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Objective: To compare adverse neonatal outcomes between trial of vaginal delivery and upfront cesarean delivery for singleton infants born at 24 to 28 weeks of gestation., Methods: This is a retrospective cohort study that was conducted at a university-affiliated tertiary medical center between 2011 and 2022, involving singleton pregnancies delivered between 24 0/7 and 27 6/7 weeks of gestation. Participants were divided into two groups based on their intended mode of delivery: a trial of labor (TOL) group and an upfront cesarean delivery (CD) group. The primary outcome was defined as neonatal death. The secondary outcome was defined as any of the following: intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, neonatal sepsis, periventricular leukomalacia, disseminated intravascular coagulation, umbilical cord arterial PH <7.1, or use of postpartum mechanical ventilation. Analyses were performed using an intention-to-treat approach., Results: Overall, 199 patients were enrolled, with 64 in the TOL group and 135 in the upfront CD group. Neonatal deaths occurred in 48 cases (24.2%) across the entire cohort, with no significant difference between the TOL (18.8%) and upfront CD (26.7%) groups (P = 0.223). Rates of other composite adverse outcome were comparable between the groups (26.6% vs. 31.9%, P = 0.448), respectively. A sub-analysis comparing patients with pre-existing contraindications for vaginal delivery, without maternal or fetal indications for delivery, to those in the TOL group who experienced spontaneous onset of labor showed no differences in primary or secondary outcomes between the groups., Conclusion: We found no difference in adverse neonatal outcomes between TOL and upfront CD for singletons born at 24-28 weeks gestation., (© 2024 International Federation of Gynecology and Obstetrics.)

Background: The American Academy of Pediatrics advises that the nutrition of preterm infants should target a body composition similar to that of a fetus in utero. Still, reference charts for intrauterine body composition are missing. Moreover, data on sexual differences in intrauterine body composition during pregnancy are limited., Objectives: The objective of this study was to create reference charts for intrauterine body composition from 30 to 36+6 weeks postconception and to evaluate the differences between sexes., Methods: In this single-center retrospective study, data from 197 normal developing fetuses in late gestation was acquired at 3T magnetic resonance imaging (MRI) scans, including True Fast Imaging with Steady State Free Precession and T 1 -weighted 2-point Dixon sequences covering the entire fetus. Deep convolutional neural networks were utilized to automatically segment the fetal body and subcutaneous adipose tissue. The fetus's body mass (BM), fat signal fraction (FSF), fat mass (FM), FM percentage (FM%), fat-free mass (FFM), and FFM percentage (FFM%) were calculated. Using the Generalized Additive Models for Location, Scale, and Shape (GAMLSS) method, reference charts were created, and sexual dimorphism was examined using analysis of covariance (ANCOVA). A P value <0.05 was deemed significant., Results: Throughout late gestation, BM, FSF, FM, FM%, and FFM increased, while the FFM% decreased. Reference charts for gestational age and sex-specific percentiles are provided. Males exhibited significantly higher BM (7.2%; 95% confidence interval [95% CI]: 1.9, 12.4), FFM (8.8%; 95% CI: 5.8, 11.9), and FFM% (1.7%; 95% CI: 1, 2.4) and lower FSF (-3.6%; 95% CI: -5.6, -1.8) and FM% (-1.7%; 95% CI: -2.4, -1), (P < 0.001) compared with females, with no significant difference in FM between sexes (P = 0.876)., Conclusions: MRI-derived intrauterine body composition growth charts are valuable for tracking growth in preterm infants. This study demonstrated that sexual differences in body composition are already present in the intrauterine phase., Competing Interests: Conflict of interest The authors declare that there is no conflict of interest., (Copyright © 2024 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Background: Small for gestational age (SGA) fetuses are at risk for perinatal adverse outcomes. Fetal body composition reflects the fetal nutrition