Assessing the Clinical Significance of Third-Trimester Post-Coital Bleeding.

INTRODUCTION: This study aimed to evaluate the impact of third-trimester post-coital bleeding (PCB) on pregnancy outcomes. METHODS: A retrospective cohort study was conducted at two tertiary medical centers, including all pregnant women between 24 and 34 weeks of gestation referred due to vaginal bleeding over an 11-year period. The study population includes all singleton deliveries; within this population, women were further classified into three groups: those admitted due to vaginal bleeding related to PCB, those admitted due to vaginal bleeding not related to PCB, and those who did not report vaginal bleeding. The primary outcome measure was delivery prior to 37 weeks of gestation, while secondary outcome measures included maternal and neonatal complications. Baseline characteristics of the two groups were compared. RESULTS: During the study period, there were a total of 51,698 deliveries. Among these, 230 cases involved bleeding between 24 and 34 weeks of gestation, 34 (14.8%) were identified as PCB, and 196 as bleeding unrelated to intercourse. In addition, 51,468 pregnancies without bleeding were analyzed as the general population for comparison. The incidence of preterm labor before 37 weeks of gestation was notably higher in both women with PCB (14.7%) and those with bleeding unrelated to coitus (20.9%) compared to the general population (5.6%); however, there was no statistically significant difference between the two bleeding groups (p = 0.403) while both were significantly different from the general population (p < 0.001). The odds ratio for preterm birth before 37 weeks of gestation after PCB was 3.29 (95% CI: 1.26-8.56, p = 0.0149). There were no significant differences between the PCB and bleeding unrelated to intercourse groups in terms of maternal and neonatal complications. CONCLUSION: This study found that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the general population without bleeding. These findings challenge the assumption that PCB is benign.

The effectiveness of vaginal progesterone in reducing preterm birth in high-risk patients diagnosed with short cervical length after 24 weeks: A retrospective cohort study.

Objective: To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation. Methods: A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group. Results: The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions (OR 0.20, 95% CI 0.05-0.74) and in the neonatal hospitalization period (mean difference in days 2.43, 95% CI 0.44-4.42). The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment. Conclusion: Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial.

BACKGROUND: External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial. OBJECTIVE: This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version. RESULTS: The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference. CONCLUSION: This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

Long-term gynecological complications after conservative treatment of placenta accreta spectrum.

Objective: To examine the association between conservative treatment for PAS (placenta accreta spectrum) and subsequent gynecological and fertility complications. Methods: All women who underwent conservative treatment for PAS between January 1990 and December 2000 were included in this retrospective cohort study conducted in a tertiary teaching hospital. Gynecological and fertility complications experienced after the index delivery were collected from the medical records and telephone questionnaires. This data was compared to an age and parity-matched control group of women without PAS. Results: The study group included 134 women with PAS managed conservatively and 134 controls with normal deliveries matched by parity and age. Women in the PAS group required significantly more postpartum operative procedures such as hysteroscopy or D&C (OR = 6.6; 95%CI: 3.36-13.28; P = <0.001). Following the index delivery, there were 345 pregnancies among 107 women who attempted conception following conservative treatment for PAS vs. 339 pregnancies among 105 women who attempted conception in the control group. Among women who attempted conception following conservative treatment for PAS 99 (92.5%) delivered live newborns (a total of 280 deliveries) vs. 94 (89.5%) in the control group, (a total of 270 live newborns, p = 0.21). The need for fertility treatments was not different between the two groups (OR = 1.22; 95%CI: 0.51-2.93; P = 0.66). Conclusion: After conservative treatment for PAS, significantly more women required complementary procedures due to retained placenta and/or heavy vaginal bleeding. There was no evidence of fertility impairment in women post-conservative treatment for PAS.

Reviewing Accuracy of First Trimester Screening for Preeclampsia Using Maternal Factors and Biomarkers.

