Single or double needle insertion in twin's amniocentesis: Does the technique influence the risk of complications?

OBJECTIVE: To compare complication rates following amniocentesis in twin gestations, according to sampling technique and number of needle insertions. STUDY DESIGN: A retrospective cohort study of all women with twin gestations who underwent amniocentesis and delivered in a single university affiliated medical center during 2002-2016. Amniocentesis was performed either through one uterine entry with passage through the inter-twin membrane or through two different entries to the two amniotic sacs. Pregnancy outcome of women that underwent single needle insertion amniocentesis, was compared to this of double needle insertion. Primary outcome was neonatal complications within 4 weeks after amniocentesis (late abortion, chorioamnionitis, preterm premature rupture of membranes, or hospitalization due to related symptoms). Secondary outcomes were gestational week at delivery and labor characteristics. RESULTS: The study group comprised 212 women. Of them, 73 (34.4%) underwent a single uterine insertion and 139 (65.6%) two separate needle insertions. Baseline characteristics did not differ between the groups. The amniocentesis complication rate was 13.7% in the single insertion group and 16.5% in the double insertion group (p = 0.587). Multivariate analysis found that a single insertion method had no statistically significant influence on complication rate, after making adjustments for potential confounders (OR = 1.085, 95% CI 0.4-2.9; p = 0.871). Other labor characteristics were similar between the groups. CONCLUSION: Needle insertion technique in twin gestation amniocentesis was not associated with procedure related complications.

Risk factors for recurrence after Le Fort colpocleisis for severe pelvic organ prolapse in elderly women.

INTRODUCTION: We investigated parameters associated with recurrence after partial (Le Fort) colpocleisis surgery for severe pelvic organ prolapse (POP) in elderly women. METHODS: A retrospective cohort study included all women who underwent partial colpocleisis in a single tertiary center from February 2007 through July 2013 for stage 3 or 4 triple compartment prolapse. Inclusion criteria were age over 60, sexually inactive, medical comorbidities, increased risk for comprehensive reconstructive pelvic surgery, and refusal or failure to use a pessary as a conservative non-surgical treatment. Exclusion criteria were post-menopausal bleeding, pelvic malignancy, and the desire to preserve coital function. RESULTS: The study group included 47 women of mean age 77.3 ± 8.2 (range 61-91 years). All had medical comorbidities. Fourteen patients (29.8%) had undergone previous hysterectomy. All patients underwent partial colpocleisis and perineorrhaphy. Seven women (14.9%) underwent mid-urethral sling for urinary incontinence. Mean follow-up was 14.8 ± 10.3 months (range, 2-37 months) and mean hospitalization, 3.5 ± 1.5 days (range, 2-9 days). There were no intraoperative complications. Postoperative complications comprised lower urinary tract infection (n = 2). Objective cure (according to vaginal examination) was 80.9% (38/47), and subjective (according to symptoms), 91.5% (43/47). No patient regretted the loss of sexual function. The main reasons for prolapse recurrence were statistically significant longer post-operative vaginal length and wider genital hiatus. CONCLUSIONS: Objective and subjective cure rates of Le Fort colpocleisis for the treatment of severe POP were high with low morbidity. Parameters associated with prolapse recurrence were longer postoperative vaginal length and wider genital hiatus.

Predictive value of cervical length in women with twin pregnancy presenting with threatened preterm labor.

