Trend Changes in the individual contribution of risk factors for postpartum hemorrhage over more than two decades.

OBJECTIVE: Postpartum hemorrhage is an obstetric emergency with a rising incidence. The aim of this study was to identify trends in the specific contribution of various risk factors for postpartum hemorrhage by observing their odds ratios throughout different time periods. STUDY DESIGN: In this population-based retrospective cohort study trends of change in odds ratios for known risk factors for postpartum hemorrhage occurring in three consecutive eight-year intervals between 1988 and 2014 were compared. Two multivariable logistic regression models were used in order to identify independent risk factors for postpartum hemorrhage in our population. Trends of various risk factors were compared along the time period of the study. RESULTS: The incidence of postpartum hemorrhage increased from 0.5% to 1988 to 0.6%. Using logistic regression models, preeclampsia, vacuum extraction delivery, retained placenta, perineal or vaginal tears and delivery of a large for gestational age neonate were recognized as independent risk factors for postpartum hemorrhage. While the odds ratios for perineal or vaginal tears significantly increased, odds ratios for delivery of a large for gestational age neonate significantly decreased. Odds ratios for the other risk factors did not change significantly. CONCLUSION: In our study, not only did the rates of statistically significant risk factors for postpartum hemorrhage change during the study period, the specific contribution of each risk factor changed as well. Having a better understanding of these trends might augment our ability to predict this grave obstetric complication and improve maternal outcomes in the future.

Temporal decline in the improved detection rates following OASIS workshops.

INTRODUCTION AND HYPOTHESIS: To evaluate the long-term sustainability of the effect of a hands-on workshop on the diagnosis of deliveries complicated by obstetrical anal sphincter injuries (OASIS). METHODS: A population-based retrospective cohort study looking over a 4-year period, 1 year before and 3 years after an OASIS workshop. All deliveries that took place at the Soroka University Medical Center during the study period were included. Data were collected from the obstetrical electronic database. Interrupted time series analysis assessing the change in the OASIS detection rate over time from the workshop was conducted, assuming that the OASIS rate remained constant during the study period. RESULTS: During the study period, 147 parturients suffered from OASIS. The baseline characteristics of the patients before and after the workshop did not differ. In the year following the workshop a significant increase in the detection rate was noted compared with the year prior to the workshop. In an interrupted time series analysis, the improved detection rate declined with time. In the last year following the workshop the detection rate declined, almost reaching the pre-workshop rate. CONCLUSIONS: Attending an OASIS workshop increases the detection rate in the year following the workshop but declines gradually. To maximize its benefits, the workshop must be repeated periodically.

Trends of changes in the specific contribution of selected risk factors for shoulder dystocia over a period of more than two decades.

Objectives Shoulder dystocia (SD) is an obstetrical emergency with well-recognized risk factors. We aimed to identify trends of changes in the specific contribution of risk factors for SD over time. Methods A nested case control study comparing all singleton deliveries with and without SD was undertaken. A multivariable logistic regression model was used in order to identify independent risk factors for SD and a comparison of the prevalence and the specific contribution (odds ratio (OR)) of the chosen risk factors in three consecutive eight-year intervals from 1988 to 2014 was performed. Results During the study period, there were 295,946 deliveries. Of them 514 (0.174%) were complicated with SD. Between 1988 and 2014 the incidence of SD has decreased from 0.3% in 1988 to 0.1% in 2014. Using a logistic regression model grandmultiparity, diabetes mellitus (DM), fetal weight, and large for gestational age (LGA) were found to be independent risk factors for SD (OR 1.25 95% CI 1.04-1.51, p=0.02; OR 1.53 95% CI 1.19-1.97, p=0.001; OR 1.002 95% CI 1.001-1.002, p < 0.001; OR 3.88 95% CI 3.09-4.87, p < 0.001; respectively). While the OR for grandmultiparity, fetal weight, and LGA has significantly changed during the study period with a mixed trend, the OR of DM has demonstrated a significant linear increase over time. Conclusions The individual contribution of selected risk factors for the occurrence of SD has significantly changed throughout the years. The contribution of DM has demonstrated a linear increase over time, emphasizing the great impact of DM on SD.

