The significance of lower uterine segment involvement in endometrial cancer.

BACKGROUND: Limited data suggests lower uterine segment involvement (LUSI) in endometrial cancer may be associated with other poor prognostic factors. We assessed the unclear impact of LUSI on prognosis in endometrial cancer. METHOD: ology: A revision of pathological samples following surgical staging between the years 2002-2022 was performed and clinical data collected from patients' records. Characteristics and outcomes of women with and without LUSI were compared and analysed. Kaplan Meyer survival curves compared overall survival (OS) and progression-free survival (PFS). RESULTS: 429 women were included, of which 45 (10.5%) had LUSI. No differences were found between the groups regarding demographic or clinical characteristics. LUSI was significantly associated with lympho-vascular space invasion (40% vs. 22% p = 0.01), lymph node involvement (6.4% vs. 9.1%, p = 0.05), shorter PFS (4 vs. 5.5 years, p = 0.01) and OS (5.6 vs. 11.5 years, p = 0.03). Multivariate analysis showed higher hazard ratios for OS and PFS (1.55 95%CI 0.79-3.04 and 1.29 95%CI 0.66-2.53, respectively) but these were insignificant even in a sub-analysis of endometrioid histology (1.76 95%CI 0.89-3.46 and 1.35 95%CI 0.69-2.65, respectively). A trend towards decreased PFS and OS was demonstrated in the Kaplan Meyer survival curves for all cases (log rank test p = 0.5 and 0.29 respectively), endometrioid histology (log rank test p = 0.06 and 0.51 respectively) and early-stage disease (log rank test p = 0.63 and 0.3 respectively). CONCLUSION: LUSI may be related to poorer outcome of endometrial cancer and may represent an additional factor to consider when contemplating adjuvant treatment, especially in endometrioid-type and early-stage disease.

von Willebrand factor antigen: a biomarker for severe pregnancy complications in women with hereditary thrombotic thrombocytopenic purpura?

BACKGROUND: Hereditary thrombotic thrombocytopenic purpura (hTTP) is associated with severe obstetric morbidity (SOM) during pregnancy. Treatment with fresh frozen plasma (FFP) mitigates the risk in some women, but others respond poorly and continue to suffer obstetric complications. OBJECTIVES: To determine a possible association between SOM and elevated nonpregnant von Willebrand factor (NPVWF) antigen levels in women with hTTP and whether the latter can predict the response to FFP transfusion. METHODS: This was a cohort-based study of women with hTTP due to homozygous c.3772delA mutation of ADAMTS-13 who had pregnancies both with and without FFP treatment. Occurrences of SOM were determined from medical records. Generalized estimated equation logistic regressions and receiver operating characteristic curve analysis determined the NPVWF antigen levels associated with the development of SOM. RESULTS: Fourteen women with hTTP had 71 pregnancies; of which 17 (24%) culminated in pregnancy loss and 32 (45%) were complicated by SOM. FFP transfusions were administered in 32 (45%) of the pregnancies. Treated women had decreased SOM (28% vs 72%, p < .001) and preterm thrombotic thrombocytopenic purpura exacerbations (18% vs 82%, p < .001) and higher median NPVWF antigen levels than those of women with uncomplicated pregnancies (p = .018). Among the treated women, median NPVWF antigen levels were higher in those with SOM than in those without SOM (225% vs 165%, p = .047). Logistic regression models demonstrated a significant 2-way association between elevated NPVWF antigen levels (for SOM, odds ratio, 1.08; 95% CI, 1.001-1.165; p = .046) and SOM (for elevated NPVWF antigen levels, odds ratio, 1.6; 95% CI, 1.329-1.925; p < .001). The receiver operating characteristic curve analysis demonstrated that an NPVWF antigen level of 195% had 75% sensitivity and 72% specificity for SOM. CONCLUSION: Elevated NPVWF antigen levels are associated with SOM in women with hTTP. Women with levels >195% may benefit from increased surveillance and more intensive FFP treatment during pregnancy.

Positive pathological margins after loop electrosurgical excision procedure - Management and outcome.

