Perinatal Outcomes of Late Preterm Rupture of Membranes with or without Latency Antibiotics.

OBJECTIVE: This study aimed to examine whether the addition of latency antibiotics in late preterm rupture of membranes (ROM) decreases neonatal infection and increases latency. STUDY DESIGN: This retrospective two-center study was conducted at Holy Family Hospital (HFH) in Nazareth and Emek Medical Center (EMC) in Afula, on data collected between January 2017 and April 2023. HFH is the smaller institution. EMC and HFH implement similar policies regarding ROM at 340/7 to 366/7 weeks' gestation; the only difference is that a 10-day course of latency antibiotics is implemented at EMC. All women with ROM between 340/7 and 366/7 weeks' gestation who were admitted to one of the centers during the study period, and had a live fetus without major malformations, were included. The primary outcome was neonatal sepsis rate. Secondary outcomes included a composite of neonatal sepsis, mechanical ventilation ≥24 hours, and perinatal death. Additionally, gestational age at delivery and delivery mode were examined. RESULTS: Overall, 721 neonates were delivered during the study period: 534 at EMC (where latency antibiotics were administered) and 187 at HFH. The gestational age at ROM was similar (35.8 and 35.9 weeks, respectively, p = 0.14). Neonatal sepsis occurred in six (1.1%) neonates at EMC and one (0.5%) neonate at HFH (adjusted p = 0.71; OR: 1.69; 95% Confidence Interval [CI]: 0.11-27.14). The composite secondary outcome occurred in nine (1.7%) and three (1.6%) neonates at EMC and HFH, respectively (adjusted p = 0.71; OR: 0.73; 95% CI: 0.14-3.83). The gestational age at delivery was 36.1 and 36.2 weeks at EMC and HFH, respectively (mean difference: 5 h; adjusted p = 0.02). The cesarean delivery rate was 24.7% and 19.3% at EMC and HFH, respectively (adjusted p = 0.96). CONCLUSION: Latency antibiotics administered to women admitted with ROM between 340/7 and 366/7 weeks' gestation did not decrease the rate of neonatal sepsis. KEY POINTS: · Latency antibiotics in late preterm ROM does not decrease neonatal sepsis.. · Latency antibiotics in late preterm ROM does not prolong gestational age at delivery.. · Latency antibiotics in late preterm ROM does not affect the mode of delivery..

Double-vs single-balloon catheter for induction of labor: Systematic review and individual participant data meta-analysis.

INTRODUCTION: Evidence comparing double-balloon vs single-balloon catheter for induction of labor is divided. We aim to compare the efficacy and safety of double-vs single-balloon catheters using individual participant data. MATERIAL AND METHODS: A search of Ovid MEDLINE, Embase, Ovid Emcare, CINAHL Plus, Scopus, and clinicaltrials.gov was conducted for randomized controlled trials published from March 2019 until April 13, 2021. Earlier trials were identified from the Cochrane Review on Mechanical Methods for Induction of Labour. Randomized controlled trials that compared double-balloon with single-balloon catheters for induction of labor in singleton gestations were eligible. Participant-level data were sought from trial investigators and an individual participant data meta-analysis was performed. The primary outcomes were rates of vaginal birth achieved, a composite measure of adverse maternal outcomes and a composite measure of adverse perinatal outcomes. We used a two-stage random-effects model. Data were analyzed from the intention-to-treat perspective. RESULTS: Of the eight eligible randomized controlled trials, three shared individual-level data with a total of 689 participants, 344 women in the double-balloon catheter group and 345 women in the single-balloon catheter group. The difference in the rate of vaginal birth between double-balloon catheter and single-balloon catheter was not statistically significant (relative risk [RR] 0.93, 95% confidence interval [CI] 0.86-1.00, p = 0.050; I2 0%; moderate-certainty evidence). Both perinatal outcomes (RR 0.81, 95% CI 0.54-1.21, p = 0.691; I2 0%; moderate-certainty evidence) and maternal composite outcomes (RR 0.65, 95% CI 0.15-2.87, p = 0.571; I2 55.46%; low-certainty evidence) were not significantly different between the two groups. CONCLUSIONS: Single-balloon catheter is at least comparable to double-balloon catheter in terms of vaginal birth rate and maternal and perinatal safety outcomes.

Impact of COVID-19 mandatory lockdown on maternal gestational weight gain and neonatal macrosomia rate at an academic medical center in Israel.

