American Journal of Obstetrics and Gynecology, 2018
changes in respiratory physiology during pregnancy and concern for fetal-acid base status may int... more changes in respiratory physiology during pregnancy and concern for fetal-acid base status may interfere with LTVV strategy. This study assessed use of LTVV in pregnancy and identified maternal and fetal outcomes of mechanically ventilated pregnant patients with ARDS. STUDY DESIGN: This is a retrospective cohort study of women with ARDS who were mechanically ventilated for greater than 24 hours between January 2012 and February 2017 at a tertiary care center. ARDS was defined clinically, and LTVV was defined as weighted daily average tidal volume 8 mL/kg of ideal body weight. Pregnant patients (N¼23) had 128 days of ventilation, and non-pregnant patients (N¼681) had 3,174 days. Demographic, pregnancy and fetal outcome data were collected on pregnant patients. Compliance with LTVV was stratified by trimester, and groups compared with chisquared analysis. RESULTS: We had no maternal deaths and extracorporeal membrane oxygenation (ECMO) was used in 8.7% of patients (N¼2). Causes of ARDS included sepsis, pneumonia, and asthma exacerbation. Obstetric complications occurred frequently, with 21.7% (N¼5) experiencing preeclampsia, and 50.0% (N¼11) delivering preterm. Mean infant birth weight was 2348g AE 14.6. There were 3 perinatal demises (2 intrauterine, 1 neonatal). In pregnant and non-pregnant patients respectively, weighted average daily tidal volume was 7.8 ml/ kg AE1.2 and 7.27 ml/kg AE1.55, and overall LTVV use was 87.0% and 81.9%. LTVV was utilized in 93.3% of patients in the first, 85.1% in the second, and 71.0% in the third trimester. Use of LTVV in the third trimester was significantly less than the first and second (p¼0.05). CONCLUSION: Pregnant patients with ARDS encountered significant adverse maternal and fetal outcomes, with half delivering preterm and over 20% developing preeclampsia. LTVV use was comparable between pregnant and non-pregnant patients, but was utilized more frequently in the first and second trimesters compared to the third. Given the significant morbidity seen with ARDS in pregnancy, additional multi-center studies are needed to evaluate factors associated with increased utilization of LTVV, and the effect of LTVV on maternal and fetal outcomes.
International journal of gynaecology and obstetrics, Jul 29, 2021
ObjectiveTo explore the indirect impact of the COVID‐19 pandemic on patterns of pregnancy‐related... more ObjectiveTo explore the indirect impact of the COVID‐19 pandemic on patterns of pregnancy‐related venous thromboembolism (VTE) events, mediated by population mobility restrictions during lockdown periods.MethodsPregnancy‐related VTE hospitalizations were identified through a code‐targeted search of the Hadassah Medical Center's computerized database. A manual analysis of relevant medical records was performed, and cases diagnosed throughout the year 2020 were compared to those diagnosed during 2019 and 2018. Statistical analyses studied obstetrical outcomes, as well as the extent and treatment of VTE events during the COVID‐19 pandemic compared to those of preceding years, stratified by pre‐, intra‐, and post‐lockdown periods.ResultsThe incidence of pregnancy‐related thromboembolic events during 2020 was 0.16% of all deliveries, significantly higher than in 2018 and 2019 (0.06% and 0.1%, respectively; P < 0.05). Higher rates of VTE events were found during post‐lockdown periods in 2020, compared with corresponding time periods in 2019 and 2018.ConclusionThe present data suggest that lockdown periods impact pregnancy‐related VTE hospitalizations, possibly as a result of restricted population mobility. Increased awareness of this undesirable outcome may aid health policymakers in the continuing struggle with epidemics.
Research using artificial intelligence (AI) in medicine is expected to significantly influence th... more Research using artificial intelligence (AI) in medicine is expected to significantly influence the practice of medicine and the delivery of health care in the near future. However, for successful deployment, the results must be transported across health care facilities. We present a cross-facilities application of an AI model that predicts the need for an emergency caesarean during birth. The transported model showed benefit; however, there can be challenges associated with interfacility variation in reporting practices.
