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

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

Placental pathology in pregnancies with late fetal growth restriction and abnormal cerebroplacental ratio.

INTRODUCTION: Late fetal growth restriction (FGR) is associated with mild growth restriction and normal or mild abnormal doppler flows. The cerebroplacental ratio (CPR) has been demonstrated as more sensitive to hypoxia than its individual components in these fetuses. We hypothesized that abnormal CPR in late FGR is reflected in specific placental vascular malperfusion lesions. METHODS: Retrospective cohort study of late FGR newborns between 2012 and 2022 in a tertiary hospital. Overall, 361 cases were included: 104 with pathological CPR (study group), and 257 with normal doppler flows (control group). The primary outcome was a composite of maternal vascular malperfusion lesions (MVM) and fetal vascular malperfusion lesions (FVM). Secondary outcomes were macroscopic placental characteristics and various obstetrical and neonatal outcomes. RESULTS: The study group had lower birthweight compared with the normal CPR group (2063.5 ± 470.5 vs. 2351.6 ± 387.4 g. P < 0.0001), higher rates of composite adverse neonatal outcomes (34.2% vs. 22.5%, p < 0.0001), lower mean placental weight (318 ± 71.6 vs. 356.6 ± 76.5 g, p < 0.0001), as well as a higher prevalence of Vascular lesions of MVM (15.3% vs. 5.0%, p = 0.002), villous lesions of FVM (37.5% vs. 24.9%, p = 0.02), and composite FVM lesions (36.5% vs. 25.6%, p = 0.04). On multivariate regression analysis for MVM lesions and composite FVM lesions, abnormal CPR was found as an independent risk factor (aOR 2.17, 95% CI 1.63-4.19, and aOR 1.31, 95% CI 1.09-3.97, respectively). DISCUSSIONS: Abnormal CPR in late FGR is reflected in placental histopathologic vascular malperfusion lesions, and the incidence of these lesions is higher than in FGR placentas with normal CPR.

Is there an association between isolated sonographic abdominal circumference below the 10th percentile and placental vascular lesions?

OBJECTIVE: To study the association between prenatal diagnosis of isolated abdominal circumference (AC) below the 10th percentile (AC <10th) in appropriate for gestational age (AGA) neonates and placental vascular lesions. METHODS: A prospective study was conducted of healthy women who underwent sonographic fetal biometric measurements, up to 7 days before delivery, and delivered AGA neonates. The study cohort was divided into those with and without prenatal isolated AC <10th. Placental histopathology lesions were classified into maternal and fetal vascular malperfusion (MVM, FVM) lesions. RESULTS: Compared to the AC over 10th percentile group (n = 85), the AC <10th group (n = 85) was characterized by lower maternal body mass index, higher rate of smokers, and increased rate of induced labor (P = 0.029, P = 0.029, P = 0.001, respectively). There were no between-group differences regarding maternal age, gestational age, and neonatal outcome. Mean placental weight was lower in the isolated AC <10th (P < 0.001). The rate of MVM or FVM lesions did not differ between the groups. By multivariate logistic regression analysis, isolated AC <10th was not found to be associated with increased risk for placental vascular lesions. CONCLUSION: Isolated AC <10th is associated with increased rate of induction of labor; however, it is not associated with increased placental vascular lesions.

Is there an association between the length of the second stage of labour and urinary incontinence in multiparous women?

OBJECTIVES: It is unclear whether the length of the second stage of labour plays a role in the development of urinary incontinence (UI). This study aimed to investigate the association between the cumulative length of the second stage of labour in multiparous women and UI. METHODS: This was a longitudinal cohort study of women who had undergone three vaginal deliveries (VDs) between 2008 and 2017. UI was assessed using the Urinary Distress Inventory (UDI-6) questionnaire. Women with a cumulative length of the second stage of labour for three deliveries in the upper 90th percentile (study group) were compared with women with a cumulative length of the second stage of labour below the 90th percentile (control group). A sample size of 280 women was needed to detect a 15-point difference in the UDI-6 score between the groups. RESULTS: Thirty-one women were included in the study group and 275 women were included in the control group. Demographic and obstetric characteristics were similar in both groups. There was no between-group difference in mean UDI-6 score: 12.3 ± 17.5 in the study group and 14.9 ± 18.2 in the control group (p = 0.55). No association was found between the cumulative length of the second stage of labour and the UDI score. A linear regression model revealed that maternal body mass index was independently associated with UDI-6 score (correlation coefficient 0.67, 95% confidence interval 0.19-1.15; p = 0.006). CONCLUSION: The cumulative length of the second stage of labour in multiparous women is not associated with UI.