BACKGROUND: In an effort to prevent the spread of coronavirus disease 2019 (COVID-19), governments restricted outdoor activities and imposed lockdown quarantine. This change in lifestyle probably affected individuals' eating habits and physical activity. OBJECTIVE: To examine the effect of lockdown due to the COVID-19 pandemic on maternal antenatal weight gain, neonatal macrosomia, and other maternal and neonatal outcomes of women delivering at an academic medical center in Israel. METHOD: A retrospective, two-period cohort study conducted at a university teaching medical center in Afula, Israel. The study period was between April and September 2020. This period signifies worsening in pandemic situations, during which citizens experienced strict prolonged lockdown measures. The parallel unexposed period (control period) was between April and September 2019. Singleton pregnancies delivered at >24 weeks were eligible. Primary outcome was incidence of macrosomia. Secondary outcomes included gestational weight gain, body mass index (BMI) at delivery, rates of gestational diabetes mellitus (GDM), mode of delivery, postpartum hemorrhage (PPH), and neonatal outcomes reflecting neonatal birth weight and condition at delivery. RESULTS: A total of 4,765 women were included, 2,442 in the study group and 2,323 in the control group. The incidence of macrosomia was significantly higher in 2020 (6.2%) than in 2019 (4.9%), (p = .048; OR: 1.29; 95% CI: 1.002- 1.65). Women gained significantly more weight (median 1 kg more), weighed more at delivery (median 1 kg), and had higher BMI at delivery in 2020 compared with those in 2019 (p < .01). The incidence of GDM was 9.5% and 8.5% in the study and control groups respectively (p = .26; OR: 1.12; 95% CI: 0.92-1.37). Greater percentage of women did not perform the glucose challenge test in 2020 (9.9%) compared with those in 2019 (7.5%) (p = .003, OR: 1.36; 95% CI: 1.11-1.67). The incidence of any hypertension related to pregnancy was significantly higher in 2020 compared to 2019 (5.8% vs 4.4% respectively, (p = .042; OR: 1.32; 95% CI: 1.02-1.71). The proportion of women who smoked during pregnancy was also significantly higher in 2020 than in 2019 (5.1% vs 3.7%, respectively, p = .02; OR: 1.40; 95% CI: 1.06-1.86). Delivery mode did not differ, while the incidence of PPH was significantly higher in 2020 than in 2019 (5.6% vs 3.4%, respectively, p = .001; OR: 1.65; 95% CI: 1.25-2.19). Neonatal condition at delivery was comparable. CONCLUSION: COVID-19-related lockdown was associated with the increased rate of macrosomic infants. This indirect effect of the pandemic is probably related to poorer maternal antenatal metabolic health status. Long-term consequences should be further examined.

Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review.

Labor pain is among the most severe types of physical pain that women may experience during their lifetime. Thus, pain relief is an essential part of medical care during childbirth. Epidural analgesia is considered to be the most efficient method of pain relief during labor. Nevertheless, patient preferences, contraindications, limited availability, and technical failure may require the use of alternative pain reliving methods during labor including systemic pharmacologic agents, and nonpharmacologic methods. Nonpharmacologic methods for pain alleviation during vaginal birth have become popular over the years, either as a complement to pharmacologic agents or at times as the principal therapy. Methods such as relaxation techniques (ie, yoga, hypnosis, and music), manual techniques (ie, massage, reflexology, and shiatsu), acupuncture, birthing ball, and transcutaneous electrical nerve stimulation are considered safe, although the evidence supporting their effectiveness for pain relief is not as robust as it is for pharmacologic agents. Systemic pharmacologic agents are mostly administered by inhalation (nitrous oxide) or through the parenteral route. These agents include opioids such as meperidine, nalbuphine, tramadol, butorphanol, morphine, and remifentanil, and non-opioid agents such as parenteral acetaminophen and nonsteroidal anti-inflammatory drugs. Systemic pharmacologic agents suggest a diverse armamentarium of medication for pain management during labor. Their efficacy in treating pain associated with labor varies, and some continue to be used even though they have not been proven effective for pain relief. In addition, the maternal and perinatal side effects differ markedly among these agents. There is a relative abundance of data regarding the effectiveness of analgesic drugs compared with epidural, but the data regarding comparisons among the different types of alternative analgesic agents are scarce, and there is no consistency regarding the drug of choice for women who do not receive epidural pain management. This review aims to present the available data regarding the effectiveness of the different methods of relieving pain during labor other than epidural. The data presented are mainly based on recent level I evidence regarding pharmacologic and nonpharmacologic methods for pain relief during labor.

Neonatal condition at birth of twins conceived by medically assisted reproductive technology compared to those conceived spontaneously: A retrospective study.