Preeclampsia is a common and important complication of pregnancy, one with potentially significant morbidity and even mortality to both mother and baby. Identifying those at high risk of developing the condition is helpful as there is evidence that the incidence of preeclampsia can be reduced with low dose aspirin taken in pregnancy. Accurately predicting the risk of preeclampsia allows for more targeted aspirin prophylaxis and a greater opportunity for early detection of maternal and/or fetal complications associated with impaired placentation through a schedule of enhanced antenatal surveillance. Traditional preeclampsia prediction models use maternal characteristics and risk factors and have been shown to be of low predictive value. Multiparametric screening tests combine patient characteristics with serum biomarkers and ultrasound Doppler indices and have been shown to be more effective at detecting those at high risk of preeclampsia - more specifically, early-onset preeclampsia (onset of preeclampsia <34 weeks' gestation). Multiparametric screening has now been validated in different populations. The true cost effectiveness of a multiparametric screening model for preeclampsia screening is not yet fully known and will vary depending on the clinical setting. Despite the growing body of evidence for its improved detection rates, first trimester preeclampsia screening using multiparametric models is not widely implemented and is not part of the recommendations for antenatal screening from most international bodies. The International Federation of Gynecology and Obstetrics has advised universal preeclampsia screening using maternal risk factors and biomarkers and has strongly encouraged its promotion worldwide. Various barriers to implementation must be considered such as the immediate cost of equipment and training, the need for audit and quality control, and the expected benefit to the population. Low to middle income settings may require a pragmatic approach to the implementation of multiparametric screening given limited resources.

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.

The association between low birth weight and outcomes of vacuum assisted vaginal delivery.

OBJECTIVE: It is often hypothesized that poor neonatal outcomes are more frequently observed in low birth weight (LBW) neonates following vacuum assisted vaginal delivery (VAVD). We sought to assess the association between low birth weight (< 2500 g) and neonatal outcomes, following vacuum extraction. STUDY DESIGN: This was a retrospective cohort study, including 1085 deliveries in a tertiary medical center between 2003 and 2015. Maternal and neonatal outcomes, including birth trauma related complications, were compared between women with singleton pregnancies beyond 34 weeks' gestation and fetal weight < 2500 g who were delivered by vacuum extraction (n=345) and a control group (n=740) with fetal weight ≥ 2500 g, matched in maternal age, parity and gestational week. RESULTS: During the study period, 370 women met the inclusion criteria for the study group, with 25 cases eventually excluded due to missing neonatal birth trauma related data. 740 patients were included in the matched control group. Induction of labor and non-reassuring fetal heart rate as an indication for VAVD were more prevalent in the LBW group. The composite birth trauma related adverse outcome was higher in the control group (9.1 % vs. 4.4 %, p = 0.008), mainly due to increased rate of cephalohematoma in this group (6.8 % vs. 2.9 %, p = 0.01). All other adverse neonatal outcomes rates did not differ between the groups. Women in the control group were more prone to post-partum hemorrhage (p < 0.001), had more episiotomies (p = 0.004) and a higher failed VAVD rate (11.4 % vs. 2.6 %, p < 0.001), leading to emergency cesarean delivery. A sub-group analysis of failed VAVD did not reveal a difference in neonatal complications between the LBW and the control group. CONCLUSION: Neonatal birth trauma and adverse outcomes following vacuum extraction are no more common in neonates weighing less than 2500 g than those with higher birth weights, even in failed vacuum cases.

Laparoscopic uterosacral ligament suspension versus vaginal colposuspension using the Uphold Lite™ mesh system: clinical outcome and patient satisfaction.