Smartphone-based counseling and support platform and the effect on postpartum lactation: a randomized controlled trial.

BACKGROUND: Human milk lactation provides health benefits for both the mother and infant. Patients commonly report stopping breastfeeding sooner than they planned. Interventions with proper accessible counseling and support to the mother can potentially increase lactation rates and duration. OBJECTIVE: This study aimed to investigate the impact of introducing a smartphone-based daily feedback and counseling platform between women after delivery and a multidisciplinary lactation support team on lactation rates and various maternal and neonatal outcomes. Counseling was provided via a specifically developed application from a multidisciplinary team (obstetricians, nurses, lactation counselors, and psychologist) in an attempt to assist and counsel to maintain lactation. STUDY DESIGN: This was a prospective, single-center, randomized controlled trial. Women planning to lactate were recruited at postpartum day 1 and were randomized to (1) routine lactation counseling and support (control group) or (2) additional daily detailed counseling and feedback on lactation from the team via the application (App group). The primary outcome was partial or full lactation at 3 months after delivery. The secondary outcomes included lactation at additional time points up to 6 months after delivery. The study was adequately powered to detect a 15% difference in the primary outcome. RESULTS: A total of 197 patients were recruited, 97 in the App group and 100 in the control group. The 2 groups did not differ in any background or delivery characteristics. The App group showed higher rates of lactation 6 weeks after delivery (96.9% vs 82.0%; P<.001) and 3 months after delivery (81.4% vs 69.0%; P=.049) than the control group. Patients in the App group reported excellent satisfaction from the use of the application and their overall postnatal care. CONCLUSION: Our study has provided further information on the growing efficacy of technology platforms in obstetrical care. The introduction of a smartphone-based daily feedback and counseling platform between postpartum patients and a multidisciplinary lactation support team increased the lactation rates after delivery with excellent patient satisfaction.

Management of pregnancies with suspected preeclampsia based on 6-hour vs 24-hour urine protein collection-a randomized double-blind controlled pilot trial.

BACKGROUND: Traditionally, the diagnosis of preeclampsia requires elevated blood pressure measurements and proteinuria demonstrated in a 24-hour urine collection. This prolonged urine collection is associated with patient discomfort, a delay in diagnosis, and in some cases, hospitalization for further management of outcomes. OBJECTIVE: We aimed to assess the feasibility, reliability, and association between maternal and neonatal outcomes of pregnancies managed according to a 6-hour vs 24-hour urine protein collection for suspected preeclampsia. STUDY DESIGN: This was a randomized controlled trial conducted at a tertiary university hospital between January 2019 and January 2021 (ClinicalTrials.gov Identifier: NCT03724786). Patients who were hospitalized for preeclampsia workup were asked to participate and randomized at a 1:1 ratio to 6- and 24-hour urine protein collection groups. Both groups collected urine for 24 hours, during which the collection was also tested after 6-hours. After 24 hours, both results were reviewed by one of the research staff, and either the 6- or 24-hour collection result was reported to the patient's managing physician and was documented in the patient's medical record. Both patient and the managing physician were blinded to group allocation. Unblinding was undertaken in cases of a discrepancy between the results (1 of 2 results of >300 mg protein), and the results were analyzed by intention to treat. The primary study outcome was defined as a composite of adverse maternal outcomes. The sample size was set empirically as per proof on concept design. RESULTS: During the study period, 115 patients participated in the trial, 101 of whom completed the follow-up and were analyzed-51 in the 6-hour group and 50 in the 24-hour group. Patient demographics were similar between the study groups. Unblinding occurred in 7 cases in the 6-hour group, in which the initial 6-hour result ranged from 168 to 475 mg. The rates of composite adverse maternal outcomes were 15.6% and 12.0% in the 6- and 24-hour groups, respectively (P=.59). No significant difference was demonstrated in the rate of adverse neonatal outcomes, cesarean delivery, induction of labor, gestational age at delivery, betamethasone treatment, or neonatal birthweight. CONCLUSION: Managing pregnancies suspected of preeclampsia with a 6-hour urine protein collection is feasible and associated with similar maternal and neonatal outcomes. In cases where the 6-hour result is in the 168 to 475 mg range, we propose completing a 24-hour collection.