OBJECTIVE: To examine neonatal outcomes at birth among twins conceived spontaneously or by medically assisted reproduction (MAR). METHODS: A retrospective study was conducted at a single university teaching hospital on data collected between January 1995 and September 2019. Live twin deliveries at more than 24 weeks of pregnancy were included. The study group consisted of women who conceived by MAR and the controls were spontaneously conceived twins. The study group was further divided into two groups: in vitro fertilization (IVF) and ovulation induction (OI) groups. The primary outcomes were umbilical artery pH less than 7.1 and/or Apgar score less than 7 of any twin 5 min after birth. RESULTS: Overall, 2235 eligible twin gestations were included, corresponding to a total of 4470 live neonates; 1009 (45.1%) conceived by MAR (762 [75.5%] IVF and 247 [24.5%] OI) and 1226 (54.9%) conceived spontaneously. Incidence of the primary outcome was 5.3% and 5.1% in the study and control groups, respectively (P = 0.71). The primary outcome was comparable among the IVF (5%), OI (6.2%), and control (5.1%) groups. The results did not change even after adjusting for demographic and obstetric variables, including mode of delivery, which differed between the groups. CONCLUSION: Neonatal condition of twin pregnancies at birth among MAR subgroups is similar to spontaneously conceived twins.

Postpartum hemorrhage among twin pregnancies - Medically assisted versus spontaneously conceived.

INTRODUCTION: In singleton pregnancies, an increased risk of Postpartum hemorrhage (PPH) have been linked with assisted reproductive technology (ART) and abnormal placentation. It is unknown wheather such association exists in twin pregnancies conceived by Medically assisted reproduction (MAR). The aim of the current study was to compare maternal blood loss among twin pregnancies conceived by different types of MAR treatments to spontaneously conceived twins and to identify the cycle characteristics if an association exits. METHODS: Retrospective study conducted on data collected between 2011 and 2020. The study cohort included all twin pregnancies conceived by MAR and born at our institution. Controls were spontaneously conceived twins matched for maternal age on a 1:2 (study: controls) ratio. RESULTS: Overall 113 MAR twin births categorized into three groups; 25 ovulation induction, 59 fresh ART, 29 frozen-thawed ART cycles, and 226 controls were included. The incidence of PPH was higher among MAR twin pregnancies (5.3%) compared to the controls (4%). The highest incidence was observed among women in the frozen-thawed group (13.8%) which differed significantly compared with the controls (p = 0.024). A significant difference was also observed in the mean decrease of postpartum hemoglobin levels between these two groups (2.13 g/dL versus 1.3 g/dL respectively, p = 0.002). Blood transfusion was nearly 2.5 times more common in the frozen-thawed group (3.4%) compared to the control group (1.3%). DISCUSSION: The present study demonstrates that frozen embryo transfer (FET) ART-conceived twin pregnancies are associated with a markedly increased rate of PPH compared to spontaneously conceived twins.

Meperidine Compared With Nitrous Oxide for Intrapartum Pain Relief in Multiparous Patients: A Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy and adverse effects of intravenous meperidine and inhaled nitrous oxide for intrapartum analgesia in multiparous patients. METHODS: This randomized controlled trial was conducted in the delivery ward of a university teaching medical center in Afula, Israel. Multiparous patients with term, singleton pregnancies who were in labor were randomized in a 1:1 ratio to 50 mg intravenous meperidine or inhaled nitrous oxide. The primary outcome was pain intensity 20-30 minutes after analgesic administration, measured on a visual analog scale (VAS) from 0 to 10 cm. Secondary outcomes included the need for additional analgesia, labor length, delivery mode, patient satisfaction, and maternal and neonatal adverse effects. To detect a 1-cm (±2.6) difference in VAS score between the groups, 214 total participants were needed to achieve 80% power with an alpha of 0.05. RESULTS: From August 2016 through May 2019, 214 participants were enrolled. Fourteen were excluded after randomization. Of the 200 analyzed, 102 received nitrous oxide, and 98 received intravenous meperidine. Demographic and obstetric variables were comparable between the two groups. The VAS score 20-30 minutes after analgesic administration did not differ between the groups (7.7±2.3 cm and 7.6±2.7 cm in the nitrous oxide and meperidine groups, respectively, P=.89). There were no significant differences between the groups in the rate of additional analgesic use, labor length, delivery mode, Apgar scores, rate of breastfeeding, patient satisfaction, or maternal and neonatal adverse effects. CONCLUSION: Pain intensity was comparable in multiparous patients 20-30 minutes after administration of meperidine and nitrous oxide. Adverse effects were also comparable. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02783508.