Background Rapid delivery is important in cases of umbilical cord prolapse to prevent hypoxic inj... more Background Rapid delivery is important in cases of umbilical cord prolapse to prevent hypoxic injury to the fetus/ neonate. However, the optimal decision-to-delivery interval remains controversial. Objective The aim of the study was to investigate the association between the decision-to-delivery interval in women with umbilical cord prolapse, stratified by fetal heart rate pattern at diagnosis, and neonatal outcome. Study design The database of a tertiary medical center was retrospectively searched for all cases of intrapartum cord prolapse between 2008 and 2021. The cohort was divided into three groups according to findings on the fetal heart tracing at diagnosis: 1) bradycardia; 2) decelerations without bradycardia; and 3) reassuring heart rate. The primary outcome measure was fetal acidosis. The correlation between cord blood indices and decision-to-delivery interval was analyzed using Spearman's rank correlation coefficient. Results Of the total 103,917 deliveries performed during the study period, 130 (0.13%) were complicated by intrapartum umbilical cord prolapse. Division by fetal heart tracing yielded 22 women (16.92%) in group 1, 41 (31.53%) in group 2, and 67 (51.53%) in group 3. The median decision-to-delivery interval was 11.0 min (IQR 9.0-15.0); the interval was more than 20 min in 4 cases. The median cord arterial blood pH was 7.28 (IQR 7.24-7.32); pH was less than 7.2 in 4 neonates. There was no correlation of cord arterial pH with decision-to-delivery interval (Spearman's Ρ = − 0.113; Ρ = 0.368) or with fetal heart rate pattern (Spearman's Ρ = .425; Ρ = .079, Ρ = − .205; Ρ = .336, Ρ = − .324; Ρ = .122 for groups 1-3, respectively). Conclusion Intrapartum umbilical cord prolapse is a relatively rare obstetric emergency with an overall favorable neonatal outcome if managed in a timely manner, regardless of the immediately preceding fetal heart rate. In a clinical setting which includes a high obstetric volume and a rapid, protocol-based, response, there is apparently no significant correlation between decision-to-delivery interval and cord arterial cord pH.
American Journal of Obstetrics and Gynecology, 2017
Pregnant women who experience diabetic screening with a 50g oral glucose tolerance test (OGTT) ha... more Pregnant women who experience diabetic screening with a 50g oral glucose tolerance test (OGTT) have reported acute symptoms of tachycardia, malaise and nausea. Our objective was to investigate whether significant changes in maternal blood levels of acute phase reactive inflammatory markers, oxidative stress and non-enzymatic protein glycosylation are modified following an acute glucose load to explain these symptoms. STUDY DESIGN: 100 non-fasting, consecutive pregnant women were prospectively allocated during the 2nd trimester to either 50g OGTT (study group, n¼50, GA median [range]: 26 [24-28] wks), or an equivalent volume of water [control (CRL), n¼50, GA: 22 [18-32] wks). Blood pressure and clinical symptoms (i.e. sweating, palpitations, anxiety) were monitored before intake and at 15 min. increments for one hour. Serum samples were collected immediately before and one hour after intake. IL-6, C-Reactive Protein (CRP), Advanced Glycation End Products (AGE), and soluble Receptor for Advanced Glycation End Products (sRAGE) were measured using sensitive and specific ELISA. Glucose concentration was assayed using the STANBIO liquicolor kit. Total serum anti-oxidative capacity was measured using the Total Anti-oxidant Capacity-Peroxyl (TACP) assay. RESULTS: 1) Following glucose or water intake, there was no significant change in blood pressure and frequency or intensity of monitored maternal clinical symptoms; 2) Compared to CRLs, the 50g OGTT women had a significant increase in their serum glucose levels (P<0.001); 3) A 50g OGTT may be associated with a minimal but significant increase in maternal blood CRP (P¼0.014); 4) There was no significant change in the serum anti-oxidant capacity, IL-6 or AGE levels following glucose load (P>0.05 for all); 5) Following correction for GA, race and parity there was no significant change in sRAGE (2-way RM ANOVA, P>0.05). CONCLUSION: The minimal increase in levels of CRP, but not IL-6, oxidative stress, and AGEs, suggests that during 2 nd trimester, a 50g OGTT load is safe and clinically well-tolerated.
American Journal of Obstetrics and Gynecology, 2018
associated with a 49% and 21% reduction in the odds of CD after adjustment for care model, matern... more associated with a 49% and 21% reduction in the odds of CD after adjustment for care model, maternal demographic and obstetric variables. The rate of multiparous women began to increase since 2013 with 40-45% of these women having had a prior CD. The CD rate was 54.4% in 2013 and 45.7% in 2016 accompanied by a rate of vaginal birth after cesarean from 0.8% to 5.1% (p-value for trend test <0.001). There were no significant changes in perinatal mortality, hypoxic ischaemic encephalopathy, meconium aspiration syndrome, birth trauma, respiratory distress syndrome, or necrotising enterocolitis in either group over time (all p>0.05). However, the frequency of neonatal infection and NICU admission increased from 2012 in the nulliparous group (p-value for trend test <0.001). CONCLUSION: A continued reduction in CD over time was observed after the termination of the one child policy. In nulliparous women this was primarily driven by a continued decrease in antepartum CD. Even among parous women a trend towards increasing vaginal delivery was seen, further underscoring the effectiveness of the multifaceted intervention to reduce CD.
