Intrapartum fever complicated with maternal bacteremia: prevalence, bacteriology, and risk factors.

PURPOSE: To assess the prevalence, microbial profile, and clinical risk factors of maternal bacteremia associated with intrapartum fever (IPF). METHODS: A retrospective cohort study, in a single tertiary university-affiliated medical center between 2012 and 2018. Demographic and labor characteristics of women, who delivered at term (37+0/7-41+6/7) and developed bacteremia following IPF were compared to a control group of women with IPF but without bacteremia. RESULTS: During the study period there were 86,590 deliveries in our center. Of them, 2074 women (2.4%) were diagnosed with IPF, of them, for 2052 women (98.93%) the blood maternal cultures were available. In 26 patients (1.25%) maternal bacteremia was diagnosed. A lower rate of epidural anesthesia (84.6% vs 95.9%, p = 0.02) and a higher rate of antibiotics prophylaxis treatment prior to the onset of fever (30.8%.vs 12.1%, p = 0.006) were observed in patients who developed maternal bacteremia in comparison to those who have not. Maternal hyperpyrexia developed after initiation of antibiotics or without epidural anesthesia remained significantly associated with maternal bacteremia after applying a multivariate analysis, (Odds Ratio 3.14 95% CI 1.27-7.14, p = 0.009; 4.76 95% CI 1.35-12.5, p = 0.006; respectively). CONCLUSION: Maternal fever developing after initiation of antibiotics or without epidural is associated with maternal bacteremia.

The Feasibility of a Trial of Labor after Two Cesarean Deliveries: Outcomes and Prognostic Factors for Success.

OBJECTIVE: This study aimed to determine whether a trial of labor after two cesarean deliveries (TOLAC2) increases the risk of adverse maternal and neonatal outcomes and identify prognostic factors for TOLAC2 success. STUDY DESIGN: A retrospective cohort study was conducted at a single medical center. The study group was comprised of women with a history of TOLAC2. Outcomes were compared with women undergoing trial of labor after one previous cesarean delivery (TOLAC1). The primary outcome was trial of labor after cesarean delivery (TOLAC) success. Secondary outcomes included mode of delivery, uterine rupture, and combined adverse outcome (CAO; uterine rupture, postpartum hemorrhage, 5-minute Apgar score < 7, pH < 7.1). Logistic regression was used for the multivariate analysis to identify prognostic factors for TOLAC2 success. RESULTS: A total of 381 women who underwent TOLAC2 were compared with 3,635 women who underwent TOLAC1. Women attempting TOLAC2 were less likely to achieve vaginal births after cesarean delivery (VBAC; 80.8 and 92.5%; odds ratio [OR]: 0.35; 95% confidence interval [CI]: 0.26-0.47; p < 0.001) and more likely to experience uterine rupture (0.8 vs. 0.2%; OR: 4.1; 95% CI: 1.1-15.9; p = 0.02) but not CAO (4.2 vs. 4.8%; OR: 0.88; 95% CI: 0.5-1.5; p = 0.3). TOLAC2 women with no previous vaginal deliveries had a lower chance of VBAC and a higher risk of uterine rupture compared with TOLAC1 women without a prior vaginal delivery (45.2 vs. 86.3%; OR: 0.13; 95% CI: 0.07-0.25; p < 0.001; 2.3 vs. 0%) and TOLAC2 women with a prior vaginal delivery (45.2 vs. 85.3%; OR: 0.14; 95% CI: 0.1-0.3; p < 0.0001; 2.4 vs. 0.6%; OR: 4.1; 95% CI: 0.4-46.3; p = 0.3). Multivariate analysis revealed that a history of vaginal delivery is an independent predictor of TOLAC2 success. CONCLUSION: Women attempting TOLAC2 are less likely to achieve VBAC and are at greater risk of uterine rupture compared with those attempting TOLAC1. Despite these risks, the overall success rates remain very high, and the absolute risk of adverse outcomes is still very low. Prior vaginal delivery seems to have a protective effect on TOLAC outcomes. These data should be used to counsel women and assist in decision-making when considering the mode of delivery in women with two previous cesarean sections. KEY POINTS: · TOLAC2 has a lower chance of success and higher rate of uterine rupture compared with TOLAC1.. · Previous vaginal delivery is an independent predictor of TOLAC2 success.. · Overall TOLAC2 outcomes are associated with high chances of success and low risk of uterine rupture..