status and hold promise as potential prognostic indicator. MRI quantification of fetal anthropometrics may enhance SGA risk stratification., Hypothesis: Smaller, leaner fetuses are malnourished and will experience unfavorable outcomes., Study Type: Prospective., Population: 40 SGA fetuses, 26 (61.9%) females: 10/40 (25%) had obstetric interventions due to non-reassuring fetal status (NRFS), and 17/40 (42.5%) experienced adverse neonatal events (CANO). Participants underwent MRI between gestational ages 30 + 2 and 37 + 2., Field Strength/sequence: 3-T, True Fast Imaging with Steady State Free Precession (TruFISP) and T 1 -weighted two-point Dixon (T 1 W Dixon) sequences., Assessment: Total body volume (TBV), fat signal fraction (FSF), and the fat-to-body volumes ratio (FBVR) were extracted from TruFISP and T 1 W Dixon images, and computed from automatic fetal body and subcutaneous fat segmentations by deep learning. Subjects were followed until hospital discharge, and obstetric interventions and neonatal adverse events were recorded., Statistical Tests: Univariate and multivariate logistic regressions for the association between TBV, FBVR, and FSF and interventions for NRFS and CANO. Fisher's exact test was used to measure the association between sonographic FGR criteria and perinatal outcomes. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. A P-value <0.05 was considered statistically significant., Results: FBVR (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.2-0.76) and FSF (OR 0.95, CI 0.91-0.99) were linked with NRFS interventions. Furthermore, TBV (OR 0.69, CI 0.56-0.86) and FSF (OR 0.96, CI 0.93-0.99) were linked to CANO. The FBVR sensitivity/specificity for obstetric interventions was 85.7%/87.5%, and the TBV sensitivity/specificity for CANO was 82.35%/86.4%. The sonographic criteria sensitivity/specificity for obstetric interventions was 100%/33.3% and insignificant for CANO (P = 0.145)., Data Conclusion: Reduced TBV and FBVR may be associated with higher rates of obstetric interventions for NRFS and CANO., Evidence Level: 2 TECHNICAL EFFICACY: Stage 5., (© 2023 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Objective: This study aimed to determine whether a trial of labor after cesarean section (TOLAC) with a macrosomic neonate is associated with adverse outcomes., Study Design: A retrospective cohort study was conducted in a population motivated for TOLAC. Women attempting TOLAC with a neonatal birth weight >4,000 g were compared with women attempting TOLAC with neonatal birth weights between 3,500 and 4,000 g. The primary outcome was TOLAC success. Secondary outcomes included mode of delivery, uterine rupture, postpartum hemorrhage (PPH), shoulder dystocia, obstetric anal sphincter injury (OASI), Apgar's score <7 at 5 minutes, and umbilical artery pH <7.1. Data were analyzed using Fisher's exact test and Chi-square test., Results: Overall, 375 women who underwent TOLAC with a neonate weighing >4,000 g comprised the study group. One thousand seven hundred and eighty-three women attempting TOLAC with a neonate weighing 3,500 to 4,000 g comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, parity, and vaginal birth after cesarean (VBAC) rate. There were no significant differences in the rates of successful TOLAC (94 vs. 92.3%, p  = 0.2, odds ratio [OR] = 0.8, 95% confidence interval [CI]: 0.5, 1.2), operative vaginal delivery (7.4 vs. 5.3%, p  = 0.18, OR = 0.7, 95% CI: 0.4, 1.1), uterine rupture (0.4 vs. 0%, p  = 0.6), PPH (3.2 vs. 2.3%, p  = 0.36, OR = 1.4, 95% CI: 0.7, 2.7), OASI (0.8 vs. 0.2%, p  = 0.1, OR = 3.6, 95% CI: 0.8, 1.6), Apgar's score <7 at 5 minutes (0 vs. 0.4%, p  = 0.37), and umbilical artery pH <7.1 (0.5 vs. 0.7%, p  = 1.0, OR = 0.73, 95% CI: 0.2, 3.2). Women with a neonate weighing >4,000 g had a significantly increased risk of shoulder dystocia (4 vs. 0.4%, p  < 0.05, OR = 9.2 95% CI: 3.9, 22) CONCLUSION:  Women attempting TOLAC with a macrosomic neonate are not at increased risk for failed TOLAC, operative vaginal delivery, uterine rupture, PPH, or OASI but are at risk of shoulder dystocia. This information may aid in prenatal counseling for women considering TOLAC with a macrosomic fetus., Key Points: · TOLAC with fetal macrosomia does not increase the risk of uterine rupture.. · TOLAC with fetal macrosomia is associated with high chances of VBAC.. · TOLAC with fetal macrosomia is not associated with adverse neonatal outcomes.