Does gonadotropin-releasing hormone agonist cause luteolysis by inducing apoptosis of the human granulosa-luteal cells?

OBJECTIVES: To evaluates the effect of different modes of final follicular maturation triggering on the degree of apoptosis of granulosa cells (GCs) and the potential effect on progesterone secretion. METHODS: Thirty patients undergoing controlled ovarian hyperstimulation for IVF who received hCG, GnRH agonist, or dual trigger for final follicular maturation were included in the study. Granulosa cells were obtained at the time of oocyte retrieval. The proportion of apoptotic cells was evaluated via TUNEL and immunohistochemistry. RESULTS: The proportion of apoptotic cells was significantly higher in the GnRH agonist-alone group compared to hCG-alone and the dual trigger groups (13.5 ± 1.5% vs. 7.8% ± 1.8 vs. 10.1% ± 2, respectively, P < 0.01). Moreover, the expression of active-caspase-3 was also significantly increased in the GnRH agonist-alone group compared with the hCG-alone and the dual trigger groups (15.5% ± 2.9 vs. 8.4% ± 1.6 vs. 12.7% ± 2.6, respectively, P < 0.01). The progesterone levels measured in the granulosa-luteal cell culture medium after 24 h of incubation were similar between the three groups. CONCLUSIONS: The levels of apoptosis are increased after GnRH agonist/dual trigger. The increased apoptosis might be one of the culprit of the subsequent premature demise of the corpus luteum post GnRH agonist trigger.

Effects of 'rescue' dose of antenatal corticosteroids on placental histopathology in preterm births.

INTRODUCTION: Antenatal corticosteroids (ACS) are frequently used to reduce neonatal morbidity in preterm births (PTBs). A 'rescue' dose of ACS can be administer, if the risk of PTB remains. Some reports indicated that repeated doses of ACS might impact placental histology and possibly its function. We aimed to study whether repeated doses of ACS effect placental histopathology and pregnancy outcome. METHODS: The medical files and placental reports of all PTB, at 24-336/7 weeks, between Nov 2008-Dec 2019, were reviewed. The study population was divided into three groups; no-ACS (PTBs without ACS treatment), one-ACS (PTBs after a full or partial ACS course), and rescue-ACS (PTBs after a 'rescue' course of ACS). Placental lesions were classified according to "Amsterdam" criteria into maternal and fetal vascular malperfusion lesions, maternal and fetal inflammatory responses and chronic villitis. Placental lesions and pregnancy outcome were compared between the study groups. RESULTS: The no-ACS group (n = 58) was characterized by increased rates of PTB<28 weeks (p = 0.003), perinatal death (p < 0.001) and composite neonatal infectious morbidity (p = 0.022), as compared to the one-ACS group (n = 331) and the rescue-ACS group (n = 53). Placental MIR lesions were more common among the rescue-ACS group, compared to the one- and no-ACS groups (p = 0.022). Other placental lesions did not differ between the groups. On multivariate logistic regression analysis, MIR lesions were independently associated with rescue-ACS treatment (aOR 3.00, 95% CI 1.10-8/17, p = 0.031). DISCUSSION: Rescue course of ACS is associated with increased rate of placental maternal inflammatory response. These findings probably result from maternal stress stimuli without an adverse impact on early neonatal outcome.

