Predictive Factors for Successful Vaginal Delivery after a Trial of External Cephalic Version: A Retrospective Cohort Study of 946 Women.

OBJECTIVE: Our aim was to find the factors which predict a vertex presentation of vaginal delivery (VD) in women who are admitted for a trial of external cephalic version (ECV). STUDY DESIGN: This is a retrospective cohort study of women who underwent a trial of ECV and delivered between November 2011 and December 2018 in a single tertiary center. The main outcome measure was successful VD of a fetus in the vertex presentation. Women who achieved VD in the vertex presentation or underwent cesarean delivery were compared on the basis of variety of predictive factors. Adverse neonatal and maternal outcomes were reported. Logistic regression was used for the multivariate analysis. RESULTS: A total of 946 women were included; 717 (75.8%) women had a successful ECV and 663 (70.1%) women had a VD in the vertex presentation. Parous women had 79.3% VD rate (570/719) and nulliparous women had 41.0% VD rate (93/227). Women with an amniotic fluid index (AFI) of 50 to 79, 80 to 200, and >200 mm had 34.8, 71.0, and 83.1% VD rate, respectively. Parous versus nulliparous women had an adjusted odds ratio (aOR) of 5.42 (95% confidence interval [CI]: 3.90-7.52, p < 0.001), women with AFI 50 to 79 mm compared with AFI 80 to 200 mm had an aOR of 0.21 (95% CI 0.12-0.37, p < 0.001), and women with an AFI >200 mm compared with AFI 80 to 200 mm had an aOR of 1.74 (95% CI: 1.03-2.92, p = 0.037) to achieve VD. The final prediction model for the chances of a VD based on data on admission for ECV was reported. The Hosmer-Lemeshow test was used to evaluate the goodness of fit of the model (p = 0.836). CONCLUSION: Being parous and having an AFI >200 mm are positive independent predictive factors for achieving VD of a vertex presenting fetus after ECV. Whereas AFI 50 to 79 mm is a negative independent predictive factor. KEY POINTS: · The goal of ECV is to achieve a vertex VD.. · Predictors for ECV success might not predict a VD.. · Parity & AFI independently predict a VD after ECV..

Titers of SARS CoV-2 antibodies in cord blood of neonates whose mothers contracted SARS CoV-2 (COVID-19) during pregnancy and in those whose mothers were vaccinated with mRNA to SARS CoV-2 during pregnancy.

OBJECTIVE: We compared neonatal immunity after vaccination against SARS-CoV-2 during pregnancy to that achieved after maternal infection. STUDY DESIGN: We tested cord blood from women infected with SARS-CoV-2 during pregnancy (group 1, n = 29), women who were vaccinated during pregnancy (group 2, n = 29) and from women not infected and not vaccinated (Group 3, n = 21) for titers of antibodies to both SARS-CoV-2 spike and 'N' proteins. RESULTS: Seventy-nine women were included: Antibodies against SARS-CoV-2 spike protein were detected in all samples from Group 1 and 2. Antibodies to the 'N' protein were detected in 25/29 samples in Group 1. None of the samples from Group 3 had antibodies to either protein. Mean titers of SARS-CoV-2 antibodies were significantly higher in Group 2 than in Group 1 (p < 0.05). CONCLUSIONS: Neonates born to mothers vaccinated during pregnancy have higher antibody titers and may therefore have more prolonged protection than those born to women infected during pregnancy.

Twin TOLAC is an independent risk factor for adverse maternal and neonatal outcome.

PURPOSE: To determine factors associated with a successful twin trial of labor after Cesarean delivery (TOLAC). METHODS: A retrospective cohort study was conducted at a single medical center in a population highly motivated for TOLAC (> 80%). The effect of maternal demographic and obstetric characteristics on the likelihood of twin TOLAC success was analyzed. Maternal complications and combined adverse outcome (uterine rupture, Apgar < 7 at 5 min, and umbilical cord pH < 7.1) were compared between singleton and twin TOLAC groups. RESULTS: Ninety-five women with a twin gestation and one previous Cesarean delivery comprised the study group. Five thousand seven hundred and three women with a singleton gestation and one previous Cesarean delivery comprised the control group. 30.5% and 83% of women with twin and singleton gestation, respectively, underwent a trial of labor. Women in the twin TOLAC group were significantly less likely to succeed and less likely to have a spontaneous unassisted vaginal delivery compared to women in the singleton TOLAC group. Maternal age less than 35 years, parity greater than two, and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, maternal complications, and for combined adverse outcome. CONCLUSIONS: Twin TOLAC is not common, even in parturients highly motivated for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture, maternal complications, and combined adverse perinatal outcome than women undergoing TOLAC with a singleton gestation. Demographic and obstetric risk factors were identified which can aid the attending obstetrician in the counseling of these challenging cases.

