 3rd trimester. In twin pregnancies, significantly lower neutralizing Anti-S-IgG levels were observed in women vaccinated during pregnancy compared to those vaccinated before conception, whether infected or not infected by COVID-19. A full course of vaccination before conception is recommended.Trial registration. ClinicalTrials.gov Protocol Registration and Results System (PRS) Receipt Release Date: October 4, 2021. https://clinicaltrials.gov/ ID: NCT04595214.

Clinical-sonographic scores for the screening of placenta accreta spectrum: A systematic review and meta-analysis.

OBJECTIVE: Clinical-sonographic scoring systems, combining clinical features and ultrasound imaging markers have been proposed for the screening of placenta accreta spectrum (PAS) but their usefulness in different set-ups remains limited. The aim of this study was to assess and compare different clinical-sonographic score systems performed from the midst of pregnancy for the prenatal evaluation of patients at risk of PAS at birth. DATA SOURCES: PubMed/MEDLINE, Google Scholar, and Embase were searched between October 1982 and October 2022 to identify eligible studies. STUDY ELIGIBILITY CRITERIA: Observational studies providing data on the use of a combined clinical-ultrasound score systems performed from the midst of pregnancy for the prenatal evaluation of PAS. METHODS: Study characteristics were evaluated by two independent reviewers using a predesigned protocol PROSPERO (CRD CRD42022332486). Heterogeneity between studies was analysed with Cochran's Q-test and the I2 statistics. Statistical heterogeneity was quantified by estimating the variance between the studies using I2 statistics. The area under the receiver operating characteristic curve AUC of ROC of each score and their summary (SROC) was calculated with sensitivity and specificity, and the integrated score of the SROC of all sonographic markers was calculated. Forest Plots were used to develop the meta-analysis of each sonographic marker and for the integrated sonographic score. RESULTS: Of 1028 articles reviewed, 12 cohorts and two case-control studies including 1630 patients screening for PAS by clinical-ultrasound scores met the eligibility criteria. A diagnosis of PAS was reported in 602 (36.9%) cases for which 547 (90.9%) intraoperative findings and/or histopathologic data were described. A wide variation in reported sensitivities and specificities was observed between studies and in thresholds used for the identification of patients with a high probability of PAS at birth. The SAUCs of the individual sonographic scores ranged between 0.85 (the lowest) for sub-placental hypervascularity to 0.91 for placental location in the lower uterine segment (LUS), myometrial thinning, and placental lacunae and 0.95 for the loss of clear zone. Only four studies included placental bulging in their sonographic score system and therefore no meta-analysis for this score was performed. The integrated SAUC was 0.83 [95% Confidence Interval (95% CI) 79 to 0.86). Forest Plot analysis revealed an integrated sensitivities and specificities of 0.68 [95% CI 0.53-0.80], and 0.88 [95% CI 0.68 to 0.96]), respectively. CONCLUSIONS: Clinical-sonographic score systems can contribute to the prenatal screening of patients at risk of PAS at birth. While we included multiple sonographic studies from the midst of pregnancy, standardized evaluation should be performed not only with strict ultrasound criteria for the placental position, mid third trimester gestational age at examination, and sonographic markers associated with PAS. Numeric sensitivities, specificities, NPVs, PPV, LR-, and LR+ should be recorded prospectively to assess their accuracy in different set-ups and PTP should be verified at delivery. The variables recommended for most predictive screening are: loss of clear zone underneath the placental bed, placentation in the LUS, and placenta lacunae.

[NUCHAL TRANSLUCENCY CONCURRENT WITH EARLY ANOMALY SCAN: TIME TO RECONSIDER].

INTRODUCTION: During the last decades, a major achievement was reported in detecting Down's syndrome in the first trimester of pregnancy. This is attributed to the use of high-resolution accurate ultrasound machine allowing the detection of a "nuchal translucency" in the back of the fetus during 11-14 weeks' gestation. This is considered to be a physiologic finding, but when increased, may alert for chromosomal abnormality (mainly Down's syndrome), cardiac and other organ anomalies and other genetic syndromes. Later additional sonographic findings were found, including nasal bone assessment, and Doppler flow studies of the ductus venosus and tricuspid regurgitation Technology advancement accompanied by sonographers' skills enhancement allows (at the time frame of the nuchal scan) a detailed anomaly scan. Additional screening for pregnancy complication was achieved using first trimester multi marker assessment, alerting for preeclamptic toxemia or placenta accreta. Currently, many national and international professional organizations recommend performing the nuchal scan concurrent with an early anomaly scan both at the same time of gestation. This approach is different than the one performed in Israel, whereas the nuchal scan is conducted separately and 2-3 weeks later an anomaly scan is offered. We call for reconsideration of the sequential approach and performing all the tests in a comprehensive first trimester clinic.

Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus.

BACKGROUND: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE: This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN: A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS: A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION: Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.

Cost-effectiveness of universal routine sonographic cervical-length measurement at 19 to 25 weeks' gestation.

BACKGROUND: National second-trimester scanning of cervical length was introduced in Israel in 2010, and in the decade thereafter, a significant systematic reduction in preterm birth and in the delivery of low birthweight babies was found among singletons. OBJECTIVE: In this study, we sought to estimate the cost-effectiveness of a national policy mandating second-trimester cervical length screening by ultrasound, followed by vaginal progesterone treatment for short cervical length in comparison with no screening strategy. STUDY DESIGN: We constructed a decision model comparing 2 strategies, namely (1) universal cervical length screening, and (2) no screening strategy. This study used the national delivery registry of Israel's Ministry of Health. All women diagnosed with a second-trimester cervical length <25 mm were treated with vaginal progesterone and were monitored with a bimonthly ultrasound scan for cervical dynamics and threat of early delivery. Preterm birth prevalence associated with short cervical length, the efficacy of progesterone in preterm birth prevention, and the accuracy of cervical length measurements were derived from previous studies. The cost of progesterone and bimonthly sonographic surveillance, low birthweight delivery, newborn admission to intensive care units, the first-year costs of managing preterm birth and low birthweight, and instances of handicaps and the cost of their follow-up were extracted from the publicly posted registry of Israel's Ministry of Health and Israel Social Securities data. Monte Carlo simulations decision tree mode, Tornado diagrams, and 1- and 2-way sensitivity analyses were implemented and the base case and sensitivity to parameters that were predicted to influence cost-effectiveness were calculated. RESULTS: Without cervical length screening, the discounted quality-adjusted life years were 30.179, and with universal cervical length screening, it increased to 30.198 (difference of 0.018 quality-adjusted life years). The average cost of no screening for cervical length strategy was $1047, and for universal cervical length screening, it was reduced to $998. The calculated incremental cost-effectiveness ratio was -$2676 per quality-adjusted life year (dividing the difference in costs by the difference in quality-adjusted life years). Monte Carlo simulation of cervical length screening of 170,000 singleton newborns (rounded large number close to the number of singleton newborns in Israel) showed that 95.17% of all babies were delivered at gestational week ≥37 in comparison with 94.46% of babies with the no screening strategy. Given 170,000 singleton births, the national savings of screening for short cervical length when compared with no cervical length screening amounted to $8.31M annually, equating to $48.84 for a base case, and the incremental cost-effectiveness ratio for each case of low birthweight or very low birthweight avoided was -$14,718. A cervical length <25 mm was measured for 30,090 women, and of those, 24,650 were false positives. The major parameters that affected the incremental cost-effectiveness ratio were the incidence of preterm birth, the specificity of cervical length measurements, and the efficacy of progesterone treatment. At a preterm birth incidence of <3%, universal screening does not lead to a cost saving. CONCLUSION: National universal cervical length screening should be incorporated into the routine anomaly scan in the second trimester, because it leads to a drop in the incidence of preterm birth and low birthweight babies in singleton pregnancies, thereby saving costs related to the newborn and gaining quality-adjusted life years.

[EFFECT OF ETHNICITY ON BACTERIAL RESISTANCE AND OBSTETRICAL OUTCOMES AMONG PREGNANT WOMEN ADMITTED TO MATERNAL-FETAL MEDICINE UNIT WITH THE DIAGNOSIS OF PYELONEPHRITIS DURING 2017-2020].

