Umbilical cord blood gases sampling in low-risk vaginal deliveries as a predictor of adverse neonatal outcome.

INTRODUCTION: There is no clear correlation between abnormal umbilical cord blood gas studies (UCGS) and adverse neonatal outcome in low-risk deliveries. We investigated the need for its routine use in low-risk deliveries. METHODS: We retrospectively compared maternal, neonatal, and obstetrical characteristics among low-risk deliveries (2014-2022) between "normal" and "abnormal" pH groups: A:normal pH ≥ 7.15; abnormal pH < 7.15; B: normal pH ≥ 7.15 and base excess (BE) > - 12 mmol/L; abnormal pH < 7.15 and BE ≤ We retrospectively compared 12 mmol/L; C: normal pH ≥ 7.1; abnormal pH < 7.1; D: normal pH > 7.1 and BE > - 12 mmol/L; abnormal pH < 7.1 and BE ≤ - 12 mmol/L. RESULTS: Of 14,338 deliveries, the rates of UCGS were: A-0.3% (n = 43); B-0.07% (n = 10); C-0.11% (n = 17); D-0.03% (n = 4). The primary outcome, composite adverse neonatal outcome (CANO) occurred in 178 neonates with normal UCGS (1.2%) and in only one case with UCGS (2.6%). The sensitivity and specificity of UCGS as a predictor of CANO were high (99.7-99.9%) and low (0.56-0.59%), respectively. CONCLUSION: UCGS were an uncommon finding in low-risk deliveries and its association with CANO was not clinically relevant. Consequently, its routine use should be considered.

Predictors of maternal and neonatal outcomes in labors complicated by shoulder dystocia: a comparative analysis.

INTRODUCTION: Studies investigating the risk factors associated with unfavorable maternal/neonatal outcomes in cases of shoulder dystocia are scarce. This study aims to uncover the predictive factors that give rise to unfavorable outcomes within the context of shoulder dystocia. MATERIALS AND METHODS: Medical records of pregnancies complicated by shoulder dystocia was obtained between 2008-2022 from a single tertiary center. This study involved the comparison of sociodemographic, sonographic, and delivery characteristics among pregnancies complicated by shoulder dystocia resulting in favorable vs. unfavorable maternal/neonatal outcomes. RESULTS: A total of 275 pregnancies were analyzed, with 111 (40.3%) classified as unfavorable outcomes and 164 (59.7%) as favorable outcomes. Employing a multivariable regression analysis, several independent associations were identified with unfavorable maternal/neonatal outcomes. Specifically, short maternal stature, pre-gestational diabetes, vacuum extraction, Wood's screw maneuver, and macrosomia merged as significant predictors of unfavorable maternal/neonatal outcomes. CONCLUSION: Short maternal stature, pre-gestational diabetes, vacuum extraction, Wood's screw maneuver, and macrosomia may all contribute to poor maternal/neonatal outcomes in shoulder dystocia cases. This knowledge allows clinicians to improve their decision-making, patient care, and counseling.

Pregnancy outcomes in correlation with placental histopathology in pregnancies complicated by fetal growth restriction with vs. without reduced fetal movements.

PURPOSE: Fetal movements are crucial indicators of fetal well-being, with reduced fetal movements (RFM) suggesting potential fetal compromise. Fetal growth restriction (FGR), often linked to placental insufficiency, is a major cause of perinatal morbidity and mortality. This study aimed to investigate the neonatal, labor, and placental outcomes of FGR pregnancies with and without RFM at term. METHODS: In this retrospective study, data from all term, singleton deliveries with FGR and concomitant RFM were obtained and compared to an equal control group of FGR without RFM. Maternal characteristics, pregnancy and neonatal outcomes, and placental histology were compared. The primary outcome was a composite of adverse neonatal outcomes. A multivariable regression analysis was performed to identify independent associations with adverse neonatal outcomes. RESULTS: During the study period, 250 FGR neonates with concomitant RFM and an equal control group were identified. The groups did not differ in maternal demographics aside from significantly higher rates of maternal smoking in the RFM group (p < 0.001). Polyhydramnios and oligohydramnios (p = 0.032 and p = 0.007, respectively) and meconium-stained amniotic fluid (p < 0.001) were more prevalent in the FGR+RFM group. Additionally, the RFM group showed higher rates of adverse neonatal outcomes despite having larger neonates (p = 0.047 and p < 0.001, respectively). No significant differences were observed in placental findings. Logistic regression identified RFM as an independent predictor of adverse neonatal outcomes (aOR 2.45, 95% CI 1.27-4.73, p = 0.008). CONCLUSION: Reduced fetal movements are significant and independent predictors of worse neonatal outcomes in FGR pregnancies, suggesting an additional acute insult on top of underlying placental insufficiency.

