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BACKGROUND: Small for gestational age (SGA) neonates are known to be at an elevated risk for neonatal morbidity. Despite this, there is a growing array of proposed size standards for identifying SGA fetuses. Given the inherent differences in design, acquisition methods, and the characteristics of the populations they represent, the generalizability of these standards to diverse populations remains uncertain. INTRODUCTION: This study aimed to assess variations in rates of SGA and severe SGA using six distinct size standards: Hadlock, Fetal Medicine Foundation (FMF), World Health Organization (WHO), Intergrowth-21 (IG-21), and two locally derived population-based size standards. The objective was to examine the differences in SGA and severe SGA rates among these size standards. METHODS: A retrospective cohort study was conducted, encompassing all singleton deliveries in two tertiary referral hospital campuses with an annual birth count exceeding 10,000, from January 2019 to July 2022. SGA and severe SGA were defined as birthweights below the 10th or 3rd percentile, respectively, based on each growth standard. The study design included details on the setting, subjects (singleton deliveries), and the chosen size standards. Comparative analyses were performed to assess variations in SGA and severe SGA rates among these size standards. RESULTS: Our study analyzed 32,912 singleton deliveries. We found that the choice of growth standard significantly impacted the rates of both SGA and severe SGA infants. Notably, the WHO criteria identified 5,548 (16.9 %) fetuses as SGA, compared to only 1,716 (5.2 %) using the INTERGROWTH-21 standard (p < 0.001). Similarly, for severe SGA, the FMF charts classified 2098 (6.37 %) infants, significantly higher than the 320 (1 %) identified by Dolberg's local population-based charts (p < 0.001). CONCLUSION: Our study demonstrates a significant variety of SGA and severe SGA rates using different size standards. Therefore, the decision on the size standards in use is critical given the significant influence on clinical management. SYNOPSIS: There are significant variations in SGA and Severe SGA rates depending on the chosen size standard.
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Objectives: To evaluate the effect of maternal parity on the association between mid-trimester cervical length and preterm birth to elucidate the potential intricacies of this relationship. Methods: A retrospective cohort study using Electronic Medical Records (EMR) data. The study population included pregnant women with a singleton fetus and a short mid-trimester cervical length, recorded in the EMR system at a large health maintenance organization. Women were categorized by parity in the current pregnancy, and a statistical analysis was conducted to examine the relationship between parity and premature delivery. Results: Data were collected from 1144 records of cervical length measurements of 738 pregnancies obtained from the HMO database. The study population consisted of 259 nulliparous women (35.1%), 451 multiparous women (61.1%), and 28 grand multiparous women (3.8%). The results from the multivariate analysis of the primary outcome showed that nulliparity was significantly associated with an increased risk of premature delivery, with a risk of 1.557 for nulliparous women compared to parous women. Conclusions: In this study, a statistically significant association was found between nulliparity and preterm birth among women with a short mid-trimester cervical length. Nulliparous women were found to have a higher risk of preterm birth in the current pregnancy compared to parous women. Further research is needed to understand the underlying mechanisms and to develop targeted interventions to reduce the risk of premature birth in this population. These findings highlight the need to consider nulliparity as a potential risk factor in the management of pregnancies with a shortened cervix.