Placental Histopathology and Pregnancy Outcomes in "Early" vs. "Late" Placental Abruption.

Placenta-associated pregnancy complications (fetal growth restriction and preeclampsia) are traditionally classified as "early" and "late" due to their different pathophysiology, histopathology, and pregnancy outcomes. As placental abruption (PA) represents another placenta-associated complication, we aimed to study if this categorization can be applied to PA as well. Pregnancy and placental reports of all pregnancies complicated by PA between November 2008 and January 2019 were reviewed. Maternal background, pregnancy outcomes, and placental histopathology were compared between cases of PA < 34 weeks (early PA group) vs. > 34 weeks (late PA group). Placental lesions were classified according to the "Amsterdam" criteria. The primary outcome was severe neonatal morbidity (≥ 1 severe neonatal complications: seizures, IVH, HIE, PVL, blood transfusion, NEC, or death). Included were 305 cases of PA, 71 (23.3%) in the early group and 234 (76.7%) in the late group. The early PA group was characterized by higher rates of vaginal bleeding upon presentation (p = 0.003), DIC (p = 0.018), and severe neonatal morbidity (p < 0.001). The late PA group was characterized by a higher rate of urgent Cesarean deliveries (p < 0.001). The early PA group was characterized by higher rates of placental maternal vascular malperfusion (MVM) lesions (p < 0.001), maternal inflammatory response (MIR) lesions (p < 0.001), placental hemorrhage (p < 0.001), and a lower feto-placental ratio (p < 0.001). Using regression analysis, we found that severe neonatal morbidity was independently associated with early abruption (aOR = 5.3, 95% CI = 3.9-7.6), placental MVM (aOR = 1.5, 95% CI = 1.2-1.9), placental MIR (aOR = 1.9, 95% CI = 1.4-2.3), and inversely associated with antenatal corticosteroids (aOR = 0.9, 95% CI = 0.6-0.98). "Early" and "late" PA significantly differ in their presentation, placental pathology, and pregnancy outcomes.

Does macroscopic estimation of the extent of placental abruption correlate with pregnancy outcomes?

INTRODUCTION: We aimed to study the correlation between the extent of placental abruption (PA), as grossly estimated immediately after delivery, and pregnancy outcomes, in correlation with placental histopathology. MATERIALS AND METHODS: Pregnancy and placental reports of all pregnancies complicated by PA (clinically diagnosed) between 11/2008-12/2018 were reviewed. We compared maternal background, pregnancy outcomes, and placental histopathology between cases of PA divided into three groups according to the extent of abruption: Group 1-<30 %, Group 2-30-49 %, and Group 3->50 % of placental surface. Placental lesions were classified according to the current "Amsterdam" criteria. The primary outcome was defined as a composite of severe neonatal morbidity and included ≥ 1 of the following complications: seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, periventricular leukomalacia, blood transfusion, necrotizing enterocolitis, intrauterine fetal demise, or neonatal death. RESULTS: A total of 260 PA cases were included: 111 (42.7 %) in Group 1, 94 (36.2 %) in Group 2, and 55 (21.1 %) in Group 3. The rate of the primary outcome (7.2 % vs. 11.7 % vs. 27.3 %, p = 0.02) was associated with the degree of PA as well as maternal heavy smoking (p = 0.04), DIC (p = 0.03), umbilical artery Ph <7.1 (p = 0.02), 5-minute Apgar scores <7 (p = 0.03), NICU admissions, placental maternal vascular malperfusion lesions (p = 0.04), and neonatal weights <5th percentile (0.04). In multivariable analysis severe adverse neonatal outcome was independently associated with the percentage of PA (aOR = 1.4, 95 % CI = 1.3-3.9). CONCLUSION: The extent of placental abruption, as estimated by the examiner, correlated with DIC and severe neonatal outcomes and may serve as an early alarming sign in deliveries complicated by PA.

