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Enhanced first trimester aneuploidy screening (eFTS) combines serum biomarkers and ultrasound. Abnormal biomarkers are associated with placental complications, such as fetal growth restriction (FGR). We aimed to evaluate whether a Midtrimester placental scan can provide reassurance regarding FGR in women with abnormal eFTS biomarkers.We conducted a retrospective cohort study of women who had eFTS and delivered at a single referral center. Women with abnormal biomarkers had a mid-trimester scan of the placenta (morphologic assessment, fetal biometry and uterine artery pulsatility index). We compared pregnancies with abnormal eFTS biomarkers and normal placental scans (study group) with those who had normal eFTS biomarkers (control group).A total of 6,514 women were included, of whom 343 (5.3%) comprised the study group. Women in the study group had an increased risk of hypertensive disorders of pregnancy [(aOR)1.96(95%CI 1.21-3.16)], and preterm birth37 weeks [aOR1.98(95%CI 1.33-2.95)] compared to the control group. Yet, their neonates were not at higher risk for FGR3A normal second trimester placental scan provided reassurance regarding the risk of FGR in women at high risk based on abnormal eFTS biomarkers.

To identify risk factors for postpartum hemorrhage (PPH) following cesarean delivery (CD).A retrospective study of all women who underwent CD in a university-affiliated tertiary hospital (2014-15). PPH was defined as any of the following: clinical PPH (≥1000 ml estimated blood loss), hemoglobin (Hb) drop ≥3 g/dl (the difference between pre-CD Hb level within a 24 h prior to the delivery) and post-CD (nadir level during the first 72 h after CD)) or the need for blood products transfusion. The characteristics of women with PPH following CD were compared to a control group of those with CD without PPH.Of the 15,564 deliveries during the study period, 3208 (20.6%) women met inclusion criteria, of them, 307 (9.6%) had PPH and 2901 (90.4%) served as controls. Women in the PPH group were younger (32.6 ± 5.3In women undergoing cesarean section, urgent CD, the duration of the surgery, and the number of the previous CD are associated with the risk of PPH and should be taken into consideration during the postpartum assessment.

To investigate clinical and sonographic features associated with sonographic accuracy for the prediction of small for gestational age (SGA) and macrosomia at birth.The database of a tertiary medical center was retrospectively searched for women who gave birth at term to a singleton healthy neonate in 2007-2014 and underwent sonographic estimated fetal weight (sEFW) evaluation within 3 d before delivery. Fetal growth restriction (FGR) and SGA were defined as sEFW or birth weight10th percentile for gestational age; macrosomia was defined as birth weight4000 grams. Data on maternal age, parity, gestational age, fetal gender, presentation, placental location, diabetes, hypertension, and oligo/polyhydramnios were compared between pregnancies with a false-negative and false-positive diagnosis of SGA or macrosomia.Of the 5425 fetal weight evaluations, 254 (4.7%) deviated by15% from the actual birth weight. Nulliparity, absence of diabetes, neonatal female gender, anterior placenta, lower birth weight, and oligohydramnios were associated with a high deviation. We identified 482 SGA neonates (8.9%) and 633 macrosomic neonates (11.7%). A false-positive diagnosis of FGR was associated with oligohydramnios, absence of diabetes, and posterior placenta, and a false-negative diagnosis, with older maternal age, nulliparity, and male gender. A false-positive diagnosis of macrosomia was associated with older maternal age, multiparity, polyhydramnios, anterior placenta, and lack of hypertensive complications, and a false-negative diagnosis, with diabetes, hypertension, oligohydramnios, and vertex presentation.The accuracy of sEFW is affected by clinical and sonographic pregnancy characteristics. Further analyses should focus on improving accuracy especially at the fetal weight extremes.