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Objective: Membrane stripping in group B streptococcus (GBS) carriers poses an increased risk of inadequate antibiotic prophylaxis, potentially due to accelerated labor, thereby potentially impacting the management of GBS colonization during delivery. We compared the adequacy of intrapartum antibiotic prophylaxis between pregnant women colonized with GBS, who underwent membrane stripping and those who did not. The study aimed to determine whether the performance of membrane stripping, by potentially shortening labor duration, increases the risk of inadequate antibiotic prophylaxis dispensation. Study design: A retrospective cohort study was conducted on GBS screen-positive women with a full-term singleton pregnancy in cephalic presentation, who were eligible for vaginal delivery. The exposed group consisted of women who underwent membrane stripping, while the unexposed group consisted of women who did not undergo membrane stripping. The primary outcome was defined as inadequate duration of antibiotic prophylaxis during labor, wherein less than 4 h of beta-lactam antibiotics were administered prior to delivery. Neonatal outcome was compared between the groups. Results: This retrospective cohort study comprised 1,609 women, with 129 in the exposed group (stripping group) and 1,480 in the unexposed group (no stripping group). Adequate intrapartum antibiotic prophylaxis was received by 64.3% (83/129) of the exposed group, compared to 46.9% (694/1,480) of the unexposed group (p = 0.003). Membrane stripping was associated with increased odds of receiving adequate prophylaxis (OR 1.897, 95% CI 1.185-3.037, p = 0.008). After excluding women who presented to the labor ward in active labor and delivered in less than 4 h, both the exposed and unexposed groups had similarly high rates of adequate intrapartum antibiotic prophylaxis (87.5% vs. 85.8%, respectively). No significant difference was observed in adverse neonatal outcomes between the groups. Conclusion: The provision of membrane stripping did not impede adequate intrapartum antibiotic prophylaxis and was correlated with a higher rate of sufficient prophylaxis in comparison to non-swept patients. These observations suggest that membrane stripping can be considered a safe option for ensuring adequate antibiotic prophylaxis in women colonized with GBS.
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INTRODUCTION: This study aimed to evaluate the impact of third-trimester post-coital bleeding (PCB) on pregnancy outcomes. METHODS: A retrospective cohort study was conducted at two tertiary medical centers, including all pregnant women between 24 and 34 weeks of gestation referred due to vaginal bleeding over an 11-year period. The study population includes all singleton deliveries; within this population, women were further classified into three groups: those admitted due to vaginal bleeding related to PCB, those admitted due to vaginal bleeding not related to PCB, and those who did not report vaginal bleeding. The primary outcome measure was delivery prior to 37 weeks of gestation, while secondary outcome measures included maternal and neonatal complications. Baseline characteristics of the two groups were compared. RESULTS: During the study period, there were a total of 51,698 deliveries. Among these, 230 cases involved bleeding between 24 and 34 weeks of gestation, 34 (14.8%) were identified as PCB, and 196 as bleeding unrelated to intercourse. In addition, 51,468 pregnancies without bleeding were analyzed as the general population for comparison. The incidence of preterm labor before 37 weeks of gestation was notably higher in both women with PCB (14.7%) and those with bleeding unrelated to coitus (20.9%) compared to the general population (5.6%); however, there was no statistically significant difference between the two bleeding groups (p = 0.403) while both were significantly different from the general population (p < 0.001). The odds ratio for preterm birth before 37 weeks of gestation after PCB was 3.29 (95% CI: 1.26-8.56, p = 0.0149). There were no significant differences between the PCB and bleeding unrelated to intercourse groups in terms of maternal and neonatal complications. CONCLUSION: This study found that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the general population without bleeding. These findings challenge the assumption that PCB is benign.
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Nacimiento Prematuro , Embarazo , Humanos , Femenino , Recién Nacido , Tercer Trimestre del Embarazo , Nacimiento Prematuro/epidemiología , Estudios Retrospectivos , Coito , Relevancia Clínica , Hemorragia Uterina/etiologíaRESUMEN
Objective: To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation. Methods: A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group. Results: The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions (OR 0.20, 95% CI 0.05-0.74) and in the neonatal hospitalization period (mean difference in days 2.43, 95% CI 0.44-4.42). The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment. Conclusion: Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation.
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BACKGROUND: External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial. OBJECTIVE: This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version. RESULTS: The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference. CONCLUSION: This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.