Does the combination of four OGTT values enhance the prediction of adverse pregnancy outcomes? Insights from a retrospective cohort study.

AIM: To explore the correlation between a singular value of additive OGTT scores and adverse maternal and neonatal outcomes. We postulated that a higher additive OGTT score would predict poorer maternal and neonatal outcomes. METHODS: In this retrospective cohort study, data were collected from all women with a documented complete OGTT result and subsequent diagnosis of GDM. The additive OGTT score was calculated by adding each individual hourly glucose measurement. Maternal demographics, pregnancy and labor characteristics, and neonatal outcomes were compared between the lower-sum and higher-sum OGTT groups. A multivariate regression analysis was performed to identify confounders associated with adverse outcomes. RESULTS: In this study, a total of 1497 patients were assessed. The group with higher-sum OGTT scores was characterized by increased rates of GDMA2 (p = 0.008), higher insulin doses (p = 0.009), and higher rates of composite maternal and neonatal adverse outcomes (p = 0.021 and p = 0.030, respectively) compared to the lower-sum OGTT group. CONCLUSION: The additive OGTT score may aid in predicting the need for insulin treatment, labor course, and neonatal outcomes in GDM patients.

Medical treatment for early pregnancy loss following in vitro fertilization compared to spontaneous pregnancies.

BACKGROUND: Misoprostol is a well-studied medical treatment for early pregnancy loss (EPL), with success rates ranging between 70 and 90%. However, treatment failure is associated with major patient discomfort, including the need for surgical intervention to evacuate the uterus. It was previously reported that medical treatment was especially successful among women who conceived after in vitro fertilization (IVF). We aimed to study if there is a difference in rates of medical treatment failures for EPL between pregnancies conceived by IVF and spontaneous pregnancies. METHODS: In this retrospective cohort study, we included all women who underwent medical treatment for EPL at our institute between 07/2015 and 12/2020. Treatment outcome was compared between IVF and spontaneous pregnancies. Treatment failure was defined as a need for surgical intervention, namely, dilation & curettage (D&C) and/or hysteroscopy, due to retained products of conception, which was defined as a gestational sac or endometrial thickness greater than 15 mm in a TVS scan. RESULTS: Overall, 775 patients were included, of which 195 (169/775 = 25.1%) ultimately required surgical intervention. There was no difference between the study groups in the rate of treatment failure. However, among IVF pregnancies, the rate of emergency D&C was lower (3.6% vs. 9.8%, p = 0.001), compared to spontaneous group. CONCLUSION: In cases of medical treatment for EPL, IVF pregnancies had no differences in rates of treatment failure compared to spontaneous pregnancies. That being said, IVF pregnancies have lower chances to undergo emergency D&C, compared to spontaneous pregnancies.

The Effect of Preemptive Local Infiltration on Postoperative Pain After Vaginal Hysterectomy: A Retrospective Study.