OBJECTIVE: To assess the accuracy and determine the optimal threshold of sonographic cervical length (CL) for the prediction of preterm delivery (PTD) in women with twin pregnancies presenting with threatened preterm labor (PTL). METHODS: This was a retrospective study of women with twin pregnancies who presented with threatened PTL and underwent sonographic measurement of CL in a tertiary center. The accuracy of CL in predicting PTD in women with twin pregnancies was compared with that in a control group of women with singleton pregnancies. RESULTS: Overall, 218 women with a twin pregnancy and 1077 women with a singleton pregnancy, who presented with PTL, were included in the study. The performance of CL as a predictive test for PTD was similar in twins and singletons, as reflected by the similar correlation between CL and the examination-to-delivery interval (r, 0.30 vs 0.29; P = 0.9), the similar association of CL with risk of PTD, and the similar areas under the receiver-operating characteristics curves for differing delivery outcomes (range, 0.653-0.724 vs 0.620-0.682, respectively; P = 0.3). The optimal threshold of CL for any given target sensitivity or specificity was lower in twin than in singleton pregnancies. However, in order to achieve a negative predictive value of 95%, a higher threshold (28-30 mm) should be used in twin pregnancies. Using this twin-specific CL threshold, women with twins who present with PTL are more likely to have a positive CL test, and therefore to require subsequent interventions, than are women with singleton pregnancies with PTL (55% vs 4.2%, respectively). CONCLUSION: In women with PTL, the performance of CL as a test for the prediction of PTD is similar in twin and singleton pregnancies. However, the optimal threshold of CL for the prediction of PTD appears to be higher in twin pregnancies, mainly owing to the higher baseline risk for PTD in these pregnancies.

Is measurement of cervical length an accurate predictive tool in women with a history of preterm delivery who present with threatened preterm labor?

OBJECTIVE: To determine whether sonographically measured cervical length is an effective predictive tool in women with threatened preterm labor and a history of past spontaneous preterm delivery. METHODS: This was a retrospective cohort study of all women with singleton pregnancies who presented with preterm labor at less than 34 + 0 weeks' gestation and underwent sonographic measurement of cervical length in a tertiary medical center between 2007 and 2012. The accuracy of cervical length in predicting preterm delivery was compared between women with and those without a history of spontaneous preterm delivery. Women with risk factors for preterm delivery other than a history of preterm delivery were excluded from both groups. RESULTS: Overall, 1023 women who presented with preterm labor met the study criteria, of whom 136 (13.3%) had a history of preterm delivery (past-PTD group) and 887 (86.7%) had no risk factors for preterm delivery (low-risk group). The rate of preterm delivery was significantly higher for women with a history of preterm delivery (36.8% vs 22.5%; P < 0.001). Cervical length was significantly correlated with the examination-to-delivery interval in low-risk women (r = 0.32, P < 0.001) but not in women who had had a previous preterm delivery (r = 0.07, P = 0.4). On multivariable analysis, cervical length was independently associated with the risk of preterm delivery for women in the low-risk group but not for women with a history of previous preterm delivery. For women with previous preterm delivery who presented with threatened preterm labor, cervical length failed to distinguish between those who did and those who did not deliver prematurely (area under the receiver-operating characteristics curve range, 0.475-0.506). When using standardized thresholds, the sensitivity and specificity of cervical length for the prediction of preterm delivery were significantly lower in women with previous preterm delivery than in women with no risk factors for preterm delivery. CONCLUSION: Cervical length appears to be of limited value in the prediction of preterm delivery among women with threatened preterm labor who are at high risk for preterm delivery owing to a history of spontaneous preterm delivery in a previous pregnancy.

The safety of fetal exposure to proton-pump inhibitors during pregnancy.

BACKGROUND: Proton-pump inhibitors (PPIs) are often needed in pregnancy due to the high rates of acid reflux. Previous studies did not include medical pregnancy terminations data, which may cause a bias toward the null hypothesis. We assessed the fetal safety of PPIs following exposure during gestation including data from medical pregnancy terminations. METHODS: A unified computerized database was created by linking a computerized database of medications dispensed from 1998 to 2009 to all women registered in "Clalit" HMO, southern district of Israel, with computerized databases containing maternal and infant hospitalization records from the district hospital. Rates of congenital malformations in PPIs exposed and unexposed pregnancies, as well as other adverse fetal effects were compared. Medical pregnancy termination data were included in the analysis. RESULTS: A total of 114,960 (75%) infants were born during the study period to women registered at "Clalit," 110,783 of them were singleton pregnancies; 1,239 women had medical pregnancy terminations, of which 468 were performed due to fetal malformations. A total of 1,186 infants and abortuses had been exposed to PPIs during the first trimester of pregnancy. Exposure to PPIs was not associated with an increased risk of congenital malformations (adjusted OR 1.06; 95% CI = 0.84-1.33). Similarly, exposure to PPIs during the third trimester of pregnancy was not associated with increased risk of perinatal mortality, premature delivery, low birth weight, or low Apgar scores. CONCLUSIONS: Intrauterine exposure to PPIs was not associated with increased risk for congenital malformations, perinatal mortality, or morbidity. These results are strengthened with the inclusion of data from medical pregnancy terminations.