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Presentación de Nalgas , Versión Fetal , Embarazo , Femenino , Humanos , Versión Fetal/métodos , Presentación de Nalgas/diagnóstico , Presentación de Nalgas/epidemiología , Presentación de Nalgas/terapia , Vejiga Urinaria , Estudios ProspectivosRESUMEN
Objective: To examine the association between conservative treatment for PAS (placenta accreta spectrum) and subsequent gynecological and fertility complications. Methods: All women who underwent conservative treatment for PAS between January 1990 and December 2000 were included in this retrospective cohort study conducted in a tertiary teaching hospital. Gynecological and fertility complications experienced after the index delivery were collected from the medical records and telephone questionnaires. This data was compared to an age and parity-matched control group of women without PAS. Results: The study group included 134 women with PAS managed conservatively and 134 controls with normal deliveries matched by parity and age. Women in the PAS group required significantly more postpartum operative procedures such as hysteroscopy or D&C (OR = 6.6; 95%CI: 3.36-13.28; P = <0.001). Following the index delivery, there were 345 pregnancies among 107 women who attempted conception following conservative treatment for PAS vs. 339 pregnancies among 105 women who attempted conception in the control group. Among women who attempted conception following conservative treatment for PAS 99 (92.5%) delivered live newborns (a total of 280 deliveries) vs. 94 (89.5%) in the control group, (a total of 270 live newborns, p = 0.21). The need for fertility treatments was not different between the two groups (OR = 1.22; 95%CI: 0.51-2.93; P = 0.66). Conclusion: After conservative treatment for PAS, significantly more women required complementary procedures due to retained placenta and/or heavy vaginal bleeding. There was no evidence of fertility impairment in women post-conservative treatment for PAS.
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OBJECTIVE: This study aimed to describe Israeli maternity departments' policies regarding cesarean delivery on maternal request, and factors associated with obstetricians' support for cesarean delivery on maternal request in specific scenarios. METHODS: This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department's cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians' socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians' support for cesarean delivery on maternal request in specific cases. RESULTS: Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the "reference scenario" describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33-3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39-0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases. CONCLUSION: Policies and obstetricians' support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians' support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.
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Obstetricia , Médicos , Femenino , Humanos , Embarazo , Israel , Estudios Transversales , Actitud del Personal de Salud , Pautas de la Práctica en Medicina , Médicos/psicología , PolíticasRESUMEN
Group A Streptococcus (GAS; Streptococcus pyogenes) is a facultative gram-positive coccus, uncommonly colonizing parturient genitalia, where its presence can potentially lead to a life-threatening invasive infection after delivery. GAS infection typically occurs within the first 4 days post-partum and is characterized by high fever, chills, flashing, abdominal pain, and uterine tenderness. Nonetheless, patients with GAS puerperal sepsis may have an unusual presentation, when fever is absent, and the symptoms and signs can be mild, non-specific, and not indicative of the severity of infection. This unusual presentation may lead to a delayed diagnosis and increase the risk for severe puerperal sepsis. Therefore, in these cases, a high index of suspicion and prompt early antibiotic and surgical treatment is crucial to saving the parturient's life.
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OBJECTIVE: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD. METHODS: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio. RESULTS: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001). CONCLUSIONS: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.
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Placenta , Hemorragia Posparto , Transfusión Sanguínea , Estudios de Casos y Controles , Femenino , Humanos , Hemorragia Posparto/epidemiología , Hemorragia Posparto/etiología , Embarazo , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To investigate the association of the timing of primary cesarean delivery with the progress of labor and the operative delivery rate at the subsequent successful trial of labor. METHODS: A retrospective study of women with a primary cesarean and subsequent term cephalic vaginal delivery in two medical centers. Cesarean deliveries were classified as planned, intrapartum first stage or intrapartum second stage. The second stage duration and the operative delivery rate, adjusted to epidural analgesia and oxytocin use, were compared between the groups. χ2 and Kruskal-Wallis tests were used for analysis of categorical and continuous variables, respectively. RESULTS: The study population included 1166 women. The second stage of labor was longer when the previous cesarean delivery occurred during the second stage compared to planned or first stage (1.7 h vs 1.3 h vs 1.3 h, p = 0.005). The proportion of operative deliveries was greater among women with previous cesarean in the second stage of labor (39.6%), compared to planned (26.9%) or first stage (28.8%), p = 0.006. CONCLUSION: Cesarean delivery at the second stage of labor is associated with a longer second stage and an increased operative delivery rate at the subsequent vaginal birth. Our findings attest to the delicate passenger-passage relations that can exist in some parent-couples.
