Impact of gestational diabetes mellitus on neonatal outcomes in small for gestational age infants: a multicenter retrospective study.

OBJECTIVE: To evaluate obstetric and perinatal outcomes among small for gestational age (SGA) infants born to patients diagnosed with Gestational diabetes mellitus (GDM). MATERIALS AND METHODS: A multicenter retrospective cohort study between 2005 and 2021. The perinatal outcomes of SGA infants born to patients with singleton pregnancy and GDM were compared to SGA infants born to patients without GDM. The primary outcome was a composite adverse neonatal outcome. Infants with known structural/genetic abnormalities or infections were excluded. A univariate analysis was conducted followed by a multivariate analysis (adjusted odds ratio [95% confidence interval]). RESULTS: During the study period, 11,662 patients with SGA infants met the inclusion and exclusion criteria. Of these, 417 (3.6%) SGA infants were born to patients with GDM, while 11,245 (96.4%) were born to patients without GDM. Overall, the composite adverse neonatal outcome was worse in the GDM group (53.7% vs 17.4%, p < 0.01). Specifically, adverse neonatal outcomes such as a 5 min Apgar score < 7, meconium aspiration, seizures, and hypoglycemia were independently associated with GDM among SGA infants. In addition, patients with GDM and SGA infants had higher rates of overall and spontaneous preterm birth, unplanned cesarean, and postpartum hemorrhage. In a multivariate logistic regression assessing the association between GDM and neonatal outcomes, GDM was found to be independently associated with the composite adverse neonatal outcome (aOR 4.26 [3.43-5.3]), 5 min Apgar score < 7 (aOR 2 [1.16-3.47]), meconium aspiration (aOR 4.62 [1.76-12.13]), seizures (aOR 2.85 [1.51-5.37]) and hypoglycemia (aOR 16.16 [12.79-20.41]). CONCLUSIONS: Our study demonstrates that GDM is an independent risk factor for adverse neonatal outcomes among SGA infants. This finding underscores the imperative for tailored monitoring and management strategies in those pregnancies.

The Correlation between Fetal Monitor Decelerations Area and Neonatal Cord pH among Preeclamptic parturient: an Automated Approach to a Clinical Challenge.

OBJECTIVE: To examine whether a correlation exists between electronic fetal monitoring (EFM) in the final 120 minute prior to delivery and neonatal cord blood pH among parturients with preeclampsia. STUDY DESIGN: A retrospective cohort study of parturients with term and near-term preeclampsia who delivered at Soroka University Medical Center between 2013 and 2020 was conducted. EFM tracings, demographical data, and obstetrical outcomes were retrieved from the patients' electronic medical records. Using MATLAB program, area under the curve (AUC) measurements were applied. Correlation was calculated using the Spearman's correlation coefficient. RESULTS: EFM of 88 parturients with preeclampsia were assessed. A significant negative correlation was demonstrated between cord blood pH and the decelerations AUC, total decelerations duration, and deceleration depth. No correlation was demonstrated between area over the curve (acceleration) and cord blood pH. In a multivariate linear regression, total deceleration AUC was found independently negatively associated with cord blood pH (beta = -0.264, p = 0.011) controlling for second stage of labor duration and induction of labor. CONCLUSION: Among parturients with preeclampsia, EFM indices may assist in the diagnosis of fetal acidemia. Further studies are needed to strengthen and establish the use of electronic EFM in the management of labor and delivery. KEY POINTS: · A negative correlation was demonstrated between cord blood pH and the decelerations AUC.. · Total deceleration AUC was found independently negatively associated.. · Among parturients with preeclampsia, EFM indices may assist in the diagnosis of fetal acidemia..

Trial of labor following cesarean in preterm deliveries: success rates and maternal and neonatal outcomes: a multicenter retrospective study.