High-Order Parity Improves the Perinatal Outcome of Twin Deliveries.

OBJECTIVE: Twin gestations are associated with an increased risk of obstetric and perinatal complications. We studied the association between parity and the rate of maternal and neonatal complications in twins deliveries. STUDY DESIGN: We performed a retrospective analysis of a cohort of twin gestations delivered between 2012 and 2018. Inclusion criteria consisted of twin gestation with two nonanomalous live fetuses at ≥24 weeks' gestation and no contraindications to vaginal delivery. Women were divided into three groups based on parity: primiparas, multiparas (parity of 1-4), and grand multiparas (parity ≥5). Demographic data were collected from electronic patient records and included maternal age, parity, gestational age at delivery, need for induction of labor, and neonatal birth weight. The primary outcome was mode of delivery. Secondary outcomes were maternal and fetal complications. RESULTS: The study population included 555 twin gestations. One hundred and three were primiparas, 312 were multiparas, and 140 were grand multiparas. Sixty-seven (65%) primiparas delivered the first twin vaginally, as did 294 (94%) multiparas and 133 (95%) grand multiparas (p <0.05). Thirteen (2.3%) women required delivery of the second twin by cesarean section. Among those who delivered both twins vaginally, there was no significant difference in the average time interval between the delivery of the first and the second twins between the groups. The need for transfusion of blood products was higher in the primiparous group compared with the other two groups (11.6 vs. 2.5 and 2.8%, p < 0.05). The rate of adverse maternal composite outcomes was higher among primiparous women compared with multiparous and grand multiparous (12.6, 3.2, and 2.8%, respectively, p < 0.05). The gestational age at delivery was earlier in the primiparous group compared with the other two groups, and the rate of preterm labor at <34 weeks' gestation was higher among the primiparas. The rate of second twin's 5-minute Apgar's score <7 and the composite adverse neonatal outcome among the primiparous group were significantly higher than the multiparous and grand multiparous groups. CONCLUSION: Our study demonstrates that there is an association between high-parity and good obstetric outcomes in twin pregnancies; high parity seems to serve as a protective, rather than a risk factor for adverse maternal and neonatal outcomes. KEY POINTS: · There is an association between high-parity and good obstetric outcome in twin pregnancies.. · High parity serves as a protective factor for adverse maternal outcomes in twin deliveries.. · High parity serves as a protective factor for adverse neonatal outcomes in twin deliveries..

Ex-Vivo MRI of the Normal Human Placenta: Structural-Functional Interplay and the Association With Birth Weight.