Efficacy and safety of intrauterine device placement during a planned cesarean section.

Objective: Approximately 79% of pregnancies conceived within the first year after delivery are unintended and 50% of the couples report having unprotected intercourse before the first routine postpartum appointment. Unintended pregnancies are associated with unsafe abortions and other poor outcomes. We aimed to determine the efficacy and safety of intrauterine device (IUD) placement during a planned cesarean section (CS) at one year after insertion. Study Design: A survey-based retrospective cohort study conducted at a university teaching hospital. The study cohort included term pregnant women delivered by a planned CS between December 2016 and July 2020, and data collection and questionnaires were completed in July 2021. In the study group, copper or Levonorgestrel IUDs were placed through the uterine incision after delivery of the fetus and placenta, while women in the control group did not receive an IUD. Other perioperative managements were similar. The primary outcome was unintended pregnancy rate during the first year after delivery. Results: The study comprised a total of 150 women, with 50 and 100 in the study and control groups, respectively. None of the women in the study group became pregnant, compared with nine (9%) in the controls (p = 0.03), of them eight (88.9%) were unplanned. Perioperative outcome was comparable between groups. The rate of contraceptive use one year after delivery was significantly higher in the study group compared to the control group (86.0% vs. 35.0%, respectively, p < 0.001). Conclusion: IUD placement during CS is effective in preventing unintended pregnancies within the first year after delivery, with operative outcomes unaffected. Implications: Intrauterine device (IUD) placement during a planned cesarean section prevented unintended pregnancies within one year after birth. Additionally, the rate of contraceptive use at one year was significantly higher compared to women who elected not to have an IUD inserted during the cesarean. IUD placement did not affect perioperative outcomes.

Efficacy of Single Wound Infiltration With Bupivacaine and Adrenaline During Cesarean Delivery for Reduction of Postoperative Pain: A Randomized Clinical Trial.

Importance: Most women report moderate to severe pain after cesarean delivery. The extent of the ability of surgical wound infiltration with local anesthetic agents during cesarean delivery for the reduction of postoperative pain is uncertain. Objective: To examine the efficacy of single wound infiltration with bupivacaine and adrenaline during cesarean delivery for the reduction of postoperative pain. Design, Setting, and Participants: This randomized clinical trial was conducted between January 25, 2018, and May 30, 2020, at a university teaching hospital in Afula, Israel. A total of 288 women with singleton pregnancy who were scheduled for a planned cesarean delivery at term were randomized to receive single wound infiltration with bupivacaine and adrenaline during cesarean delivery (intervention group) or no single wound infiltration (control group) at a 1:1 ratio. Interventions: In the intervention group, the subcutaneous layer was infiltrated on both sides of the wound by a mixture of bupivacaine and adrenaline before wound closure. Other perioperative techniques were similar between the groups. Main Outcomes and Measures: The primary outcome was mean pain intensity over the course of 24 hours after the operation, as measured by a visual analog scale (VAS) score ranging from 0 to 10 (with higher scores indicating greater pain intensity). To detect a mean (SD) reduction of 1 (3) points in the VAS score in the intervention group, 286 women were needed in total. Secondary outcomes included VAS score greater than 4 (indicating moderate pain) at 2 hours after the operation, use of rescue opioids, maternal satisfaction with the pain management procedure (using a scale of 1-5, with higher scores indicating greater satisfaction), duration of the operation, scar complications (hematoma, infection, and separation), and length of stay. Results: Among 288 women (mean [SD] age, 32.5 [5.1] years; all of Arab or Jewish ethnicity), 143 were randomized to the intervention group, and 145 were randomized to the control group. Demographic and obstetric variables were similar between groups. The primary outcome (VAS pain score) was significantly lower in the intervention group (mean [SD], 2.21 [0.56]) compared with the control group (mean [SD], 2.41 [0.73]; P = .02). In the intervention group, 11 women (7.7%) had a VAS score greater than 4 at 2 hours compared with 22 women (15.2%) in the control group (odds ratio, 0.47; 95% CI, 0.22-1.00; P = .05). In addition, compared with the control group, the intervention group had significantly lower postpartum use of rescue opioid analgesics (19 women [13.3%] vs 37 women [25.5%]; P = .009) and greater satisfaction with pain management (mean [SD] score, 4.65 [0.68] vs 4.44 [0.76]; P = .007). In the intervention vs control groups, duration of the operation, scar complications (hematoma, infection, or separation), and length of stay were comparable. Conclusions and Relevance: In this study, wound infiltration with a single administration of bupivacaine and adrenaline during cesarean delivery reduced postoperative pain and opioid use and may have improved maternal satisfaction with pain management. These findings suggest the technique is efficacious, safe, and easy to perform. Trial Registration: ClinicalTrials.gov Identifier: NCT03395912.