INTRODUCTION AND HYPOTHESIS: The objective was to compare clinical and anatomical outcomes between laparoscopic uterosacral ligament suspension (LUSLS) and vaginal colposuspension using the Uphold Lite™ mesh system for the treatment of apical prolapse. METHODS: We performed a comparative, retrospective cohort study. All women who underwent either vaginal colposuspension with the Uphold Lite™ System or LUSLS for treatment of apical prolapse between 2010 and 2019 were included. The groups were compared with regard to demographic, pre-operative, intra-operative, and post-operative data. Outcome measures included clinical and anatomical cure, as well as a composite outcome. The PGI-I questionnaire was used to determine patient satisfaction. RESULTS: One-hundred and nineteen women met the inclusion criteria, including 70 women who underwent LUSLS and 49 women who underwent vaginal colposuspension with the Uphold Lite™ mesh system. At a mean follow-up of 31.7 (SD = 18.1) months, the clinical cure rate was high for both groups, reaching 98.6% in the LUSLS group compared with 89.8% in the Uphold group (NS). Anatomical cure rate was 83.6% in the LUSLS group compared with 69.7% for the Uphold group (NS). With regard to the composite outcome, no difference was found, although a trend towards a higher success rate was noted in the LUSLS group (83.6% vs 66.7%, p = 0.055). Patient satisfaction measured using the PGI-I questionnaire was high, at 98.6% in the LUSLS group and 87.8% in the Uphold group (NS). CONCLUSION: Laparoscopic uterosacral ligament suspension and vaginal colposuspension using the Uphold Lite™ mesh system both have high clinical cure rates.

Obstetrical and neonatal outcomes after a single episode of third-trimester vaginal bleeding†.

Objective: The objective of this study is to determine whether a single episode of vaginal bleeding occurring between 24 and 34 weeks gestation is associated with preterm delivery and other adverse maternal and neonatal outcomes.Study design: We conducted a retrospective cohort study in the Maternal-Fetal unit of two campuses of a large tertiary, medical center with approximately 12,000 deliveries annually. The study group consisted of all women with a singleton pregnancy between 24 + 0/7 and 33 + 6/7 weeks of gestation, admitted to the high-risk antenatal ward due to a single episode of vaginal bleeding of unknown origin between May 2003 and December 2014. Maternal and neonatal parameters of the study group were compared to the maternal and neonatal parameters of the rest of the singleton deliveries occurring in our institution during the study period. The primary outcome was rate of preterm delivery while secondary outcomes were other adverse maternal and neonatal outcomes. Multivariate logistic regression was performed to identify risk factors for preterm delivery in the study group.Results: Two hundred thirty women met the inclusion criteria and 51,468 women were in the comparison group. Preterm delivery rates were 20% and 5.5% in the study and the comparison group, respectively OR = 3.55 [2.63-4.78] (p < .001). The aOR for preterm delivery among the study group for women with a previous preterm delivery was 4.62 [1.17-18.20] (p = .029) and for women with a short cervix was 9.35 [2.30-37.95] (p = .002).Conclusions: A single episode of third-trimester vaginal bleeding is an independent risk factor for spontaneous preterm delivery. The presence of a shortened cervix or a history of a prior spontaneous preterm delivery increases this risk significantly.Key messageThird trimester vaginal bleeding is strongly associated with preterm delivery. Knowledge of this relationship has valuable clinical implications for practicing obstetricians.

Laparoscopic Uterosacral Ligament Hysteropexy vs Total Vaginal Hysterectomy with Uterosacral Ligament Suspension for Anterior and Apical Prolapse: Surgical Outcome and Patient Satisfaction.