American Journal of Obstetrics and Gynecology, 2018
¼11.15, p<.001; adjusted R 2 of 0.31), supporting that prepregnancy state has a strong influence ... more ¼11.15, p<.001; adjusted R 2 of 0.31), supporting that prepregnancy state has a strong influence on inflammation. CONCLUSION: DII score and fat mass were the strongest predictors of IL-6 levels, while LTPA remained nonsignificant. Diet and fat mass in early pregnancy are more predictive of inflammation later in pregnancy than late gestation diet and fat mass. The data suggest that behaviors and metabolic factors before or at the onset of pregnancy have a greater influence on inflammatory processes observed in pregnancy than do changes that occur during pregnancy. These data corroborate the overarching concept that the maternal prepregnancy metabolic condition is the baseline for the longitudinal metabolic changes during pregnancy.
American Journal of Obstetrics and Gynecology, 2018
long-term pediatric outcomes traditionally associated with dysbiosis of the neonatal microbiome. ... more long-term pediatric outcomes traditionally associated with dysbiosis of the neonatal microbiome. This suggests that differences in pediatric outcomes may be more dependant on postnatal exposures, rather than exposure at birth.
American Journal of Obstetrics and Gynecology, 2018
comparison to those delivered by VD (9.7% and 7.6%, p¼0.009). Factors that were independently ass... more comparison to those delivered by VD (9.7% and 7.6%, p¼0.009). Factors that were independently associated with notable adverse outcome were birth at 34-37 weeks and being 2nd born twin in CS (Table). CONCLUSION: Our results strengthen the original TBS finding that showed that there are no benefits to planned CS, as compared with planned VD, in twins between 34+0 weeks and 38+6 weeks of gestation if the first twin is in the cephalic presentation. These findings are reassuring for a woman with twin pregnancy choosing planned VD as a mode of delivery.
American Journal of Obstetrics and Gynecology, 2018
7.1% respectively) as compared with those conceived spontaneously (5.4%; p¼0.05). Selected gastro... more 7.1% respectively) as compared with those conceived spontaneously (5.4%; p¼0.05). Selected gastrointestinal morbidities are presented in the Table. The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of gastrointestinal morbidity following IVF and OI (Figure, log rank p¼0.001). Using the Cox proportional hazards model, controlled for maternal age, preterm delivery, birthweight, maternal diabetes and hypertensive disorders in pregnancy, IVF (adjusted HR¼1.27, CI 1.08-1.49, p¼0.004), but not OI (adjusted HR¼1.19, CI 0.99-1.42, p¼0.054), was noted as independent risk factors for long-term pediatric gastrointestinal morbidity. CONCLUSION: Singletons conceived by IVF appear to be at an increased risk for long-term gastrointestinal morbidity.
American Journal of Obstetrics and Gynecology, 2018
monochorionic and dichorionic group (2.6% compared with 2.2%; adjusted odds ratio 0.92 [95% CI 0.... more monochorionic and dichorionic group (2.6% compared with 2.2%; adjusted odds ratio 0.92 [95% CI 0.61-1.37]). Results were similar after exclusion of intrauterine fetal deaths and twin-to-twin transfusion syndromes (2.4% compared with 2.2%; adjusted odds ratio 0.93 [95% CI 0.61-1.44]). Subgroup analyses for the first and second twin failed to show differences for the primary outcome according to chorionicity. CONCLUSION: Monochorionic compared with dichorionic twin pregnancies with a cephalic first twin are not associated with increased composite neonatal mortality and morbidity in case of planned vaginal delivery at or after 32 weeks of gestation.
American Journal of Obstetrics and Gynecology, 2018
bioactive monoclonal antibody against the interferon alpha receptor was administered intraperiton... more bioactive monoclonal antibody against the interferon alpha receptor was administered intraperitoneally in preceding and proceeding days from ZIKV inoculation (Fig. 1). On postnatal-day 1 (P1), pups were weighed and assessed for biparietal head (BPD) dimensions. Brain weights were obtained by necropsy for half of the pups, while the other half were spared and assessed weekly for BPD and evidence of disease until sacrifice at 6 weeks of age. Brain, intestine, liver, and kidney tissues were assayed for ZIKV viral levels for neonates & juveniles. RESULTS: ZIKV infected dams at e8 had smaller IUGR pups with smaller BPD (p<0.0001, n¼13-16) and brain weights (p<0.0001, n¼6) (Fig.1). However, when pregnant dams were ZIKV infected at e4, only the BPD was demonstrably smaller (p¼0.005, n¼13-16) with no difference in brain weights and overall weight (Fig. 1). Of note, some but not all e8 ZIKV-infected pups demonstrated moribund lethal findings later in juvenile life; this was accompanied by multi-organ infectivity with ZIKV. CONCLUSION: These findings indicate that both early and midgestation ZIKV infection results in congenital ZIKV syndrome in a murine model, and suggest a possible temporal severity. These studies represent the first animal model to specifically evaluate the effects of timing of ZIKV infection on postnatal microcephaly development and later lethal morbidity and mortality.