STUDY OBJECTIVE: To investigate the effect of preemptive infiltration on postoperative pain and the use of analgesics after vaginal hysterectomy (VH). DESIGN: A retrospective study. SETTING: An urogynecology unit in a tertiary medical center. PATIENTS: A total of 120 patients who had undergone VH. INTERVENTIONS: The study group contained 60 patients who participated in a former randomized control study, in which preemptive local infiltration of bupivacaine (n = 30) or sodium chloride 0.9% (n = 30) was performed. The control group included 60 consecutive patients who underwent a VH, for whom no local infiltration was performed. MEASUREMENTS AND MAIN RESULTS: Postoperative pain at rest was assessed using the 10 cm visual analog scale at 3, 8, and 24 hours after surgery. The levels of pain, as well as the use of analgesics, postoperatively, were compared between the groups. The mean surgery length in the infiltration group was shorter (86.4±29 vs 118.6±30, p <.001) and the rate of posterior colporrhaphy was lower (73.1% vs 91.3%, p = .010) than the control group. There were no differences in levels of pain at all points of time. However, the infiltration group required a lower morphine dose in the recovery unit (3.7 ± 2.3 mg vs 5.3 ± 2.4 mg, p <.001) and less use of analgesia (all kinds) 24 hours after surgery (54.2% vs 79.6%, p <.001) compared with the control group. On multivariant analysis, preemptive infiltration was found to be independently inversely associated with the dose of morphine used in recovery, as well as analgesics used 24 hours after surgery. CONCLUSION: Preemptive local infiltration of either bupivacaine or sodium chloride 0.9% reduced the use of morphine in the recovery unit, as well as the use of analgesics 24 hours after VH, compared with no infiltration at all.

Pregnancy and placental outcomes according to maternal BMI in women with preeclampsia: a retrospective cohort study.

PURPOSE: Obesity and preeclampsia share similar patho-mechanisms and can both affect placental pathology. We aimed to investigate pregnancy outcomes in correlation with placental pathology among pregnancies complicated by preeclampsia in three different maternal body mass index (BMI, kg/m2) groups. METHODS: In this retrospective cohort study, medical and pathological records of patients with preeclampsia and a singleton pregnancy delivered between 2008 and 2021 at a single tertiary medical center were reviewed. Study population was divided into three BMI groups: BMI < 22.6 kg/m2 (low BMI group), 22.7 ≤ BMI ≤ 28.0 kg/m2 (middle-range BMI group), and BMI > 28.0 kg/m2 (high BMI group). Data regarding maternal characteristics, neonatal outcomes, and placental histopathological lesions were compared. RESULTS: The study groups included a total of 295 patients diagnosed with preeclampsia-98, 99, and 98 in the low, middle-range, and high BMI groups respectively. Neonatal birth weight was significantly decreased in the low maternal BMI group compared to both middle and high BMI groups (p = 0.04) with a similar trend seen in placental weight (p = 0.03). Villous changes related to maternal malperfusion were more prevalent in the low and high BMI groups compared to middle-range BMI group (p < 0.01) and composite maternal vascular malperfusion lesions were also more prevalent in the groups of BMI extremities compared to the middle-range BMI group (p < 0.01). CONCLUSION: Maternal BMI might influence neonatal outcomes and placental pathology in pregnancies complicated by preeclampsia. Both extremes of BMI were associated with higher rates of placental maternal vascular malperfusion. Balanced BMI in women at risk for preeclampsia may reduce the incidence of placental lesions.

The effect of watching an informational video prior amniocentesis on maternal anxiety: a randomized controlled trail.

PURPOSE: This randomized controlled trial aimed to ascertain the effect of a pre-procedure informational video on anxiety, pain perception, and satisfaction levels in patients undergoing amniocentesis. METHODS: Patients were randomized into two groups: a video group who watched an informational video prior to the procedure, and a control group who received standard care. Anxiety was gauged both pre- and post-procedure via the State-Trait Anxiety Inventory (STAI) score. Post-procedure, patients' perceived pain, anxiety, and satisfaction levels were evaluated using the Visual Analog Scale questionnaire (VAS). RESULTS: Of 110 randomized patients, 100 completed the study and were included in the final analysis. No significant difference was noted in overall anxiety levels between the study and control groups. However, in-procedure anxiety was significantly lower in the video group compared to the control group (p = 0.04). Among patients undergoing amniocentesis for the first time, the subgroup analysis revealed reduced levels of anxiety during the procedure and diminished pain 10 min after the procedure in the video group compared to the control group. (p = 0.041 and p = 0.025, respectively). CONCLUSION: A pre-procedural informational video could help in alleviating anxiety and mitigating pain during amniocentesis. CLINICAL TRIAL REGISTRATION: The study was registered at 27.3.2022 in clinical-trials.gov (identifier NCT05463549).

Isolated oligohydramnios in previous pregnancy is a risk factor for a placental related disorder in subsequent delivery.