BACKGROUND: Advanced magnetic resonance imaging (MRI) methods are increasingly being used to assess the human placenta. Yet, the structure-function interplay in normal placentas and their associations with pregnancy risks are not fully understood. PURPOSE: To characterize the normal human placental structure (volume and umbilical cord centricity index (CI)) and function (perfusion) ex-vivo using MRI, to assess their association with birth weight (BW), and identify imaging-markers for placentas at risk for dysfunction. STUDY TYPE: Prospective. POPULATION: Twenty normal term ex-vivo placentas. FIELD STRENGTH/SEQUENCE: 3 T/ T1 and T2 weighted (T1 W, T2 W) turbo spin-echo, three-dimensional susceptibility-weighted image, and time-resolved angiography with interleaved stochastic trajectories (TWIST), during passage of a contrast agent using MRI compatible perfusion system that mimics placental flow. ASSESSMENT: Placental volume and CI were manually extracted from the T1 W images by a fetal-placental MRI scientist (D.L., 7 years of experience). Perfusion maps including bolus arrival-time and full-width at half maximum were calculated from the TWIST data. Mean values, entropy, and asymmetries were calculated from each perfusion map, relating to both the whole placenta and volumes of interest (VOIs) within the umbilical cord and its daughter blood vessels. STATISTICAL TESTS: Pearson correlations with correction for multiple comparisons using false discovery rate were performed between structural and functional parameters, and with BW, with P < 0.05 considered significant. RESULTS: All placentas were successfully perfused and scanned. Significant correlations were found between whole placenta and VOIs perfusion parameters (mean R = 0.76 ± 0.06, range = 0.67-0.89), which were also significantly correlated with CI (mean R = 0.72 ± 0.05, range = 0.65-0.79). BW was correlated with placental volume (R = 0.62), but not with CI (P = 0.40). BW was also correlated with local perfusion asymmetry (R = -0.71). DATA CONCLUSION: Results demonstrate a gradient of placental function, associated with CI and suggest several ex-vivo imaging-markers that might indicate an increased risk for placental dysfunction. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 1.

Maternal presentation and neonatal outcome in peripartum enterovirus infection.

AIM: Enterovirus is a common pathogen. Although mostly asymptomatic, this infection has the potential to be life-threatening in neonates. This article aims to describe the early neonatal outcomes in peripartum infection. METHODS: We performed a retrospective cohort study in a tertiary hospital between 1/2014 and 5/2019. The enterovirus infection was established by real-time polymerase chain reaction analysis. RESULTS: Out of 161 neonates tested for the enterovirus infection 13 (8%) were positive. Maternal fever was the most common sign (n = 8, 66.7%). The mean gestational age at delivery was 36 + 5 (range 30 + 5 to 40 + 6 weeks). The mean time interval from birth to neonatal manifestations of infection was 5.2 (0-9) days. The most common presenting sign in the neonates was fever (n = 8, 61.5%). All neonates required the neonatal intensive care unit. The neonatal mortality rate was 3/13 (23%). CONCLUSION: The neonatal morbidity and mortality from the enterovirus infection may have been associated with the severity of maternal presentation at the time of admission. Enterovirus real-time polymerase chain reaction analysis should be considered as part of the maternal evaluation in cases of maternal fever of unknown origin. Deferral of the induction of delivery for term pregnancies with confirmed enterovirus infections should be considered.

The Contribution of an Infectious Workup in Understanding Stillbirth.

OBJECTIVE: This study was aimed to assess the utility of diagnostic tests of maternal and fetal infection in the evaluation of stillbirth. STUDY DESIGN: A single-center retrospective study from January 2011 to December 2016 of all women presenting to the hospital with intrauterine fetal death at or after 20 weeks of gestation. Standard evaluation included review of medical records, clinical and laboratory inflammatory workup, maternal serologies, fetal autopsy, placental pathology, and fetal and placental cultures. A suspected infectious etiology was defined as meeting at least two diagnostic criteria, and only after exclusion of any other identifiable stillbirth cause. RESULTS: During the 7-year study period, 228 cases of stillbirth were diagnosed at our center. An infectious etiology was the suspected cause of stillbirth in 35 cases (15.3%). The mean gestational age of infection-related stillbirth was 28 1/7 (range: 22-37) weeks, while for a noninfectious etiology, it was 34 0/7 (range: 25-38) weeks (p = 0.005). Placental histological findings diagnostic of overt chorioamnionitis and funisitis were observed in 31 (88.5%) cases. In 16 (45.7%) cases the placental and fetal cultures were positive for the same pathogen. Serology of acute infection was positive in three (8.5%) of the cases. CONCLUSION: Maternal and fetal infectious workup is valuable in the investigation of stillbirth, particularly before 30 weeks of gestation and should be considered a part of standard evaluation.