Archives of Gynecology and Obstetrics, Jan 30, 2022
Purpose: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempt... more Purpose: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. Methods : A retrospective cohort study was conducted, including women who underwent TOLACs from 2003-2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥24 weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders. Results: A total of 11,235 women undergoing TOLAC were included, 6,795 of whom had a PVD. Women with PVD had signi cantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p<0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p<0.0001), were more likely to undergo labor induction (OR 1.56, p<0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p<0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22. Conclusion: PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients. Introduction: Cesarean delivery (CD) rates have increased signi cantly worldwide over the past decades. Latest available data show that 21% of women worldwide gave birth by CD (in 2018) ranging from 5% in sub-Saharan Africa to 43% in Latin America and the Caribbean. It is estimated that at this growth rate, by 2030, 28.5% of women worldwide will give birth by CD. Beyond medical indications, many of the CDs are performed as a result of women's and families' preferences as well as due to health professionals' views and beliefs [1]. Rates of trial of labor after cesarean (TOLAC) have uctuated over time. The main reason for the observed reduction in attempted TOLACs is the concern from uterine rupture, occurring in 0.5% of cases [2-5]. Nevertheless, the potential short-and long-term bene ts of a successful vaginal birth after cesarean (VBAC) and the relatively low incidence of uterine rupture, warrant identi cation of subgroups of women with low risk for such an event, who may substantially bene t from TOLAC. Previous studies concluded that TOLAC is a reasonable option for women with a single past CD [6-9]. It was also demonstrated that vaginal birth history, either before or after the CD, was associated with both higher rates of TOLAC success and lower rates of uterine rupture [10-14]. However, most of these studies
American Journal of Obstetrics and Gynecology, 2018
hospitalizations, among children born to mothers who smoked during pregnancy versus those who did... more hospitalizations, among children born to mothers who smoked during pregnancy versus those who did not. Pediatric respiratory related morbidities were pre-defined based on ICD-9 codes, as recorded in the hospital computerized medical files. Deliveries occurred between the years 1991-2014 at a regional tertiary medical center. Kaplan-Meier survival curves were used to compare cumulative respiratory related hospitalizations in both groups over time and Cox proportional hazards models were constructed to control for confounders. RESULTS: During the study period 241,273 newborns met the inclusion criteria; 2841 of which were born to mothers who smoked during pregnancy. Offspring of smokers presented a significantly higher risk for total respiratory related hospitalizations (OR¼1.70, 95% CI 1.48-1.95) including a higher cumulative incidence, as presented in the Kaplan-Meier survival curves (Figure, Log rank p<0.001). Selected respiratory related morbidities are presented in the table. In the Cox regression model, which controlled for maternal age, maternal diabetes, gestational age, and hypertensive disorders, smoking remained an independent risk factor for total pediatric respiratory related hospitalizations (adjusted HR 1.6; 95% CI 1.4-1.8). CONCLUSION: Smoking during pregnancy, possibly an indicator of childhood exposure to smoking, is associated with an increased risk for childhood respiratory-related morbidities in the offspring.
American Journal of Obstetrics and Gynecology, 2018
by rectovaginal culture at 35-37 weeks. Those who test positive at 35-37 weeks receive intrapartu... more by rectovaginal culture at 35-37 weeks. Those who test positive at 35-37 weeks receive intrapartum treatment with antibiotics. The objective of this study was to investigate the accuracy of GBS rectovaginal cultures at 35-37 weeks (antepartum) in predicting GBS colonization intrapartum. STUDY DESIGN: An IRB-approved prospective cohort study of women admitted to the Labor and Delivery Unit was conducted from from October 2015 through April 2017. In addition to both standard-ofcare screening tests for GBS, a rectovaginal culture was obtained intrapartum. The primary outcome was the accuracy of 35-37 week GBS status when compared to that at delivery via McNemar's test. Secondarily, we compared demographic and delivery outcomes between groups with varying GBS status at third trimester and intrapartum, utilizing Chi-square and t-test as appropriate. Firsttrimester and third-trimester GBS statuses were also compared via McNemar's test. RESULTS: A total of 300 patients were enrolled in the study. There was a statistically-significant disparity (p¼0.001) between GBS status at 35-37 weeks and at intrapartum; 230 women were negative at both screenings, 25 were positive at both, 33 were positive and became negative, while 11 were newly positive at delivery. Thus, 44 (14.67%) of the women were not treated appropriately at delivery. The 11 women who were newly positive at delivery had a higher pregravid BMI (31.34AE6.55 kg/m 2) than that among the 230 women negative at both screenings (24.62AE5.32 kg/m 2 ; p<0.001). No other demographic or outcome differences were found between those groups. No neonatal GBS infections were reported. CONCLUSION: GBS culture at 35-37 weeks is a statistically poor predictor of GBS colonization at time of delivery, leaving 11(3.6%) of fetuses vulnerable to infection and 33(11%) overtreated. This may indicate the utility of a rapid intrapartum screen to prevent inappropriate chemoprophylaxis. However, clinical significance of this difference in terms of neonatal outcomes warrants further study.