BACKGROUND: We aimed to assess the association between isolated oligohydramnios in previous pregnancy and the incidence of placental related complications in subsequent pregnancy. METHODS: This was a retrospective cohort study of live singleton births from a single university affiliated medical center during an eleven-year period of women with two subsequent deliveries at our center. An analysis of outcomes was performed for all second deliveries, comparing women for whom their first delivery was complicated by isolated oligohydramnios (previous oligohydramnios group), and women without isolated oligohydramnios in their first delivery (control group). Patients for whom their first delivery was complicated by small for gestational age, pregnancy induced hypertension and preterm birth were excluded. The study groups were compared for obstetric and early neonatal outcomes, recurrence of oligohydramnios and a composite of placental related pregnancy complications. RESULTS: A total of 213 in the previous oligohydramnios group and 5348 in the control group were compared. No differences were found between the groups in maternal age, body mass index, smoking and comorbidities. Gestational age at delivery was, 39.6 ± 1.3 vs. 39.3 ± 1.4 weeks, p = 0.006, in the previous oligohydramnios and controls respectively, although preterm birth rate was similar between the groups. The previous oligohydramnios group had a significantly higher incidence of oligohydramnios in second delivery, aOR 3.37, 95%CI 1.89-6.00, small for gestational age neonates, aOR 1.94, 95% CI 1.16-3.25, and overall placental related disorders of pregnancy, aOR 2.13, 95%CI 1.35-3.35. CONCLUSION: Pregnancies complicated by isolated oligohydramnios are associated with an increased risk of placental related disorders in subsequent pregnancy. Isolated oligohydramnios may be the first sign of placental insufficiency and an independent manifestation of the placental related complications spectrum.

Placental vascular lesions differ between male and female fetuses in early-onset preeclampsia.

PURPOSE: A growing body of evidence accumulate pointing to sex-specific differences in placental adaptation to pregnancy complications. We aimed to study if there is a difference in placental histopathology lesions, between female and male fetuses in pregnancies complicated with preeclampsia. METHODS: The medical files of all patients with preeclampsia, were reviewed. Placental lesions were classified to lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. Comparison was performed between the male and the female groups. RESULTS: The study included 441 preeclamptic patients. Women in the male preeclampsia group (n = 225) had higher rate of chronic hypertension (p = 0.05) and diabetes mellitus (p < 0.005), while women in the female preeclampsia group (n = 216) had higher rate of thrombophilia. There were no between groups differences in neonatal outcome or placental histopathology lesions. The early preeclampsia cohort included 91 patients. Placentas from the female early preeclampsia group (n = 44) had more vascular changes related to MVM lesions (decidual arteriopathy), as compared to the male early preeclampsia group (n = 47), 50% vs. 25%, p = 0.01. CONCLUSIONS: Higher rate of placental MVM lesions in the female as compared to male group correspond with sex-specific difference of placental pathophysiological adaptation, in early preeclampsia.

Comparison of sonographic fetal weight estimation formulas in patients with preterm premature rupture of membranes.

BACKGROUND: Estimation of fetal weight (EFW) by ultrasound is useful in clinical decision-making. Numerous formulas for EFW have been published but have not been validated in pregnancies complicated by preterm premature rupture of membranes (PPROM). The purpose of this study is to compare the accuracy of EFW formulas in patients with PPROM, and to further evaluate the performance of the most commonly used formula - Hadlock IV. METHODS: A retrospective cohort study of women with singleton gestations and PPROM, admitted to a single tertiary center between 2005 and 2017 from 220/7-330/7 (n = 565). All women had an EFW within 14 days of delivery by standard biometry (biparietal diameter, head circumference, abdominal circumference and femur length). The accuracy of previously published 21 estimated EFW formulas was assessed by comparing the Pearson correlation with actual birth weight, and calculating the random error, systematic error, proportion of estimates within 10% of birth weight, and Euclidean distance. RESULTS: The mean gestational was 26.8 ± 2.4 weeks at admission, and 28.2 ± 2.6 weeks at delivery. Most formulas were strongly correlated with actual birth weight (r > 0.9 for 19/21 formulas). Mean systematic error was - 4.30% and mean random error was 14.5%. The highest performing formula, by the highest proportion of estimates and lowest Euclidean distance was Ott (1986), which uses abdominal and head circumferences, and femur length. However, there were minimal difference with all of the first 10 ranking formulas. The Pearson correlation coefficient for the Hadlock IV formula was strong at r = 0.935 (p < 0.001), with 319 (56.5%) of measurements falling within 10%, 408 (72.2%) within 15% and 455 (80.5%) within 20% of actual birth weight. This correlation was unaffected by gender (r = 0.936 for males, r = 0.932 for females, p < 0.001 for both) or by amniotic fluid level (r = 0.935 for mean vertical pocket < 2 cm, r = 0.943 for mean vertical pocket ≥2 cm, p < 0.001 for both). CONCLUSIONS: In women with singleton gestation and PPROM, the Ott (1986) formula for EFW was the most accurate, yet all of the top ten ranking formulas performed quite well. The commonly used Hadlock IV performed quite similarly to Ott's formula, and is acceptable to use in this specific setting.