Safety of vaginal delivery in women infected with COVID-19.

BACKGROUND: There is limited data regarding the safety of vaginal delivery in women infected with COVID-19. Our goal was to assess the safety of vaginal delivery in women infected with COVID-19 and the risk of neonatal infection. METHODS: This was a single medical center cohort study. Data were collected about the outcome of twenty-one women with laboratory-confirmed COVID-19 infection who delivered between March 23, 2020, and May 8, 2020. RESULTS: Twenty-one gravidas were diagnosed with COVID-19 infection. None required admission to the intensive care unit (ICU) and there were no fatalities. Seventeen delivered vaginally and four by caesareans. Apgar scores of all neonates were 9 at 1 min and 10 at 5 min. One neonate was diagnosed with COVID-19 infection 24 h after birth. CONCLUSIONS: Vaginal delivery in women infected with COVID-19 is not associated with a significant risk of neonatal infection.

The Role of Children in the Dynamics of Intra Family Coronavirus 2019 Spread in Densely Populated Area.

We examined the dynamics of coronavirus 2019 (COVID-19) transmission within families. Our investigation demonstrated significantly lower rates of COVID-19 positivity in children compared with adults residing in the same household. Children of 5-17 years of age were 61% and children of 0-4 years of age were 47% less likely to have positive polymerase chain reaction results compared with adults residing in the same household.

Major liver resection in pregnancy: three cases with different etiologies and review of the literature.

BACKGROUND: Major liver resection during pregnancy is extremely rare. When required, the associated physiologic and anatomic changes pose specific challenges and greater risk for both mother and fetus Materials and methods: Three cases of major liver resection during pregnancy due to different etiologies are presented. The relevant literature is reviewed and discussed. RESULTS: We present three cases of major liver resection due to giant liver hemangioma with Kasabach-Merrit syndrome, giant hydatid cyst, and intrahepatic cholangiocarcinoma, at gestational week (GW) 17, 19, and 30, respectively. All patients had an uneventful postoperative course, continued the pregnancy and gave birth at GW 38. CONCLUSION: Major liver resection can be performed safely during pregnancy. A multidisciplinary team of surgeons, anesthesiologists and gynecologists, in a highly experienced tertiary hepatobiliary center, should be involved.

Severe intrahepatic cholestasis of pregnancy is a risk factor for preeclampsia in singleton and twin pregnancies.

OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP) is known to be associated with fetal complications. It recently was suggested to be associated possibly with preeclampsia (PET) as well. The objective of this study was to investigate that possibility. STUDY DESIGN: The study group included 78 women (54 singleton and 24 twin pregnancies) who had been diagnosed with ICP based on clinical presentation, elevated liver enzymes, and elevated total bile acids (>10 µmol/L). Disease severity was based on total bile acids levels as being severe (>40 µmol/L), moderate (20-40 µmol/L), or mild (10-20 µmol/L). The course of disease was reviewed carefully in each case. The control groups were comprised of apparently healthy women with singleton (n = 200) and twin (n = 100) pregnancies that were drawn randomly from a computerized registry of all the deliveries in our institution during the study period. RESULTS: The total incidence of PET was significantly higher for the patients with ICP who had singleton and twin pregnancies compared with the control groups (singletons: 7.4% vs 1.5%; P < .05; twins: 33.3% vs 6.2%; P < .05, respectively). The incidence of severe PET was also significantly higher in both singleton (11-fold) and twin (8-fold) pregnancies compared with control subjects. Severe ICP, but not mild ICP, was a major risk factor for PET among women with either singleton or twin pregnancies. The timing of the initial presentation of ICP had no effect on PET incidence rates. Preeclampsia occurred usually 2-4 weeks after the diagnosis of ICP, and proteinuria preceded elevated blood pressure in all cases. Moreover, the total bile acid levels among 33 women who were diagnosed as having PET, but not ICP, were within normal range. CONCLUSION: ICP increases the incidence of PET; severe disease was a major risk factor for preeclampsia. Therefore, we strongly suggest including routine evaluation for preeclampsia in the treatment of women with moderate and severe ICP.

The role of C-reactive protein measurement as a diagnostic aid in early pregnancy.