Enhancing patient mobility following cesarean-delivery - the efficacy of an improved postpartum protocol assessed with pedometers.

BACKGROUND: The incidence of thromboembolic complications is highest in the immediate postpartum period, especially following caesarean delivery (CD). Ambulation following CD is important in their prevention. We examined the effect of an educational protocol on patients' mobility following CD, with the use of digital step counters (pedometers). METHODS: Starting February 2018, we implemented an educational protocol at the maternity ward, which included nurses' tutoring and subsequent patients' education, regarding the importance of early ambulation. Following CD, ambulation was initiated 4 h following surgery (as compared to 6 h prior). Scheduled IV acetaminophen was administered at six-hour intervals for 48 h (as compared to only 24 h prior), while additional analgesics were given upon patient request. We compared maternal demographics, delivery and postpartum course between the pre-protocol group (n = 101) and the post-protocol group (n = 100). All patients were asked to wear pedometers for 48 h following the delivery to assess ambulation. RESULTS: Patients' demographics, surgical and post-partum course were non-significant between the groups, except for surgical length (48.5 ± 14.6 vs. 53.5 ± 15.3 min in the pre and post protocol groups, respectively, p = 0.02). The pre-protocol group was treated with more additional analgesics (p = 0.02). A higher number of steps was taken in the post-protocol group as compared to the pre-protocol group (4394 ± 2985 vs.3551 ± 2931, respectively p = 0.04). In a linear regression analysis in which the number of steps served as the dependent variable, this educational protocol was independently associated with a higher number of steps [coefficient 988 steps, 95% CI 137-1838, p = 0.02], as was smoking, after adjustment for surgical length, emergent surgery, maternal age and body mass index. CONCLUSION: An educational protocol which included earlier ambulation and regular interval pain control was associated with improved ambulation following CD.

Histologic chorioamnionitis concomitant placental abruption and its effects on pregnancy outcome.

INTRODUCTION: Two possible causative pathways have been suggested to participate in the development of placental abruption (PA), an acute inflammatory pathway and placental vascular derived, a chronic pathway. We aimed to study the impact of the inflammatory pathway on maternal and neonatal outcome. METHODS: The computerized medical files and placental reports of all pregnancies diagnosed with PA, between 11/2008-1/2019, at 24-42 weeks, were reviewed. Placental lesions were classified according to "Amsterdam" criteria into maternal and fetal vascular malperfusion lesions, acute inflammatory responses and chronic villitis. Composite neonatal morbidity included ≥1 of the following: seizures, intra-ventricular hemorrhage (IVH), hypoxic-ischemic encephalopathy, periventricular leukomalacia (PVL), blood transfusion, necrotizing enterocolitis (NEC), neonatal sepsis, respiratory distress syndrome, or neonatal death. Maternal and neonatal outcome were compared between PA with and without histologic chorioamnionitis (HC). RESULTS: As compared to the PA without HC group (n = 267), the PA with HC group (n = 77) was characterized by lower gestational age (GA) at delivery (32.9 ± 5.5 vs. 35.6 ± 4.1 weeks, p < 0.001), higher rates of oligohydramnios (p < 0.001), bloody amniotic fluid at labor (p < 0.001), maternal postpartum fever (p < 0.001), longer maternal hospitalization (<0.001), and increased composite adverse neonatal morbidity (41.6% vs. 22.8%, p = 0.002). By multivariate analysis, GA and HC were found to be independently associated with adverse neonatal outcome, aOR 0.63 95% CI 0.43-0.78, p < 0.001, and aOR1.12, 95% CI 1.02-3.87, p = 0.04, respectively. DISCUSSION: The involvement of the inflammatory causative pathway in the development of placental abruption, is associated with increased maternal and neonatal morbidity.