Should the interval between doses of antenatal corticosteroids be shortened in certain cases? Factors predicting preterm delivery < 48 h from presentation.

PURPOSE: Treatment with antenatal corticosteroids (ACS) to women at risk for preterm birth (PTB) is associated with a reduction in adverse neonatal outcomes. Obstetricians occasionally shorten the interval between the doses of steroids if delivery is predicted to occur before ACS are fully administered. In this study, we aimed to investigate predicting factors to identify patients that will deliver prematurely, less than 48 h from presentation. METHODS: The computerized medical files of all PTBs (< 34 weeks) were reviewed. Maternal demographics, pregnancy and delivery characteristics were compared between PTB that occurred < 48 h vs. > 48 h from triage presentation. RESULTS: In total, 494 PTB cases were included: 302 women in the study group (PTB < 48 h) and 192 women in the control group (PTB > 48 h). No significant differences were found in demographic characteristics between the groups. At presentation, the study group had higher rates of uterine contractions (p < 0.001) and cervical length < 25 mm (p < 0.001) as well as a higher rate of non-reassuring fetal (NRFHR) monitor (p < 0.001). In contrast, the control group presented with higher rates of preeclampsia (p = 0.003) and preterm premature rupture of membranes (p = 0.038). In multivariable analysis, all of the above factors remained significant after controlling for background confounders. CONCLUSIONS: Various factors at presentation can predict delivery < 48 h. These factors can be used to predict patients to whom the ACS interval should be shortened. Future prospective studies should investigate the effect of this shortening on neonatal outcomes.

The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study.

BACKGROUND: The association between the number of vaginal examinations (VEs) performed during labor and the risk of infection is unclear. The literature regarding this issue is not consensual, and the available studies are relatively small. Therefore, we aimed to study the association between the number of VEs during labor, and maternal febrile morbidity, in a very large cohort. METHODS: This is a retrospective cohort study. All women who delivered vaginally ≥37 weeks, at our institute, between 2008 and 2017 were included. Patients who underwent cesarean delivery or who were treated with prophylactic antibiotics, or had a fever ≥38.0 °C prior to the first VE were excluded. Cases of intrauterine fetal death, known malformations, or missing data were excluded as well. The cohort was divided according to the number of VEs performed: up to 4 VEs (n = 9716), 5-6 VEs (n = 4624), 7-8 VEs (n = 2999), and 9 or more VEs (n = 4844). The rates of intrapartum febrile morbidity (intrapartum fever and chorioamnionitis), postpartum febrile morbidity (postpartum fever and endometritis), and peripartum febrile morbidity (any of the mentioned complications) were compared. RESULTS: Overall, 22,183 women were included in the study. On multivariate analysis, we found that performing 5 VEs or more during labor was independently associated with intrapartum febrile morbidity (5-6 VEs: aOR = 1.83, 95% CI (1.29-2.61), 7-8 VEs: aOR = 2.65 95% CI (1.87-3.76), 9 or more VEs aOR = 3.47 95% CI (2.44-4.92)), postpartum febrile morbidity (5-6 VEs: aOR = 1.29, 95% CI (1.09-1.86), 7-8 VEs: aOR = 1.94 95% CI (1.33-2.83), 9 or more VEs aOR = 1.91 95% CI (1.28-2.82)), and peripartum morbidity (5-6 VEs: aOR = 1.48, 95% CI (1.15-1.91), 7-8 VEs: aOR = 2.15 95% CI (1.66-2.78), 9 or more VEs: aOR = 2.57 95% CI (1.97-3.34)). CONCLUSION: The number of VEs performed during labor is directly correlated with febrile morbidity. Performing five or more VEs during labor is independently associated with febrile morbidity; For intrapartum and peripartum febrile morbidity the risk rises as more VEs are performed.