Peritoneal adhesions do not increase intra-operative organ injury or adverse neonatal outcomes during a repeated cesarean delivery.

PURPOSE: To examine whether the presence of peritoneal adhesions at the second cesarean delivery (CD), attributable to the first CD, are associated with maternal intra-operative organ injury and adverse neonatal outcomes. METHODS: A retrospective cohort study was conducted, comparing severe maternal intra-operative organ injury and adverse neonatal outcomes, between women with and without peritoneal adhesions. All women with two CDs during the follow-up period were included. Women with adhesions diagnosed during the first CD, history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies and newborns with known chromosomal or structural abnormalities were excluded, resulting in 7925 women. Intra-operative peritoneal organ injury was defined as a composite of bladder injury, ureteral injury, small bowel injury or hysterectomy. The examined adverse neonatal outcomes were low 1 and 5 min Apgar scores, intrapartum death (IPD) and postpartum death (PPD). Multivariate logistic regression was performed. RESULTS: Peritoneal adhesions at the second CD, attributable to the first CD were diagnosed in 32.6% of patients (n = 2581). The presence of peritoneal adhesions was not found to be independently associated with intra-operative organ injury nor with 5 min Apgar scores, IPD and PPD. Second CDs complicated with adhesions were found to be associated with low (< 7) 1 min Apgar scores (adjusted OR 1.38, CI 1.20-1.58, p < 0.001). CONCLUSION: Adhesions attributable to a previous CD do not seem to increase the risk for intra-operative organ injury and adverse neonatal outcomes. These findings may assist in reassuring patients who are facing a second CD.

The use of metronidazole in women undergoing obstetric anal sphincter injuries: a systematic review of the literature.

PURPOSE: Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. STUDY DESIGN: To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. RESULTS: The electronic database search yielded a total of 54,356 results (Fig. 1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.

Correction to: Trends of change in the individual contribution of risk factors for small for gestational age over more than 2 decades.

In the original article published, the name of the corresponding author is published incorrectly.

Trends of change in the individual contribution of risk factors for small for gestational age over more than 2 decades.

PURPOSE: Over the past years, the prevalence of various risk factors for small for gestational age (SGA) neonates has changed. Little is known if there was also a change in the specific contribution of these risk factors to the prevalence of SGA. We aim to identify trends in the specific contribution of various risk factors for SGA by observing their odds ratios (ORs) throughout different time periods. METHODS: A nested case-control study was conducted. The ORs for selected known risk factors for SGA occurring in three consecutive 8-year intervals between 1988 and 2014 (T1 - 1988-1996; T2 - 1997-2005; T3 - 2006-2014) were compared. Data were retrieved from the medical centre's computerized perinatal database. Multivariable logistic regression models were constructed and ORs were compared to identify the specific contribution of independent risk factors for SGA along the study period. RESULTS: During the study period, 285,992 pregnancies met the study's inclusion criteria, of which 15,013 (5.25%) were SGA. Between 1988 and 2014, the incidence of SGA increased from 2.6% in 1988 to 2.9% in 2014. Using logistic regression models, nulliparity, maternal age, gestational age, hypertensive disorders of pregnancy, oligohydramnios and pre-gestational diabetes mellitus were found to be independently associated with SGA. While the adjusted ORs (aOR) of hypertensive disorders of pregnancy and pre-gestational diabetes mellitus had increased, aORs for nulliparity, maternal age and gestational age had remained stable over time. Oligohydramnios had demonstrated a mixed trend of change over the time. CONCLUSION: In our study, the specific contribution of factors associated with SGA had changed over time. Having a better understating of the changes in the specific contribution of different risk factors for SGA may enable obstetricians to provide consultations.