Effect of Digital Step Counter Feedback on Mobility After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To assess the effect of a personalized repeated feedback approach using digital step counters (pedometers) on mobility after cesarean delivery in high-risk patients. METHODS: This was a randomized controlled trial at a tertiary university hospital. Patients who underwent cesarean delivery and were defined as high risk for thromboembolic events were asked to wear a pedometer around their wrists postpartum for 48 hours. Patients were randomized to the feedback group, which received personalized feedback by the research staff regarding their mobility at three set timepoints, or the control group, which received standard care. The number of steps taken by patients was compared between the groups and served as the primary outcome. Secondary outcomes included patient reported pain, physical and mental recovery, and overall satisfaction. Sample size was predetermined to detect a 25% between-group difference in the primary outcome. RESULTS: From December 2018 to July 2019, 215 patients were recruited, randomized and completed follow-up-108 in the feedback group and 107 in the control group. Patients' demographics and intrapartum course were similar between the groups. The number of steps taken was significantly higher in the feedback group compared with the control group: 5,918±3,116 vs 4,161±2,532 steps, P<.001. Pain scores were similar between the groups, as was analgesic consumption. Patients in the feedback group reported a significantly easier physical and mental postpartum recovery and were significantly more satisfied with their delivery experience. Postpartum complications did not differ between the groups. CONCLUSION: In high-risk patients after cesarean delivery, mobility was improved by using a personalized feedback approach. Enhanced mobility was not associated with a higher rate of complications or pain and was positively associated with patient satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03724760.

Reduced fetal movements is twin pregnancies and the association with adverse neonatal outcomes.

OBJECTIVE: Reduced fetal movements (RFM) is an obstetric complaint known to be associated with adverse neonatal outcomes and should serve as an alarming sign in obstetric triage. Whether this assumption holds for twin pregnancies, is still an obstetric enigma, and this complaint is sometimes overlooked in twins. We, therefore, aimed to study neonatal outcomes in twin pregnancies complicated by RFM. We hypothesised that in twin pregnancy, maternal ability to perceive RFM will be limited, and therefore, will not be associated with adverse neonatal outcome. STUDY DESIGN: Included were all dichorionic twin pregnancies between 2009-2019 who presented to our obstetric triage at a gestational age >34 weeks with an isolated complaint of RFM and delivered during the subsequent two weeks (RFM group). The control group included patients with twin pregnancies (matched for gestational age and maternal age) who presented for routine assessment and reported regular fetal movements throughout pregnancy (no RFM group). Data regarding pregnancy, delivery, and neonatal outcomes were compared between the groups. The primary outcome was a composite of adverse neonatal outcomes, which included one or more of the following: neonatal hypoglycemia, respiratory morbidity, cerebral morbidity, phototherapy, neonatal sepsis, blood transfusions, necrotizing enterocolitis, or neonatal death. Multivariable regression analysis was used to identify independent associations with adverse neonatal outcomes. RESULTS: Maternal demographics and gestational age at delivery did not differ between the RFM group (n = 83 pregnancies and 166 neonates) and the no RFM group (n = 83 pregnancies and 166 neonates). Neonatal birthweights, as well as the rate of birthweights <10th centile, did not differ between the groups. There were 2 cases of fetal demise diagnosed at triage in the RFM group. The rate of the primary outcome, as well as NICU admissions, were significantly higher in the RFM group compared to the no RFM group (29.5 % vs. 19.2 %, p = 0.01 and 32.5 % vs. 19.2 %, p = 0.001). In multivariable analysis RFM (aOR = 1.18, 95 % CI = 1.06-2.73), and GA at delivery (aOR = 0.88, 95 % CI = 0.67-0.97) were associated with adverse neonatal outcome-independent from background confounders. CONCLUSION: Patients presented to obstetric triage with twin pregnancies and isolated RFM had higher rates of adverse neonatal outcomes and NICU admissions compared to twin pregnancies without RFM.

Protracted postpartum urinary retention-a long-term problem or a transient condition?