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Trabajo de Parto , Parto Vaginal Después de Cesárea , Embarazo , Humanos , Femenino , Estudios Retrospectivos , Cesárea , Parto , Esfuerzo de Parto , Segundo Periodo del Trabajo de PartoRESUMEN
OBJECTIVE: Published series regarding interventions for facilitating external cephalic version (ECV) have concluded that parenterally administered beta-stimulant tocolytics, increased ECV success rate and reduced the number of cesarean sections. However, there were insufficient data regarding calcium channel blockers to provide good evidence regarding its efficacy. Given the paucity of literature, we aimed to compare the efficacy of nifedipine to that of ritodrine on ECV success rates. METHODS: This is a retrospective case control study of prospectively collected data of patients who underwent ECV between January 2012 and December 2013 at Bikur Cholim Medical Center and Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Patient undergoing ECV with tocolysis by ritodrine were compared with those using nifedipine as tocolysis. Patients were matched in a one-to-one ration by parity and placental location. RESULTS: Overall, 148 women received ritodrine and 148 women received nifedipine before ECV procedure. Overall success rate was higher among the ritodrine group (82.4 vs. 63.5%, p < .001). Among nulliparous and among parous, success rate was higher in the ritodrine group (78.9 vs. 57.9 and 88.6 vs. 73.5%, p = .001, p = .04, respectively). Vaginal delivery rate was higher among the ritodrine group (86.5 vs. 68.9%, p < .001). Cesarean delivery rate was 31.1% for the nifedipine group versus 13.5% in the ritodrine group (p < .001). Number needed to treat to benefit (NNTb) 5.7 (95% confidence interval 3.7-12.1). Overall, 216 of 296 (72.9%) of ECV were successful. Ritodrine was associated with higher success rates as compared with nifedipine (56.5 vs. 32.5%, p < .001). In a multivariate analysis, ritodrine tocolytic therapy was independently associated higher ECV success rates as compared to nifedipine (OR 4.54, 95% CI 2.38-9.09). Higher amniotic fluid index (OR 1.16, 95% CI 1.05-1.28) and nulliparity (OR 0.16, 95% CI 0.08-0.30) were additional independent predictors of ECV outcome. CONCLUSION: Ritodrine significantly improve the success of ECV compared with nifedipine. Both drugs are shown to be safe.
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Presentación de Nalgas , Ritodrina , Versión Fetal , Estudios de Casos y Controles , Femenino , Humanos , Israel , Nifedipino , Placenta , Embarazo , Estudios RetrospectivosRESUMEN
OBJECTIVE: It is often hypothesized that poor neonatal outcomes are more frequently observed in low birth weight (LBW) neonates following vacuum assisted vaginal delivery (VAVD). We sought to assess the association between low birth weight (< 2500 g) and neonatal outcomes, following vacuum extraction. STUDY DESIGN: This was a retrospective cohort study, including 1085 deliveries in a tertiary medical center between 2003 and 2015. Maternal and neonatal outcomes, including birth trauma related complications, were compared between women with singleton pregnancies beyond 34 weeks' gestation and fetal weight < 2500 g who were delivered by vacuum extraction (n=345) and a control group (n=740) with fetal weight ≥ 2500 g, matched in maternal age, parity and gestational week. RESULTS: During the study period, 370 women met the inclusion criteria for the study group, with 25 cases eventually excluded due to missing neonatal birth trauma related data. 740 patients were included in the matched control group. Induction of labor and non-reassuring fetal heart rate as an indication for VAVD were more prevalent in the LBW group. The composite birth trauma related adverse outcome was higher in the control group (9.1 % vs. 4.4 %, p = 0.008), mainly due to increased rate of cephalohematoma in this group (6.8 % vs. 2.9 %, p = 0.01). All other adverse neonatal outcomes rates did not differ between the groups. Women in the control group were more prone to post-partum hemorrhage (p < 0.001), had more episiotomies (p = 0.004) and a higher failed VAVD rate (11.4 % vs. 2.6 %, p < 0.001), leading to emergency cesarean delivery. A sub-group analysis of failed VAVD did not reveal a difference in neonatal complications between the LBW and the control group. CONCLUSION: Neonatal birth trauma and adverse outcomes following vacuum extraction are no more common in neonates weighing less than 2500 g than those with higher birth weights, even in failed vacuum cases.