OBJECTIVE: Pathological involvement of cervical conization margins is a risk factor for recurrence, although management of these patients is controversial. We aimed to define risk factors for positive margins and compare recurrence following additional surgical intervention compared to conservative management. METHODS: A retrospective study of all conizations at our center between 2010 and 2019. Univariate analysis identified characteristics associated with positive margins. Women were stratified by mode of management comparing three groups (surveillance, repeat conization or hysterectomy) then two groups (surveillance vs. additional surgery). Kaplan Meyer survival curves compared cumulative recurrence stratified by mode of management. Pathological results of subsequent surgical procedures were examined for residual disease. RESULTS: Of 448 conizations performed, 131 (29.2%) had positive margins which were associated with menopause, high-grade cytology and endocervical gland involvement. Women who underwent surveillance (n = 45) were more likely to be nulliparous, with low-grade histology and less endocervical gland involvement. Women who underwent hysterectomy (n = 61) were more likely to be postmenopausal and parous. Recurrence did not differ significantly in the three-group (p = 0.073) or two-group model (6.4% vs. 7.1% p = 0.869). Kaplan Meyer survival curves depicting cumulative recurrence did not differ significantly in either model (log rank test p = 0.642 for the three-group model, and p = 0.868 for the two-group model). Residual disease was found in 51.6% of hysterectomy specimens and 52.6% of repeat conizations. CONCLUSION: Surveillance is non-inferior to additional surgery in cases with positive conization margins and constitutes a valid option specifically for younger women at risk of future obstetric complications and those susceptible post-hysterectomy complications.

Critical analysis of risk factors for intrapartum fetal death.

PURPOSE: Intrapartum fetal death is devastating for both parents and medical caregivers. The purpose of this study was to evaluate the risk factors for intrapartum fetal death, which often influence management in subsequent pregnancies. METHODS: This population-based cohort study included all singleton deliveries between the years 1991-2016 at Soroka University Medical Center. Trends over the years, risk factors for intrapartum fetal death and the effect of day of the week were examined. A generalized estimation equation (GEE) model was used to control for confounders. RESULTS: During the study period 344,536 deliveries were recorded, of which 251 (0.1%) suffered intrapartum fetal death. Rates did not change significantly over the years (p = 0.130, using the chi-square test for trends). Preterm delivery, placental abruption, uterine rupture, shoulder dystocia, congenital malformations, severe preeclampsia and fetal malpresentation were significantly more common in pregnancies complicated by intrapartum death. Using a GEE model; shoulder dystocia (aOR 23.8, 95% CI 9.9-57.3, p < 0.005), uterine rupture (aOR 19.0, 95% CI 7.0-51.4, p < 0.05), preterm delivery (aOR 11.9, 95% CI 8.6-16.5, p < 0.001), placental abruption (aOR 6.2, 95% CI 4.1-9.4, p < 0.001), fetal malpresentation (aOR 3.6, 95% CI 2.6-4.9, p < 0.005) and congenital malformations (aOR 2.6, 95% CI 1.9-3.5, p < 0.05) were all independent risk factors for intrapartum fetal death. Weekend deliveries were not at increased risk of intrapartum fetal death. CONCLUSION: Several risk factors were identified for intrapartum fetal death, with shoulder dystocia demonstrating the highest risk. Unfortunately most factors are neither preventable nor predictable and interventions to decrease the rate of intrapartum fetal death remain elusive.

Cesarean versus vaginal delivery for breech presentation is an independent risk factor for long-term pediatric respiratory hospitalization of the offspring.