Reduced fetal movements at term in singleton low risk pregnancies-Is there an association with placental histopathological findings?

INTRODUCTION: Maternal perception of fetal movements has long been considered an indicator of fetal well-being. A sudden decrease in the number of fetal movements is suggestive of fetal compromise. We aimed to determine whether the maternal perception of reduced fetal movements (RFM) is associated with placental pathological lesions in a low-risk term population. MATERIAL AND METHODS: Our study was a case-control study that was performed in a single university center. Placental histopathology, maternal demographics, labor characteristics, and neonatal outcomes of term, singleton pregnancies with maternal perception of RFM during the 2 weeks prior to delivery were collected. To isolate the effect of RFM on placental pathology, we excluded cases complicated by preterm birth, hypertensive disorders, diabetes mellitus, small-for-gestational-age and congenital/genetic anomalies. We compared pregnancy outcomes and placental pathology between the RFM group and a control group matched for gestational age and mode of delivery. Placental lesions were classified according to the "Amsterdam" criteria. Composite adverse neonatal outcome was defined as one or more of the following: sepsis, transfusion, hypoglycemia, phototherapy, respiratory morbidity, cerebral morbidity, necrotizing enterocolitis and fetal/neonatal death. Multivariable regression analysis was performed to identify independent associations with adverse neonatal outcome. RESULTS: We included patients who gave birth from January 2008 until May 2019. The study group included 203 term pregnancies with RFM during the 2 weeks prior to delivery, which was matched with 203 controls. The RFM group was characterized by a higher rate of placental weight <10th percentile (22.6% vs. 3.9%, P < .001), a higher rate of maternal vascular malperfusion lesions (30.5% vs. 18.7%, P = .007) and lesions of maternal inflammatory response (43.3% vs. 29.5%, P = .005). At delivery, the RFM group had higher rates of cesarean delivery due to non-reassuring fetal heart rate monitoring (P = .01), 5-minute Apgar score ≤7 (P = .03), neonatal intensive care unit admissions (P < .001) and composite adverse neonatal outcomes (P = .007). Using multivariable analysis, RFM (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.1-4.8), and placental maternal vascular malperfusion lesions (aOR 1.2, 95% CI 1.0-2.9) were independently associated with adverse neonatal outcome. CONCLUSIONS: After excluding important placental-related morbidities, RFM was associated with a higher rate of placental weight <10th percentile and placental maternal vascular malperfusion lesions vs. controls. This study suggests a placental involvement in the association between RFM at term and adverse pregnancy outcomes.

The effect of the implementation of institutional checklist on expert opinion of oxytocin use in labor.

PURPOSE: Oxytocin is a commonly used drug in the labor and delivery unit. There are wide variations in oxytocin use between countries and medical centers, which may reflect the lack of structured guidelines. The aim of our study was to evaluate the need of oxytocin checklist in labor and delivery unit, while assessing the management of oxytocin with and without such a checklist. METHODS: This study was conducted in a single, university-affiliated medical center in two phases: before and after the implementation of an oxytocin checklist in the labor and delivery unit (2016-2017). Six experts reviewed cardiotocographs of deliveries performed in an urgent Cesarean delivery due to non-reassuring fetal heart rate, after completing at least 4 h of oxytocin infusion for induction or augmentation of labor. The experts included three obstetricians, a midwife, and two obstetrical expert nurses, who were tasked to conclude whether oxytocin was managed properly or not. Each case was reviewed by two reviewers separately. A total of 100 cases were reviewed; 50 before the oxytocin checklist implementation, and 50 after that implementation. RESULTS: We did not find a difference in the reviewers' assessment of oxytocin management before and after the institutional implementation of the checklist. Additionally, there were significant inconsistencies and inter-observer variations in their assessment before and after the checklist implementation. CONCLUSION: The implementation of an institutional oxytocin checklist did not affect expert assessment of the use of oxytocin in labor.