PURPOSE: To evaluate the rates of vaginal birth after cesarean (VBAC) among parturients attempting preterm trial of labor following a cesarean delivery (TOLAC) vs. term TOLAC. METHODS: A multicenter historic cohort study was conducted at two university-affiliated centers between August 2005 and March 2021. Parturients in their second delivery, attempting TOLAC after a single low segment transverse cesarean delivery were included. We retrospectively examined computerized medical records of all preterm (< 37 weeks) and term (37-42 weeks) births. Multifetal gestations and postterm deliveries (≥ 42 weeks) were excluded. A univariate analysis was conducted, followed by a multivariate analysis. RESULTS: 4865 second deliveries following previous cesarean were identified: 212 (4.4%) preterm and 4653 (95.6%) term. Hypertensive disorders, diabetes and fertility treatments were significantly more prevalent in the preterm group. VBAC rate was significantly lower in preterm group (57.5 vs 79.7%., p < 0.01), including both spontaneous and vaginal-assisted deliveries. In multivariate analysis, preterm TOLAC was independently associated with TOLAC failure [adjusted odds ratio 2.24, [95% confidence interval 1.62-3.09]. Overall, maternal outcomes were favorable. Rates of uterine rupture, re-laparotomy and postpartum hemorrhage were comparable between groups. Neonatal outcomes were less favorable among the preterm group; however, preterm vs. term TOLAC was not associated with low 5 min Apgar score (aOR 1.76, 95% CI 0.92-3.40). CONCLUSION: In our study, VBAC rates were lower in preterm compared to term deliveries. Maternal outcomes were comparable. Neonatal outcomes were less favorable in the preterm group, more likely due to prematurity than delivery mode.

Trial of labor following cesarean in patients with bicornuate uterus: a multicenter retrospective study.

OBJECTIVE: This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus. METHODS: A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses. RESULTS: Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC. CONCLUSIONS: This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients.

Factors Associated With Operatively Confirmed Adnexal Torsion Among Pregnant Women - A Multicenter Cohort Study.

PURPOSE: The aim of this study was to investigate the association of clinical, laboratory, and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy. MATERIALS AND METHODS: A multicenter retrospective study of pregnant women who underwent urgent laparoscopy for suspected adnexal torsion during 2004-2019 in three tertiary medical centers. RESULTS: Adnexal torsion was found in 143/208 (68.8 %) cases. Women with adnexal torsion had lower parity and lower rates of previous cesarean section, but higher rates of fertility treatments and multiple gestations, and were more likely to report right lower abdominal pain, with shorter duration of symptoms (< 24 hrs) and vomiting but not nausea. Women with adnexal torsion were found to have higher rates of sonographic findings suggestive of ovarian edema, while normal-appearing ovaries on ultrasound were more common in women without torsion. A multivariate logistic regression analysis showed that complaints of right abdominal pain were positively associated with adnexal torsion (aOR [95 % CI] 5.03 (1.45-17.49), while previous cesarean delivery and ultrasound findings of normal-appearing ovaries were negatively associated with adnexal torsion (aOR of 0.17 (0.05-0.52) and 0.10 (0.02-0.43), respectively). CONCLUSION: Clinical characteristics and ultrasound findings may be incorporated into the emergency room workup of pregnant women with suspected adnexal torsion.

Maternal and perinatal outcomes following laparoscopy for suspected adnexal torsion during pregnancy: a multicenter cohort study.

PURPOSE: To investigate the association of maternal and perinatal outcomes with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy. STUDY DESIGN: This is a multicenter retrospective study and telephone questionnaire of urgent laparoscopies that occurred during pregnancy for suspected torsion between 2004 and 2019 in three tertiary medical centers. Pregnancy outcomes of women with the surgical diagnosis were compared with those whose laparoscopy was negative for adnexal torsion. Multivariable regression modeling was applied to control for possible confounders ((adjusted odds ratios (aOR) ± 95% confidence intervals (CI)]. RESULTS: The study cohort included 186 women. Adnexal torsion was surgically found in 129/186 (69.4%) cases. The torsion group was characterized by higher rate of nulliparity, fertility treatments and multiple gestations as well as lower rates of previous cesarean delivery. Live birth was reported for 171 (91.9%) pregnancies, and the miscarriage rate was significantly higher in the non-torsion group. Women with torsion were more likely to be hospitalizes due to preterm labor; however, rates of preterm delivery were comparable between the groups (10.8% vs. 10.9%, p = 0.99). Logistic regression analysis had demonstrated that the performance of laparoscopy prior to 8 weeks of gestation was the only independent factor associated with miscarriage (8.23, 2.01-33.67). CONCLUSION: Pregnancy outcomes following the diagnosis of adnexal torsion throughout gestation were overall favorable. Laparoscopic procedure during early stages of pregnancy was associated with higher rates of miscarriage, regardless of the surgical diagnosis of adnexal torsion.