Long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse: a systematic review.

PURPOSE: To focus attention on the long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse. METHODS: A systematic review was conducted including only studies with mean follow-up ≥ 5 years. We searched using combinations of the following keywords and text words: "episiotomy", "perineal laceration", "perineal tear", "perineal damage" and "long term", "long term outcomes", "prolapse", "pelvic organ prolapse", "pelvic floor", "pelvic floor dysfunction", "urinary incontinence", "hysterocele", "cystocele" and "rectocele". RESULTS: The electronic database search provided a total of 6154 results. After exclusions, 24 studies were included yielding the following results: (1) episiotomy might be detrimental with respect to urinary incontinence symptoms; (2) the relationship between episiotomy and anti-incontinence surgery is not clear; (3) episiotomy does not seem to negatively influence genital prolapse development and might even be protective with respect to prolapse severity and prevalence; (4) episiotomy does not seem to affect genital prolapse surgery rate. CONCLUSIONS: We did not find evidence for a long-term beneficial effect of episiotomy in the prevention of urinary incontinence symptoms and anti-incontinence surgery. Episiotomy does not seem to negatively influence genital prolapse development and might even be protective with respect to prolapse severity and prevalence without affecting surgery rates.

Recovery from pelvic floor dysfunction symptoms in the postpartum is associated with the duration of the second stage of labor.

PURPOSE: Pregnancy and labor are known risk factors for pelvic floor dysfunction (PFD). Yet not much is known regarding recovery from PFD. We hypothesized that the recovery from PFD during the postpartum period would be associated with the duration of the second stage of labor (SSL). METHODS: We conducted a case-control study of patients who gave birth at the Soroka University Medical Center, Beer-Sheva, Israel. Those who consented completed the Pelvic Floor Distress Inventory-20 (PFDI-20), a questionnaire developed to measure the extent of injury to the pelvic floor, after delivery and 3-month postpartum. The difference between the scores was calculated, representing recovery of symptoms. The duration of the SSL, and clinical and obstetrical characteristics were retrieved from the patients' medical records. Wilcoxon rank test was used, assessing the significance of the recovery. The association between the degree of the recovery and the duration of SSL was tested using Mann-Whitney ranking. RESULTS: A total of 92 patients completed the PFDI-20 after delivery and 3-month postpartum. We found a significant difference between PFD symptoms during pregnancy and 3-month postpartum (P < 0.001). This difference remained consistent in all components of the PFDI-20. In addition, a more profound recovery of colorectal and anal dysfunction (CRAD) symptoms was associated with a shorter duration of the SSL (P = 0.03). CONCLUSIONS: There is a statistically significant recovery of PFD symptoms in the postpartum period. Furthermore, greater recovery from CRAD symptoms is associated with a shorter duration of the SSL.

Independent association between uterine malformations and cervical insufficiency: a retrospective population-based cohort study.

OBJECTIVE: The purpose of our study was to explore maternal and fetal outcomes in the second and third trimester in women with uterine malformations. STUDY DESIGN: This was a retrospective population-based cohort study including women with a diagnosis of uterine malformation arised from workup for infertility or recurrent pregnancy loss, was accidental during pregnancy, or was noticed at the time of cesarean delivery. RESULTS: A total of 280,721 pregnancies met the inclusion criteria and were divided into two study groups: (1) pregnancies in women with uterine malformations (n = 1099); and (2) controls (n = 279,662). The rate of women presenting uterine malformations was 0.39%. The prevalence of cervical os insufficiency was significantly higher in women with a uterine malformation than in the control group (3.6 vs. 0.4%, p < 0.001). A multivariate analysis, performed to evaluate risk factors for cervical insufficiency in women with uterine malformations. Mullerian anomalies (OR 6.19, 95% CI 4.41-8.70, p < 0.001), maternal age (OR 1.05, 95% CI 1.04-1.06, p < 0.001), recurrent abortions (OR 12.93, 95% CI 11.43-14.62, p < 0.001), and ethnicity (OR 2.86, 95% CI 2.454-3.34, p < 0.001) were found to be independently associated with the development of cervical insufficiency. CONCLUSION: Uterine anomalies have a strong association with cervical insufficiency. Women with uterine anomalies have an increased risk to develop pregnancy complications that arise from a loss in cervical function during the midtrimester or early third trimester.