Association between betamethasone levels and respiratory distress syndrome in preterm births: A prospective cohort study.

The recommended fixed dosage of betamethasone for pregnancies at risk of preterm birth was determined in the 1970s, regardless of gestational age (GA), number of fetuses, and maternal weight. We aimed to examine the association between maternal and neonatal betamethasone serum levels and neonatal respiratory distress syndrome (RDS) and to examine whether levels correlate with maternal weight, GA, or number of fetuses. A prospective study was conducted at a single academic medical center between August 2016 and February 2019. Women received betamethasone and delivered between 28+0 and 34+6 weeks were included. Maternal serum levels (MSLs), and neonatal serum levels (NSLs) of betamethasone at delivery were analyzed using Corticosteroid enzyme-linked immunosorbent assay kit. RDS was diagnosed according to clinical and radiographic findings. We assumed that the sensitivity of NSLs to detect RDS is 95%; hence, 150 neonates were needed (power 80%, alpha 0.05). Overall, 124 women were included; including 96 (77.4%) singletons, 26 (21.0%) twins, and 2 (1.6%) triplets, corresponding to 154 neonates. RDS was diagnosed in 35 neonates (22.7%). After adjusting for GA, time elapsed from the last dose, and number of doses, NSLs were associated with RDS (relative risk: 0.97, 95% confidence interval: 0.94-0.99, p = 0.011). A level of 6.00 ng/ml predicted RDS with a sensitivity of 80.0% and specificity of 64.7%. Adjusted MSLs were not associated with RDS. Both maternal and neonatal serum levels were not associated with the number of fetuses and maternal weight. In conclusion, NSLs are associated with RDS whereas MSLs are not.

Tocolysis with nifedipine versus atosiban and perinatal outcome: an individual participant data meta-analysis.

BACKGROUND: Worldwide, nifedipine and atosiban are the two most commonly used tocolytic agents for the treatment of threatened preterm birth. The aim of this study was to evaluate the effectiveness of nifedipine and atosiban in an individual participant data meta-analysis (IPDMA). METHODS: We investigated the occurrence of adverse neonatal outcomes in women with threatened preterm birth by performing an IPDMA, and sought to identify possible subgroups in which one treatment may be preferred. We searched PubMed, Embase, and Cochrane for trials comparing nifedipine and atosiban for treatment of threatened preterm birth between 240/7 and 340/7 weeks' gestational age. Primary outcome was a composite of perinatal mortality and neonatal morbidities including respiratory distress syndrome, intraventricular haemorrhage, periventricular leucomalacia, necrotising enterocolitis, and sepsis. Secondary outcomes included NICU admission, prolongation of pregnancy and GA at delivery. For studies that did not have the original databases available, metadata was used. This led to a two-stage meta-analysis that combined individual participant data with aggregate metadata. RESULTS: We detected four studies (N = 791 women), of which two provided individual participant data (N = 650 women). The composite neonatal outcome occurred in 58/364 (16%) after nifedipine versus 69/359 (19%) after atosiban (OR 0.76, 95%CI 0.47-1.23). Perinatal death occurred in 14/392 (3.6%) after nifedipine versus 7/380 (1.8%) after atosiban (OR 2.0, 95%CI 0.80-5.1). Nifedipine results in longer prolongation of pregnancy, with a 18 days to delivery compared with 10 days for atosiban (HR 0.83 (96% CI 0.69-0.99)). NICU admission occurred less often after nifedipine (46%) than after atosiban (59%), (OR 0.32, 95%CI 0.14-0.75). The sensitivity analysis revealed no difference in prolongation of pregnancy for 48 hours (OR 1.0, 95% CI 0.73-1.4) or 7 days (OR 1.3, 95% CI 0.85-5.8) between nifedipine and atosiban. There was a non-significant higher neonatal mortality in the nifedipine-exposed group (OR 1.4, 95% CI 0.60-3.4). CONCLUSIONS: In this IPDMA, we found no differences in composite outcome between nifedipine and atosiban in the treatment of threatened preterm birth. However, the non-significant higher mortality after administering nifedipine warrants further investigation of the use of nifedipine as a tocolytic drug. STUDY REGISTRATION: We conducted this study according to a prospectively prepared protocol, registered with PROSPERO (the International Prospective Register of Systematic Reviews) under CRD42016024244.