American Journal of Obstetrics and Gynecology, 2018
changes in respiratory physiology during pregnancy and concern for fetal-acid base status may int... more changes in respiratory physiology during pregnancy and concern for fetal-acid base status may interfere with LTVV strategy. This study assessed use of LTVV in pregnancy and identified maternal and fetal outcomes of mechanically ventilated pregnant patients with ARDS. STUDY DESIGN: This is a retrospective cohort study of women with ARDS who were mechanically ventilated for greater than 24 hours between January 2012 and February 2017 at a tertiary care center. ARDS was defined clinically, and LTVV was defined as weighted daily average tidal volume 8 mL/kg of ideal body weight. Pregnant patients (N¼23) had 128 days of ventilation, and non-pregnant patients (N¼681) had 3,174 days. Demographic, pregnancy and fetal outcome data were collected on pregnant patients. Compliance with LTVV was stratified by trimester, and groups compared with chisquared analysis. RESULTS: We had no maternal deaths and extracorporeal membrane oxygenation (ECMO) was used in 8.7% of patients (N¼2). Causes of ARDS included sepsis, pneumonia, and asthma exacerbation. Obstetric complications occurred frequently, with 21.7% (N¼5) experiencing preeclampsia, and 50.0% (N¼11) delivering preterm. Mean infant birth weight was 2348g AE 14.6. There were 3 perinatal demises (2 intrauterine, 1 neonatal). In pregnant and non-pregnant patients respectively, weighted average daily tidal volume was 7.8 ml/ kg AE1.2 and 7.27 ml/kg AE1.55, and overall LTVV use was 87.0% and 81.9%. LTVV was utilized in 93.3% of patients in the first, 85.1% in the second, and 71.0% in the third trimester. Use of LTVV in the third trimester was significantly less than the first and second (p¼0.05). CONCLUSION: Pregnant patients with ARDS encountered significant adverse maternal and fetal outcomes, with half delivering preterm and over 20% developing preeclampsia. LTVV use was comparable between pregnant and non-pregnant patients, but was utilized more frequently in the first and second trimesters compared to the third. Given the significant morbidity seen with ARDS in pregnancy, additional multi-center studies are needed to evaluate factors associated with increased utilization of LTVV, and the effect of LTVV on maternal and fetal outcomes.
International journal of gynaecology and obstetrics, Jul 29, 2021
ObjectiveTo explore the indirect impact of the COVID‐19 pandemic on patterns of pregnancy‐related... more ObjectiveTo explore the indirect impact of the COVID‐19 pandemic on patterns of pregnancy‐related venous thromboembolism (VTE) events, mediated by population mobility restrictions during lockdown periods.MethodsPregnancy‐related VTE hospitalizations were identified through a code‐targeted search of the Hadassah Medical Center's computerized database. A manual analysis of relevant medical records was performed, and cases diagnosed throughout the year 2020 were compared to those diagnosed during 2019 and 2018. Statistical analyses studied obstetrical outcomes, as well as the extent and treatment of VTE events during the COVID‐19 pandemic compared to those of preceding years, stratified by pre‐, intra‐, and post‐lockdown periods.ResultsThe incidence of pregnancy‐related thromboembolic events during 2020 was 0.16% of all deliveries, significantly higher than in 2018 and 2019 (0.06% and 0.1%, respectively; P &lt; 0.05). Higher rates of VTE events were found during post‐lockdown periods in 2020, compared with corresponding time periods in 2019 and 2018.ConclusionThe present data suggest that lockdown periods impact pregnancy‐related VTE hospitalizations, possibly as a result of restricted population mobility. Increased awareness of this undesirable outcome may aid health policymakers in the continuing struggle with epidemics.
Research using artificial intelligence (AI) in medicine is expected to significantly influence th... more Research using artificial intelligence (AI) in medicine is expected to significantly influence the practice of medicine and the delivery of health care in the near future. However, for successful deployment, the results must be transported across health care facilities. We present a cross-facilities application of an AI model that predicts the need for an emergency caesarean during birth. The transported model showed benefit; however, there can be challenges associated with interfacility variation in reporting practices.