Native tissue repair for central compartment prolapse: a narrative review.

Central descent due to a level 1 defect is a main component in pelvic organ prolapse (POP) reconstructive surgery, whether for symptomatic apical prolapse or for the prolapse repair of other compartments. A recent growth in the rate of native tissue repair procedures for POP, following the US Food and Drug Administration (FDA) warnings regarding the safety and efficacy of synthetic meshes, requires a re-evaluation of these procedures. The safety, efficacy, and determination of the optimal surgical approach should be the center of attention. Functional outcome measures and patient-centered results have lately gained importance and received focus. A comprehensive literature review was performed to evaluate objective and subjective outcomes of apical prolapse native tissue repair, with a special focus on studies reporting impact on patients' functional outcomes, quality of life, and satisfaction. We performed a MEDLINE search for articles in the English language by using the following key words: apical prolapse, sacrospinous ligament fixation, uterosacral ligament suspension, sacral colpopexy, McCall culdoplasty, iliococcygeus vaginal fixation, and functional outcomes. We reviewed references as well. Despite a prominent shortage of studies reporting standardized prospective outcomes for native tissue repair interventions, we noted a high rate of safety and efficacy, with a low complication rate for most procedures and low recurrence or re-treatment rates. The objective and subjective results of different procedures are reviewed. Functional outcomes of native tissue repair procedures have not been studied sufficiently, though existing data present those procedures as favorable and not categorically inferior to sacrocolpopexy. Apical compartment prolapse repair using native tissue is not a compromise. Functional outcomes of native tissue repair procedures are favorable, have a high rate of success, improve women's quality of life (QoL), and result in high rates of patient satisfaction. This subject requires further long-term, standardized prospective studies following the International Continence Society/International Urogynecologists Association guidelines for surgical outcomes report, with the focus on patient-centered functional outcomes.

Safety and short term outcomes of a new truly minimallyinvasive mesh-less and dissection-less anchoring system for pelvic organ prolapse apical repair.

OBJECTIVE: To evaluate the safety and short term outcomes of a new, truly minimallyinvasive, mesh-less and dissection-less anchoring system for pelvic floor apical repair. METHODS: A prospective study was conducted using the NeuGuide™ device system for pelvic floor apical repair. The primary effectiveness outcome was centro-apical pelvic floor prolapse by POP-Q after six months. The primary safety outcome was intra-operative, immediate (first 48 h) post-operative complications and adverse effects after six months. A standardized questionnaire (UDI-6) to assess quality of life at entry and during follow-up visits was used. Patients' six months-follow-up and evaluation are reported. RESULTS: The mean age of the study population (n=10) was 63.8±12.0 years. All patients had a previous prolapse surgery. Five had a previous hysterectomy and two had stress urinary incontinence symptoms. During surgery six patients had a concurrent colporrhaphy. There was no injury to the bladder, rectum, pudendal nerves, or major pelvic vessels and no febrile morbidity was recorded. At six months, no cases of centro-apical recurrence were noted. Patients were satisfied with the procedure and had favorable quality of life scores. Using the UDI-6 questionnaire an improvement, in all domains was seen. Moreover, although the sample size was small, the improvement in urge and overflow incontinence related domains were demonstrated to be statistically significant. CONCLUSIONS: This new NeuGuide™ device allows rapid and safe introduction of a suspending suture through the sacrospinous ligament and makes sacrospinous ligament fixation easy to perform, while avoiding dissection and mesh complications.