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Parity is a prognostic variable when considering trial of labor after cesarean section (TOLAC). This study aimed to determine whether grandmultiparous patients are at increased risk of poor TOLAC outcomes such as uterine rupture., Study Design: A retrospective cohort was conducted at a single university-affiliated medical center with approximately 10,000 deliveries per year. The study group included women post one cesarean section who attempted TOLAC carrying a singleton fetus in vertex presentation. We divided the cohort into three groups: group 1 - women who had a parity of 1; group 2 - parity of 2-4; group 3 - parity of 5 and above. The primary outcome was successful VBAC. Secondary outcomes included mode of delivery, uterine rupture, and combined maternal and neonatal adverse outcomes. Data were analyzed using Fisher's exact test, Chi-square test, ANOVA, and paired t -test., Results: Five thousand four hundred and forty-seven women comprised the study group: group 1 - 879 patients, group 2 - 2374 patients, and group 3 - 2194 patients. No significant between-group differences were found in gestational age at delivery. Rates of a successful VBAC were 80.6%, 95.4%, and 95.5%, respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 (OR 5.02, 95% CI 3.9-6.5, p <.001) and group 3 (OR 5.17, 95% CI 4.0-6.7, p <.001). There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8-1.4, p =.89). Operative delivery rate differed significantly between all three groups; 25.1%, 6.2%, and 3.6%, for groups 1, 2, and 3, respectively ( p <.001). The rate of uterine rupture was significantly higher in group 1 compared to group 2 (1.02% vs. 0.29% p =.02) and group 3 (1.02% vs. 0.2%, p =.01, respectively). There were no differences between group 2 and group 3 (0.29% vs. 0.2% p =.78)., Conclusions: Grandmultiparity is not associated with an increased risk of uterine rupture during TOLAC.

Objectives: Fat-water MRI can be used to quantify tissues' lipid content. We aimed to quantify fetal third trimester normal whole-body subcutaneous lipid deposition and explore differences between appropriate for gestational age (AGA), fetal growth restriction (FGR), and small for gestational age fetuses (SGAs)., Methods: We prospectively recruited women with FGR and SGA-complicated pregnancies and retrospectively recruited the AGA cohort (sonographic estimated fetal weight [EFW] ≥ 10th centile). FGR was defined using the accepted Delphi criteria, and fetuses with an EFW < 10th centile that did not meet the Delphi criteria were defined as SGA. Fat-water and anatomical images were acquired in 3 T MRI scanners. The entire fetal subcutaneous fat was semi-automatically segmented. Three adiposity parameters were calculated: fat signal fraction (FSF) and two novel parameters, i.e., fat-to-body volume ratio (FBVR) and estimated total lipid content (ETLC = FSF*FBVR). Normal lipid deposition with gestation and differences between groups were assessed., Results: Thirty-seven AGA, 18 FGR, and 9 SGA pregnancies were included. All three adiposity parameters increased between 30 and 39 weeks (p < 0.001). All three adiposity parameters were significantly lower in FGR compared with AGA (p ≤ 0.001). Only ETLC and FSF were significantly lower in SGA compared with AGA using regression analysis (p = 0.018-0.036, respectively). Compared with SGA, FGR had a significantly lower FBVR (p = 0.011) with no significant differences in FSF and ETLC (p ≥ 0.053)., Conclusions: Whole-body subcutaneous lipid accretion increased throughout the third trimester. Reduced lipid deposition is predominant in FGR and may be used to differentiate FGR from SGA, assess FGR severity, and study other malnourishment pathologies., Clinical Relevance Statement: Fetuses with growth restriction have reduced lipid deposition than appropriately developing fetuses measured using MRI. Reduced fat accretion is linked with worse outcomes and may be used for growth restriction risk stratification., Key Points: • Fat-water MRI can be used to assess the fetal nutritional status quantitatively. • Lipid deposition