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Traumatismos del Nacimiento , Parto Obstétrico , Traumatismos del Nacimiento/epidemiología , Traumatismos del Nacimiento/etiología , Peso al Nacer , Femenino , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Embarazo , Estudios Retrospectivos , Extracción Obstétrica por Aspiración/efectos adversosRESUMEN
BACKGROUND: Previous cesarean delivery is the most important risk factor for subsequent uterine rupture. Data are inconsistent regarding grand multiparity (≥6th delivery) and a risk for uterine rupture. Specifically, no data exist regarding the risk that is associated with labor induction or augmentation in grand multiparous women after cesarean delivery. OBJECTIVE: This study aimed to examine whether grand multiparity elevates the risk for uterine rupture in trials of labor after 1 previous cesarean that involved induction or augmentation of labor. STUDY DESIGN: A retrospective multicenter study was conducted that included all trials of labor after cesarean delivery at 24-42 gestational weeks with vertex presentation between the years 2003-2015. The study groups were defined in the following manner: (1) grand multiparous parturients (current delivery ≥6) who underwent labor induction or augmentation; (2) multiparous parturients (delivery 2-5) who underwent induction or augmentation; (3) grand multiparous parturients with no induction or augmentation of labor. The primary outcome was uterine rupture rate, which was defined as complete separation of all uterine layers. Secondary outcomes were obstetric and neonatal complications. RESULTS: A total of 12,679 labors were included in the study. The study group included 1304 labors of grand multiparous parturients after 1 previous cesarean delivery, of which 800 parturients underwent induction of labor and 504 parturients received labor augmentation. The multiparous group included 3681 parturients with either labor induction or augmentation. The third group included 7694 grand multiparous parturients without induction or augmentation. Incidence of uterine rupture was similar among the 3 study groups (0.3%, 0.3%, and 0.2%, respectively; P=.847). In the multivariable model that was adjusted for maternal age, ethnicity, diabetes mellitus, birthweight, and prolonged second stage of labor, no association was found between grand multiparity and uterine rupture in women with a scarred uterus who underwent labor induction or augmentation. CONCLUSION: Labor induction/augmentation during trial of labor after cesarean delivery in grand multiparous parturients appears to be a reasonable option that has a similar uterine rupture risk as in multiparous parturients. Avoiding a mandatory cesarean delivery enables reduction of the risk for future multiple cesarean deliveries.
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Rotura Uterina , Femenino , Humanos , Recién Nacido , Trabajo de Parto Inducido/efectos adversos , Paridad , Embarazo , Estudios Retrospectivos , Rotura Uterina/epidemiologíaRESUMEN
OBJECTIVE: To evaluate factors associated with subgaleal hemorrhage (SGH) severity following attempted vacuum-assisted delivery (VAD). STUDY DESIGN: This retrospective cohort study was conducted in a tertiary medical center. The population comprised parturients who delivered at our medical center during 2009-2018, and who underwent attempted VAD with singleton pregnancies that resulted in neonatal SGH formation. SGH severity was classified as mild and non-mild (moderate or severe). The main outcome measures were determinants associated with SGH severity. RESULTS: Among 350 neonates with SGH, the degree of severity was non-mild for 48 (13.7%). Compared to the mild group, in the non-mild group, small for gestational age was more common (8.2% vs. 2.6%, p = 0.04). Compared to the mothers in the mild group, in the non-mild group, the proportion with two or more deliveries was lower (0% vs. 7.3%, p = 0.05), gestational diabetes was more common (12.5% vs. 4.6%, p = 0.02), the rate of cervical ripening was higher (27.1% vs. 12.9%, p = 0.02), the duration of the second stage of delivery was longer (mean 177 vs. 152 min, p = 0.04), and the rate of two dislodgments was higher (31.2% vs. 15.2%, p = 0.006). On multivariate analysis, only cervical ripening (adjusted odds ratio [OR]: 2.50; 95% confidence interval [CI]: 1.20-5.26; P = 0.01 and second stage duration (adjusted OR: 1.13; 95% [CI]: 1.00-1.29; P = 0.05) were independently associated with more severe SGH. CONCLUSIONS: The duration of second stage and ripening of the cervix during induction of labor are independently associated with SGH severity following attempted VAD.