Placental pathology in pregnancies complicated by fetal growth restriction: recurrence vs. new onset.

OBJECTIVE: In an attempt to shed new light on the pathogenesis of fetal growth restriction (FGR), we aimed to study pregnancy characteristics, neonatal outcomes, and placental histopathological lesions of FGR pregnancies in two different subgroups: when developed after appropriate for gestational age (AGA) pregnancy and when developed after previous pregnancy with FGR. STUDY DESIGN: Pregnancy and placental reports of all singleton pregnancies complicated by FGR (defined as actual birthweight below the 10th percentile according to local birthweight nomograms) between 2008 and 2018 were reviewed. Included were only cases with previous delivery. Maternal background, neonatal outcomes, and placental histopathology were compared between FGR that occurred after FGR (recurrent FGR group) and FGR that occurred after an AGA pregnancy (FGR after AGA group). Placental lesions were classified according to the current "Amsterdam" criteria. Continuous variables were compared using the Student's t test or the Mann-Whitney test as appropriate. Categorical variables were compared using Chi-square or Fisher's exact test as appropriate. RESULTS: A total of 334 FGR cases with a previous delivery were included in the study. Of them, 111 cases constituted the recurrent FGR group and 223 constituted the FGR after AGA group. The recurrent FGR group was characterized by higher rates of maternal diabetes during pregnancy and hypertensive diseases (9% versus 2.7%, p = 0.01 and 19.8% versus 11.6%, p = 0.04). The FGR after AGA group was characterized by a higher rate of fetal vascular malperfusion (FVM) lesions (29.6% versus 18.0%, p = 0.02), and by lower mean birthweight (1842 ± 424.9 versus 1977.4 ± 412.2, p = 0.005), as compared to the recurrent FGR group. CONCLUSION: Recurrent FGR was associated with maternal background morbidities during pregnancy which represents a chronic repeated insult, while "new" FGR cases (those followed an AGA pregnancy) were characterized by a higher rate of FVM lesions and lower birthweight which probably represent an "accident" in placentation. These findings may suggest that different mechanisms of placental dysfunction exist in the two subgroups of FGR.

Reduced fetal movements at term, low-risk pregnancies: is it associated with adverse pregnancy outcomes? Ten years of experience from a single tertiary center.

OBJECTIVE: We aimed to assess the outcomes of low-risk pregnancies complicated by isolated reduced fetal movements (RFM) at term. STUDY DESIGN: The study population were patients at term, with singleton, low-risk, pregnancies who presented to our obstetric-triage and delivered during the subsequent 2 weeks. The study group included patients with an isolated complaint of RFM (RFM group). The control group included patients without history of RFM (control group). The pregnancy, delivery, and neonatal outcomes were compared between the groups. Severe and mild composites of adverse neonatal outcomes were defined. Multivariate regression analyses were performed to identify independent association with adverse neonatal outcomes. RESULTS: Among the 13,338 pregnant women, 2762 (20.7%) were included in the RFM group and 10,576 (79.3%) in the control group. The RFM group had higher rates of nulliparity (p < 0.001), and smoking (p < 0.001). At admission, the RFM group had higher rates of IUFD (p < 0.001). The RFM group had higher rates of Cesarean delivery due to non-reassuring fetal monitor (p < 0.001), and mild adverse neonatal outcomes (p = 0.001). RFM was associated with mild adverse outcome independent of background confounders (aOR = 1.4, 95% CI 1.2-2.6, p < 0.001). CONCLUSION: Patients presented with isolated RFM at term had higher rates of IUFD at presentation and significant adverse outcomes at delivery.

The association between the number of vaginal examinations during labor and perineal trauma: a retrospective cohort study.