Objective: To evaluate the relationship between adipocytokines and glycemic control.Study design: Prospective observational trial of gestations with gestational diabetes mellitus (GDM). Fasting glucose (FG), insulin, adiponectin, leptin, chemerin, retinol-binding protein 4 (RBP-4), osteocalcin, and resistin were measured. HomeOstasis model assessment of insulin resistance (HOMA-IR) and QUantitative insulin sensitivity ChecK Index (QUICKI) were calculated. Women who required medications for glycemic control were compared to women using nutritional therapy only.Results: Overall, 75 women were included -26 (34.7%) required medications to achieve good glycemic control. Factors associated with poor control are as follows: low resistin (aOR 0.84), HOMA-IR (aOR 1.96), QUICKI (aOR 0.62), first trimester FG (aOR 1.43), and maternal age (aOR 1.26). HOMA-IR and QUICKI performed highest for prediction. Resistin, first trimester FG, maternal age, and QUICKI had an AUC of 0.878, sensitivity and specificity of 87.5% for the prediction of the need for medications.Conclusions: Low resistin is associated with poor control. A model utilizing maternal age, first trimester fasting glucose, and first visit QUICKI yields good predictability.

Objective: To evaluate the outcomes of vacuum-assisted vaginal deliveries (VAD) among neonates of mothers with gestational diabetes mellitus (GDM).Study design: Retrospective cohort study of women ...

Amniotic fluid embolism (AFE) is a rare and potentially lethal obstetric complication, commonly occurring during labor, delivery, or immediately postpartum. There is a paucity of data regarding incidence, risk factors, and clinical management. Our primary objective in this study was to evaluate clinical presentation of AFE and delineate anesthesia management of these cases.This 10 years retrospective multi-center cohort study was performed in five tertiary university-affiliated medical centers, between the years 2005 and 2015. All documented cases of AFE identified according to the ICD guidelines were reviewed manually to determine eligibility for AFE according to Clark's criteria. All cases confirming Clark's diagnosis were included in the cohort.Throughout the study period, 20 cases of AFE were identified, with an incidence of 4.1 per 100,000 births. Average age at presentation was 35 ± 5 years. Seventy percent of cases presented during vaginal delivery, 20% occurred throughout a cesarean delivery, and 10% occurred during a dilation and evacuation procedure. The most common presenting symptom was sudden loss of consciousness in 12 parturients (66.7%), fetal bradycardia in 11 parturients (55%), and shortness of breath in 10 parturients (50%). Perimortem cesarean section was performed in 55% of cases, although only one case was performed in the delivery suite, while all others were performed in the operating room. Echocardiography was performed in 60% of the cases and all were pathological. Furthermore, 20% of cases were connected to an extracorporeal membrane oxygenation machine. There was a 15% mortality rate of 15%. A further 15% suffered major neurological disability, 25% suffered minor neurological morbidity, and 45% survived without severe complications.AFE is associated with significant maternal morbidity. This study highlights the importance of providing advanced training for the delivery suite staff for cases of maternal cardiovascular collapse secondary to AFE and increasing awareness for this rare and devastating obstetric condition.

Intrapartum fetal heart rate (FHR) monitoring is well recommended during labor to assess fetal wellbeing. Though commonly used, the external Doppler and fetal scalp electrode monitor have significant shortcomings. Lately, non-invasive technologies were developed as possible alternatives.The objective of this study is to compare the accuracy of FHR trace using novel Electronic Uterine Monitoring (EUM) to that of external Doppler and fetal scalp electrode monitor.A comparative study conducted in a single tertiary medical center. Intrapartum FHR trace was recorded simultaneously using three different methods: internal fetal scalp electrode, external Doppler, and EUM. The latter, a multichannel electromyogram (EMG) device acquires a uterine signal and maternal and fetal electrocardiograms. FHR traces obtained from all devices during the first and second stages of labor were analyzed. Positive percent of agreement (PPA) and accuracy (by measuring root means square error between observed and predicted values) of EUM and external Doppler were both compared to internal scalp electrode monitoring. A Bland-Altman agreement plot was used to compare the differences in FHR trace between all modalities. For momentary recordings of fetal heart rate110 bpm or160 bpm level of agreement, sensitivity, and specificity were also evaluated.Overall, 712,800 FHR momentary recordings were obtained from 33 parturients. Although both EUM and external Doppler highly correlated with internal scalp electrode monitoring (rIntrapartum FHR using EUM is both valid and accurate, yielding higher correlations with internal scalp electrode monitoring than external Doppler. As such, it may provide a good framework for non-invasive evaluation of intrapartum FHR.