INTRODUCTION AND HYPOTHESIS: Protracted postpartum urinary retention (P-PUR) is a rare puerperal complication of overt urinary retention that proceeds beyond the 3rd postpartum day. Long-term consequences of P-PUR are poorly reported. The objective of the study was to compare the long-term outcome of patients with P-PUR with a matched control group, using a validated pelvic floor distress questionnaire. METHODS: All medical files of women diagnosed with P-PUR between 2005 and 2016 were reviewed. The control group was comprised of women who had a consecutive birth, matched in a 1:2 ratio, by maternal age, parity, neonatal birth weight, analgesia, and route of delivery. All women were evaluated for long-term symptoms of urinary or fecal incontinence and pelvic-organ-prolapse-related complaints by a telephone interview, at least 1 year following their delivery, using the Pelvic Floor Distress Inventory-Short Form (PFDI-20) questionnaire. RESULTS: During the study period, there were 27 cases of P-PUR out of 52,662 deliveries (0.051%). There were no differences between the study group (n = 27) and controls (n = 54) in age, BMI (kg/m2), parity, birth weight, route of delivery, and rate of episiotomy. The majority of patients in both groups opted for epidural analgesia. Second stage of labor was longer in the study group than in controls, 134.1 ± 74.6 min vs. 73.4 ± 71.6 min, respectively, p < 0.001. The scores of the PFDI-20, UDI-6, and POPDI-6 did not differ between the groups. However, the study group had minimally elevated scores on the CARDI-8 scale (1.0 ± 2.6 vs. 0.0 ± 0.0, p = 0.012). CONCLUSIONS: P-PUR is a rare postpartum complication, yet this disturbing condition has negligible if any clinical impact on long-term urogynecologic disorders. These findings carry a reassuring message to both patients and their health care providers.

The role of umbilical cord gas studies in the prediction of adverse neonatal outcomes in scheduled nonlaboring term singleton cesarean deliveries.

BACKGROUND: Most major societies do not state a specific recommendation against or in favor of routine umbilical cord gas studies sampling. OBJECTIVE: We aimed to study the correlation between abnormal umbilical cord gas studies (using 5 different definitions) and adverse neonatal outcomes in scheduled nonlaboring term singleton cesarean deliveries. STUDY DESIGN: The medical charts, surgical records, and neonatal charts of all singleton cesarean deliveries at 370/7-416/7 weeks of gestation between January 2009 and May 2018 from a single tertiary center were reviewed. The cohort of singleton cesarean deliveries was divided into those with "normal" vs "abnormal" umbilical cord gas studies with the 5 different definitions: (1) definition A: pH ≤7.15; (2) definition B: pH ≤7.15 and base excess ≤-12 mmol/L; (3) definition C: pH ≤7.1l (4) definition D: pH ≤7.1 and base excess ≤-12 mmol/L, and (5) definition E: pH <7.0 and base excess ≤-12 mmol/L. Adverse neonatal outcomes included Apgar scores at 5 minutes ≤7, neonatal sepsis, blood transfusion, phototherapy, respiratory morbidity (presence of respiratory distress syndrome, transient tachypnea of the newborn infant, mechanical ventilation, need for respiratory support, or meconium aspiration), cerebral morbidity (presence of intraventricular hemorrhage, seizures, or hypoxic-ischemic encephalopathy), necrotizing enterocolitis, or death. Composite adverse outcome was ≥1 of the aforementioned complications. RESULTS: Overall, 3001 singleton cesarean deliveries were included. The rate of abnormal umbilical cord gas studies with the use of definitions A-E was 2.6%, 0.3%, 1.2%, 0.3%, and 0.1%, respectively. The overall rate of adverse neonatal outcome for the entire cohort was 14.43% (433/3001). There was no correlation between abnormal umbilical cord gas studies and composite adverse neonatal outcome with the use of any of the definitions A-E (P=.2, P=.3, P=.2, P=.3, P=.1, respectively). The sensitivity and specificity of abnormal umbilical cord gas studies as a predictor of composite adverse neonatal outcome were calculated for each of the abnormal umbilical cord gas studies definitions; although the sensitivity was extremely low (0-2.07%), the specificity was high (97.2-99.9%) CONCLUSION: Abnormal umbilical cord gas studies are an uncommon finding in cases of singleton term singleton cesarean deliveries and do not correlate with adverse neonatal outcomes. Therefore, the clinical usefulness and cost-effectiveness of obtaining these studies routinely should be questioned.