Background Rapid delivery is important in cases of umbilical cord prolapse to prevent hypoxic inj... more Background Rapid delivery is important in cases of umbilical cord prolapse to prevent hypoxic injury to the fetus/ neonate. However, the optimal decision-to-delivery interval remains controversial. Objective The aim of the study was to investigate the association between the decision-to-delivery interval in women with umbilical cord prolapse, stratified by fetal heart rate pattern at diagnosis, and neonatal outcome. Study design The database of a tertiary medical center was retrospectively searched for all cases of intrapartum cord prolapse between 2008 and 2021. The cohort was divided into three groups according to findings on the fetal heart tracing at diagnosis: 1) bradycardia; 2) decelerations without bradycardia; and 3) reassuring heart rate. The primary outcome measure was fetal acidosis. The correlation between cord blood indices and decision-to-delivery interval was analyzed using Spearman's rank correlation coefficient. Results Of the total 103,917 deliveries performed during the study period, 130 (0.13%) were complicated by intrapartum umbilical cord prolapse. Division by fetal heart tracing yielded 22 women (16.92%) in group 1, 41 (31.53%) in group 2, and 67 (51.53%) in group 3. The median decision-to-delivery interval was 11.0 min (IQR 9.0-15.0); the interval was more than 20 min in 4 cases. The median cord arterial blood pH was 7.28 (IQR 7.24-7.32); pH was less than 7.2 in 4 neonates. There was no correlation of cord arterial pH with decision-to-delivery interval (Spearman's Ρ = − 0.113; Ρ = 0.368) or with fetal heart rate pattern (Spearman's Ρ = .425; Ρ = .079, Ρ = − .205; Ρ = .336, Ρ = − .324; Ρ = .122 for groups 1-3, respectively). Conclusion Intrapartum umbilical cord prolapse is a relatively rare obstetric emergency with an overall favorable neonatal outcome if managed in a timely manner, regardless of the immediately preceding fetal heart rate. In a clinical setting which includes a high obstetric volume and a rapid, protocol-based, response, there is apparently no significant correlation between decision-to-delivery interval and cord arterial cord pH.
American Journal of Obstetrics and Gynecology, 2017
Pregnant women who experience diabetic screening with a 50g oral glucose tolerance test (OGTT) ha... more Pregnant women who experience diabetic screening with a 50g oral glucose tolerance test (OGTT) have reported acute symptoms of tachycardia, malaise and nausea. Our objective was to investigate whether significant changes in maternal blood levels of acute phase reactive inflammatory markers, oxidative stress and non-enzymatic protein glycosylation are modified following an acute glucose load to explain these symptoms. STUDY DESIGN: 100 non-fasting, consecutive pregnant women were prospectively allocated during the 2nd trimester to either 50g OGTT (study group, n¼50, GA median [range]: 26 [24-28] wks), or an equivalent volume of water [control (CRL), n¼50, GA: 22 [18-32] wks). Blood pressure and clinical symptoms (i.e. sweating, palpitations, anxiety) were monitored before intake and at 15 min. increments for one hour. Serum samples were collected immediately before and one hour after intake. IL-6, C-Reactive Protein (CRP), Advanced Glycation End Products (AGE), and soluble Receptor for Advanced Glycation End Products (sRAGE) were measured using sensitive and specific ELISA. Glucose concentration was assayed using the STANBIO liquicolor kit. Total serum anti-oxidative capacity was measured using the Total Anti-oxidant Capacity-Peroxyl (TACP) assay. RESULTS: 1) Following glucose or water intake, there was no significant change in blood pressure and frequency or intensity of monitored maternal clinical symptoms; 2) Compared to CRLs, the 50g OGTT women had a significant increase in their serum glucose levels (P<0.001); 3) A 50g OGTT may be associated with a minimal but significant increase in maternal blood CRP (P¼0.014); 4) There was no significant change in the serum anti-oxidant capacity, IL-6 or AGE levels following glucose load (P>0.05 for all); 5) Following correction for GA, race and parity there was no significant change in sRAGE (2-way RM ANOVA, P>0.05). CONCLUSION: The minimal increase in levels of CRP, but not IL-6, oxidative stress, and AGEs, suggests that during 2 nd trimester, a 50g OGTT load is safe and clinically well-tolerated.
American Journal of Obstetrics and Gynecology, 2018
associated with a 49% and 21% reduction in the odds of CD after adjustment for care model, matern... more associated with a 49% and 21% reduction in the odds of CD after adjustment for care model, maternal demographic and obstetric variables. The rate of multiparous women began to increase since 2013 with 40-45% of these women having had a prior CD. The CD rate was 54.4% in 2013 and 45.7% in 2016 accompanied by a rate of vaginal birth after cesarean from 0.8% to 5.1% (p-value for trend test <0.001). There were no significant changes in perinatal mortality, hypoxic ischaemic encephalopathy, meconium aspiration syndrome, birth trauma, respiratory distress syndrome, or necrotising enterocolitis in either group over time (all p>0.05). However, the frequency of neonatal infection and NICU admission increased from 2012 in the nulliparous group (p-value for trend test <0.001). CONCLUSION: A continued reduction in CD over time was observed after the termination of the one child policy. In nulliparous women this was primarily driven by a continued decrease in antepartum CD. Even among parous women a trend towards increasing vaginal delivery was seen, further underscoring the effectiveness of the multifaceted intervention to reduce CD.