We sought to evaluate perinatal outcomes in women with epilepsy.We performed a retrospective cohort study between 2007 and 2014, at a tertiary, university-affiliated medical center. All women with singleton gestation who delivered during the study period were included, except for pregnancies in which fetuses with chromosomal or structural anomalies were diagnosed. Perinatal outcome was compared between two groups: women diagnosed with epilepsy and women without epilepsy.Out of 62,102 deliveries during the study period, 61,455 met the inclusion criteria, of whom 206 (0.3%) had epilepsy. The only difference found in maternal demographics was higher rate of nulliparity in the epilepsy group (p = .02). As for maternal adverse outcome, higher rates of placental abruption and longer postpartum admission were found in women with epilepsy (p = .02 and p .001, respectively). Comparing neonatal outcomes between the two groups, higher rates of neonatal intensive care unit admission (16.5 versus 9.2%), seizures (1.9 versus 0.4%), transient tachypnea of the newborn (2.4 versus 1.0%) and respiratory distress syndrome (1.9 versus 0.4%) were significantly higher to newborns of women with epilepsy (p .05 for all). On multivariable logistic regression, epilepsy was found to be independently and significantly associated with placental abruption (OR 4.04, 95%CI 1.27-12.83, p = .02), neonatal intensive care unit (NICU) admissions (OR 1.84, 95%CI 1.25-2.70, p = .002), seizures (OR 4.33, 95%CI 1.60-11.77, p = .004), transient tachypnea of the newborn (OR 2.47, 95%CI 1.005-6.05, p = .049) and respiratory distress syndrome (OR 7.16, 95%CI 2.47-20.76, p .001).Epilepsy in pregnant women is associated with adverse perinatal outcomes, including neonatal seizures, placental abruption and respiratory problems.

To estimate the association between intrapartum fever and adverse perinatal outcome.A retrospective cohort study of women attempting vaginal delivery at term in a tertiary hospital (2012-2015). Perinatal outcome of deliveries complicated by intrapartum fever (≥38.0 °C) were compared to women with no intrapartum fever matched by parity and gestational age at delivery in a 1:2 ratio. Maternal outcome included cesarean section (CS), operative vaginal delivery (OVD), retained placenta or post-partum hemorrhage. Neonatal outcome included 5-minute Apgar score7, umbilical artery pH7.1, meconium aspiration syndrome, need for mechanical ventilation or hypoxic ischemic encephalopathy.Overall, 309 women had intrapartum fever and 618 served as controls. Women with intrapartum fever had higher rates of OVD (34.3 versus 19.6%, p .001) and CS (20.7 versus 8.7%, p .001). In multivariate analysis, intrapartum fever was independently associated with adverse maternal (3.75, 95%CI 2.65-5.30, p .001) and neonatal outcome (3.39, 95%CI 1.78-6.45, p .001). In febrile women, fever duration was related to maternal complications, specifically to CS. In addition, maternal bacteremia and positive placental cultures were risk factors for neonatal complications compared to those with negative cultures (23.3 versus 9.8%, p = .01).Intrapartum fever was associated with adverse perinatal complications. The duration of intrapartum fever, maternal bacteremia, and positive cultures further increase this risk.

Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p .001), increased blood components transfusions (p .001), and significant increase in cesarean hysterectomy rate (p .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p .001).Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.

This study describes a retrospective analysis of all women admitted for induction of labour (IoL), carrying a viable singleton foetus, after 34 + 0 weeks of gestation. We aimed to evaluate if foetal sex has an impact on the rate of caesarean delivery following labour induction. Our results demonstrate that among the 1062 women who met the inclusion criteria, 49% (521/1062) were carrying a male foetus. Other than a lower rate of Oxytocin use for the female sex pregnancies, there were no significant differences in pre-labour and labour characteristics between male or female sex pregnancies. There was no difference in caesarean delivery rate between groups (14.4% vs. 14.2%, male vs. female, respectively, p = .505). We concluded conclude that foetal sex does not impact the caesarean delivery rate among women undergoing IoL, regardless of the indication for induction and the indication for the caesarean delivery. Impact statement Male sex foetuses are at increased risk for adverse perinatal outcomes including, among others, an increased risk for caesarean delivery. The possible contribution of male sex to caesarean delivery after labour induction has not been specifically explored. Following induction of labour, there is no difference in failed induction or caesarean delivery rate between male and female sex pregnancies. Induction of labour may be safely employed for both male and female foetuses.