Knotless Barbed versus Conventional Suture for Closure of the Uterine Incision at Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE: To compare perioperative outcomes between knotless barbed sutures (KBSs) and conventional smooth sutures for uterine incision closure at cesarean section. DATA SOURCES: MEDLINE, EMBASE, Web of Sciences, Scopus, the Cochrane Library, and ClinicalTrials.gov were searched from the inception of the study to March 2021 without language restriction. The search terms were as follows: ["Stratafix" OR "Quill" OR "V-Loc" OR "Barbs" OR "barbed"] AND ["Cesarean" OR "Caesarean"] AND ["Suturing" OR "Suture" OR "Closure" OR "Repair"]. Moreover, these terms were combined to complete the search. METHODS OF STUDY SELECTION: Retrospective and randomized peer-reviewed studies comparing the use of KBSs and conventional sutures for uterine incision closure at cesarean section were included. The studies' quality was assessed by the Cochrane risk-of-bias tool. The primary outcome was the time of uterine incision closure in seconds. The secondary outcomes included total operating time (minutes), use of additional hemostatic sutures, rates of blood transfusion, and postoperative complications. TABULATION, INTEGRATION, AND RESULTS: Of 20 reports identified, 4 representing 3332 women (1473 with KBSs and 1859 with conventional sutures) were eligible. All studies were judged to be at low risk of bias. The uterine incision closure time was significantly lower in the KBS group (mean difference, -110.58; 95% confidence interval [CI], -127.37 to -93.79; p = .001). Furthermore, the rate of use of additional hemostatic sutures was significantly lower in the KBS group (odds ratio, 0.14; 95% CI, 0.07-0.26; p = .001). Total operative time, rates of blood transfusion, febrile morbidity, and length of postoperative stay were comparable. The incidence of postoperative ileus was significantly lower in the KBS group (odds ratio, 0.31; 95% CI, 0.11-0.89; p = .029). CONCLUSION: The use of KBSs for uterine incision closure was associated with decreased hysterotomy closure time and less frequent need for the placement of additional hemostatic sutures. Other perioperative outcomes were not affected, although the risk of postoperative ileus was reduced.

Impact of "natural" cesarean delivery on peripartum blood loss: a randomized controlled trial.

BACKGROUND: Early skin-to-skin contact after vaginal delivery increases milk production and may increase oxytocin release, leading to a reduction in the rate of postpartum hemorrhage. OBJECTIVE: This study aimed to examine the effect of "natural" cesarean deliveries on perioperative maternal blood loss. STUDY DESIGN: This was a randomized controlled trial conducted at a single university-affiliated medical center, between August 2016 and February 2018. Term singleton pregnancies scheduled for a planned cesarean delivery under spinal anesthesia were included. Women were randomized at a ratio of 1:1 to natural cesarean delivery (study group) or traditional cesarean delivery (control group) during the routine preoperative assessment. Women in the study group watched fetal extraction, had early skin-to-skin contact, and breastfed until the end of surgery. Neonates in the control group were presented to the mother for a few minutes. Blood samples were drawn from all women, during fascia closure, to determine oxytocin levels using an enzyme-linked immunosorbent assay kit. The laboratory component was performed after recruitment completion and was accomplished in February 2019. The primary outcome was postpartum hemoglobin levels. To detect a difference of 0.5 g/dL between the groups with α=0.05 and ß=80%, 214 women were needed. RESULTS: Of 214 randomized women, 23 were excluded. There was no difference in demographic and obstetrical variables between the groups. Postpartum hemoglobin levels were 10.1±1.1 and 10.3±1.3 g/dL in the study and control groups, respectively (P=.19). There was no difference in the rates of postpartum hemorrhage and blood transfusion. Maternal pain scores, satisfaction, and exclusive breastfeeding were comparable. Maternal oxytocin blood levels were 389.5±183.7 and 408.5±233.6 pg/mL in the study and control groups, respectively (P=.96). The incidence of neonatal hypothermia was comparable between the groups (P=.13). CONCLUSION: Natural cesarean delivery did not affect perioperative hemoglobin level or maternal oxytocin blood concentration.

Effect of nitrous oxide use on external cephalic version success rate; a systematic review and meta-analysis.