Creatinine level as a predictor of hypertensive disorders during pregnancy.

This study aims to examine the association between creatinine level during the first 20 weeks of pregnancy and the development of pre-eclampsia in the second half of the pregnancy. The study population included all registered births (n=9341) between 2001 and 2007 in a tertiary medical centre. Student's t-test and receiver operating characteristic (ROC) curves were used to determine any association. Significant association was documented between creatinine level in the first 20 weeks and the prevalence of hypertensive disorders. The mean plasma creatinine value in women with mild pre-eclampsia versus healthy women was 0.59 mg/dL +/- 0.14 versus 0.57 mg/dL +/- 0.15, respectively (P = 0.023). The mean plasma creatinine value in women with severe pre-eclampsia versus healthy women was 0.61 mg/dL +/- 0.17 versus 0.58 mg/dL +/- 0.15, respectively (P = 0.040). The mean plasma creatinine value in women with hypertensive disorders versus healthy women was 0.60 mg/dL +/- 0.15 versus 0.58 mg/dL +/- 0.15, respectively (P=0.003). The ROC curve demonstrated a significant association between creatinine level in the first 20 weeks of pregnancy and the development of mild and severe pre-eclampsia in the second half of pregnancy (area under the curve: 0.54, 95% confidence interval [CI]: 0.51-0.57, P = 0.02, and 0.56, 95% CI: 0.50-0.62, P = 0.033, respectively). Higher creatinine levels during the first 20 weeks of pregnancy are associated with a higher risk of developing mild and severe pre-eclampsia.

Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes.

BACKGROUND: Infants born to diabetic women are at higher risk for hypoglycaemia related to hyperinsulinism in response to maternal hyperglycaemia during pregnancy. As such, recommendations to prevent neonatal hypoglycaemia include infant feeding in the early postpartum period. The present study aimed to examine the effect of early breastfeeding and type of nutrition used for the first feed (human milk or formula) on glucose levels in infants born to women with gestational diabetes. METHODS: The prospective pilot study of 84 infants born to gestational diabetic women examined the glycaemic levels of infants who were breastfed in the delivery room compared to glycaemic levels of those who were not. The study also compared the glycaemic levels of infants who breastfed with those who received formula for their first feed. RESULTS: Infants who were breastfed in the delivery room had a significantly lower rate of borderline hypoglycaemia than those who were not breastfed in the early postpartum period (10% versus 28%; Fisher's exact test., P = 0.05,). Likewise, infants breastfed in the delivery room had significantly higher mean blood glucose level compared to infants who were not breastfed in the delivery room (3.17 versus 2.86 mmol L(-1), P = 0.03). Additionally, breastfed infants had a significantly higher mean blood glucose level compared to those who were formula fed for their first feed (3.20 versus 2.68 mmol L(-1), P = 0.002). CONCLUSIONS: Early breastfeeding may facilitate glycaemic stability in infants born to women with gestational diabetes.

Idiopathic bleeding during the second half of pregnancy as a risk factor for adverse perinatal outcome.

