Outcomes in Maternal Graves' Disease: A Population-Based Mother-Infant Dyad Cohort Study.

Background: Graves' disease has been associated with adverse pregnancy, labor and delivery, and neonatal outcomes. Thyroid function levels, assessed during newborn screening (NBS), can serve as indicators of the adaptation in the hypothalamic-pituitary-thyroid axis. We utilized data from the national thyroid NBS program to investigate the characteristics of the mother-infant dyad of term infants born to mothers with past or active Graves' disease. Methods: The dataset of the Israeli NBS for thyroid function was linked with the electronic records of a tertiary medical center to generate a unified database of mothers and their term infants born between 2011 and 2021. The MDClone big data platform extracted maternal, pregnancy, disease course, labor and delivery, and neonatal characteristics of the mother-infant dyads. Results: Out of 103,899 registered mother-infant dyads, 292 (0.3%) mothers had past or active Graves' disease. A forward multivariate linear regression demonstrated that Graves' disease did not significantly affect NBS total thyroxine (tT4) levels (p = 0.252). NBS tT4 levels in infants born to mothers with active Graves' disease were higher than those observed in the general Israeli population (p < 0.001). Mothers with Graves' disease more frequently used assisted reproductive technology (12.7% vs. 9.0%, respectively, p = 0.012; odds ratio [OR] = 1.46 [CI 1.03-2.07], p = 0.031), and had more gestational hypertension (3.9% vs. 1.1%, p < 0.001; OR = 3.53 [CI 1.92-6.47], p < 0.001), proteinuria (2.5% vs. 0.9%, p < 0.001; OR = 3.03 [CI 1.43-6.45], p = 0.004), cesarean sections (26.4% vs. 19.7%, p = 0.029; OR = 1.46 [CI 1.13-1.90], p = 0.004), prelabor rupture of membranes (15.4% vs. 4.1%, p < 0.001; OR = 4.3 [CI 3.13-5.91], p < 0.001), and placental abnormalities (5.1% vs. 2.0%, p < 0.001; OR = 2.64 [CI 1.57-4.44]; p < 0.001). Their infants had lower adjusted birthweight z-scores (-0.18 ± 0.94 vs. -0.03 ± 0.90, p = 0.007) and were more likely to be small for gestational age (12.0% vs. 8.1%, p = 0.005; OR = 1.54 [CI 1.08-2.19], p = 0.018). Conclusions: Neonatal thyroid function levels were affected by maternal Graves' disease only when the disease was active during gestation. Moreover, maternal Graves' disease was also associated with an increased risk of adverse outcomes for the mother-infant dyad.

Pregnancy: The Impact of Maternal Nutrition on Intrauterine Fetal Growth.

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Twin Pregnancies-More to Be Done.

Over the past few decades, we have been experiencing an increase in the incidence of multiple gestations, mostly due to the widespread use of assisted reproduction technologies [...].

Blood fatty acid analysis reveals similar n-3 fatty acid composition in non-pregnant and pregnant women and their neonates in an Israeli pilot study.

Maternal docosahexaenoic acid (DHA) is required during pregnancy to supply for normal fetal growth and development. This pilot study aimed to assess the unknown fatty acid (FA) composition in a cohort of non-pregnant and pregnant Israeli women at term and their offspring on a normal diet without n-3 FA supplementation. The fatty acid profile, analyzed using gas chromatography, showed significantly higher plasma monounsaturated (MUFA) and lower n-6 FA percent distribution with similar n-3 index, in pregnant compared to non-pregnant women. RBC exhibited significantly higher MUFA with similar n-3 index, in pregnant compared to non-pregnant women. N-3 FA significantly correlated between neonates' plasma, with higher n-3 index, and pregnant women's DHA. Conclusion: DHA levels in non-pregnant and pregnant Israeli women at term were comparable and the DHA in pregnant women's plasma positively correlated with their neonate's level, suggesting an efficient mother-fetus FA transfer and/or fetal fatty acid metabolism to longer FA products.

Acute pulmonary edema due to severe preeclampsia in advanced maternal age women.