American Journal of Obstetrics and Gynecology, 2018
¼11.15, p<.001; adjusted R 2 of 0.31), supporting that prepregnancy state has a strong influence ... more ¼11.15, p<.001; adjusted R 2 of 0.31), supporting that prepregnancy state has a strong influence on inflammation. CONCLUSION: DII score and fat mass were the strongest predictors of IL-6 levels, while LTPA remained nonsignificant. Diet and fat mass in early pregnancy are more predictive of inflammation later in pregnancy than late gestation diet and fat mass. The data suggest that behaviors and metabolic factors before or at the onset of pregnancy have a greater influence on inflammatory processes observed in pregnancy than do changes that occur during pregnancy. These data corroborate the overarching concept that the maternal prepregnancy metabolic condition is the baseline for the longitudinal metabolic changes during pregnancy.
American Journal of Obstetrics and Gynecology, 2018
long-term pediatric outcomes traditionally associated with dysbiosis of the neonatal microbiome. ... more long-term pediatric outcomes traditionally associated with dysbiosis of the neonatal microbiome. This suggests that differences in pediatric outcomes may be more dependant on postnatal exposures, rather than exposure at birth.
American Journal of Obstetrics and Gynecology, 2018
comparison to those delivered by VD (9.7% and 7.6%, p¼0.009). Factors that were independently ass... more comparison to those delivered by VD (9.7% and 7.6%, p¼0.009). Factors that were independently associated with notable adverse outcome were birth at 34-37 weeks and being 2nd born twin in CS (Table). CONCLUSION: Our results strengthen the original TBS finding that showed that there are no benefits to planned CS, as compared with planned VD, in twins between 34+0 weeks and 38+6 weeks of gestation if the first twin is in the cephalic presentation. These findings are reassuring for a woman with twin pregnancy choosing planned VD as a mode of delivery.
American Journal of Obstetrics and Gynecology, 2018
7.1% respectively) as compared with those conceived spontaneously (5.4%; p¼0.05). Selected gastro... more 7.1% respectively) as compared with those conceived spontaneously (5.4%; p¼0.05). Selected gastrointestinal morbidities are presented in the Table. The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of gastrointestinal morbidity following IVF and OI (Figure, log rank p¼0.001). Using the Cox proportional hazards model, controlled for maternal age, preterm delivery, birthweight, maternal diabetes and hypertensive disorders in pregnancy, IVF (adjusted HR¼1.27, CI 1.08-1.49, p¼0.004), but not OI (adjusted HR¼1.19, CI 0.99-1.42, p¼0.054), was noted as independent risk factors for long-term pediatric gastrointestinal morbidity. CONCLUSION: Singletons conceived by IVF appear to be at an increased risk for long-term gastrointestinal morbidity.
American Journal of Obstetrics and Gynecology, 2018
monochorionic and dichorionic group (2.6% compared with 2.2%; adjusted odds ratio 0.92 [95% CI 0.... more monochorionic and dichorionic group (2.6% compared with 2.2%; adjusted odds ratio 0.92 [95% CI 0.61-1.37]). Results were similar after exclusion of intrauterine fetal deaths and twin-to-twin transfusion syndromes (2.4% compared with 2.2%; adjusted odds ratio 0.93 [95% CI 0.61-1.44]). Subgroup analyses for the first and second twin failed to show differences for the primary outcome according to chorionicity. CONCLUSION: Monochorionic compared with dichorionic twin pregnancies with a cephalic first twin are not associated with increased composite neonatal mortality and morbidity in case of planned vaginal delivery at or after 32 weeks of gestation.
American Journal of Obstetrics and Gynecology, 2018
bioactive monoclonal antibody against the interferon alpha receptor was administered intraperiton... more bioactive monoclonal antibody against the interferon alpha receptor was administered intraperitoneally in preceding and proceeding days from ZIKV inoculation (Fig. 1). On postnatal-day 1 (P1), pups were weighed and assessed for biparietal head (BPD) dimensions. Brain weights were obtained by necropsy for half of the pups, while the other half were spared and assessed weekly for BPD and evidence of disease until sacrifice at 6 weeks of age. Brain, intestine, liver, and kidney tissues were assayed for ZIKV viral levels for neonates & juveniles. RESULTS: ZIKV infected dams at e8 had smaller IUGR pups with smaller BPD (p<0.0001, n¼13-16) and brain weights (p<0.0001, n¼6) (Fig.1). However, when pregnant dams were ZIKV infected at e4, only the BPD was demonstrably smaller (p¼0.005, n¼13-16) with no difference in brain weights and overall weight (Fig. 1). Of note, some but not all e8 ZIKV-infected pups demonstrated moribund lethal findings later in juvenile life; this was accompanied by multi-organ infectivity with ZIKV. CONCLUSION: These findings indicate that both early and midgestation ZIKV infection results in congenital ZIKV syndrome in a murine model, and suggest a possible temporal severity. These studies represent the first animal model to specifically evaluate the effects of timing of ZIKV infection on postnatal microcephaly development and later lethal morbidity and mortality.