The use of absorbable adhesion barriers to reduce the incidence of intraperitoneal adhesions at repeat cesarean delivery.

PURPOSE: We aimed to evaluate the effect of an absorbable adhesion barrier (oxidized regenerated cellulose) for the prevention of peritoneal adhesions in women undergoing repeat cesarean delivery (CD). METHODS: This is a retrospective, single center study that included all women who underwent two consecutive CDs, 2011-2018. Women in whom an absorbable adhesion barrier (oxidized regenerated cellulose) was placed at the time of the initial CD (index CD) were compared to women in whom no such barrier was placed. The association between absorbable adhesion barrier placement at index CD and the presence of intraperitoneal adhesions at subsequent CD was assessed. Factors evaluated included intraperitoneal adhesion severity, time from skin incision to newborn delivery and total duration of surgery. RESULTS: We identified 2125 women that met the inclusion criteria. They were divided into two groups; those in whom an absorbable adhesion barrier was placed at index CD and those in whom no such absorbable barrier was placed. 161 (7.6%) had an absorbable adhesion barrier placed at index CD. At the time of index CD, the rate of intra-peritoneal adhesions was 34.8% in the absorbable adhesion barrier group vs 26.5% in the group without the absorbable adhesion barrier (p = 0.02). At the time of subsequent CD, the rate of intraperitoneal adhesions was 39.8% in the absorbable adhesion barrier group vs 46% in the group without the absorbable adhesion barrier (p = 0.13). Notably, the use of an absorbable adhesion barrier lowered the mean increase in adhesions rate 0.05 ± 0.55 vs 0.20 ± 0.55 (p < 0.01). Absorbable adhesion barrier placement at index CD was found to be independently associated with a lower rate of intraperitoneal adhesions at subsequent CD, aOR 0.67 (0.47-0.96). Overall, absorbable adhesion barrier placement at index CD was associated with a shorter mean duration of subsequent surgery (min), 37.7 ± 18.9 vs. 42.7 ± 27.1 (p = 0.02). CONCLUSION: Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.

Cesarean Uterine Lacerations and Prematurity in the Following Delivery: A Retrospective Longitudinal Follow-Up Cohort Study.

(1) Background: We aimed to investigate whether second-stage cesarean delivery (SSCD) had a higher occurrence of low-segment uterine incision extensions compared with cesarean delivery (CD) at other stages of labor and to study the association of these extensions with preterm birth (PTB). (2) Methods: In this retrospective longitudinal follow-up cohort study, spanning from 2006 to 2019, all selected mothers who delivered by CD at first birth (P1) and returned for second birth (P2) were grouped by cesarean stage at P1: planned CD, first-stage CD, or SSCD. Mothers with a PTB at P1, multiple-gestation pregnancies in either P1 or P2 and those with prior abortions were excluded. (3) Results: The study included 1574 selected women who underwent a planned CD at P1 (n = 483 (30.7%)), first-stage CD (n = 878 (55.8%), and SSCD (n = 213 (13.5%)). There was a higher occurrence of low-segment uterine incision extensions among SSCD patients compared to first-stage CDs and planned CDs: 50/213 (23%), 56/878 (6.4%), and 5/483 (1%), respectively (p < 0.001). A multivariate logistic regression showed that women undergoing an SSCD are at risk for low-segment uterine incision extensions compared with women undergoing a planned CD, OR 28.8 (CI 11.2; 74.4). We observed no association between the occurrence of a low-segment uterine incisional extension at P1 and PTB ≤ 37 gestational weeks in the subsequent delivery, with rates of 6.3% (7/111) for those with an extension compared to 4.5% (67/1463) for those without an extension (p = 0.41). Notably, parturients experiencing a low-segment uterine incisional extension during their first childbirth were six times more likely to have a preterm delivery before 32 weeks of gestation compared to those without extensions, with two cases (1.8%) compared to four cases (0.3%), respectively. A similar trend was observed for preterm deliveries between 32 and 34 weeks of gestation, with those having extensions showing twice the prevalence of prematurity compared to those without, with a p-value of 0.047. (4) Conclusions: This study highlights that mothers undergoing SSCD experience higher prevalence of low uterine incision extensions compared to other CDs. To further ascertain whether the presence of these extensions is associated with preterm birth (PTB) in subsequent births, particularly early PTB before 34 weeks of gestation, larger-scale future studies are warranted.