OBJECTIVES: To compare the long-term respiratory morbidity of offspring born by cesarean delivery for breech presentation with that of those delivered vaginally. METHODS: A population-based cohort analysis including all singleton breech deliveries between the years 1991 and 2014, comparing long-term respiratory morbidity of offspring born in breech presentation, according to mode of delivery. Offspring with congenital malformations, perinatal deaths, and instrumental deliveries were excluded. Respiratory morbidity included hospitalizations (up to age 18 years), as recorded in hospital records. A Kaplan-Meier survival curve compared cumulative respiratory morbidity. A Weibull parametric survival model controlled for confounders and repeat deliveries. RESULTS: A total of 7337 breech deliveries were included; 6376 (86.9%) cesarean deliveries and 961 (13.1%) vaginal breech deliveries. The Kaplan-Meier survival curve demonstrated higher cumulative incidence of respiratory morbidity in the cesarean delivery group compared with vaginal delivery (log rank test P = 0.006). Using a Weibull parametric survival model to control for confounders, cesarean delivery was found to be an independent risk factor for long-term respiratory morbidity of the offspring (adjusted hazard ratio 1.87, 95% confidence interval 1.32-2.65, P < 0.001). CONCLUSIONS: Cesarean versus vaginal delivery for breech presentation is an independent risk factor for long-term pediatric respiratory morbidity of the offspring.

Risk factors for antepartum death in term pregnancies.

OBJECTIVE: To identify risk factors for antepartum fetal death (APD) in term pregnancies while considering maternal, pregnancy and fetal characteristics. MATERIALS AND METHODS: Our study took place between the years 1988-2013. A total of 272,527 singleton births at term were recorded during this time period, including 524 cases of APD (0.2%). Cases of known chromosomal or other fetal abnormalities and cases with poor prenatal care were excluded. In order to identify independent risk factors contributing to antepartum fetal death in term we conducted a multivariate analysis using logistic regression. RESULTS: The main risk factors found to be significantly associated with APD in term were suspected intrauterine growth restriction (OR = 2.70, p < .001), diabetes (OR = 1.37, p = .05), hypertensive disorders (OR = 1.59, p = .01), advanced maternal age (OR = 1.03, p < .001) and grand-multiparity (OR = 1.79, p < .001). Advanced gestational age was not significantly associated with APD (38.95 vs. 39.44, p < .001). CONCLUSIONS: Most of the risk factors for antepartum fetal death in term pregnancies found in this study coincide with known risk factors for APD as described in previous studies. We believe that in the presence of these risk factors, closer surveillance and careful medical management of the pregnancy are required, in order to reduce the incidence of APD, including induction of labor at advanced gestational age.

Mode of delivery and long-term gastrointestinal-related hospitalization of the offspring.

OBJECTIVE: We set out to ascertain a possible association between mode of delivery (cesarean vs. vaginal delivery) and gastrointestinal hospitalization of the offspring. STUDY DESIGN: A population based cohort analysis including all uncomplicated singleton deliveries occurring between the years 1991-2014 at a tertiary medical center was performed, comparing long-term gastrointestinal hospitalization of offspring, according to mode of delivery. Multiple gestations, fetuses with congenital malformations and perinatal deaths were excluded, as were cases of urgent cesarean delivery and pregnancy complications. Gastrointestinal hospitalizations (up to age 18 years) were defined using predefined ICD9 codes, as recorded in hospital records. A Kaplan Meier survival curve was constructed to compare cumulative incidence of first gastrointestinal hospitalizations. A Cox proportional hazard model was used to control for confounders. RESULTS: During the study period 139,232 deliveries met the inclusion criteria; 13,242 (9.5%) of which were elective cesarean deliveries, and the remaining 125,990 (90.5%) were delivered vaginally. Cesarean delivery was associated with more offspring hospitalizations for gastrointestinal morbidity (p < .001). The Kaplan Meier survival curve demonstrated higher cumulative incidence of gastrointestinal hospitalizations in the cesarean delivery group (log rank test p < .001). Utilizing a Cox proportional hazards model to control for confounders, cesarean delivery was found to be an independent risk factor for long-term gastrointestinal hospitalization of the offspring (adjusted HR 1.409, 95%CI 1.306-1.521, p < .001). Specifically, inflammatory bowel disease was more common among offspring following cesarean delivery aHR 1.386 95% CI 1.215-1.582 p < .001. CONCLUSION: Elective cesarean delivery is an independent risk factor for long-term gastrointestinal-related hospitalization of the offspring.

Maternal known drug allergy and long-term neurological hospitalizations of the offspring.