Archives of Gynecology and Obstetrics, Jan 30, 2022
Purpose: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempt... more Purpose: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. Methods : A retrospective cohort study was conducted, including women who underwent TOLACs from 2003-2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥24 weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders. Results: A total of 11,235 women undergoing TOLAC were included, 6,795 of whom had a PVD. Women with PVD had signi cantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p<0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p<0.0001), were more likely to undergo labor induction (OR 1.56, p<0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p<0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22. Conclusion: PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients. Introduction: Cesarean delivery (CD) rates have increased signi cantly worldwide over the past decades. Latest available data show that 21% of women worldwide gave birth by CD (in 2018) ranging from 5% in sub-Saharan Africa to 43% in Latin America and the Caribbean. It is estimated that at this growth rate, by 2030, 28.5% of women worldwide will give birth by CD. Beyond medical indications, many of the CDs are performed as a result of women's and families' preferences as well as due to health professionals' views and beliefs [1]. Rates of trial of labor after cesarean (TOLAC) have uctuated over time. The main reason for the observed reduction in attempted TOLACs is the concern from uterine rupture, occurring in 0.5% of cases [2-5]. Nevertheless, the potential short-and long-term bene ts of a successful vaginal birth after cesarean (VBAC) and the relatively low incidence of uterine rupture, warrant identi cation of subgroups of women with low risk for such an event, who may substantially bene t from TOLAC. Previous studies concluded that TOLAC is a reasonable option for women with a single past CD [6-9]. It was also demonstrated that vaginal birth history, either before or after the CD, was associated with both higher rates of TOLAC success and lower rates of uterine rupture [10-14]. However, most of these studies
American Journal of Obstetrics and Gynecology, 2018
hospitalizations, among children born to mothers who smoked during pregnancy versus those who did... more hospitalizations, among children born to mothers who smoked during pregnancy versus those who did not. Pediatric respiratory related morbidities were pre-defined based on ICD-9 codes, as recorded in the hospital computerized medical files. Deliveries occurred between the years 1991-2014 at a regional tertiary medical center. Kaplan-Meier survival curves were used to compare cumulative respiratory related hospitalizations in both groups over time and Cox proportional hazards models were constructed to control for confounders. RESULTS: During the study period 241,273 newborns met the inclusion criteria; 2841 of which were born to mothers who smoked during pregnancy. Offspring of smokers presented a significantly higher risk for total respiratory related hospitalizations (OR¼1.70, 95% CI 1.48-1.95) including a higher cumulative incidence, as presented in the Kaplan-Meier survival curves (Figure, Log rank p<0.001). Selected respiratory related morbidities are presented in the table. In the Cox regression model, which controlled for maternal age, maternal diabetes, gestational age, and hypertensive disorders, smoking remained an independent risk factor for total pediatric respiratory related hospitalizations (adjusted HR 1.6; 95% CI 1.4-1.8). CONCLUSION: Smoking during pregnancy, possibly an indicator of childhood exposure to smoking, is associated with an increased risk for childhood respiratory-related morbidities in the offspring.
American Journal of Obstetrics and Gynecology, 2018
by rectovaginal culture at 35-37 weeks. Those who test positive at 35-37 weeks receive intrapartu... more by rectovaginal culture at 35-37 weeks. Those who test positive at 35-37 weeks receive intrapartum treatment with antibiotics. The objective of this study was to investigate the accuracy of GBS rectovaginal cultures at 35-37 weeks (antepartum) in predicting GBS colonization intrapartum. STUDY DESIGN: An IRB-approved prospective cohort study of women admitted to the Labor and Delivery Unit was conducted from from October 2015 through April 2017. In addition to both standard-ofcare screening tests for GBS, a rectovaginal culture was obtained intrapartum. The primary outcome was the accuracy of 35-37 week GBS status when compared to that at delivery via McNemar's test. Secondarily, we compared demographic and delivery outcomes between groups with varying GBS status at third trimester and intrapartum, utilizing Chi-square and t-test as appropriate. Firsttrimester and third-trimester GBS statuses were also compared via McNemar's test. RESULTS: A total of 300 patients were enrolled in the study. There was a statistically-significant disparity (p¼0.001) between GBS status at 35-37 weeks and at intrapartum; 230 women were negative at both screenings, 25 were positive at both, 33 were positive and became negative, while 11 were newly positive at delivery. Thus, 44 (14.67%) of the women were not treated appropriately at delivery. The 11 women who were newly positive at delivery had a higher pregravid BMI (31.34AE6.55 kg/m 2) than that among the 230 women negative at both screenings (24.62AE5.32 kg/m 2 ; p<0.001). No other demographic or outcome differences were found between those groups. No neonatal GBS infections were reported. CONCLUSION: GBS culture at 35-37 weeks is a statistically poor predictor of GBS colonization at time of delivery, leaving 11(3.6%) of fetuses vulnerable to infection and 33(11%) overtreated. This may indicate the utility of a rapid intrapartum screen to prevent inappropriate chemoprophylaxis. However, clinical significance of this difference in terms of neonatal outcomes warrants further study.
Uploads
Papers by Asnat Walfisch