OBJECTIVE: To investigate pregnancy outcome in women suffering from idiopathic vaginal bleeding (IVB) during the second half of pregnancy. METHODS: A comparison between patients admitted to the hospital due to bleeding during the second half of pregnancy and patients without bleeding was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the analysis. Stratified analyses using the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 173,621 singleton deliveries occurred at our institute. Of these, 2077 (1.19%) were complicated with bleeding upon admission during the second half of pregnancy. After excluding cases with bleeding due to placental abruption, placenta previa, cervical problems, etc., 67 patients were classified as having IVB (0.038%). Independent risk factors associated with IVB, using a backward, stepwise multivariable analysis were oligohydramnios (OR=6.2; 95% CI 3.1-12.7; p < 0.001), premature rupture of membranes (OR=3.4; 95% CI 1.8-6.2; p < 0.001), intrauterine growth restriction (IUGR, OR 5.6; 95% CI 2.5-12.2; p < 0.001), and Jewish ethnicity (OR=1.9; 95% CI 1.0-3.5; p=0.036). These patients subsequently were more likely to deliver preterm (<37 weeks, 56.7% vs. 7.3%; mean gestational age of 33.6+/-5.7 weeks vs. 39.2+/-2.1 weeks; p < 0.001) and by cesarean delivery (CD, 35.8% vs. 12.1%, OR=4.0; 95% CI 2.4-6.6; p < 0.001). Higher rates of low Apgar scores (<7) at 1 and 5 minutes were noted in these patients (OR=10.3; 95% CI 5.9-17.8; p < 0.001 and OR=17.8; 95% CI 7.1-44.5; p < 0.001, respectively). Moreover, perinatal mortality rate among patients admitted due to idiopathic bleeding was significantly higher as compared to patients without bleeding (9.6% vs. 1.2%, OR=8.4; 95% CI 3.3-21.2; p < 0.001). However, when controlling for preterm delivery, using the Mantel-Haenszel technique, the association lost its significance. CONCLUSION: Idiopathic vaginal bleeding during the second half of pregnancy is a risk factor for adverse perinatal outcome, mostly due to its significant association with preterm delivery. Careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome.

Ovarian ossification associated with endometriosis.

BACKGROUND: Bone formation in the ovary, with the exception of developing in the setting of mature cystic teratoma, is exceedingly rare. CASE: A 46-year-old woman with a history of endometriosis and chronic pelvic pain underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. A 3 cm solid heavily calcified mass with a stony hard consistency was detected within the right ovary. Microscopic examination revealed extensive calcification of the right ovarian stroma with formation of abundant mature bone, adjacent to small foci of endometriosis. CONCLUSIONS: Endometriosis can be associated with ovarian ossification, forming an extensively calcified adnexal mass. Conservative treatment with close follow-up may be adequate in patients with a history of endometriosis who present with a small heavily calcified ovarian mass and wish to preserve their fertility.

Twelve cases of placental chorioangioma. Pregnancy outcome and clinical significance.

INTRODUCTION: To determine perinatal complications and pregnancy outcome in 12 women with chorioangioma of placenta. STUDY DESIGN: During the period between January 1986 and December 1997, 12 women with histologic diagnosis of chorioangioma of placenta who delivered in our institution were studied. Case-control study was designed. Sixty women with histologic examination of the placenta without chorioangioma were randomly identified as control group matched for maternal age and parity. Statistical analyses included t-test, Chi-square test and Fisher's exact test when appropriate. RESULTS: Nine cases (75%) were diagnosed postnatal. The mean gestational age was significantly lower and preterm delivery rate was significantly higher among the chorioangioma group (34 vs. 38.8 weeks P<0.0001; 66% vs. 10%; P<0.001 respectively). CONCLUSIONS: Chorioangioma of the placenta, in a high risk population, although small, is associated with significantly higher risk for preterm delivery. This emphasizes the need for pathologic examination of all placentas of patients with preterm delivery

Gestational diabetes complicated by hydramnios was not associated with increased risk of perinatal morbidity and mortality.