Superimposed versus de novo pre-eclampsia: Is there a difference?

OBJECTIVE: To investigate whether pre-eclampsia is a single clinical entity or whether de novo pre-eclampsia and superimposed pre-eclampsia are distinct entities, with respect to baseline maternal characteristics, obstetrical complications, and perinatal outcomes. METHODS: A retrospective cohort study comparing singleton pregnancies complicated with de novo pre-eclampsia (n = 10 979, 93%) and superimposed pre-eclampsia (n = 804, 7%). Maternal baseline characteristics, pregnancy and labor complications, and neonatal outcomes were evaluated in the univariate analysis. Multivariable logistic regression models were performed for the prediction of different pregnancy outcomes while controlling for confounders. RESULTS: In the multivariate regression models controlling for confounders, superimposed pre-eclampsia was found to be a significant risk factor for placental dysfunction, a composite outcome composed of severe pre-eclampsia (rather than mild), placental abruption, oligohydramnios, and small-for-gestational-age neonate (odds ratio [OR] 2.23, 95% confidence interval [CI] 1.90-2.62, P < 0.001), preterm delivery (OR 2.79, 95% CI 2.39-3.26, P < 0.001), and perinatal mortality (OR 1.79, 95% CI 1.11-2.88, P = 0.02). CONCLUSION: De novo and superimposed pre-eclampsia demonstrated significant differences in most studied variables, suggesting that these may be two distinct clinical syndromes. In our population, superimposed pre-eclampsia was found to be significantly associated with adverse pregnancy outcomes such as placental dysfunction, preterm delivery, and perinatal mortality compared with de novo pre-eclampsia.

Is there a correlation between pelvic floor dysfunction symptoms during pregnancy and the duration of the second stage of labor?

BACKGROUND: Pelvic floor dysfunction (PFD) most commonly results from weakened or injured muscles and ligaments whose purpose is to support the pelvic floor. Many studies have placed vaginal delivery and prolonged second stage of labor (SSL) as major risk factors for PFD, supposedly through generating enhanced pressure in the pelvic area. Although many studies describe the effects of vaginal delivery and labor on structure and function of the pelvic floor, not much is known regarding PFD deriving from pregnancy and its prevalence and severity in the postpartum. We aimed to evaluate whether a correlation exists between PFD symptoms during pregnancy and the duration of the SSL. METHODS: We conducted a cross sectional study of 200 women who gave birth at Soroka University Medical Center, Beer-Sheva, Israel. Those who had consented completed the Pelvic Floor Distress Inventory-20 (PFDI-20), a condition specific questionnaire developed to measure quality-of-life and the extent of injury to the pelvic floor in women with all forms of PFD. The duration of the SSL and clinical and obstetrical characteristics were retrieved from the participants' medical records. We assessed correlations using Spearman's correlation coefficient. RESULTS: PFD during pregnancy was found to be correlated to the duration of the SSL (R = -0.183, p = .021). When evaluating each component of the PFDI-20 separately, CRAD was significantly correlated with the duration of the SSL (R = -0.195, p = .014). CONCLUSIONS: There is a correlation between PFD symptoms during pregnancy, specifically symptoms of CRAD and the duration of the SSL.

Easily generated hematological biomarkers and prediction of placental abruption.