To determine the association between the myometrial electrical activity in the active and second stages of labor at term using electrical uterine myography (EUM).A prospective observational study of 47 singleton deliveries at term in a tertiary hospital. All women were assessed using noninvasive 9-channel surface electrodes of the EUM during labor. EUM index (EUMi) was calculated as the mean electrical activity during a 30 min monitoring period and expressed as microjouls (MJ). Mean EUMi of the active and second stages of labor were compared accordingly.Mean EUMi during the active phase was 3.53 ± 0.43 MJ, whereas mean EUMi in the second stage was 3.66 ± 0.48 MJ (p = 0.02). Correlation analysis between mean EUMi of the active and second stages of labor produced rA positive correlation of myometrial electrical activity exists between active phase and second stage of labor. However, while EUMi was associated with the duration of the active phase, no correlation was found between EUMi and the duration of the second stage.

To identify predictors for prolonged interval from premature rupture of membranes (PROM) to spontaneous onset of labor in women presenting with PROM and low Bishop score at term.A retrospective study of women presenting with PROM and Bishop score 7 at term (≥37weeks) in a tertiary hospital (2013-14). Spontaneous onset of labor was defined as presence of regular uterine contractions and Bishop score ≥ 7. Women with interval from PROM to spontaneous onset of labor of 24hours (short interval group) were compared to those with interval ≥ 24 hours (prolonged interval group). Women who underwent induction of labor at 24 hours from PROM were excluded.Among 625 women who met inclusion criteria, 155 (24.8%) had a prolonged interval to onset of labor. In multivariate analysis, prolonged PROM was associated with (OR, 95%CI) cervical dilatation (0.35, 0.24-0.52, p 0.001), effacement (0.97, 0.96-0.99, p 0.001) and uterine contraction (0.51, 0.32-0.80, p = 0.004). A multivariable prediction model including maternal age, parity, cervical dilatation and effacement, gestational age and neonatal birthweight was associated with an AUC of receiver-operator characteristic curve of 0.739 (0.631-0.847, p 0.001) for predicting prolonged PROM.Uterine contractions and cervical examination parameters can be used for prediction of prolonged interval to spontaneous onset of labor in women with term PROM.

To compare perinatal outcomes of interventions for prolonged second stage of labor.Retrospective cohort study, in a single, university-affiliate, medical center (2007-2014). Eligibility: singleton gestations at term, diagnosed with prolonged second stage of labor and head station of S + 1 and lower. We compared perinatal outcomes of cesarean deliveries (CD) with vacuum assisted deliveries (VAD).Of 62 102 deliveries, 3449 (5.6%) were eligible: 356 (10.3%) underwent CD and 3093 (89.7%) underwent VAD. The rate of five-minute Apgar scores7 was higher in the CD group as well as rates of NICU admission, neonatal asphyxia and composite neonatal adverse outcome. After adjusting for different confounders, CD was associated with adverse neonatal composite outcome (aOR 1.57, 95% CI 1.21-2.05, p = 0.001) and VAD with cephalhematoma (aOR 4.06, 95% CI 2.64-6.25, p 0.001). No other differences were found between the groups with regards to other traumatic outcomes.Our data suggests that in deliveries complicated by prolonged second stage, CD yield poorer neonatal outcome than VAD, with no apparent major difference in traumatic composite outcome.

To identify risk factors for mediolateral episiotomy, and evaluate the risk of obstetrical anal sphincter injury (OASI) among women with an episiotomy.A retrospective cohort study of all singletons vaginal deliveries at term between 2007 and 2014. Spontaneous and operative vaginal deliveries were compared separately, as well as nulliparous and multiparous women.Overall, 41,347 women were included in the spontaneous vaginal delivery group: 12,585 (30.4%) nulliparous and 28,762 (69.6%) multiparous women. Risk factors for episiotomy (nulliparous) were maternal age (aOR 0.98), gestational age (GA, aOR 1.07), regional analgesia (RA, aOR 1.18), labor induction (aOR 1.17), meconium (aOR 1.37) and birth weight (BW, aOR 1.04). Episiotomy was associated with PPH (aOR 1.49). Among multiparous, risk factors were maternal age (aOR 1.04), previous vaginal delivery (aOR 0.38), GA (aOR 1.06), RA (aOR 1.22), meconium (aOR 1.22) and BW (aOR 1.05). Episiotomy was associated with 3rd degree perineal tear (aOR 2.26, 95% CI 1.03-4.97). Only birth weight (nulliparous) and previous vaginal deliveries (multiparous) were contributors for episiotomy in the OVD group.Several risk factors for mediolateral episiotomy exist. Episiotomy does not protect nulliparous women, and may be associated with an increased risk for multiparous, for OASI. Therefore, the practice of routine episiotomy should be abandoned, and the practice of selective episiotomy reconsidered.

Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity.Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4 cm dilation). The primary measured outcome was the length of second stage of labor.Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery.Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.

To explore post-partum white blood cell (WBC) count, and possible factors affecting it.Retrospective cohort analysis of 12 079 healthy women, delivering a singleton term fetus with an uncomplicated course of labor, delivery and puerperium. All women delivered in a single tertiary, university-affiliated medical center from 2009 to 2014. Student's t-test, Mann-Whitney's U-test, χ(2) test and ANOVA were used to compare between variables. Multiple variable analyses was performed to allow adjustment for potential covariates and confounders. The main outcome measures included post-partum WBC count and the difference in the post-partum versus ante-partum WBC count, in association to mode of delivery, type of analgesia, timing of cesarean delivery and perineal trauma.The mean post-partum WBC count was 13.39 ± .24 × 10(9)/L (range 1.20-37.30 × 10(9)/L). There is a significant increase in the WBC after delivery (2.1 9 ± 3.33 × 10(9)/L) with significant differences according to mode of delivery (2.34 ± 3.48, 3.32 ± 3.69 and 1.6 0 ± 2.87 × 10(9)/L for spontaneous, assisted and cesarean deliveries. Multiple variables can affect post-partum leukocytosis, including: age, parity, gestational age, mode of delivery, type of anesthesia, timing of cesarean delivery in relation to labor onset and the extent of perineal trauma.Post-partum leukocytosis is a physiological phenomenon with a wide normal variation and multiple contributing factors. As a single parameter, post-partum leukocytosis should not prompt further work up.

To determine the association between Mullerian anomalies (MuAs) and short-term perinatal outcome.A retrospective cohort study, comparing pregnancy outcome in women with and without MuAs matched by age, number of fetuses and parity in a 1:2 ratio.Among 243 women with MuAs, 156 (64.2%) had bicornuate uterus, 38 (15.6%) had septate uterus, 27 (11.1%) had unicornuate uterus and 22 (9.1%) had didelphic uterus. Compared to controls (n = 486), women with MuAs had higher rates of previous preterm deliveries (PTDs) (20.2 versus 5.9%, p0.001) and previous cesarean section (CS) (50.6% versus 12.5%, p0.001). Women with MuAs had higher rates of PTDs 37 weeks (25.1% versus 6.1%, p0.001) and32 weeks (4.1% versus 0.6%, p = 0.001), preterm premature rupture of membranes (PPROM) (12.8% versus 2.7%, p0.001) and small for gestational age (SGA) infants (12.3 versus 6.8%, p = 0.01). There was higher rate of CS in the MuA group (82.3 versus 22.1%, p0.001), mainly due to higher rates of malpresentation and previous CS. In multivariate analysis, MuA was associated with SGA (2.04, 1.15-3.63), PTDs 37 weeks (3.72, 1.79-7.73), PTDs 32 weeks (7.40, 1.54-35.56), PPROM (6.31, 3.04-13.12), malpresentation (21.62, 12.49-37.45) and retained placenta (4.13, 1.73-9.86). No increased risk was observed in the rate of in-labor CS (0.52, 0.21-1.30, p = 0.16). When the rate of adverse outcomes was stratified according to MuAs subtypes, women with unicornuate uterus had the highest rate of breech presentation at delivery (55.6%) and women with didelphy uterine had the highest proportion of PTDs 37 weeks (40.9%).Women with MuAs are at increased risk for adverse pregnancy outcome, mainly PTDs + and PPROM, SGA infants and CS due to malpresentation. However, the risk of in-labor CS is not increased compared to the general population.