STUDY OBJECTIVE: To compare anatomic and clinical cure rates as well as patient satisfaction between uterine-preserving laparoscopic uterosacral ligament suspension and total vaginal hysterectomy with uterosacral ligament suspension in women with apical and anterior prolapse. DESIGN: Single-center clinical comparative retrospective cohort study. SETTING: A female pelvic medicine and reconstructive surgery service at a tertiary teaching hospital. PATIENTS: Women with pelvic organ prolapse who underwent surgical treatment for their condition between July 2010 and December 2015. INTERVENTIONS: All women underwent laparoscopic uterosacral ligament suspension or total vaginal hysterectomy with uterosacral ligament suspension for apical and anterior prolapse. Concomitant procedures included anterior and posterior repair, as well as a midurethral sling when indicated. MEASUREMENTS AND MAIN RESULTS: Preoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements were obtained. The primary outcome was clinical cure rate. Secondary outcomes included anatomic cure rate and outcomes of site-specific POP-Q points Ba, C, and Bp for the whole cohort. Patient satisfaction was measured using the Patient Global Impression of Improvement questionnaire. During the study period, 106 women underwent transvaginal hysterectomy with uterosacral ligament suspension, and 53 women had laparoscopic uterosacral ligament suspension. At a mean follow-up of 14.7 ± 13.23 months for the vaginal group and 17.5 ± 15.84 months for the laparoscopic group (p = .29), there were significant improvements of POP-Q points Ba, C, and Bp (p < .0001 for all comparisons in both groups). The clinical cure rate was 96% in the vaginal group and 98% in the laparoscopic group (p = .50). The anatomic cure rate was 85.4% in the vaginal group and 93.75% in the laparoscopic group (p = .11) Patient satisfaction was high in both groups. CONCLUSION: In appropriately selected patients, laparoscopic uterosacral ligament suspension is a valid uterus-preserving option for women with anterior and apical prolapse, associated with high anatomic and clinical cure rates and patient satisfaction.

Development of a nomogram for prediction of successful membrane sweeping.

OBJECTIVE: To evaluate the association of obstetric, maternal, and fetal variables with successful membrane sweeping and to develop a calculator that can predict spontaneous delivery within 24 hours of membrane sweeping. METHODS: This secondary analysis of the STRIP-G Study included all singleton term parturients who underwent membrane sweeping in a tertiary center in October 2011 to July 2013. Primary end point was a 24-hour time interval from sweeping to delivery. Women who delivered without formal induction within the 24-hour interval were included in the "successful sweeping group". Stepwise logistic regression was used to calculate the adjusted odds ratio (aOR) for successful membrane sweeping and to create the calculator. The predictive power of the calculator was evaluated by area under the curve (AUC) of the receiver operating characteristic (ROC) curve and by Nagelkerke R-square. The model was validated by the Hosmer-Lemeshow test and by these validation measures: sensitivity, specificity, and positive and negative predictive value. RESULTS: We analyzed data from 542 women. Parity (aOR = 1.66, 95% confidence interval [CI] 1.1-2.54), cervical dilation (aOR = 3.33, 95%CI 2.04-5.44), and gestational age (aOR = 1.44, 95%CI 1.21-1.72) were independent predictors of spontaneous delivery during the first 24 hours. A cross validation procedure showed that the calculator had a good accuracy (68%). CONCLUSIONS: A simple calculator based on maternal age, parity, gestational age, cervical dilatation, effacement and station, can accurately predict the chances of delivery within 24 hours of membrane sweeping. This may assist physicians better counseling of women regarding the likelihood of successful membrane sweeping.

[PROLONGED SECOND STAGE OF LABOR: CAUSES AND OUTCOMES].

INTRODUCTION: Professional bodies have published guidelines defining the length of the second stage of labor and when it is "prolonged", according to parity and epidural anesthesia administration. Recently these guidelines have been extended, aiming to reduce rates of unplanned cesarean deliveries. AIMS: To examine the risk factors and outcomes of a prolonged second stage of labor, in order to understand its causes and implications for mothers and neonates, including the delivery mode. METHODS: A retrospective study based on 26,476 electronic medical records of deliveries to primiparous mothers of a term singleton fetus, at Hadassah Medical Center, between 2003 and 2015. RESULTS: A prolonged second stage of labor was recorded in 3,225 (12.2%) of mothers (i.e. exceeding 2 hours without epidural anesthesia and 3 hours with it). Epidural anesthesia, persistent occiput posterior, and head circumference or birth weight above the 90th percentile, increased the risk of the prolonged second stage. The risk of unplanned cesarean delivery rose significantly before the 2- or 3-hour cut-off defining a prolonged second stage. Risks of maternal and neonatal complications included: grade III-IV perineal tear, maternal hemorrhage, 5-minute Apgar≤7, umbilical artery pH<7.1, neonatal intensive care admission were also increased. CONCLUSIONS: Epidural anesthesia and fetal parameters increased the risk of prolonged second stage; risks of maternal and fetal complications were also increased. The risk of interventional delivery increased significantly well before the defined cut-off. DISCUSSION: Prolongation of the second stage of labor is a common pathway of many obstetric outcomes. Obstetric management should be based on considerations of individual maternal and neonatal well-being, rather than administrative goals. While reducing cesarean rates is an important goal, attempts to achieve this by prolonging the second stage of labor exposes mothers and neonates to excess risk of cesarean and vacuum delivery as well as obstetric and neonatal complications.