INTRODUCTION: Antibiotic resistance is a worldwide concern. No study has ever examined the correlation between ethnicity and antibiotic resistance. We examined those parameters among hospitalized pregnant patients diagnosed with pyelonephritis. AIMS: Should ethnic origin play a role in optimizing antibiotic therapy? To better comprehend, we have chosen a cohort of hospitalized pregnant patients with a pyelonephritis diagnosis. METHODS: A total of 105 cases of patients hospitalized in the Shamir Medical Center between the years 2017-2020 were analysed. Feto-maternal outcomes and antibiotic resistance in relation to ethnicity were plotted statistically using chi-square tests (Arab, 40%; North Africa, 13%; Europe-Ashkenaz,10%; Ethiopia/Iran/Kavkaz/Iraq/other, 3%; Turkey/Uzbekistan/Yemen 2%). RESULTS: Ethnic groups included Arab (40%), others referred as "None-Arab". The antibiotic resistance panel revealed differences comparing the two largest groups (Arab% VS non-Arab%), whereas there was no correlation between any ethnic group and obstetrics parameter. Arab women were more resistant to ciprofloxacin (33% vs 7%, P= 0.026) and less sensitive to imipenem (60% vs 90.9%, P= 0.03); less sensitive to ceftriaxone and cefuroxime. CONCLUSIONS: There was a correlation between ethnic origin of pregnant patients diagnosed with pyelonephritis and antibiotic resistance. We hope ethnicity, might, in some cases, assist physicians choosing the optimal therapy.

[TERMINATION OF PREGNANCY DUE TO FETAL ABNORMALITIES PERFORMED AFTER 24 WEEKS OF GESTATION: THE EXPERIENCE OF THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY AT SHAMIR (ASSAF HAROFE) MEDICAL CENTER BETWEEN THE YEARS 1998-2021].

BACKGROUND: Termination of pregnancy is a difficult moral dilemma that provokes a discussion in the public, from an ethical, moral and religious point of view. This process is complex, especially when it comes to a fetus at a viability age (late abortion, after week 24), which requires the approval of a regional supreme committee. OBJECTIVES: To examine the various causes of abortion both before and after the fetal viability age (24 weeks of gestation and beyond) in a singleton pregnancy, as well as to examine the sequence of events that led to a late abortion. METHODS: In this cohort study, 4,057 patients who had abortions due to fetal abnormalities in the Shamir Medical Center during the years 1998-2021, were divided according to the abortion indications. Of these, 3539 (91.28%) had early abortion (24 weeks and below) and 338 (8.72%) had late abortions (24 week and later). RESULTS: In general, the leading reasons for abortions are chromosomal and genetic (1862 [46%]) as well as anatomical indication (1868 [46%]). It was found that the leading indication for early abortion is the chromosomal or genetic abnormalities (1702 [48.1%]), while the leading indication for late abortion is anatomical defects (204 [60.4%]) (p=0.000). In late abortion, the leading anatomical cause is heart defects (62 [30.54%]) followed by central nervous system defects (56 [26.6%]), and the leading chromosomal cause is trisomy 21 (Down syndrome) (23 [22.33%]). When examining the sequence of events that led to late abortion, the leading reason is abnormal findings that required further studies (125 [37%]). CONCLUSIONS: There is great importance in trying to reduce late pregnancy abortion by understanding the sequence of events and the reasons that led to it. Changing the processes that need to be performed can be implemented by combining pathways: improving the technological means, using more accurate instrumentation and advanced molecular genetics. Furthermore, it is essential to raise the awareness of the pregnant women on screening tests, and conducting this as early as possible. Additionally, it is important to raise the skill of the operators. We believe that incorporating all those actions will lead to earlier diagnosis and to a decrease in late abortions, a promising message both from the point of view of the women and the medical staff, due to the difficulty in carrying out late pregnancy terminations.