Planned oocyte cryopreservation: a systematic review and meta-regression analysis.

BACKGROUND: Awareness of the age-related decline in fertility potential has increased the popularity of planned oocyte cryopreservation (POC). However, data regarding outcomes of POC, including rates of women returning to thaw oocytes, as well as pregnancy and live birth rates, are scarce and based mostly on small case series. OBJECTIVE AND RATIONALE: POC was defined as cryopreservation exclusively for prevention of future age-related fertility loss. The primary outcome was live birth rate per patient. The secondary outcomes included the return to thaw rate and laboratory outcomes. A meta-regression analysis examining the association between live birth and age above 40 or below 35 was conducted. SEARCH METHODS: We conducted a systematic database search from inception to August 2022. The search included PubMed (MEDLINE) and EMBASE. Our search strategies employed a combination of index terms (Mesh) and free text words to compile relevant concepts. The systematic review and meta-regression were undertaken following registration of systematic review (PROSPERO registration number CRD42022361791) and were reported following guidelines of Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 (PRISMA 2020). OUTCOMES: The database search yielded 3847 records. After the selection process, 10 studies, conducted from 1999 to 2020, were included. Overall, 8750 women underwent POC, with a mean cryopreservation age of 37.2 (±0.8). Of those, 1517 women returned to use their oocytes with a return rate of 11.1% (± 4.7%). The mean age at the time of cryopreservation for women who returned to use their oocytes was 38.1 (±0.4), with an average of 12.6 (±3.6) cryopreserved oocytes per woman. In a meta-analysis, the oocyte survival rate was 78.5% with a 95% CI of 0.74-0.83 (I2 = 93%). The live birth rate per patient was 28% with a 95% CI of 0.24-0.33 (I2 = 92%). Overall, 447 live births were reported. In a sub-group analysis, women who underwent cryopreservation at age ≥40 achieved a live birth rate per patient of 19% (95% CI 0.13-0.29, I2 = 6%), while women aged ≤35 years old or younger had a higher live birth rate per patient of 52% (95% CI 0.41-0.63, I2 = 7%). WIDER IMPLICATIONS: POC emerges as a feasible option for women aiming to improve their chances of conceiving at a later reproductive age. Nonetheless, it must be acknowledged that the overall success rates of POC are limited and that the likelihood of successful live birth declines as the age at cryopreservation rises. With increasing interest in POC, the collation of comprehensive and high-quality data is imperative to clearly define the outcomes for various age groups. REGISTRATION NUMBER: CRD42022361791.

Pravastatin and placental insufficiency associated disorders: A systematic review and meta-analysis.