OBJECTIVE: To determine whether gestational diabetes (GDM) complicated with hydramnios is associated with higher rates of perinatal morbidity and mortality than those with normal amniotic fluid (AFI). STUDY DESIGN: A case control study of 368 pregnant women with GDM was conducted between January 1995 and December 1996. The study group consisted of 184 women with hydramnios (AFI>25 cm) that were matched for maternal age, parity, and gestational age to 184 women with gestational diabetes and normal AFI. A Student's t-test, McNemar test and logistic regression test were used to compare the two groups. RESULTS: Both groups were under strict metabolic control; mean glucose levels of 5.2+/-2.4 mmol/l in the study group and 5.5+/-2.4 mmol/l in the controls (P>0.05). There were no significant differences between groups in the rates of severe preeclampsia, premature rupture of membranes (PROM), cesarean section rate, intrauterine growth restriction (IUGR), antepartum fetal death, fetal distress, prolapse of umbilical cord and placenta abruption. Even though the prevalence of large for gestational age (LGA) and birth weight were significantly higher in the study group (31 versus 19% and 3441+/-477 versus 3232+/-554 g, respectively), the prevalence of neonatal trauma was the same in both groups (2.6%). There was no significant difference in the Apgar scores (1 and 5 min), newborn hypoglycemia, metabolic acidosis and hyperbilirubinemia. CONCLUSIONS: Hydramnios in women with GDM was not associated with increased risk of perinatal morbidity and mortality.

Fetal serum levels of insulin, growth hormone and insulin-like growth factor-I in concordant and discordant twin gestations.

OBJECTIVE: To examine the role of insulin, growth hormone and insulin-like growth factor (IGF)-I in concordant and discordant twin pairs. METHODS: Umbilical cord serum samples were obtained from 20 twin pairs with weight discordancy (intertwin birth weight difference > 20%) and from 20 concordant twins (intertwin birth weight difference < 20%), both groups of similar gestational age, gravidity, and parity. The serum samples were analyzed for the levels of IGF-I, growth hormone and insulin in both maternal and fetal compartments. RESULTS: Among the group of discordant twins, the normally grown twin, in all cases, had significantly higher cord serum IGF-I levels than their growth-restricted co-twin (108 +/- 73 ng/ml vs. 39 +/- 24 ng/ml; p < 0.01). There were no significant intertwin differences in the cord blood IGF-I levels in the concordant twin pairs (87 +/- 44 vs. 88 +/- 48 ng/ml; p = 0.986). Insulin and growth hormone levels did not correlate with intertwin birth weight differences. CONCLUSION: These data demonstrate that IGF-I is important in the regulation of both normal and restricted fetal growth in utero, and its action appears to be, at least in part, through an endocrine action. The precise role of growth hormone and insulin in fetal growth restriction remains uncertain.

Wilson's disease in pregnancy: five successful consecutive pregnancies of the same woman.

Wilson's disease is an autosomal recessive disorder of copper metabolism characterized mainly by liver cirrhosis and neurological disorders. Appropriate treatment with chelating agents allows normal fertility function. We report five consecutive successful pregnancies of the same woman, treated in the high-risk unit at our medical center. The management dilemmas and treatment options are discussed.

Cord leptin level and fetal macrosomia.

OBJECTIVE: To determine the relationships among serum leptin, insulin-like growth factor-I, and insulin levels in large for gestational age (LGA) infants. METHODS: Serum samples were collected from maternal veins and umbilical arteries of 52 consecutive, term, LGA neonates of nondiabetic mothers. Maternal and neonatal serum samples were analyzed for levels of leptin, insulin-like growth factor-I, and insulin by specific radioimmunoassays. Multiple regression analysis was used to determine independent risk factors for fetal macrosomia. RESULTS: The independent risk factor significantly associated with fetal macrosomia was umbilical cord leptin concentration (P <.01, beta = 0.59). There was a statistically significant correlation between umbilical cord leptin and insulin-like growth factor-I levels and birth weight (r = 0.51, P <.01; r = 0.37, P <.01; respectively). The correlation between umbilical cord insulin levels and birth weight was not statistically significant (r = 0.06, P =.63), nor was that between maternal body mass index and birth weight (r = 0.09, P =.50). CONCLUSION: Our data showed that umbilical cord leptin concentration was an independent risk factor for fetal macrosomia.

[Premature delivery in diabetes: etiology and risk factors].