The VEGF and PEDF levels in the follicular fluid of patients co- treated with LETROZOLE and gonadotropins during the stimulation cycle.

BACKGROUND: Previous studies have shown that androgens, in addition to serving as precursors for ovarian estrogen synthesis, also have a fundamental role in primate ovarian follicular development by augmentation of FSH receptor expression on granulosa cells. Recent studies have shown that aromatase inhibitor, letrozole, improves ovarian response to FSH in normal and poor responder patients, possibly by increasing intraovarian androgen levels. Studies in mice also showed an effect of letrozole to increase pigment epithelium-derived factor (PEDF) and to lower vascular epithelial growth factor (VEGF), which might be expected to reduce the risk of ovarian hyperstimulation syndrome (OHSS) with stimulation. The aim of this study was to compare the VEGF and PEDF levels in the follicular fluids of normal responders treated with letrozole and gonadotropins during the ovarian stimulation with patients treated with gonadotropins only. METHODS: A single center, prospective clinical trial. We collected follicular fluid from 26 patients, on a GnRH antagonist protocol, dual triggered with hCG and GnRH agonist. The patients in one group were co-treated with letrozole and gonadotropins during the ovarian stimulation and the patients in the other group were treated with gonadotropins only. VEGF, PEDF, estrogen, progesterone and testosterone levels were measured by ELISA kits. RESULTS: The age of the patients, the total dose of gonadotropins and the number of oocytes were comparable between the two groups. In the follicular fluid, the estrogen levels (2209 nmol/l vs. 3280 nmol/l, p = 0.02) were significantly decreased, and the testosterone levels (246.5 nmol/l vs. 40.7 nmol/l, p < 0.001) were significantly increased in the letrozole group compared to the gonadotropin only group. The progesterone levels (21.4 µmol/l vs. 17.5 p = NS) were comparable between the two groups. The VEGF levels (2992 pg/ml vs. 1812 pg/ml p = 0.02) were significantly increased and the PEDF levels (9.7 ng/ml vs 17.3 ng/ml p < 0.001) were significantly decreased in the letrozole group. CONCLUSIONS: Opposite to observations in the mouse, we found that VEGF levels were increased and PEDF levels were decreased in the follicular fluid in patients treated with letrozole during the stimulation cycles. Further investigation is required to determine if patients treated with letrozole during the IVF stimulation protocol are at increased risk for developing OHSS as a result of these findings.

Does daily co-administration of letrozole and gonadotropins during ovarian stimulation improve IVF outcome?

BACKGROUND: For the last year we have been treating normal responders with gonadotropins and letrozole during the whole stimulation in order to improve response to FSH by increasing the intrafollicular androgen concentration, and to reduce circulating estrogen concentrations. The aim of this study was to compare the IVF outcome of normal responders treated with letrozole and gonadotropins during ovarian stimulation with patients treated with gonadotropins only. METHODS: A single centre retrospective cohort study of 174 patients (87 in each group). RESULTS: The age of the patients was comparable between the groups. Estradiol levels were significantly higher in the control group (6760 pmol/L vs. 2420 pmol/L respectively, p < 0.01), and the number of follicles ≥15 mm at the trigger day was significantly lower in the control group (7.9 vs. 10, p = 0.02). The number of retrieved oocytes (10 vs. 14.5, p < 0.01), MII oocytes (7.9 vs. 11.2, p < 0.01) and blastocysts (2.7 vs. 4.0, p = 0.02) was significantly higher in the study group. We found no significant differences in the cumulative pregnancy outcome between the two groups (65.2% vs 58.3% p = NS). CONCLUSIONS: We conclude that co-treatment with letrozole improves the IVF outcome in normal responders in terms of increased number of blastocysts obtained without increasing the pregnancy rate or the risk of OHSS.