Obstetrical outcomes of ART pregnancies in patients with male factor infertility.

PURPOSE: Pregnancies conceived by in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are associated with an increased incidence of obstetrical and neonatal complications. With the growing rate of male factor infertility, which is unique by not involving the maternal milieu, we aimed to assess whether obstetrical outcomes differed between IVF/ICSI pregnancies due to male factor infertility and those not due to male factor infertility. METHODS: A retrospective cohort study of women receiving IVF/ICSI treatments at a single hospital over a five-year period was involved in the study. Inclusion criteria were women with a viable pregnancy that delivered at the same hospital. Pregnancies were divided into male factor only related and non-male factor-related infertility. The groups were compared for several maternal and neonatal complications. RESULTS: In total, 225 patients met the study criteria, with 94 and 131 pregnancies belonging to the male factor and non-male factor groups, respectively. Demographic and clinical characteristics were comparable, except for younger maternal age and higher incidence of twin pregnancies in the male factor group. A sub-analysis for singleton pregnancies revealed a less likelihood of cesarean delivery, preterm birth, and male gender offspring in the male factor group (p < 0.05). These differences were not observed in the sub-analysis for twin pregnancies. Other outcome measures were similar in both groups, both for singleton and twin pregnancies. CONCLUSION: Singleton IVF pregnancies due to male factor infertility are associated with a reduced incidence of some adverse outcomes, likely due to lack of underlying maternal medical conditions or laboratory conditions related to ICSI. Our findings require validation by further studies on larger samples.

Risk factors for overt postpartum urinary retention-the effect of the number of catheterizations during labor.

INTRODUCTION AND HYPOTHESIS: Our aim was to examine the effect of the number of catheterizations during labor on the development of overt postpartum urinary retention (PUR) in women who had a vaginal delivery with epidural anesthesia. METHODS: A single-center retrospective matched case-control study between 1 January 2015 and 31 December 2016. Women who developed overt PUR were compared with those who did not following a singleton vaginal delivery with epidural anesthesia. For each study two controls, matched for maternal age, gestational age at delivery, and parity, were selected. Each woman's controls were the immediate subsequent or previous delivery that met matching criteria. RESULTS: Two hundred parturients with overt PUR were matched with 400 parturients without overt PUR. In univariate analysis, women with PUR underwent significantly more catheterizations during labor, had an epidural for a longer period of time, and were more likely to have undergone a vacuum-assisted delivery and a mediolateral episiotomy (p < 0.01 for all). In multivariate analysis controlling for epidural duration, episiotomy, and vacuum-assisted delivery, the risk of PUR among women with at least two catheterizations was greater when fewer catheterizations were performed (OR = 0.78, 95% CI 0.61-0.99). When controlling for the number of catheterizations overall, episiotomy, and vacuum-assisted delivery, PUR risk significantly increased with a longer epidural duration (OR 1.23, 95% CI 1.17-1.29). Episiotomy and vacuum-assisted delivery had no significant effect on PUR. CONCLUSIONS: The risk of PUR decreases as the number of catheterizations increases. Although longer epidural duration independently increases the risk of PUR, episiotomy and vacuum-assisted delivery do not.

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions.

INTRODUCTION: Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions. METHODS: A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results. RESULTS: Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ±â€¯5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%. CONCLUSIONS: A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.

Is There a Benefit to Culturing Intra-Uterine Devices in Pelvic Inflammatory Disease?