OBJECTIVE: Acute pulmonary edema is a rare complication in women with preeclampsia especially at advanced maternal age. We aimed to determine the cardiovascular hemodynamics in advanced maternal age women who developed acute pulmonary edema and preeclampsia. STUDY DESIGN: Retrospective cohort study of women aged over 45 years giving birth at single university affiliated tertiary medical center which developed acute pulmonary edema due to severe preeclampsia. Clinical features were identified in order to predict and potentially prevent this severe complication of pregnancy. MAIN OUTCOME MEASURES: Advanced maternal age women who developed acute pulmonary edema due to preeclampsia. RESULTS: Overall, during the study period 90,540 women delivered in our hospital, of them, 540 women (0.6%) above the age of 45 years gave birth. Of those, 67 women (12.4%) had preeclampsia in which 4 women (6%) were complicated with acute pulmonary edema. The common clinical relevant characteristics for all four women were: preterm delivery by cesarean section for preeclampsia with severe features, non-restrictive fluid management around the time of delivery, post-partum pain control medication with non-steroidal anti-inflammatory drug, blood pressure stabilization with oral labetalol and a sudden hemodynamic deterioration to hypertensive crisis and pulmonary edema between post-operative days 4-9. CONCLUSION: Although the precise trigger for the sudden presentation of acute pulmonary edema remains unknown, we suggest that there is a multi-factorial combination of etiologies that are common to women of advanced maternal age and women with preeclampsia that could have contributed to the development of pulmonary edema.

Effects of the COVID-19 pandemic on timely care for extrauterine pregnancies: A retrospective analysis.

BACKGROUND: The COVID-19 pandemic may have taken a toll upon the rate of extrauterine pregnancy (EUP)-related admissions and emergent surgeries. METHODS: This retrospective study compared current and past visits to the emergency services of a large metropolitan university-affiliated medical center in Tel-Aviv, Israel. Data on EUP-related and regular early pregnancy care-related presentations to the emergency department (ED) during the COVID-19 pandemic were collected and compared to a historical control group admitted during 2018-2019. The primary outcome was the rate of ruptured EUP. Secondary outcomes included the rate of EUPs requiring surgery, symptoms, blood products, blood loss, embryonic heart rate, ß-HCG levels, and intensive care unit transfer. FINDINGS: During the COVID-19 pandemic there was a 28.3% reduction in women seeking early pregnancy and emergent gynecological medical care. ED visits due to suspected EUP were similar: After exclusion, the study group comprised of 100 women and the combined control group from previous years included 208 women with confirmed EUP. Baseline maternal characteristics were similar between the groups. The rate of ruptured EUP's was significantly more common during the COVID-19 pandemic than in previous years [odds ratio (OR) 2•403 (1•272-4•539), p = 0•006]. Moreover, during the pandemic patients admitted due to EUP were significantly more symptomatic [OR 1•815 (1•072-3•074), p = 0•017] and had more blood loss demonstrated as substantial hemoglobin decline [OR 2•441 (1•07-5•565), p = 0•028] as well as hemoperitoneum during surgery [OR 2•672 (1•095-6•52), p = 0•035] The number of women receiving blood products was higher in the study group yet not reaching statistical significance [7% vs 3•4%, OR 2•161 (0•737-6•339) p = 0•128]. The overall rate of surgically treated EUP was similar between the groups [OR 1•070 (0•660-1•734), p = 0•439] and there was no significant difference in non-surgical management. INTERPRETATION: The COVID-19 pandemic has a toll on early pregnancy emergent care due to EUP with a significantly higher risk of tubal rupture and morbidity. Physicians should expect delayed presentation of symptomatic EUP and act accordingly. FUNDING: This research received no funding.

Cesarean delivery with and without uterine artery embolization for the management of placenta accreta spectrum disorder-A comparative study.

INTRODUCTION: The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder. MATERIAL AND METHODS: A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used. RESULTS: During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups. CONCLUSIONS: Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.

Risk factors and complications of manual placental removal after vaginal delivery - how common are additional invasive procedures?

PURPOSE: The purpose of this study is to assess risk factors and complications of manual placental removal. MATERIALS AND METHODS: An historical prospective study of all parturients undergoing manual placental removal between 2012 and 2014. Parturients were matched by time of delivery with parturients delivering vaginally with spontaneous placental separation. Multiple gestations, preterm deliveries, incomplete placental separation and uterine malformations were excluded. Delivery characteristics and short-term complications were studied. Telephone questionnaires were conducted to assess the likelihood of invasive procedures performed for retained products of conception (RPOC) up to 12 weeks postpartum. RESULTS: Overall 293 (1.5% of all vaginal deliveries) were complicated by manual placental removal. Independent risk factors included advanced maternal age (odds ratio (OR) 1.08, 95% CI 1.03-1.12), previous manual removal (OR 9.27, 95% CI 3.15-27.31), regional anesthesia (OR 3.49, 95% CI 2.14-5.70), and labor induction (OR 1.80, 95% CI 1.12-2.88). Short-term complications included blood product transfusions (OR 18.26 95% CI 5.37-62.13) and prolonged hospitalization (OR 1.51 95% CI 1.06-2.16). Invasive procedures for removal of RPOC occurred in 12.2% of women in the study groups and in none of the women in the control group (p < .001). CONCLUSIONS: Manual placental removal harbors short- and long-term complications, including a high likelihood of RPOC necessitating further invasive procedures.