Background: Uteroplacental insufficiency associated disorders, such as preeclampsia, fetal growth restriction and obstetrical antiphospholipid syndrome, share pathophysiology and risk factors with cardiovascular diseases treated with statins. Objective: To evaluate pregnancy outcomes among women with uteroplacental insufficiency disorders who were treated with statins. Search Strategy: Electronic databases were searched from inception to January 2022 Selection Criteria: Cohort studies and randomized controlled trials. Data collection and analysis: Pooled odds ratios were calculated using a random-effects model; meta-regression was utilized when applicable. Main Results: The analysis included ten studies describing 1,391 women with uteroplacental insufficiency disorders: 703 treated with pravastatin and 688 not treated with statins. Women treated with pravastatin demonstrated significant prolongation of pregnancy (mean difference 0.44 weeks, 95%CI:0.01-0.87, p = 0.04, I2 = 96%) and less neonatal intensive care unit admissions (OR = 0.42, 95%CI: 0.23-0.75, p = 0.004, I2 = 25%). In subgroup analysis, prolongation of pregnancy from study entry to delivery was statistically significant in cohort studies (mean difference 8.93 weeks, 95%CI:4.22-13.95, p = 0.00) but not in randomized control studies. Trends were observed toward a decrease in preeclampsia diagnoses (OR = 0.54, 95%CI:0.27-1.09, p = 0.09, I = 44%), perinatal death (OR = 0.32, 95%CI:0.09-1.13, p = 0.08, I2 = 54%) and an increase in birth weight (mean difference = 102 g, 95%CI: -14-212, p = 0.08, I2 = 96%). A meta-regression analysis demonstrated an association between earlier gestational age at initiation of treatment and a lower risk of preeclampsia development (R2 = 1). Conclusion: Pravastatin treatment prolonged pregnancy duration and improved associated obstetrical outcomes in pregnancies complicated with uteroplacental insufficiency disorders in cohort studies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/ identifier CRD42020165804 17/2/2020.

The effect of statins exposure during pregnancy on congenital anomalies and spontaneous abortions: A systematic review and meta-analysis.

Objective: To assess the effect of statin exposure during pregnancy on congenital anomalies and spontaneous abortions. Data sources: Electronic databases were searched from inception to January 2022. Study Eligibility Criteria: Cohort studies and randomized controlled trials (RCTs) evaluate the effect of treatment with statins on congenital anomalies in general and cardiac malformations in particular. Studies evaluating spontaneous abortions were included as a secondary outcome. Study appraisal and synthesis methods: Pooled odds ratio was calculated using a random-effects model and meta-regression was utilized when applicable. Results: Twelve cohort studies and RCTs were included in the analysis. Pregnancy outcomes of 2,447 women that received statins during pregnancy were compared to 897,280 pregnant women who did not. Treatment with statins was not associated with a higher risk of overall congenital anomalies (Odd Ratio = 1.1, CI (0.9-1.3), p = 0.33, I2 = 0%). Yet, cardiac malformations were more prevalent among neonates born to statins users (OR = 1.4, CI (1.1-1.8), p = 0.02, I2 = 0%). The risk was higher when exposure occurred during the first trimester. This finding was statistically significant in cohort studies, but not in RCTs. Statin treatment was also associated with a higher rate of spontaneous abortions (OR = 1.5, CI (1.1-2.0), p = 0.005, I2 = 0%). In meta-regression analysis, no significant association between lipophilic statins and the rate of congenital anomalies was found. Conclusion: Overall, treatment with statins during pregnancy was not associated with an increased risk of congenital anomalies. A slight risk elevation for cardiac malformation and spontaneous abortions was seen in cohort studies but not in RCTs. Systematic Review Registration: clinicaltrials.gov, identifier [CRD42020165804 17/2/2020] The meta-analysis was presented online at 42nd annual meeting of SMFM. January 31-5 February 2022.

Delayed diagnosis of intrapartum uterine rupture - maternal and neonatal consequences.