AIMS: The study aimed to compare the clinical course and disease severity between culture positive and culture negative patients with intra-uterine devices (IUD)-associated pelvic inflammatory disease (PID). METHODS: A retrospective study of all IUD-associated PID patients admitted to tertiary medical center between 2010 and 2015. All patients received standard empiric antibiotic therapy upon admission. The study cohort was divided into 2: patients with culture positive IUDs and patients with negative cultures. Electronic medical records and culture results were analyzed from the time of admission. RESULTS: During the study period, 480 hospitalized patients were diagnosed with PID. Of these, 94 patients had IUD-associated PID, 59 with positive cultures and 35 with negative cultures. While fever was more common in the latter (p = 0.01), no significant differences were found in disease severity in patient outcomes (i.e., length of stay, rates of invasive treatment, and total abdominal hysterectomies). In a sub-analysis of patients with IUD cultures of established PID pathogens only, there were no differences in disease severity and outcome in patients with antibiotic susceptible or resistant strains. CONCLUSIONS: IUD removal for culture in PID patients is probably unnecessary. Alteration of treatment according to the culture results may have little impact on disease course and outcome.

Fertility outcomes in patients with tubo-ovarian abscesses after an oocyte retrieval: a longitudinal cohort analysis.

PURPOSE: To determine the impact of pelvic inflammation caused by tubo-ovarian abscess (TOA) on ovarian response to stimulation. METHODS: This retrospective longitudinal cohort analysis that was carried out in a tertiary university-affiliated medical center included 15 women with TOA during in vitro fertilization (IVF) cycles. The ovarian response to stimulation and the pregnancy rate were compared in two subsequent cycles, the initial IVF cycle that was complicated by TOA after oocyte retrieval (first treatment cycle) and the following IVF treatment (second treatment cycle) that occurred within a period of a year from the first cycle. RESULTS: The mean number of retrieved oocytes was significantly higher in the first IVF cycle compared to the second cycle (8.1 ± 3.2 vs. 5.4 ± 2.5, P = .003], corresponding to a 30% reduction in ovarian response to gonadotropin stimulation. Fertilization rates were significantly lower in the second cycle (4.1 ± 2.9 vs. 2.9 ± 1.7, P = .015). Twelve women (80%) reached embryo transfer in the first cycle compared to 14 women (93.3%) in the second cycle. The mean number of transferred embryos was similar between the two cycles. There were no clinical pregnancies following the first cycle, and only one patient (6.6%) had a clinical pregnancy in the second treatment cycle. CONCLUSIONS: TOA following fertility treatment has a detrimental effect on ovarian function. The pregnancy rate in the immediate period following TOA is poor. Current data for recommending the deferral of fertility treatment following a TOA episode are insufficient, calling for more studies to address these issues.

Maternal cardiovascular hemodynamics in normotensive versus preeclamptic pregnancies: a prospective longitudinal study using a noninvasive cardiac system (NICaS™).

BACKGROUND: Preeclampsia is among the most common medical complications of pregnancy. The clinical utility of invasive hemodynamic monitoring in preeclampsia (e.g., Swan-Ganz catheter) is controversial. Thoracic impedance cardiography (TIC) and Doppler echocardiography are noninvasive techniques but they both have important limitations. NICaS™ (NI Medical, PetachTikva, Israel) is a noninvasive cardiac system for determining cardiac output (CO) that utilizes regional impedance cardiography (RIC) by noninvasively measuring the impedance signal in the periphery. It outperformed any other impedance cardiographic technology and was twice as accurate as TIC. METHODS: We used the NICaS™ system to compare the hemodynamic parameters of women with severe preeclampsia (PET group, n = 17) to a cohort of healthy normotensive pregnant women with a singleton pregnancy at term (control group, n = 62) (1/2015-6/2015). Heart rate (HR), stroke volume (SV), CO, total peripheral resistance (TPR) and mean arterial pressure (MAP) were measured 15-30 min before CS initiation, immediately after administering spinal anesthesia, immediately after delivery of the fetus and placenta, at the abdominal fascia closure and within 24-36 and 48-72 h postpartum. RESULTS: The COs before and during the CS were significantly higher in the control group compared to the PET group (P < .05), but reached equivalent values within 24-36 h postpartum. CO peaked at delivery of the newborn and the placenta and started to decline afterwards in both groups. The MAP and TPR values were significantly higher in the PET group at all points of assessment except at 48-72 h postpartum when it was still significantly higher for MAP while the TPR only exhibited a higher trend but not statistically significant. The NICaS™ device noninvasively demonstrated low CO and high TPR profiles in the PET group compared to controls. CONCLUSIONS: The immediate postpartum period is accompanied by the most dramatic hemodynamic changes and fluid shifts, during which the parturient should be closely monitored. The NICaS™ device may help the clinician to customize the most optimal management for individual parturients. Our findings require validation by further studies on larger samples.