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Lesiones Prenatales/etiología , Hemorragia Subaracnoidea Traumática/etiología , Índices de Gravedad del Trauma , Extracción Obstétrica por Aspiración/efectos adversos , Adulto , Maduración Cervical , Femenino , Humanos , Recién Nacido , Segundo Periodo del Trabajo de Parto , Trabajo de Parto Inducido/efectos adversos , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
PURPOSE: The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH METHODS: A retrospective cohort study was conducted. All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011-2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups. RESULTS: The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively. Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group. A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%, P = 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups. CONCLUSIONS: SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.
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Trastornos de la Coagulación Sanguínea/etiología , Parto Obstétrico/efectos adversos , Hemorragia/etiología , Adulto , Trastornos de la Coagulación Sanguínea/terapia , Femenino , Hemorragia/terapia , Humanos , Embarazo , Estudios RetrospectivosRESUMEN
Background: Women may be unaware of the potential impact on subsequent deliveries of the decision to undergo primary breech cesarean (PBC) delivery rather than attempt external cephalic version (ECV). We investigated cesarean delivery rates and adverse maternal outcomes in the subsequent delivery following management of breech presentation by ECV versus PBC.Methods: This retrospective study identified women who delivered subsequent to breech presentation managed by attempted ECV or PBC. We assessed cesarean delivery rates and adverse maternal outcomes including hemorrhage, placental complications, infection, and obstetric complications in the subsequent delivery following attempted ECV versus PBC.Results: We identified 307 women who had attempted ECV and 508 with PBC in the index breech pregnancy. Following attempted ECV, 47 (15.3%) women had cesarean delivery in the subsequent pregnancy versus 246 (48.4%) following PBC, adjusted OR 0.24, 95% CI 0.16-0.35 for subsequent cesarean delivery after attempted ECV in the index pregnancy. The frequency of composite adverse outcomes related to cesarean delivery was 30 (9.8%) following attempted ECV versus 104 (20.5%) after PBC, p < .0001. The frequency of composite severe adverse maternal outcome was similar following attempted ECV 25 (8.8%) versus PBC 59 (11.9%).Conclusions: The current study suggests that attempted external cephalic version was associated with a five-fold decrease risk to undergo cesarean in the subsequent delivery and a significantly decreased frequency of composite adverse outcomes related to cesarean delivery in the subsequent delivery.
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Presentación de Nalgas/terapia , Cesárea/estadística & datos numéricos , Versión Fetal/estadística & datos numéricos , Adulto , Estudios de Casos y Controles , Cesárea/efectos adversos , Femenino , Humanos , Israel , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Esfuerzo de Parto , Versión Fetal/efectos adversos , Versión Fetal/métodosRESUMEN
Objective: The objective of this study is to determine whether a single episode of vaginal bleeding occurring between 24 and 34 weeks gestation is associated with preterm delivery and other adverse maternal and neonatal outcomes.Study design: We conducted a retrospective cohort study in the Maternal-Fetal unit of two campuses of a large tertiary, medical center with approximately 12,000 deliveries annually. The study group consisted of all women with a singleton pregnancy between 24 + 0/7 and 33 + 6/7 weeks of gestation, admitted to the high-risk antenatal ward due to a single episode of vaginal bleeding of unknown origin between May 2003 and December 2014. Maternal and neonatal parameters of the study group were compared to the maternal and neonatal parameters of the rest of the singleton deliveries occurring in our institution during the study period. The primary outcome was rate of preterm delivery while secondary outcomes were other adverse maternal and neonatal outcomes. Multivariate logistic regression was performed to identify risk factors for preterm delivery in the study group.Results: Two hundred thirty women met the inclusion criteria and 51,468 women were in the comparison group. Preterm delivery rates were 20% and 5.5% in the study and the comparison group, respectively OR = 3.55 [2.63-4.78] (p < .001). The aOR for preterm delivery among the study group for women with a previous preterm delivery was 4.62 [1.17-18.20] (p = .029) and for women with a short cervix was 9.35 [2.30-37.95] (p = .002).Conclusions: A single episode of third-trimester vaginal bleeding is an independent risk factor for spontaneous preterm delivery. The presence of a shortened cervix or a history of a prior spontaneous preterm delivery increases this risk significantly.Key messageThird trimester vaginal bleeding is strongly associated with preterm delivery. Knowledge of this relationship has valuable clinical implications for practicing obstetricians.