Patterns of use and optimal timing of antenatal corticosteroids in twin compared with singleton pregnancies.

INTRODUCTION: Previous reports have shown that suboptimal antenatal corticosteroids administration occurs in most cases. However, as multifetal gestations were either excluded or constituted a small proportion of the participants in these studies, little is known about the patterns of use of antenatal corticosteroids in twin pregnancies. MATERIAL AND METHODS: We reviewed the records of women who received antenatal corticosteroids and delivered between 240/7 and 346/7 weeks of gestation during 2015-2017 at 2 university hospitals. Optimal antenatal corticosteroids timing was defined as delivery ≥24 hours ≤7 days from the previous antenatal corticosteroids course. RESULTS: Of 424 pregnancies, 307 (72.4%) were singleton and 117 were (27.6%) twin. For twin compared with singleton pregnancies, gestational age at initial antenatal corticosteroids administration was lower (P = 0.02), the proportion of deliveries within the optimal window of the initial antenatal corticosteroids course was lower (19.7% vs 33.2%, P = 0.001), and the proportion of women eligible for a rescue antenatal corticosteroids course was higher (58.1% vs 32.9%, P < 0.0001). However, despite similar rates of rescue antenatal corticosteroids administration (P = 0.64), the overall rate of delivery within any optimal window (either initial or rescue course) was lower in twin than singleton pregnancies (26.5% vs 42.3%, P = 0.004), and the antenatal corticosteroids-to-delivery interval was longer (median 6.9 vs 4.2 days, P = 0.0009). In multivariate analysis, optimal antenatal corticosteroids administration was negatively associated with twin pregnancy (P = 0.04) and preterm labor (P = 0.05), and positively associated with the presence of gestational hypertensive disorders (P = 0.03). CONCLUSIONS: Twin pregnancy is an independent risk factor for suboptimal antenatal corticosteroids administration. Directed efforts should be made to improve the utilization of antenatal corticosteroids in this vulnerable group of women.

Risk factors for cesarean delivery and adverse neonatal outcome in twin pregnancies attempting vaginal delivery.

INTRODUCTION: Twin vaginal delivery presents a unique clinical challenge for obstetricians. The Twin Birth Study demonstrated the safety of planned vaginal delivery regarding neonatal outcomes. However, that study lacked a description of the risk factors associated with and the outcome of unplanned cesarean section. The aim of this study is to identify potential risk factors for cesarean section and delivery related neonatal morbidity and mortality in women with twin pregnancy attempting vaginal delivery. MATERIAL AND METHODS: A retrospective cohort study including 1070 women with twin pregnancy that underwent a trial of labor between 2003 and 2015. The study population was divided according to the mode of delivery: vaginal delivery, combined vaginal-cesarean and intrapartum cesarean delivery of both twins. Several risk factors and neonatal outcomes were examined by both univariate analysis and multinomial logistic regression analysis. RESULTS: The rate of vaginal delivery of both twins was 88.3%, whereas the rates of combined vaginal cesarean and unplanned cesarean delivery were 4.6% and 7.1%, respectively. Nulliparity and nonvertex presentation of twin B were found to be independently associated with cesarean delivery for both twins. Additionally, nonvertex presentation of twin B was independently associated with combined vaginal-cesarean delivery. The proportion of neonates with Apgar score <7 at 5 min was increased for both twins in the combined vaginal-cesarean group compared with those delivered by the vaginal route alone. CONCLUSION: Nulliparity and nonvertex presentation of twin B were found to be associated with intrapartum cesarean delivery in twin pregnancies.