Maternal hemodynamics in late gestation and immediate postpartum in singletons vs. twin pregnancies.

PURPOSE: Differences in hemodynamic changes during a cesarean section (CS) between twin and singleton pregnancies are poorly defined. The Non-Invasive Cardiac System (NICaS) is an impedance device that measures cardiac output (CO) and its derivatives. We compared maternal cardiac parameters using NICaS™ in singleton and twins before and during delivery, as well at the early puerperium in healthy women undergoing CS at term. METHODS: This prospective longitudinal study included women with twin (n = 27) or singleton pregnancies (n = 62) whose hemodynamic parameters were assessed by NICaS before an elective CS, after spinal anesthesia, immediately after delivery, after fascia closure, and within 24-36 and 48-72 h postpartum. RESULTS: By 24-36 h postpartum, the mean arterial pressure and the total peripheral resistance equaled preoperative values in both groups. The CO increased throughout the CS and peaked immediately after delivery in the singleton group (P < 0.0001), after which it abruptly began to decline until reaching a nadir 24-36 h after delivery (P < 0.0001), while it remained steady throughout the CS and then dropped until 24-36 h after delivery in the twin group (P < 0.05). None of the studied parameters differed significantly between the groups for the 24-36 and 48-72 h postpartum measurements. CONCLUSIONS: Hemodynamic parameters immediately before, during and shortly after CS in singleton and twin pregnancies are equivalent. Further evaluations of the value of NICaS™ in assessing cardiovascular-related pregnancy complications are warranted.

Automatic Measurement of Fetal Brain Development from Magnetic Resonance Imaging: New Reference Data.

BACKGROUND: Accurate fetal brain volume estimation is of paramount importance in evaluating fetal development. The aim of this study was to develop an automatic method for fetal brain segmentation from magnetic resonance imaging (MRI) data, and to create for the first time a normal volumetric growth chart based on a large cohort. SUBJECTS AND METHODS: A semi-automatic segmentation method based on Seeded Region Growing algorithm was developed and applied to MRI data of 199 typically developed fetuses between 18 and 37 weeks' gestation. The accuracy of the algorithm was tested against a sub-cohort of ground truth manual segmentations. A quadratic regression analysis was used to create normal growth charts. The sensitivity of the method to identify developmental disorders was demonstrated on 9 fetuses with intrauterine growth restriction (IUGR). RESULTS: The developed method showed high correlation with manual segmentation (r2 = 0.9183, p < 0.001) as well as mean volume and volume overlap differences of 4.77 and 18.13%, respectively. New reference data on 199 normal fetuses were created, and all 9 IUGR fetuses were at or below the third percentile of the normal growth chart. DISCUSSION: The proposed method is fast, accurate, reproducible, user independent, applicable with retrospective data, and is suggested for use in routine clinical practice.

Obstetric and neonatal outcomes of pregnancies conceived after preimplantation genetic diagnosis: cohort study and meta-analysis.