Preterm birth is the leading cause of perinatal morbidity and mortality, while preterm labor and delivery in diabetes mellitus (DM) carries an increased risk of perinatal complications. We investigated the hypothesis that DM (gestational and pregestational) is an independent risk factor for preterm birth and evaluated the hypothesis that the risk factors for preterm birth in diabetics are different from those in non-diabetics. The study population consisted of all singleton deliveries at this hospital between 1990-1997. Excluded were those of mothers who had not had prenatal care, or who had only partial care or multiple gestations. There were 3 subgroups: 834 women with pregestational DM, 3,841 with gestational DM, and 66,253 non-diabetics. The combined spontaneous and induced preterm delivery rate was determined in each subgroup. Potential risk factors for spontaneous preterm deliveries were assessed by a univariate model. A logistic regression model was used to assess the unique contribution of DM (gestational and pregestational) to preterm delivery in the presence of the other risk factors, and to compare risk factors for preterm delivery between subgroups. The prevalence of spontaneous preterm delivery was: 7.1% in non-diabetics, 10.0% in those with gestational DM and 25.5% in those with pregestational DM. When adjusted by a multivariate model for other risk factors for preterm delivery, DM still remained an independent risk factor for spontaneous preterm delivery (gestational DM: odds ratio 1.28, 95% CI: 1.1-1.48; pregestational diabetes: odds ratio 3.4, 95% CI: 2.65-4.36). The main difference in risk factors for preterm birth between the 3 subgroups was the amount of amniotic fluid. Polyhydramnios was an independent risk factor for preterm delivery in non-diabetics and in pregestational DM, but not in gestational DM. On the other hand, oligohydramnios was associated with a higher risk for preterm delivery only in gestational DM compared to non-diabetics. DM (gestational and pregestational) is an independent risk factor for spontaneous preterm delivery. Polyhydramnios is an independent risk factor for preterm delivery in pregestational but not in gestational DM. Oligohydramnios is a greater risk factor for preterm delivery in gestational DM compared to non-diabetics.

Prenatal diagnosis of a fetal abdominal cyst.

Hepatic liver cysts are rare and few cases have been described in the literature. Initially, these cysts are detected by a prenatal ultrasound as abdominal, and consequently, the final diagnosis of hepatic cysts is done during the postnatal period. We present a case of a giant hepatic cyst found incidently during a routine ultrasound examination. The diagnosis and management of a fetal intraabdominal cyst is discussed.

The role of prostanoids in the development of diabetic embryopathy.

In infants of diabetic mothers, congenital anomalies occur about two-three times as often as in normal population. Many etiologic factors have been proposed regarding the mechanism of diabetes related birth defects. The metabolic alterations associated with hyperglycemia include myo-inositol and arachidonic acid deficiency, and as a result disturbed metabolism of prostaglandins. Recent studies provide evidence that a deficiency in prostaglandins adversely affects membranogenesis and membrane function. These changes in membrane function permit the influx of high levels of glucose into the cells, inducing the generation of free oxygen radicals that cause morphologic damage of the embryo, involving aberrant mitochondrial function and enhanced peroxidation of embryonic lipids. The functional deficiency of prostaglandins at a critical time of fetal development can cause embryonic malformations. This paper reviews the role of prostanoids in the development of diabetic embryopathy.

Multiple pregnancies in women after renal transplantation. Case report that rises a management dilemma.

OBJECTIVES: To report the pregnancy outcome in women with multiple pregnancies after renal transplantation. MATERIALS AND METHODS: We report two cases of multiple pregnancies (triplets and twins) in renal allograft recipients and evaluate the pregnancy courses and maternal and fetal outcome of these patients. RESULTS: After fetal reduction from triplet to twin pregnancy the first patient delivered healthy twin babies at 36 weeks gestation. Six months after delivery the woman is well with no signs of renal function impairment. Although the second patient did not meet the optimal criteria for consideration of pregnancy in renal transplant recipients, she delivered normal twin babies at 33 weeks' gestation. Maternal complications during pregnancy included preeclampsia, mild deterioration of renal function tests, and secondary complications due to drug therapy that was resolved after delivery. No graft rejection episodes were noted in either case during pregnancy. CONCLUSIONS: Multifetal gestation in renal allograft recipients represents a high-risk pregnancy that should be managed at a tertiary care institution. The overall outcome in properly consulted patients can be considered favorable. Based on our limited experience with two cases, we suggest reduction of triplets to a twin pregnancy which is consistent with the current literature data.