OBJECTIVE: To investigate the values of C-reactive protein (CRP) in early pregnancy for detection of any abnormality of the conceptus and especially the condition of extra-uterine pregnancy (EUP). STUDY DESIGN: In this prospective observational study, we established reference values for CRP in early pregnancy. Next, we tested whether a single, wide-range CRP measurement could serve as a diagnostic tool for abnormal first trimester pregnancy by comparing CRP levels in three different pregnancy statuses: viable intrauterine pregnancy (Group A), EUP (Group B) and delayed abortion (Group C). RESULTS: CRP levels were significantly higher in normal pregnancy (Group A) compared to abnormal pregnancy (Group B+C and Group B alone). CRP level was influenced only by the pregnancy status (normal, EUP or delayed abortion) and not by age, BMI, hematocrit or gravidity. The multiple logistic regression model (adjusted for age, gravidity, gestational age, hematocrit and BMI) revealed CRP as being a predictor for normal intrauterine pregnancy. CONCLUSION: This study examined the association between CRP levels and abnormal first trimester pregnancies. Our results support single CRP measurement as a diagnostic tool in early pregnancy.

Persistent abdominal pain over uterine scar during labor as a predictor of delivery complications.

OBJECTIVE: To evaluate the significance of persistent lower abdominal pain in women with previous cesarean delivery. METHODS: Various maternal outcomes were compared between women who underwent repeated cesareans owing to persistent lower abdominal pain (study group) and women who underwent repeated cesareans without persistent abdominal pain (control group). RESULTS: The incidence of uterine rupture was significantly higher in the study group than in the control group (8/81 [9.9%] vs 0/119 [0.0%]; P<0.001). While all women with persistent lower abdominal pain and uterine rupture had an additional sign or symptom, only 6/73 (8.2%) women with persistent abdominal pain without uterine rupture had any additional symptoms (P<0.001). There was no difference in incidence of uterine scar dehiscence between the groups. However, the hospitalization period was significantly longer in the study group (4 vs 3.7days; P<0.05). Trial of labor was a contributing factor to uterine rupture. CONCLUSION: Isolated persistent lower abdominal pain in women with previous cesarean is a poor indicator of uterine rupture. However, the positive predictive value for uterine rupture is 57% when an additional sign or symptom is present. Dehiscence of the uterine scar is relatively common and it is not associated with persistent abdominal pain.

Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum.

OBJECTIVE: To compare the safety and feasibility of operative laparoscopy versus laparotomy in women with ruptured ectopic pregnancy and massive hemoperitoneum. METHODS: In a retrospective cohort study at a university-affiliated medical center, records of women with ruptured ectopic pregnancy and massive hemoperitoneum (>800mL) were reviewed. RESULTS: Sixty women were diagnosed with ruptured ectopic pregnancy and massive hemoperitoneum: 48 underwent emergency laparoscopy; 12 underwent emergency laparotomy. There was no difference in hemodynamic status at presentation between the groups. Median operating time was significantly shorter in the laparoscopy group (50minutes [range, 43-63minutes] vs 60minutes [range, 60-72minutes]; P=0.01). Median intra-abdominal blood loss was significantly greater in the laparotomy group (1500mL [range, 1400-2000mL] vs 1000mL [range, 800-1200mL]; P=0.002). There was no difference between the groups regarding treatment with blood products, perioperative complications, and hospitalization period. CONCLUSION: In patients with ruptured ectopic pregnancy and massive hemoperitoneum, laparoscopy is feasible and safe, with significantly shorter operating times compared with laparotomy. While the mode of surgery should be based on the surgeon's experience and preference, the significantly lower hemoperitoneum volume associated with laparoscopy may be a reflection of shorter operating times and quicker hemorrhage control.

Can we reduce the surgical site infection rate in cesarean sections using a chlorhexidine-based antisepsis protocol?

OBJECTIVE: To determine whether chlorhexidine-based antisepsis reduces the rate of surgical site infections (SSIs) in elective and non-elective cesarean sections (CS) compared with povidone-iodine protocol. METHODS: This was a retrospective study. Women undergoing elective and non-elective CS during two periods of time who were treated with two different antisepsis protocols were included. The protocols for antisepsis were povidone-iodine 10% scrub followed by 10% povidone-iodine in 65% alcohol (n = 163) and chlorhexidine 2% followed by 70% alcohol (n = 163). The rate of SSIs and the risk factors for their occurrence were calculated and compared between the two groups. RESULTS: Antisepsis with chlorhexidine and alcohol was associated with a lower rate of SSIs, 10.43% versus 3.07% with povidone-iodine (p = 0.08). The two groups of patients were similar in baseline characteristics. Risk factors associated with SSIs were body mass index, urgent CS, and the use of the povidone-iodine protocol. CONCLUSIONS: Antisepsis with Chlorhexidine-based regimen was associated with a significant reduction in the rate of SSIs compared to povidone-iodine antisepsis in women undergoing elective and non-elective CS. This is of extreme clinical importance, as a change in antisepsis protocol can significantly reduce the morbidity and healthcare costs regarding cesarean sections.