PROBLEM: Drug allergies are increasingly common. Immunological factors, implicated in many neurological diseases, also influence an individual's susceptibility. We sought to ascertain a possible association between maternal drug allergy and long-term neurological-related hospitalizations in the offspring. METHOD OF STUDY: This is a population-based cohort analysis, comparing the long-term risk of neurological-related hospitalization, involving a predefined set of ICD9 codes as recorded in hospital records, of children born to mothers with and without drug allergies. Deliveries occurred between the years 1991 and 2014 in a tertiary medical center. Twin pregnancies, fetal malformations, and cases of perinatal mortality were excluded. A Kaplan-Meier survival curve was constructed to compare cumulative neurological hospitalizations. A Cox proportional hazards model was used to control for time to event. RESULTS: The study included 242 342 patients, 9714 with known drug allergy (4%). Offspring born to mothers with drug allergies had significantly more neurological hospitalizations compared to controls (4.2% vs 3.1%; P ≤ .001; Kaplan-Meier log-rank test P ≤ .001), specifically for psychiatric disorders including eating disorders (0.3% vs 0.2%;P = .002), attention-deficit/hyperactivity disorder (0.124% vs 0.056%; P = .008), emotional disorders (0.8% vs 0.5%; P ≤ .001), and movement disorders (2.3% vs 1.8%; P = .002). While controlling for birth year, gestational age, maternal age, maternal diabetes, hypertensive disorders, and cesarean delivery, using a Cox proportional hazards model, maternal drug allergy was found to be an independent risk factor for neurological hospitalization of the offspring (adjusted HR 1.3, 95% CI 1.19-1.45 P < .001). CONCLUSION: Being born to a mother with known drug allergy is an independent risk factor for long-term neurological hospitalization of the offspring.

Prenatal exposure to preeclampsia as a risk factor for long-term endocrine morbidity of the offspring.

Objective: To analyze preeclampsia as a risk factor for pediatric endocrine disease. Study Design: A population-based cohort analysis comparing the risk of endocrine morbidity of children born between 1991-2014 to mothers with and without preeclampsia. Results: The study included 253,808 deliveries. Exposed offspring had significantly more endocrine hospitalizations (0.7% vs 0.4%; p < 0.001), specifically obesity (0.4% vs 0.2%, p < 0.001). While controlling for confounders, the exposed offspring had significantly more endocrine morbidity (OR 1.433 95% CI 1.115-1.841 p = 0.005). Conclusion: Preeclampsia is an independent risk factor for long-term endocrine disease of the offspring, specifically obesity.

Long-Term Infectious Morbidity of Premature Infants: Is There a Critical Threshold?

In this study, we sought to ascertain a relationship between gestational age at birth and infectious morbidity of the offspring via population-based cohort analysis comparing the long-term incidence of infectious morbidity in infants born preterm and stratified by extremity of prematurity (extreme preterm birth: 24 + 0-27 + 6, very preterm birth: 28 + 0-31 + 6, moderate to late preterm birth: 32 + 0-36 + 6 weeks of gestation, and term deliveries). Infectious morbidity included hospitalizations involving a predefined set of International Classification of Diseases 9 (ICD9) codes, as recorded in hospital records. A Kaplan-Meier survival curve compared cumulative incidence of infectious-related morbidity. A Cox proportional hazards model controlled for confounders and time to event. The study included 220,594 patients: 125 (0.1%) extreme preterm births, 784 (0.4%) very preterm births, 13,323 (6.0%) moderate to late preterm births, and 206,362 term deliveries. Offspring born preterm had significantly more infection-related hospitalizations (18.4%, 19.8%, 14.9%, and 11.0% for the aforementioned stratification, respectively, p < 0.001). Multivariate analysis found being born very or late to moderate preterm was independently associated with long-term infectious morbidity (adjusted hazard ratio (aHR) 1.5, 95% confidence interval (CI) 1.27-1.77 and aHR 1.23, 95% CI 1.17-1.3, respectively, p < 0.001). A comparable risk of long-term infectious morbidity was found in the two groups of premature births prior to 32 weeks gestation. In our population, a cutoff from 32 weeks and below demarks a significant increase in the risk of long-term infectious morbidity of the offspring.