increased throughout the third trimester in AGA fetuses. • FGR and SGA have reduced lipid deposition compared with AGA fetuses, more predominant in FGR., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Aim: Demand for upper gastrointestinal contrast series (UGI) to investigate bilious vomiting (BV) has increased in recent years, mostly due to greater awareness of the need to rule out malrotation and midgut volvulus (MGV). We aimed to examine predictive value of clinical parameters in the management of healthy neonates presenting with BV and re-assess the role of UGI in their management., Methods: A retrospective cohort study including medical, imaging and surgical data of neonates who underwent UGI due to BV., Results: A total of 157 term neonates, eight neonates (5.1%) had confirmed surgical diagnosis of malrotation, five of them had malrotation with MGV, including two neonates who underwent extensive intestinal resection due to necrosis. Neonates with a combination of abnormal plain radiograph and abdominal distention had 10 times higher odds of malrotation diagnosis, adjusting for age at first BV (p = 0.017). Neonates with a combination of abnormal plain radiograph, abdominal distention and abdominal tenderness had 25 times higher odds of MGV (p = 0.002)., Conclusion: This study reaffirms the role of UGI as the current main diagnostic tool for malrotation and MGV. Physical examination and plain radiograph findings can help but cannot substitute UGI study., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

The incidence of spontaneous intestinal perforation (SIP) increases up to 10% with decreasing gestational age (GA). We aimed to explore early biomarkers for predicting SIP in preterm infants. In this case-control study, neonates born at ≤34 weeks GA diagnosed with SIP were compared with GA and/or birth-weight-matched neonates diagnosed with necrotizing enterocolitis (NEC). Laboratory markers assessed prior and adjacent to the day of SIP or NEC diagnosis were evaluated. The cohort included 16 SIP and 16 matched NEC infants. Hyperlactatemia was less frequent in SIP than in NEC infants (12% vs. 50%, p = 0.02). The platelets count was lower in SIP than in NEC infants ( p < 0.001). Glucose levels strongly correlated with lactate levels ( p = 0.01) only in the NEC group. The odds of being diagnosed with SIP decreased as lactate levels increased (OR = 0.607, 95% CI: 0.377-0.978, p = 0.04). Our results suggest that a combination of laboratory markers, namely glucose and lactate, could help differentiate SIP from NEC at early stages so that, in the presence of an elevated blood glucose, an increase in blood lactate was associated with a decrease in the odds of being diagnosed with SIP.

Human milk oligosaccharides (HMOs) stimulate the growth of gut commensals, prevent the adhesion of enteropathogens and modulate host immunity. The major factors influencing variations in the HMO profile are polymorphisms in the secretor (Se) or Lewis (Le) gene, which affect the activity of the enzymes fucoslytransferase 2 and 3 (FUT2 and FUT3) that lead to the formation of four major fucosylated and non-fucosylated oligosaccharides (OS). This pilot study aimed to determine the HMO profile of Israeli breastfeeding mothers of 16 term and 4 preterm infants, from a single tertiary center in the Tel Aviv area. Fifty-two human milk samples were collected from 20 mothers at three-time points: colostrum, transitional milk and mature milk. The concentrations of nine HMOs were assessed using liquid chromatography coupled with mass spectra chromatograms. Fifty-five percent of the mothers were secretors and 45% were non-secretors. Infant sex affected HMO levels depending on the maternal secretor status. Secretor mothers to boys had higher levels of FUT2-dependent OS and higher levels of disialyllacto-N-tetraose in the milk of mothers to girls, whereas non-secretor mothers to girls had higher levels of 3'-sialyllactose. In addition, the season at which the human milk samples were obtained affected the levels of some HMOs, resulting in significantly lower levels in the summer. Our findings provide novel information on the irregularity in the HMO profile among Israeli lactating women and identify several factors contributing to this variability.