Preimplantation genetic diagnosis (PGD) may pose risks to pregnancy outcome owing to the invasiveness of the biopsy procedure. This study compares outcome of singleton and twin clinical pregnancies conceived after fresh embryo transfers of PGD (n = 89) and matched intracytoplasmic sperm injection (ICSI) pregnancies (n = 166). The study was carried out in a single university affiliated centre. Because of the paucity of available data, a literature-based meta-analysis of studies comparing neonatal outcome of PGD and ICSI pregnancies was also conducted. In the retrospective cohort study, obstetric and neonatal outcome were available in 67 PGD and 118 ICSI pregnancies. Perinatal outcomes were comparable between PGD and ICSI pregnancies. Meta-analysis revealed similar outcomes, except for higher rate of low birth weight (<2500 g) neonates in ICSI twin pregnancies (RR 0.86, 95% CI 0.74 to 1.0). Mean birth weight, gestational age at birth, pre-term deliveries (<37 weeks) and malformations were all comparable. In this cohort study and subsequent meta-analysis, no association was found between PGD conceived pregnancies and risks of adverse neonatal or obstetrical outcomes compared with ICSI pregnancies. Hence, blastomere biopsy for PGD does not seem to increase the risk for adverse perinatal outcome compared with ICSI pregnancies.

Twin pregnancy in women above the age of 45 years: maternal and neonatal outcomes.

Childbearing age continues to rise and, with the increasing implementation of assisted reproductive technology (ART), the number of multiple pregnancies has also risen. This is a retrospective cohort study on maternal and neonatal outcomes of the twin pregnancies of 57 women aged ≥45 years compared to 114 younger women who gave birth in our institution between January 2011 and August 2015. Data were extracted from the real-time computerized database. The rates of hypertensive complications and pre-eclampsia (PE) were much higher in the study group compared to the controls (24/57 vs. 19/114, P=0.000 and 15/57 vs. 13/114, P=0.013, respectively). The respective incidence of very low birth weight (VLBW) was also significantly higher (14/114 vs. 12/228, P=0.021). Infants in the study group required four times more intubation and had a higher admission rate to the neonatal intensive care unit (NICU) compared to control infants (14/114 vs. 6/228 P=0.000 and 42/114 vs. 57/228, P=0.023, respectively). We conclude that women older than 45 years with twin pregnancies have higher maternal and perinatal complications with worse outcomes in comparison with younger women. When pregnancy is attempted via ART, embryo transfer of only one embryo should be considered in this age group.

Is There a Role for Placental Cultures in Cases of Clinical Chorioamnionitis Complicating Preterm Premature Rupture of Membranes?

Objective To assess the role of placental cultures in cases of preterm premature rupture of membranes (PPROM) complicated by chorioamnionitis and to determine the effect of positive cultures on short-term neonatal outcomes. Design A retrospective single-center study. The medical records of all women with PPROM between January 1, 2011, and December 31, 2015, were reviewed. Cases were divided into placental culture positive (group A) and placental culture negative (group B) groups. Maternal and pregnancy characteristics as well as short-term neonatal outcomes were compared between groups. Results During the 5-year study period, 61 cases of clinical chorioamnionitis complicating PPROM were diagnosed: 25 cases were culture positive (group A) and 36 were culture negative (group B). Neonatal outcome measures, including Apgar score at 5 minutes (p = 0.028; odds ratio [OR]: 5.27; confidence interval [CI]: 1.19-23.34), respiratory distress syndrome (p = 0.026; OR: 4.11; CI: 1.18-14.25), and neonatal infection (p < 0.0001; OR: 11.59; CI: 3.37-39.87) were significantly more common in group A newborns, regardless of gestational age at delivery as was the composite neonatal outcome (p = 0.017; OR: 7.35: CI: 1.42-37.79). Placental isolates were primarily Streptococci and Escherichia coli. Conclusion Placental cultures may be an essential predictor of neonatal morbidity in PPROM and may contribute to the modification of neonatal treatment.

Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery.