Maternal history of recurrent pregnancy loss increases the risk for long-term pediatric respiratory morbidity of the offspring.

BACKGROUND: While the etiology in many cases of recurrent pregnancy loss (RPL) is unclear, recent evidence suggests possible immunological dysfunction, which is also implicated in the pathophysiology of many pediatric respiratory diseases. OBJECTIVE: We sought to investigate whether maternal history of RPL is associated with long-term respiratory morbidity of the offspring. STUDY DESIGN: A population based cohort analysis was performed comparing the risk of long-term respiratory morbidity (up to the age of 18 years) of children born to mothers with and without a history of RPL (defined as two or more losses). Respiratory morbidity included hospitalizations involving a predefined set of ICD-9 codes, as recorded in the hospital medical records. Deliveries occurred between the years 1991 and 2014 in a tertiary medical center. A Kaplan-Meier survival curve was constructed to compare cumulative respiratory morbidity, and a Cox proportional hazards model was used to control for confounders. RESULTS: During the study period, 242 187 newborns met the inclusion criteria; 5% (n = 12 182) of which were offspring to mothers with a history of RPL. Respiratory morbidity was significantly more common in the exposed group (6.0% vs 4.8%, P < .001). Specifically, offspring to mothers with a history of RPL had higher rates of obstructive sleep apnea and asthma (P < .05). The Kaplan-Meier survival curve exhibited a higher cumulative incidence of total respiratory morbidity in offspring of mothers with a history of RPL (Log rank P < .001). In the Cox regression, maternal history of RPL was independently associated with increased pediatric respiratory morbidity of the offspring with an adjusted hazard ratio of 1.24 (95 % confidence interval [95%CI], 1.15-1.34, P < .001). CONCLUSION: Maternal history of RPL is associated with a higher risk of future pediatric respiratory morbidity of the offspring; possibly explained by a common immunological etiology.

Short- and long-term outcomes of intraoperative spillage during laparoscopic removal of benign ovarian cysts.

BACKGROUND: To compare the short- and long-term outcomes in patients with and without intraoperative spillage from benign adnexal masses during laparoscopic removal. METHODS: We conducted a retrospective analysis of all cases of laparoscopic removal of ovarian cysts (cystectomy or adnexectomy) in our institution between the years 2013 and 2017, excluding malignant lesions. RESULTS: During the study period, 186 cases of ovarian cyst removal were identified. Intraoperative ovarian cyst spillage (IOCS) occurred in 104 cases (study group), while in the remaining 82 cases no spillage was reported (control group). Baseline clinical characteristics were comparable between groups. Large cyst diameter and intraperitoneal adhesions were significantly associated with the occurrence of IOCS (P  = 0.008 and < 0.001, respectively). The use of an endoscopic retrieval bag was significantly inversely associated with IOCS. Postoperative complications (pain score, hospital stay, febrile illness and recurrence of ovarian cyst) were comparable between groups. CONCLUSIONS: IOCS during laparoscopic cystectomy is associated with larger cyst diameter and intraperitoneal adhesions, but not with adverse short- or long-term outcomes nor with recurrence rates.

Online medicine for pregnant women.

Objective. To assess the use of cell phones and email as means of communication between pregnant women and their gynecologists and family physicians. Study Design. A cross-sectional study of pregnant women at routine followup. One hundred and twenty women participated in the study. Results. The mean age was 27.4 ± 3.4 years. One hundred nineteen women owned a cell phone and 114 (95%) had an email address. Seventy-two women (60%) had their gynecologist's cell phone number and 50 women (42%) had their family physician's cell phone number. More women contacted their gynecologist via cell phone or email during pregnancy compared to their family physician (P = 0.005 and 0.009, resp.). Most preferred to communicate with their physician via cell phone at predetermined times, but by email at any time during the day (P < 0.0001). They would use cell phones for emergencies or unusual problems but preferred email for other matters (P < 0.0001). Conclusions. Pregnant women in the Negev region do not have a preference between the use of cell phones or email for medical consultation with their gynecologist or family physician. The provision of the physician's cell phone numbers or email address together with the provision of guidelines and resources could improve healthcare services.