OBJECTIVE: Placental abruption (PA) is associated with adverse maternal and neonatal outcomes. Increasing evidence has shown an association between abruption and inflammation as well as utilization of hematological biomarkers to predict the later. We aimed to evaluate the feasibility of using neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ration (PLR) taken early in pregnancy in predicting later occurrence of PA. STUDY DESIGN: A nested case control study, which compared parturient with PA (cases) to parturient without PA (controls). Parturient were matched by hospitalization date and maternal age. Demographic, clinical, and obstetrical characteristics were retrieved. Hematological indices derived from complete blood count taken during the first trimester of pregnancy, specifically NLR and PLR were retrieved and compared between the groups. Mann-Whitney and T-test were performed for not normally and normally distributed continuous variables respectively, categorical variables were analyzed using Chi-Square or Fisher Exact test as appropriate. RESULTS: The study comprised of 232 patients. Of these, 131 had suffered from PA and 131 without PA. Parturient who had PA has significantly higher rates of hypertensive disorders of pregnancy, mean neutrophil, lymphocyte and platelet count did not differ between the groups. A comparison of NLR and PLR between the study groups yielded no significant differences. CONCLUSION: NLR and PLR taken early in the course of pregnancy were not found associated with PA. Given the potentially severe consequences of PA, the biological plausibility and the readiness of these hematological markers, further investigation of this method with larger, prospective studies are needed.

Third stage of labor placental complications and placenta-associated syndromes.

OBJECTIVE: To evaluate the association between third stage placental complications and placental insufficiency associated disorders, also known as, placenta associated syndromes. STUDY DESIGN: A population-based retrospective cohort study comparing placental-related perinatal outcomes of parturient with (study group) and without third stage placental complications, defined as a composite of retained placenta, adherent placenta, placenta accrete, need for manual removal of the placenta, postpartum curettage and revision of the uterine cavity. A univariate analysis was followed by a multivariable logistic regression model. RESULTS: During the study period, 263,023 deliveries met inclusion criteria, of which, 10,281 (3.9%) experienced placental complications during the third stage of labor. Parturient in the study group had significantly higher rates of placental insufficiency associated disorders which included among others: hypertensive disorders of pregnancy (6.5 versus 5.6%, p < .001), stillbirth (1.9 versus 0.7%, p < .001) and preterm delivery (9.9 versus 7.7%, p < .001). Using a multivariable regression model, while controlling for confounders such as maternal age and induction of labor, third stage placental complications were independently associated with placental insufficiency associated disorders. CONCLUSION: Our findings suggest that placental associated adverse pregnancy outcomes and third stage placental complications may represent different manifestations of a common pathological or inadequate placentation process.

Adhesion barriers and topical hemostatic agents are risk factors for post-cesarean section infections.

BACKGROUND: Cesarean sections are the most common surgery worldwide, and post-cesarean section infections and hemorrhage are a major cause for morbidity and mortality. In recent years, many surgeons use adhesion barriers as well as hemostatic agents during primary and repeated cesarean section. The data regarding the safety of these agents is relatively limited. The objective of this study was to investigate whether the use of adhesion barriers and topical hemostatic agents pose a risk for post-cesarean section infections. METHOD: A case-control study composed of women who were admitted to the Soroka University Medical Center between the years 2012 and 2016 was conducted. The study group was composed of women admitted owing to post-cesarean section infections (cases) and those who underwent cesarean sections without post-cesarean section infection (control subjects). Matching was done according to date and surgery setting (elective versus emergency). A univariate analysis was followed by a multiple regression model in order to examine the association between adhesion barriers/hemostatic agents and post-cesarean section infections. RESULTS: During the study period, 113 patients developed postoperative infection (cases); 71.7% were diagnosed with surgical site infection, 7.1% with endometritis, and 21.2% with other infections. These were compared with 226 control subjects. In the univariate analysis, the use of adhesion barriers/hemostatic agents were found to be associated with post-cesarean section infection. Using a multivariable analysis controlling for previous cesarean section, skin closer technique, preterm delivery, and duration of surgery >60 minutes, the use of adhesion barriers as well as hemostatic agents was found to be independently associated with post-cesarean section infection (adjusted odds ratio = 2.11, 95% confidence interval = 1.17-3.84; adjusted odds ratio = 2.29, 95% confidence interval = 1.37-3.8, respectively) CONCLUSION: Adhesion barriers and hemostatic agents were found to be independently associated with post-cesarean section infections. Further larger studies are needed to reinforce our findings. The use of these materials should be carefully considered, and their cost-effectiveness re-examined.