Objective: To assess the maternal and neonatal outcomes following delayed diagnosis of uterine rupture (diagnosis during the early postpartum period) in comparison to women with an intrapartum diagnosis of uterine rupture.Methods: Retrospective study of electronic medical records (EMR) from 2005 to 2018 in a single large academic tertiary care. Demographic, obstetric and maternal characteristics and outcomes were retrieved and compared. Univariate, followed by multivariate analyses were applied to evaluate the association between maternal and neonatal outcomes. Only complete uterine ruptures were included. The primary outcome of this study was defined as hysterectomy rates. Secondary outcomes were maternal and neonatal morbidity parameters.Results: During the study period, 143 parturients with uterine rupture were identified from 174,189 deliveries (0.08%). Of these, 29 (20.3%) had delayed diagnosis with a median time from delivery to the operation of 4.5 hours (IQR 0.83-28 hours). Factors that were identified as independent risk factors for delayed diagnosis: an unscarred uterus (aOR 27.0, 95% CI 6.58-111.1), epidural analgesia during labor (aOR 7.9, 95% CI 2.32-27.05) and grand-multiparity (aOR 4.6, 95% CI 1.40-14.99). Maternal outcomes demonstrated that parturients with a delayed diagnosis had significantly higher rates of blood transfusions, puerperal fever, and hysterectomy (p<.001 for all). In a multivariate model, the delayed diagnosis was found to be independently associated with hysterectomy (aOR 4.90, 95% CI 1.28-19.40). There were no differences regarding to neonatal outcomes.Conclusion: Parturients with delayed diagnosis of uterine rupture have unique characteristics and poorer maternal outcomes. It is possible that awareness of this population will enable earlier diagnosis and may help improve outcomes.

Maternal and Neonatal Outcomes Following Trial of Labor After Two Previous Cesareans: a Retrospective Cohort Study.

The objective of this study is to evaluate the maternal and neonatal outcomes of parturients attempting trial of labor (TOL) after two previous CD versus those who had an elective third repeat CD. A retrospective computerized database cohort study was conducted at a single tertiary center between 2005 and 2019. Various maternal and neonatal outcomes were compared between parturients attempting TOL after two CD versus parturients opting for elective third repeat CD. TOL after two CD was allowed only for those who met all the criteria of our departments' protocol. Parturients with identified contraindication to vaginal delivery were excluded from the analysis. A univariate analysis was conducted and was followed by a multivariate analysis. A total of 2719 eligible births following two CD were identified, of which 485 (17.8%) had attempted TOL. Successful vaginal delivery rate following two CDs was 86.2%. Uterine rupture rates were higher among those attempting TOL (0.6% vs 0.1% p = 0.04). However, rates of hysterectomy, re-laparotomy, blood product infusion, and intensive care unit admission did not differ significantly between the groups. Neonatal outcomes following elective repeat CD were less favorable (specifically, neonatal intensive care unit admission and composite adverse neonatal outcome). Nonetheless, when controlling for potential confounders, an independent association between composite adverse neonatal outcome and an elective repeat CD was not demonstrated. In a subgroup analysis, diabetes mellitus and hypertensive disorders of pregnancy were found independently associated with failed TOLAC. When following a strict protocol, TOL after two CD is a reasonable alternative and associated with favorable outcomes.

The use of a strict protocol in the trial of labor following two previous cesarean deliveries: Maternal and neonatal results.

OBJECTIVE: Over the past few decades, the rate of repeat cesarean deliveries (CD) have taken on pandemic proportions. As part of the global effort to reduce the rate of CD, trail of labor (TOL) following one and even two previous CDs is encouraged. We aimed to evaluate maternal and neonatal outcomes of parturients attempting a TOL after two previous CDs, in which a strict departmental protocol was adopted. STUDY DESIGN: A retrospective cohort study of TOL following CD (TOLAC) at a single tertiary center, between 2005 and 2019. Various maternal and neonatal outcomes were assessed, in which parturients attempting TOL after two CD were compared to those after one previous CD. TOL after two CDs was permitted only to those parturients who fulfilled all the criteria of our department's protocol. A univariate analysis was initially conducted and was then followed by a multivariate analysis. RESULTS: A total of 11,620 TOLAC were identified, of which 515 (4.4 %) were after two previous CDs. Overall, vaginal delivery rates were high, however, following two CDs the rate was lower than following one CD (83.1 % vs. 88.5 %, p < 0.01). Rates of uterine rupture, peripartum hysterectomy, and postpartum hemorrhage did not differ significantly between the groups. Neonatal results following two CDs were less favorable (specifically, one minute APGAR, neonatal care unit admissions and mechanical ventilation rates), yet, when controlling for potential confounders, an independent association between neonatal composite outcome and TOL following two CDs was not demonstrated. CONCLUSION: For parturients with a history of two CDs, when a strict protocol for selecting appropriate candidates is followed, TOL is a reasonable alternative to repeat CD and is associated with favorable maternal and neonatal outcomes.