Purpose: The incidence of pediatric onset ulcerative colitis (UC) is increasing, with increasing rate of children eventually requiring surgical treatment. Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment. Although transanal IPAA (ta-IPAA) is becoming widely accepted for adult UC patients, data regarding this procedure in children are scarce. Nevertheless, some adult publications also include patients under 18 years old. This systematic review and meta-analysis aimed to summarize surgical and functional outcomes following ta-IPAA, and extract conclusion regarding pediatric UC patients., Methods: PubMed, Cochrane Library databases, Embase, Web of science and Google Scholar databases were searched, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. The final search was updated in April 2022. Four comparative cohorts (n = 868) and 11 non-comparative case series (n = 241) were included. Six reports included children. Anastomotic leak, complications, operative time, conversion rate, length of stay and functional outcomes were examined., Results: A total of 1103 patients, ranging 9-79 years were included in this review. We found no difference in risk for anastomotic leak (OR 1.36, 95% CI 0.46-4.06), minor and major complications (OR 0.92, 95% CI 0.48-1.76 and OR 0.78 95% CI 0.36-1.69, respectively) comparing ta-IPAA to transabdominal IPAA. Short- and long-term follow-up showed satisfying functional outcomes and quality of life., Conclusions: Our review suggests that ta-IPAA is not inferior to transabdominal IPAA. Implementation of this method in children is technically feasible due to familiarity with the dissection plane. Long-term functional outcomes and quality of life are paramount in the pediatric population and should be particularly investigated. Multicenter prospective studies are required to investigate pediatric UC patients undergoing ta-IPAA., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

To examine the outcomes of preterm infants born to women with preterm premature rupture of membranes (PPROM) at periviable gestational age. This is an observational retrospective cohort study analyzing data collected on singleton deliveries complicated by prolonged premature rupture of membranes occurring between 17 and 33 weeks of gestation. Neonatal outcomes including birth weight, Apgar score, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, hearing impairment and mortality were evaluated. Ninety-four preterm infants who were born after a prolonged premature rupture of membranes of at least 7 days were included in the study. Median gestational week at onset of membrane rupture was 27.1 ± 4.2 weeks (range 17-33) and median latency period in days was 16 ± 21.8 (range 7-105). The cohort was stratified by gestational week (GW) at onset of PPROM (group 1: 17-23, group 2: 24-27, and group 3: 28-33). We found that the survival rate to discharge within neonates born after prolonged rupture of membrane at gestational week less than 24 weeks is 79.2% and 88.9% in group 2. These neonates did not show an increased rate of major morbidities compared to neonates born following membrane rupture at gestational week 24 to 27. We described a high survival rate to discharge without major morbidities following prolonged preterm membrane rupture of at least 7 days of latency before viability., (© 2022. The Author(s).)

Introduction: Cord blood (CB) is becoming a valuable source for stem cells utilized in a variety of cell therapy applications, as well as for newborn diagnostics. Some parameters of the CB cellular components can be provided by automated analyzers, while others, such as immature or aberrant cells, require blood film morphological assessment. The objectives of the study were to establish normal CB morphology and to determine the prevalence of morphologically aberrant leukocytes in CB., Methods: We performed a comprehensive morphological analysis of 100 CB samples taken from healthy term and appropriate-for-gestational-age neonates born to healthy mothers, preterm neonates, neonates of diabetic mothers, and small-for-gestational-age neonates. Blood counts were assessed, and manual morphological analyses were performed by laboratory specialists., Results: The manual differential count of normal CB samples established the following values: 47.8 ± 10.7% neutrophils, 31.2 ± 9.8% lymphocytes, 10.0 ± 4.0% monocytes, and 3.0 ± 2.5% eosinophils, with no significant sex-related differences. Blasts were observed in 44/100 samples with an average of 0.5 ± 0.7% per sample, and only a minor left shift was observed. There were significant populations of large granular lymphocytes (19.1 ± 10.6% of the total lymphocytes) and morphologically aberrant lymphocytes (12.4 ± 5.4% of the total lymphocytes) in the samples, irrespective of neonatal status. The differentials of preterm CB samples differ significantly from normal term CB samples, including the reverse of neutrophils/lymphocytes ratio, and the lack of basophils., Conclusions: Normal values and unique morphological features in the CB of neonates are described. The abundant morphologically aberrant lymphocytes in CB may represent an immature state of the immune system at birth., (© 2021 The Author(s). Published by S. Karger AG, Basel.)