INTRODUCTION: Several adjuvant interventions have been evaluated for improving the success rate of the external cephalic version (ECV) and reducing the rate of cesarean delivery (CD). Evidence regarding the effect of Nitrous oxide is limited to a small number of participants with inconsistent results on pain score and success rate. This study aims to examine the effect of inhaled nitrous oxide on the success rate and pain score for women undergoing ECV. MATERIAL AND METHODS: Survey on ECV reports from inception till June 2020 were made from MEDLINE, EMBASE, PubMed, Ovid Medline, ClinicalTrials.gov, the Cochrane Library and Google Scholars. Peer-review studies that examined the success rate of ECV from the application of nitrous oxide during ECV attempts compared with or without the use of other analgesic agents were obtained. The study population comprising women with singleton pregnancies having a non-vertex presentation at least 36 weeks, were categorized into one of two treatment groups: ECV attempt with nitrous oxide (nitrous oxide group) and ECV attempt with or without another analgesia (control group). The primary outcome was the ECV success rate, defined by conversion to vertex-presentation following the procedure. The secondary outcomes were pain scores during ECV attempt and CD rate. The study quality scores were evaluated as a source of heterogeneity by fitting meta-regression models to the individual study effect sizes. RESULTS: Of the 26 records identified, two randomized trials and one prospective cohort study (720 women; 434 in the nitrous oxide group and 286 controls) were deemed adequate for meta-analysis. ECV success rate did not differ significantly between the nitrous oxide group and the control group (p = .825; OR 1.036; 95% CI, 0.756, 1.419). In addition, the use of nitrous oxide did not affect pain scores during ECV attempt (p = .457; OR 0.759; 95% CI, -1.240, 2.759) and there was no difference in the incidence of CD as well (p = .943; OR 1.013; 95% CI, 0.703, 1.46). CONCLUSION: The use of nitrous oxide during ECV attempts was not associated with an increase in ECV success rate and does not affect pain scores. PROSPERO Registration No. CRD42020197933.

The association between ABO blood groups and gestational diabetes mellitus: a retrospective population-based cohort study.

OBJECTIVE: There is a lot of evidence that connects blood type to several diseases, including the development of diabetes mellitus type 2. The evidence for an association between ABO blood groups and the possibility of developing gestational diabetes mellitus (GDM) is scant and inconclusive. We aimed to examine the link between ABO blood group types and GDM by the use of a large population-based cohort of pregnant women. STUDY DESIGN: A retrospective population-based cohort study was conducted using data collected from January 2013 to December 2017 from the Emek Medical Center, Afula, Israel. All pregnant women who underwent the two-step screening and diagnosed with GDM and delivered at >24 weeks were included. Women who had pre-gestational diabetes or whose pregnancies were terminated were excluded. The odds ratio (OR) were obtained through binary logistic regression analysis and the corresponding 95% confidence interval (CI) by the use of both the univariable and multivariable analysis. RESULTS: Of all 16,067 women included in the study cohort, 1712 (10.7%) had GDM. The incidence of GDM was 11.0%, 10.8%, 10.6%, and 8.8% in blood group A, B, O, and AB, respectively. After adjusting for maternal age, parity, and number of fetuses, AB blood group was associated with reduced risk for developing GDM compared to the other blood groups (p = .038; adjusted OR: 0.79; 95% CI: 0.64-0.99). There was no difference in Rhesus factor between GDM and controls. CONCLUSIONS: Women with AB blood group have a lower risk for developing GDM compared to other blood group types.

Effectiveness of antimicrobial prophylaxis at 30 versus 60 min before cesarean delivery.

This study aimed to examine the effect of antibiotic prophylaxis (AP) given within 30 compared to 30-60 min before skin incision on the incidence of infectious morbidity after cesarean delivery (CD). A retrospective cohort study was conducted at a single institution on data between 2014 and 2018. Women who delivered by CD were divided into two groups according to AP timing before skin incision: group 1 within 30 min, and group 2 from 30 to 60 min. The primary outcome was the incidence of any infectious morbidity. Overall, 2989 women were eligible: 2791 in group 1 and 198 in group 2. The primary composite outcome occurred in 125 women (4.48%) in group 1 and 8 women (4.04%) in group 2 (OR, 1.11; 95% CI 0.54-2.31; P = 0.77). The rate of surgical site infection only, was 1.08% in group 1 and 0.51% in group 2 (OR, 2.13; 95% CI 0.29-15.70; P = 0.72). The incidence was comparable between the groups in a separate sub-analysis restricted to laboring CDs and obese women. The rate of infectious morbidity was similar among women who received AP within 30 min and from 30 to 60 min before skin incision.

Risk Factors for Mortality among Newborns with Neonatal Seizures.