The effect of multidrug exposure on neurological manifestations in carbamazepine intoxication: a nested case-control study.

BACKGROUND: In acute intoxication, carbamazepine concentration above 40 mcg/ml is associated with a risk of severe neurological consequences, including depressed consciousness, respiratory depression, cardiac conduction disorders, seizures, and death. Carbamazepine intoxication is often associated with the use of concomitant medications. However, the effect of exposure to other central-nervous-system (CNS) acting medications on the neurological manifestations of carbamazepine toxicity has not been evaluated. OBJECTIVE: To examine the effect of exposure to CNS-acting medications on the neurological effects of carbamazepine toxicity. METHODS: A retrospective nested case-control study of all patients > 18 years of age, with at least one test of carbamazepine levels > 18 mcg/ml recorded at the Hadassah Hospital Central Laboratory, between the years 2004-2016. Sociodemographic and clinical data were collected from the computerized medical records, and the characteristics of patients with and without severe neurological symptoms of carbamazepine intoxication were compared. RESULTS: Eighty patients were identified. In bivariate analyses, the odds of severe neurological symptoms was higher in patients with antidepressants use (odds ratio 8.7, 95% confidence interval: 1.8-41.2, p = 0.007), benzodiazepines use (8.6, 2.0-37.1, p = 0.004), and carbamazepine concentration above 30 mcg/ml (8.1, 1.9-33.3, p = 0.004). Multivariate models demonstrated that antidepressants and benzodiazepines were associated with severe neurological manifestations during carbamazepine intoxication, independently of carbamazepine concentration over 30 mcg/ml. ICU admission was associated in multivariate analysis with antidepressants (but not benzodiazepines) use, and with carbamazepine levels > 30 mcg/ml. CONCLUSIONS: Among patients with carbamazepine intoxication, severe neurological symptoms are associated with exposure to benzodiazepines or antidepressants and with carbamazepine levels higher than 30 mcg/ml.

Screening for gestational diabetes mellitus - Can we use the 50-g glucose challenge test of the previous pregnancy?

AIM: To assess the association between previous pregnancy glucose challenge test (GCT) result among non-diabetic women and the rate for gestational diabetes mellitus (GDM) in the subsequentpregnancy. METHODS: Retrospective database study in a university affiliated medical center from 2005 to 2017. Women who had a singleton pregnancy and two consecutive deliveries in our medical center were included. GDM diagnosis was based on either National Diabetes Data Group or Carpenter and Coustan criteria. Univariate analysis was followed by multivariate logistic regression. RESULTS: A total of 31,861 women were included. GDM incidence among the subsequent pregnancies was 2.1% (670 women). Parturients with GDM had higher mean GCT results in their previous pregnancy compared with parturients without GDM (127.5 ±â€¯28 VS. 98.7 ±â€¯24 mg/dl, p < 0.001). Women with GDMA2 had higher former GCT results than women with GDMA1 (135.9 ±â€¯28 VS. 125.7 ±â€¯27 mg/dl, p < 0.001). Positive association between GCT results in previous pregnancy and rates of GDM in the subsequent pregnancy was noted. Using a GCT value of 107 mg/dl (65th percentile), the area under the receiver-operating curve was 0.79. CONCLUSION: GCT results in previous pregnancy is associated with GDM incidence in the subsequent pregnancy. Future prospective studies are warranted to better delineate the best screening approach for this subset of patients.