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Trabajo de Parto Prematuro/epidemiología , Nacimiento Prematuro/epidemiología , Hemorragia Uterina/epidemiología , Adulto , Estudios de Casos y Controles , Causalidad , Femenino , Humanos , Recién Nacido , Masculino , Embarazo , Tercer Trimestre del Embarazo , Estudios Retrospectivos , Factores de Riesgo , Hemorragia Uterina/etiologíaRESUMEN
INTRODUCTION: Uterine rupture is a critical complication causing fetal and maternal morbidity and mortality. Data are conflicting regarding whether grandmultiparity (parity ≥ 6) is a risk factor. This multicenter cohort study aimed to determine whether grandmultiparity (parity ≥ 6) poses a risk for uterine rupture in women with no previous cesarean delivery. MATERIAL AND METHODS: A multicenter retrospective study of deliveries that occurred between the years 2003 and 2015 in three tertiary medical centers. Deliveries of grandmultiparous women were compared with those of multiparous women (parity 2-5). Women with previous cesarean deliveries were excluded. Multivariable regression modeling was applied to control for possible confounders. RESULTS: A total of 388 784 deliveries of multiparous women with unscarred uteri were recorded during the study period, including 53 965 deliveries of grandmultiparous women and 334 819 deliveries of multiparous women. Grandmultiparous women were significantly older (33.9 ± 5 vs 27.3 ± 5 years; P < 0.0001). Fourteen cases of uterine rupture were recorded in the grandmultiparae group (1 per 3855 labors) vs 41 in the multiparae group (1 per 8166 labors) (odds ratio [OR] 2.07, 95% confidence interval [95% CI] 1.13-3.81; P = 0.030). However, in a multivariable model controlling for maternal age, the association between grandmultiparity and uterine rupture lost its significance (adjusted OR 1.26, 95% CI 0.66-2.41; P = 0.491), and maternal age emerged as an independent predictor of uterine rupture (adjusted OR 1.08, 95% CI 1.04-1.13; P < 0.0001). Additionally, the risk for uterine rupture was elevated in a linear fashion, concomitant with age. CONCLUSIONS: Maternal age is a risk factor for uterine rupture. Grandmultiparity does not increase the risk beyond that associated with maternal age.
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Edad Materna , Paridad , Rotura Uterina/etiología , Adulto , Femenino , Humanos , Embarazo , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To examine trial of labor after cesarean delivery (TOLAC) success rates and its associated factors among women with a previous failed vacuum-assisted vaginal delivery. METHODS: We conducted a retrospective cohort study. The study group comprised all women with a prior failed vacuum-assisted vaginal delivery who subsequently delivered from 2008 to 2017 at a university hospital. RESULTS: Overall, 166 women with prior history of failed vacuum-assisted vaginal delivery delivered during the study period, with a median interdelivery interval of 28 (21-36) months. Of them, 53 (32%) had an elective repeat cesarean delivery, and 113 (68%) had a TOLAC. Although there were small statistical differences in the predelivery characteristics of the two groups, there were not clinically significant differences. Of the 113 women who underwent TOLAC in the subsequent pregnancy, the overall success rate was 67%. Neonatal 1- and 5-minute Apgar scores were lower among neonates born to women who experienced a failed TOLAC attempt compared with those who underwent successful TOLAC: 1-minute Apgar score less than 7 (6 [16%] vs 2 [3%], odds ratio [OR] 7.16, 95% CI 1.36-37.45, P=.01), 5-minute Apgar score less than 8 (3 [8%] vs 0 [0%], OR 15.5, 95% CI 1.78-308.7, P=.03). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among women who underwent TOLAC. CONCLUSION: Trial of labor after cesarean delivery in women with a previous failed vacuum-assisted vaginal delivery appears to be associated with an acceptable success rate. These data should improve patient counseling and provide reassurance for those who wish to deliver vaginally after a previous failed vacuum-assisted vaginal delivery.