PURPOSE: Sterilization via bilateral total salpingectomy is slowly replacing partial salpingectomy, as it is believed to decrease the incidence of ovarian cancer. Our objective was to compare short-term intra and post-operative complication rates of bilateral total salpingectomy versus partial salpingectomy performed during the course of a cesarean delivery. METHODS: A large series of tubal sterilizations during cesarean sections were studied in a single tertiary medical center between 1/2014 and 8/2016 before and after a policy change was made, switching from partial salpingectomy to total salpingectomy. Patients who underwent bilateral partial salpingectomy using the modified Pomeroy technique were compared with those who underwent total salpingectomy. Operative length, estimated blood loss, postpartum fever, wound infection, need for re-laparotomy, hospitalization length, and blood transfusions were compared. RESULTS: During the study period, 149 women met inclusion criteria. Fifty parturients underwent bilateral total salpingectomy and 99 underwent partial salpingectomy in the course of the cesarean section. Demographic, obstetrical, and surgical characteristics were similar in both groups. Mean cesarean section duration was comparable for partial salpingectomy and total salpingectomy (a median of 35 min in both groups, P = 0.92). Complications were rare in both groups with no significant differences in rates of postpartum fever, wound infection, re-laparotomy, hospitalization length, estimated blood loss, transfusions, and readmissions within 1-month postpartum. CONCLUSION: Rates of short-term complications are similar in patients undergoing bilateral partial salpingectomy and total salpingectomy during cesarean deliveries, making the latter a feasible alternative to the former.

How Long Is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study.

OBJECTIVE: The aim of our study was to determine the optimal time for manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion. Risk factors for postpartum blood transfusions were studied. METHODS: Computerized data of all vaginal deliveries at our labor and delivery unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation up to 60 minutes into the third stage of labor were extracted for analysis. Patient demographics, obstetrical history, delivery course, and outcome were assessed as well as blood product requirements during the postpartum period. Receiver-operating curves (ROC) for prediction of blood transfusion during the third stage were calculated and risk factors were assessed. RESULTS: 31,226 vaginal deliveries occurred during the study period and 28,586 deliveries culminated with complete and spontaneous placental separation, 25,160 of which met inclusion criteria. Independent risk factors for blood transfusions were primiparity, longer second and third stage length, labor induction, and maternal intrapartum fever. ROC curves showed that the optimal cutoff for the prediction of blood transfusions was 17 minutes into the third stage of labor. Waiting more than 30 minutes for placental separation increases the risk for blood transfusion more than threefold. CONCLUSIONS: A third stage longer than 17 minutes is associated with an increased risk for blood transfusion postpartum. After more than 30 minutes, the risk for blood transfusions increases more than threefold.

Is epidural analgesia during labor related to retained placenta?

OBJECTIVES: To explore the influence of epidural analgesia on the course of the third stage of labor and on the incidence of the complete retained placenta as well as retained parts of the placenta. STUDY DESIGN: This is a population-based cohort study in a tertiary medical center. We collected data from all 4227 spontaneous singleton vaginal deliveries during 6 months and compared the incidence of retained placenta in deliveries with epidural analgesia with those without analgesia. Multivariable logistic regression was used to control for possible confounders. RESULTS: More than two-thirds of the women (69.25%) used epidural analgesia during their delivery. A need for intervention due to placental disorder during the third stage of labor was noted in 4.2% of all deliveries. Epidural analgesia appeared to be significantly (P=0.028) related to placental disorders compared with no analgesia: 4.8% vs. 3%, respectively. Deliveries with manual interventions during the third stage, for either complete retained placenta or suspected retained parts of the placenta, were associated with the use of epidural analgesia (P=0.008), oxytocin (P=0.002) and older age at delivery (P=0.000), but when including all factors in a multivariable analysis, using a stepwise logistic regression, the factors that were independently associated with interventions for placental disruption during the third stage of delivery were previous cesarean section, oxytocin use and, marginally, older age. CONCLUSIONS: Complete retained placenta and retained parts of the placenta share the same risk factors. Epidural analgesia does not directly influence the incidence of complete retained placenta or retained parts, though clinically linked through increased oxytocin use. The factors that were independently associated with interventions for placental disruption during the third stage of delivery were previous cesarean section, oxytocin use and older age.