Incidence and causes of perinatal death in prenatally diagnosed vasa previa: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to estimate the perinatal mortality associated with prenatally diagnosed vasa previa and to determine what proportion of those perinatal deaths are directly attributable to vasa previa. DATA SOURCES: The following databases have been searched from January 1, 1987, to January 1, 2023: PubMed, Scopus, Web of Science, and Embase. STUDY ELIGIBILITY CRITERIA: Our study included all studies (cohort studies and case series or reports) that had patients in which a prenatal diagnosis of vasa previa was made. Case series or reports were excluded from the meta-analysis. All cases in which prenatal diagnosis was not made were excluded from the study. METHODS: The programming language software R (version 4.2.2) was used to conduct the meta-analysis. The data were logit transformed and pooled using the fixed effects model. The between-study heterogeneity was reported by I2. The publication bias was evaluated using a funnel plot and the Peters regression test. The Newcastle-Ottawa scale was used to assess the risk of bias. RESULTS: Overall, 113 studies with a cumulative sample size of 1297 pregnant individuals were included. This study included 25 cohort studies with 1167 pregnancies and 88 case series or reports with 130 pregnancies. Moreover, 13 perinatal deaths occurred among these pregnancies, consisting of 2 stillbirths and 11 neonatal deaths. Among the cohort studies, the overall perinatal mortality was 0.94% (95% confidence interval, 0.52-1.70; I2=0.0%). The pooled perinatal mortality attributed to vasa previa was 0.51% (95% confidence interval, 0.23-1.14; I2=0.0%). Stillbirth and neonatal death were reported in 0.20% (95% confidence interval, 0.05-0.80; I2=0.0%) and 0.77% (95% confidence interval, 0.40-1.48; I2=0.0%) of pregnancies, respectively. CONCLUSION: Perinatal death is uncommon after a prenatal diagnosis of vasa previa. Approximately half of the cases of perinatal mortality are not directly attributable to vasa previa. This information will help in guiding physicians in counseling and will provide reassurance to pregnant individuals with a prenatal diagnosis of vasa previa.

High sensitivity and specificity in fetal gender identification in the first trimester, using ultrasound and Noninvasive Prenatal Screening (NIPS) in twin pregnancies, a prospective study.

INTRODUCTION: Determination of the fetal gender in the first trimester is important in twin pregnancy cases of familial X-linked genetic syndromes and helps determine chorionicity. We assessed and compared the accuracy of first-trimester ultrasound scans, and cell-free fetal DNA (CfDNA) in determining fetal gender in the first trimester of twin pregnancies. METHODS: Women with twin pregnancies were recruited prospectively during the first trimester. Fetal gender was determined using both ultrasound scans and CfDNA screening. Both results were compared to the newborn gender after delivery. RESULTS: A total of 113 women with twin pregnancies were enrolled. There was 100% sensitivity and specificity in Y chromosome detection using CfDNA. Gender assignment using ultrasound in any first-trimester scans was 79.7%. Accuracy level increased from 54.2% in CRL 45-54 mm to 87.7% in CRL 55-67 mm and 91.5% in CRL 67-87 mm. Male fetuses had significantly higher chances of a gender assignment error compared to female fetuses, odds ratio = 23.574 (CI 7.346 - 75.656). CONCLUSIONS: CfDNA is highly sensitive and specific in determining the presence of the Y chromosome in twin pregnancies in the first trimester. Between CRL 55-87 mm, ultrasound scanning offers a highly accurate determination of fetal gender in twin pregnancies.

Pregnancy with Facial Cleft: 20 Years of Experience at a Single Center.

BACKGROUND: Fetal facial clefts are among the most common congenital anomalies detected prenatally. This finding may lead to termination of pregnancy in some cases. OBJECTIVES: To compare a cohort of fetuses with facial clefts in which the pregnancy was terminated to the cohort of cases that were born with facial clefts. To investigate risk factors for facial clefts. METHODS: We conducted a retrospective chart review of all women with prenatal and postnatal diagnosis of facial cleft that were managed in our institute. A telephone questionnaire was conducted regarding a positive family history and/or genetic predisposition for facial clefts abnormalities. RESULTS: The final cohort consisted of two group. One group included 54 cases of termination of pregnancy (TOP) that were performed due to cleft lip (CL) or cleft palate (CLP); 27 women answered the telephone questionnaire. The second group comprised 99 women who delivered children with facial cleft during the same period; 60 answered the questionnaire. Only seven cases were diagnosed prenatal. Among the two groups, no correlation to family history was discovered. Of note, there was one case of three consecutive fetuses with CL in one woman, without any significant genetic findings. CONCLUSIONS: To the best of our knowledge, this is the first study to describe an anatomical malformation posing an ethical dilemma before TOP. Primary prevention with folic acid and early sonographic detection of CL/CLP with multidisciplinary consultation should be considered.

First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry.

BACKGROUND: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria.

OBJECTIVES: Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation. METHODS: A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus. RESULTS: The ß-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01). CONCLUSIONS: The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.

Spontaneous Hemoperitoneum in Pregnancy and Endometriosis: A New Challenge in a Known Disease.