Peritoneal adhesions during cesarean delivery are an independent risk factor for peri-partum hemorrhagic complications.

OBJECTIVE: To investigate whether the presence of peritoneal adhesions at the second cesarean delivery (CD) are associated with peri-partum hemorrhagic complications. STUDY DESIGN: A retrospective cohort study was undertaken, comparing hemorrhagic complications in the second CD, between women with and without adhesions. All women with two CDs who delivered a singleton in their second CD between the years 1988-2016 at a large regional medical center in Israel were included. Women with adhesions diagnosed at the first CD and women with a history of other abdominal or pelvic surgery, pelvic infection or inflammatory disease, endometriosis, uterine Mullerian anomalies and fetal chromosomal or structural abnormalities were excluded from the analysis, resulting in a sample of 7925 women. Peri-partum hemorrhagic complications were defined as a composite of vessel ligation, B lynch procedure during the CD or uterine rupture, third stage or immediate postpartum hemorrhage, blood component transfusion, hemorrhagic shock and maternal anemia [hemoglobin (Hb) levels prior to maternal discharge below 9.0 g\dl]. In order to identify variables that are independently associated with the composite peri-partum hemorrhagic complications a multivariate logistic regression analysis was performed, to control for potential confounders. In addition, a linear regression model was constructed with Hb levels as the outcome variable. RESULTS: During the study period, 32.6 % of patients (n = 2581) suffered from adhesions during the second CD. After adjusting for potential confounders, peri-partum hemorrhagic complications were found to be significantly associated with the presence of peritoneal adhesions (adjusted OR 1.18, CI 1.04-1.33, P = 0.008). A multivariate linear regression analysis revealed that peritoneal adhesions were independently associated with a decline in post-partum Hb levels (ß=-0.055, P < 0.001). CONCLUSION: Adhesions attributable to a previous CD increase the risk for hemorrhagic complications. Interventions aimed at preventing adhesions formation during the primary CD may have a role in reducing hemorrhagic complications in subsequent CDs.

Early prediction of post cesarean section infection using simple hematological biomarkers: A case control study.

OBJECTIVE: We aimed to investigate whether the neutrophil to lymphocyte ratio (NLR) may assist in the prediction of post CS infections. STUDY DESIGN: This was a case control study performed at the Soroka University Medical Center, a large tertiary teaching medical center, between the years 2012-2016. Cases (post CS infection) were matched to controls (without post CS infection) in a proportion of 2:1. Matching was done according to surgery setting (elective vs. urgent) and date of surgery. Various demographic, clinical and obstetrical characteristics were collected. Laboratory tests that were taken 6-24 h postoperatively were compared between the study groups. Univariate analysis was followed by a multivariate one. Area under the curve was calculated for selected indices. RESULTS: During the study period 113 patients who developed postoperative infection were compared with 224 healthy controls. Among patients in the study group, 71.7 % were diagnosed with surgical site infection, 7.1 % with endometritis and 21.2 % with other infections. Total neutrophil and lymphocyte counts were significantly higher among patient in the study group. NLR as well as platelet to lymphocyte (PLR) ratio were significantly higher among patients during the first 24 postoperative hours. NLR and PLR were found to be independently associated with post CS infection controlling for surgery length, use of hemostatic agents/adhesion barrier and skin closure technique (aOR 1.11 95 % CI 1.06-1.17, aOR 1.004 95 % CI 1.001-1.006, respectively). A performance analysis for NLR showed an area-under-the receiver operating curve (AUC) of 67 % (P = 0.006). CONCLUSION: NLR is an easy readily available tool that may have a predictive value in early detection of post CS infection. Further studies are needed in order to support our findings before clinical implications of these findings can be recommended.