[Anti mullerian hormone (AMH)--is it a new reliable marker of the ovarian reserve? Its role in predicting the ovarian response in assisted reproductive technology (ART)].

Anti-Müllerian hormone (AMH) is predominantly known for its important role in the differentiation of the male and female sexual system during the early embryonic period. Recently, many animal and human researches have been studying the role of the AMH in the postnatal ovarian function. In the female, AMH is produced by the granulosa cells of early developing follicles. It plays a major role in the folliculogenesis and seems to be able to inhibit the initiation of the growth of primordial follicles and FSH-induced follicles. As AMH is expressed throughout the folliculogenesis, from the primary follicular stage to the antral stage, the serum levels of AMH may represent both the quantity and the quality of ovarian follicles. Thus, the AMH levels may be useful as a new potential marker of the ovarian reserve. As compared to other ovarian reserve tests, the AMH has unique characteristics which make it a favorable marker. The measurement of AMH levels may be useful in the prediction of poor response and cycle cancellation as well as hyper-response and the ovarian hyperstimulation syndrome in assisted reproductive technology (ART). We assume that the measurement of AMH Levels may play a role in the individualization of treatment strategies among patients who are treated by ART. However, the AMH cannot predict the qualitative ovarian response in ART. In men, the AMH was not found to have satisfactory clinical utility as a single marker of spermatogenesis.

Outcomes of mid-trimester emergency cerclage in twin pregnancies.

INTRODUCTION: Placement of emergency cerclage at mid-trimester is controversial. At present, clinical trials comparing outcomes of mid-trimester cerclage to bed rest in twin pregnancies are lacking. Our aim was to examine the efficacy, safety and outcomes of mid-trimester cerclage in patients carrying twin gestations. MATERIAL AND METHODS: We retrospectively studied the outcomes of 14 patients carrying twin gestations with significant cervical dynamics who underwent cerclage. Outcomes of patients with cervical effacement only and patients with bulging membranes through the external os were examined. The interval between cerclage and delivery and the complication rates were calculated. RESULTS: The average time interval between cerclage placement and delivery was 71.1 days overall. Patients with cervical shortening or effacement only (n = 10) gave birth an average of 80.2 days after the procedure, while 4 patients with bulging membranes gave birth an average of 48.5 days after cerclage placement. The overall procedure failure rate, defined as delivery before 28 completed weeks, was 14.2%. DISCUSSION: Patients carrying twin gestations with advanced cervical changes might benefit from therapeutic cerclage. Further studies are required to demonstrate whether there is a difference compared to bed rest alone.

Risk factors for relaparotomy after cesarean delivery.

OBJECTIVE: To identify risk factors for relaparotomy after cesarean delivery. METHODS: Cases of exploratory laparotomy at Lis Maternity Hospital, Tel Aviv, Israel, following cesarean delivery between 2000 and 2010 were reviewed retrospectively. Each case in the study group was matched randomly with 5 control cases in which the patient underwent cesarean delivery only. Demographic and clinical data before and during the primary procedure were compared. RESULTS: Twenty-eight (0.2%) of 17482 cesarean deliveries were followed by exploratory relaparotomy. Significant differences between the study and the control (n=140) groups were found in: placental abruption as an indication for cesarean (17.8% vs 0.6%; P=0.004); duration of primary operation (45.3 ± 21.1 vs 29.9 ± 11.8 minutes; P=0.007; 95% CI, 5.1-19.2); and experience of chief surgeon (10.1 ± 1.6 vs 5.8 ± 0.4 years; P=0.02; 95% CI, 0.0-5.0). Findings during relaparotomy were: abdominal wall bleeding/hematoma (n=4 [14.2%]); uterine scar bleeding (n=4 [14.2%]); retroperitoneal bleeding (n=1 [3.5%]); adhesions causing bowel obstruction (n=1 [3.5%]); and uterine scar gangrene (n=1 [3.5%]). There were no findings for 17 (60.7%) patients. CONCLUSION: The incidence of relaparotomy following cesarean was 0.2% (1 per 624 cesarean deliveries). Significant risk factors were placental abruption and longer operative time.

Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence.

OBJECTIVE: To report our clinical experience in adnexal torsion. STUDY DESIGN: A retrospective case review of surgically proven adnexal torsion. RESULTS: 216 cases were identified. Mean age was 29±12. Twenty-two were premenarchal, 59 had ovarian stimulation, 48 were pregnant (with a median gestational age of 7 weeks) and 14 were post-menopausal. The most common risk factor was a previous history of adnexal torsion. The main clinical features were sudden, intermittent pain. Forty-five percent of Doppler examinations demonstrated normal flow: premenarchal and postmenopausal patients had higher rates of abnormal flow, compared to pregnant patients or after ovarian stimulation. Median time from admission to diagnosis was 6 h. Laparoscopy was conducted in 81.0% of the cases, and laparotomy in the rest. Twenty-three cases of recurrent torsion were documented. The majority of these events occurred following detorsion only. An enlarged ovary was found in 77 cases, dermoid cyst in 8 cases, and one case was malignant. Sixty eight-cases underwent detorsion, in 82 cases a combined detorsion and cystectomy or fenestration were performed and 43 patients underwent partial or total adnexectomy. Adnexal fixation was conducted in 21 cases. Cyst drainage or cystectomy significantly reduced the chance of retorsion by 50% and 75%, respectively, compared to detorsion only. CONCLUSION: Ovarian stimulation and early pregnancy are predisposing factors for ovarian torsion. Doppler flow studies may be a helpful diagnostic tool among premenarchal and post-menopausal women. Cystectomy should be considered in order to reduce the risk of retorsion.

Maternal and neonatal outcome of pregnant women infected with H1N1 influenza virus (swine flu).

OBJECTIVE: To investigate maternal and neonatal outcome of pregnant women infected with H1N1 influenza virus. METHODS: We prospectively followed all pregnant women hospitalized with positive H1N1 influenza virus nasal polymerase chain reaction tests between September 2009 and April 2010. Maternal and neonatal complications were recorded. RESULTS: Twenty-four women positive for H1N1 were hospitalized. Only 2 women suffered from asthma, all others had no co-morbidities. Most women were in the third trimester (14 women, 58%). Common presenting symptoms were dyspnea (83%) and Fever (79%). Eleven women (46%) had pneumonia/Adult Respiratory Distress syndrome (ARDS) on chest X-rays. Six women were actively delivered due to maternal or fetal distress. Gestational age at delivery for these women was significantly lower (34 weeks vs. 39 weeks, p = 0.005). Of women delivered, five were admitted to intensive care units (ICU), three needed mechanical ventilation, and one tracheostomy. Patients admitted to ICU had significantly higher white blood cell (WBC) and C-reactive protein (CRP) levels (p < 0.01, p < 0.01, respectively). The main neonatal complication was prematurity where delivery was indicated. CONCLUSIONS: H1N1 flu pandemic has the potential of causing serious maternal morbidity during pregnancy. ARDS, elevated WBC and CRP levels correlate with more severe cases. Prematurity is associated with severity of maternal disease.

Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center.

OBJECTIVE: To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT). STUDY DESIGN: A retrospective case review (Canadian Task Force Classification II-2). SETTING: Teaching and research hospital, a tertiary center. PATIENTS: Premenarchal children with surgically verified OT. INTERVENTIONS: Patients underwent either laparoscopy or laparotomy. RESULTS: Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst. CONCLUSIONS: Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence.

Umbilical cord blood collection carry increased maternal bleeding risk during cesarean section.

OBJECTIVE: Concern has recently been raised over the issue of maternal bleeding during umbilical cord blood (UCB) collection. The risk of maternal hemorrhage and subsequent drop in maternal hemoglobin after UCB collection during elective cesarean section (CS) was assessed. METHODS: In this retrospective cohort study, we have compared maternal hemoglobin drop after elective CS in women who choose to collect UCB vs. controls. RESULTS: UCB collection during CS was associated with an increased drop in hemoglobin levels. Significantly more women who chose to collect UCB had drops in hemoglobin levels of >3 g/dL compared to control women (8.70 vs. 1.03%, respectively, p=0.015). CONCLUSIONS: These results demonstrated an increased risk for maternal bleeding when UCB is collected in utero during a CS.