Importance: Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare life-threatening event previously associated with endometriosis. Although pregnancy is thought to improve the symptoms of endometriosis, abrupt intraperitoneal bleeding can occur, jeopardizing both maternal and fetal outcomes. Objective: The aim of this study was to review the published information regarding SHiP pathophysiology, presentation, diagnosis, and management in a flowchart approach. Evidence Acquisition: A descriptive review of published articles in the English-language was carried out. Results: SHiP most commonly presents in the second half of pregnancy with a combination of abdominal pain, hypovolemia, a decline in hemoglobin level, and fetal distress. Nonspecific gastrointestinal symptoms are not uncommon. Surgical management is suitable in most scenarios and avoids complications such as recurrent bleeding and infected hematoma. Maternal outcome has improved greatly, whereas perinatal mortality remained unchanged. In addition to physical strain, SHiP was reported to have a psychosocial sequela. Conclusions and Relevance: A high index of suspicion is required when patients present with acute abdominal pain and signs of hypovolemia. Early use of sonography contributes to narrowing down the diagnosis. Health care providers should be familiar with the SHiP diagnosis because early identification is crucial when attempting to safeguard maternal and fetal outcomes. Maternal and fetal requirements are often contradictory, creating a greater challenge in decision-making and treatment. A multidisciplinary team approach should coordinate the treatment, whenever a SHiP diagnosis is suspected.

Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE: To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes. METHODS: A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests. RESULTS: Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%). CONCLUSION: CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

[MATERNAL SERUM ANGIOGENIC FACTORS AS AN AIDING TOOL FOR SCREENING WOMEN WITH SUSPECTED PREECLAMPSIA NEAR DELIVERY - INITIAL DATA AND AN ESTIMATED COST-BENEFIT].

INTRODUCTION: Preeclampsia (PE) is a major pregnancy complication, posing considerable morbidity and mortality. The maternal serum angiogenic factors - PlGF and sFlt-1, and their ratio appear to be promising markers to predict PE. Aims: To assess whether the evaluation of PlGF and sFlt-1 adds to the clinical workup of women with suspected PE, and to estimate the cost/benefit. METHODS: We prospectively enrolled pregnant women with suspected PE who were admitted to the Maternal-Fetal Medicine Unit (MFM) at Shamir Medical Center. Pregnancy and delivery records were collected from their computerized electronic medical records. PlGF<150pg/ml and sFlt-1/PlGF>38 measured prospectively were used to predict PE. RESULTS: Of 105 women included, 28 were in the control group with unrelated complications and none developed PE. Among 66 women with suspected PE, 27(41%) developed the syndrome, with a positive predictive value (PPV) of 90.3% for PlGF<150 pg/ml and 88.9% for sFlt-1/PlGFabove 38. Out of 11 women with suspected intrauterine growth restriction (IUGR), six developed the syndrome, and among them, the negative predictive value (NPV) was ~ 90%. CONCLUSIONS: Angiogenic factors are reliable in predicting PE near delivery. Of 8355 annual deliveries, 584 were admitted for suspected PE. The annual test cost was NIS 66,576 (NIS 140 per single test). Cost-saving was NIS 2.18 million, the ratio of cost saved vs. test cost was 32.7. DISCUSSION: The angiogenic factors are efficient and cost-saving in PE prediction near delivery. A larger study is necessary to determine the inclusion of angiogenic factors in the workup for suspected PE.

[THE FALL AND RISE OF PROGESTERONE PREPARATIONS IN THE PREVENTION OF PRETERM LABOR].

INTRODUCTION: Preterm labor involves about 7.4% of live births in Israel and constitutes over 85% of morbidity and mortality in newborns. Risk factors for preterm labor include a history of preterm delivery shortening of the uterine cervix, cervical procedures, uterine malformations, polyhydramnios, intrauterine growth restriction, preeclampsia, multiple gestations, and more. Progesterone is an essential hormone in the process of fertilization and is involved in the menstrual cycle, implantation and preservation of pregnancy. Due to its various functions in the prevention of preterm labor, the use of progesterone as a preventive treatment has been extensively studied since the second half of the last century and tested in various forms of administration, mainly intramuscular injection and vaginal root. For years, women with a history of preterm labor were treated with intramuscular progesterone once a week between 16 to 36 weeks' gestation or until birth. Recently, vaginal progesterone treatment was initiated in women with cervical length > 25 mm measured by ultrasound between 18-24 weeks gestation. Studies have shown that progesterone treatment reduces the incidence of preterm labor given in the proper indication. This update overview examines progesterone treatment for the prevention of preterm labor.