OBJECTIVE: The aim of the study is to examine the incidence and risk factors for death among neonates who developed neonatal seizures (NS) in an ethnically distinctive community with high consanguinity rate in Israel. METHODS: Retrospective study was conducted at a single institution on data between January 2001 and January 2016. All neonates diagnosed with NS developed up to age 28 days were included. Mortality was defined as death within the first year of life. RESULTS: Of all 69,460 neonates born during the study period, 118 (1.7 per 1,000 live births) developed NS; 35 (29.7%) died within the first year while 83 (70.3%) survived. The leading causes of death were developmental brain malformation (31.4%), genetic/metabolic (20%), hypoxic ischemic encephalopathy (20%), intracranial hemorrhage (11.4%) and infections (11.4%). Any consanguinity between the parents was found in 18 and 14.6% among the survivors and deceased groups, respectively (p = 0.24). Developmental brain malformations that lead to death were present in 3.6 and 31.4% in the survivors and deceased groups, respectively (p = 0.001; relative risk 8.70; 95% confidence interval 2.58-29.27). Stepwise backward logistic regression analysis revealed that developmental brain malformations (p < 0.0001), use of more than one antiepileptic medication (p = 0.006), and multiorgan failure (p = 0.004) were significant risk factors that predicted death. CONCLUSION: The results of the current study show that developmental brain malformations that cause NS were the leading risk factor for death.

Effect of lactation on the recurrence rate of gestational diabetes mellitus: a retrospective cohort study.

PURPOSE: To examine the impact of lactation on the recurrence rate of gestational diabetes mellitus (GDM). METHODS: Retrospective cohort study performed in a single teaching hospital on data between 2009 and 2016. The study group consisted of women who had a diagnosis of GDM and breastfed exclusively for ≥ 1 month. The control group consisted of women who had a diagnosis of GDM and did not breastfeed or added formula < 1 month postpartum. Data regarding breastfeeding duration, timing and amount of formula supplementation were obtained by a telephone questionnaire. We hypothesized that the recurrence of GDM would be lower in women who breastfed exclusively for ≥ 1 month. Therefore, to detect a decrease from 50 to 30% in the recurrence rate of GDM with alpha (one-sided) of 0.05 and 80% power, a sample size of 168 (84 per group) was needed. RESULTS: Overall, 229 women were found eligible; 139 and 90 in the study and control groups, respectively. Except for parity, baseline demographic and obstetric variables were not different between the two groups. After adjusting for parity, the incidence of GDM in subsequent pregnancy was significantly lower among the study compared to the control group [48 (34.5%) and 41 (45.6%), respectively; one-tailed p = 0.043; RR 0.56; 95% CI 0.35-0.90)]. The cesarean delivery (CD) rate was significantly lower as well [28 (20.1%) and 31 (34.4%), respectively; two-tailed p = 0.02; RR 0.48, 95% CI 0.26-0.89)]. CONCLUSION: Exclusive lactation for ≥ 1 month reduced the recurrence rate of GDM and possibly the risk of CD in the subsequent pregnancy.

Trend in cesarean delivery rate among twin pregnancies over a 20 years epoch and the accompanied maternal and perinatal outcomes.

OBJECTIVE: To examine the trend of cesarean delivery (CD) rate among twin pregnancies and the trend in maternal and neonatal morbidities within two decades. STUDY DESIGN: Population-based cohort study, conducted at a single teaching hospital in Israel on data between January 1995 and December 2015. All pregnant women with twin gestation who delivered at a gestational age of 24 weeks or more were included. Data on mode of deliveries, Apgar score <7 at 5 min, cord artery pH < 7.1, early postpartum hemorrhage, blood transfusion, and intrapartum fever for each year were extracted and plotted, and trends were analyzed. CDs performed for one or both twins were divided to laboring, i.e., after a trial of labor, and non-laboring CDs. Data was obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. The Cochran-Armitage Trend Test was used to identify trends and correlations. RESULTS: Of all 88,145 deliveries that took place during this period, 1955 (2.2%) were twins. Of these 53 were ineligible and were excluded. There was a statistically significant trend (increase) in twins birth over time (p = 0.004). CD rate increased significantly from 43.4% in 1995 to 66.0% in 2015 (p = 0.001). This increase was observed only among non-laboring cesareans (p = 0.001). Multivariate logistic regression analysis revealed that maternal and early neonatal morbidities examined did not differ significantly during the study period. CONCLUSION: Non-laboring CD rate increased significantly over the past two decades among twin pregnancies. Despite this increase, maternal and early neonatal morbidities did not change.