PURPOSE: To study the association between the number of vaginal examinations (VEs) performed during labor and subsequent severe perineal trauma. METHODS: This is a retrospective cohort study. We included all women admitted to the delivery ward between 2008 and 2017, in active labor. Exclusion criteria included preterm deliveries (< 37 weeks), Cesarean deliveries and episiotomy during delivery. The primary outcome, severe perineal trauma, was defined as perineal tears grades 3-4. The cohort was divided into 4 groups, based on the number of VEs performed during labor: Group 1-up to two VEs (n = 4588), Group 2-three to four VEs (n = 5815), Group 3-five to six VEs (n = 4687), and Group 4-seven or more VEs (n = 7297). RESULTS: Overall, 22,387 women were included in the study. The rate of severe perineal trauma in groups 1, 2, 3 and 4 was 0.4%, 0.1%, 0.8%, and 0.4%, respectively (p < 0.001). Performing five or more VEs during labor was associated with a higher risk of severe perineal trauma (0.26% vs. 0.53%, p < 0.01), as compared to four VEs or less. Using a logistic regression model, we found that performing five or more VEs during labor (aOR = 1.72 CI 95% (1.21-2.47), p < 0.001) or performing an instrumental delivery (aOR = 2.65 CI 95% (1.72-4.07), p < 0.001) were directly associated with the risk for severe perineal trauma. Applying epidural anesthesia showed an inverse association with severe perineal trauma (aOR = 0.54 CI 95% (0.38-0.77), p < 0.001). CONCLUSION: Performing five or more VEs during active labor is associated with an increased risk for severe perineal trauma.

Is advanced maternal age associated with placental vascular malperfusion? A prospective study from a single tertiary center.

PURPOSE: Pregnancy at advanced maternal age (AMA) has become more common. There has been concern regarding the adverse effect deferring pregnancy might have on pregnancy outcomes. We aimed to prospectively study the effect of AMA on placental pathology. METHODS: A prospective case-control study was performed in a single university center. Placental histopathology, maternal demographics, labor characteristics, and neonatal outcomes of pregnancies with AMA were collected and compared to matched controls. We defined AMA as maternal age > 35 years at delivery. In attempt to isolate the effect of maternal age, we excluded cases complicated by preterm birth, hypertensive disorders, diabetes mellitus, small for gestational age, and congenital/genetic anomalies. RESULTS: The study group included 110 AMA patients that were matched with controls. The groups did not differ in maternal demographics, but the AMA group had a higher rate of assisted reproductive technologies (ART) as compared to the control group (p < 0.001). Placentas in the AMA group were characterized by a higher rate of maternal vascular lesions (MVM) (39.1% vs. 24.5%, p = 0.003), but not fetal vascular malperfusion lesions (p = 0.576). In multivariable analysis maternal age was associated with placental MVM lesions independent of all other maternal demographics (aOR 1.18 95% CI 1.06-3.17). Neonatal outcomes did not significantly differ between the groups. CONCLUSIONS: After excluding all background morbidities-AMA was associated with a higher rate of placental MVM lesions vs. controls. These findings suggest an independent effect of AMA on placental function. Large prospective trials are needed to study the clinical importance of these findings.

[PLACENTAL PATHOLOGY - IS IT JUST THE "BLACK BOX" OF PREGNANCY OR CAN IT SERVE AS A "CRYSTAL BALL" TO PREDICT RECURRENCE OF PREGNANCY COMPLICATIONS?]

INTRODUCTION: Analysis of placental histopathology lesions may assist in a better understanding of the underlying mechanisms that lead to different clinical phenotypes in complicated pregnancy. Categorization of placental lesions provide us with a tool to determine the placental reaction and adaptation to abnormal placentation that occurs during pregnancy complications. Placental pathology has traditionally been the "black box" of pregnancy. The associations between placental histopathology and pregnancy complications have been studied comprehensively. After more than a decade of experience in collecting detailed placental pathological reports from various pregnancy complications, we looked for placental characteristics that could serve as predictors in patients with recurrence of pregnancy complications. It was found that in cases of preeclampsia, intrauterine growth restriction and preterm birth, prediction models involving placental pathology performed better than models based only on clinical factors. The placenta histopathology reports should be used not only as records from the "black-box of pregnancy" but more as records from the "crystal ball" for future pregnancies.