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To identify risk factors associated with bladder injury during placenta accreta spectrum (PAS) surgeries.This retrospective cohort study was conducted at the Chaim Sheba Medical Center. The study population included pregnant women diagnosed with PAS undergoing uterine-preserving surgery or hysterectomy. Women with and without operative bladder injury were compared by univariate analysis followed by multivariate analysis. A sub-analysis of women without preoperative sonographic suspicion of bladder invasion was performed.A total of 312 women were included in the study. Bladder injury incidence was 9.3% (n = 29). Uterine preservation was performed in 267/312 (85.6%) women. The number of previous cesarean deliveries and a preoperative sonogram suspicious for placenta percreta were found to be independent risk factors for intraoperative bladder injury (odds ratio [OR] 1.30, P = 0.019, and OR 5.23, P = 0.002, respectively). The number of previous cesarean deliveries and preoperative sonographic suspicion of placenta percreta were also associated with bladder injury in the sub-analysis (OR 1.30, P = 0.044 for previous cesarean deliveries, and OR 3.36, P = 0.036, for preoperative suspicion of bladder injury).The number of previous cesarean deliveries and preoperative suspicion of placenta percreta are preoperative factors that can assist in preoperative planning and intraoperative management of PAS cases.

To study obstetric outcomes of a second pregnancy among women with a first ectopic pregnancy (EP) treated with methotrexate compared with laparoscopic salpingectomy.A retrospective cohort study including all women with a first EP and a following pregnancy that concluded by delivery at ≥24 weeks of gestation between March 2011 and April 2021. Second pregnancy outcomes were compared between women treated with methotrexate and those treated with salpingectomy in their first pregnancy.Overall, 125 women were included, of which 64 (51.2%) were treated with methotrexate and 61 (48.8%) were treated with salpingectomy. In women treated with salpingectomy, the proportion of women conceiving by in vitro fertilization and those with measured gestational sac diameter or β-subunit human chorionic gonadotropin was higher. The proportion of women conceiving by in vitro fertilization in their second pregnancy was higher in the salpingectomy group (55.2% versus 18.0%, P 0.001). All maternal and neonatal outcomes were similar in both groups. The rate of low birth weight 2500 g was 7.8% in the methotrexate group versus 18% in the salpingectomy group (P = 0.111).Maternal and neonatal outcomes of a second pregnancy among women treated for EP in their first pregnancy are similar in women treated by methotrexate and those treated by salpingectomy.

Multiple pregnancies are at increased risk of placental-related complications. The aim of the study was to investigate the prevalence and cumulative incidence of placental-related complications in twin pregnancies undergoing a late selective termination, compared to matched singleton and twin controls.A retrospective case-control study of post-selective late termination (≥20 weeks of gestation) singletons performed between 2009 and 2020 at a single tertiary center. Each post-termination pregnancy was matched to 2 singleton and 2 dichorionic twin pregnancies for: mode of conception, maternal age group and parity. The prevalence of composite placental related outcome was determined and compared. Kaplan-Meier curves were constructed, and log rank test was performed to compare the cumulative incidence of placental complications among groups.Included were 90 post-selective termination pregnancies and 360 matched singletons and twins. These were subdivided according to trimester at procedure: 1) late 2nd trimester (N = 43, 20-27.6 weeks); 2) 3rd trimester (N = 47, ≥28 weeks). Placental-related complications presented earlier in the 3rd trimester selective termination group compared to singletons (median 35.5 vs median 37.4 weeks of gestation, P = 0.01). The cumulative incidence of placental-related complications in twins and post-selective termination singletons rose significantly earlier compared to singletons (P 0.0001). A late 2nd trimester selective termination resulted in a comparable gestational age and cumulative incidence of placental-related complications as singletons.Compared to singletons, the cumulative incidence of placental complications rises significantly earlier in post-third trimester selective termination singleton pregnancies. While a late 2nd trimester selective termination results in a cumulative incidence comparable to singletons.

BackgroundSevere early-onset fetal growth restriction (FGR) causes significant fetal and neonatal mortality and morbidity. Predicting the outcome of affected pregnancies at the time of diagnosis is difficult, preventing accurate patient counselling. We investigated the use of maternal serum protein and ultrasound measures at diagnosis to predict fetal or neonatal death and three secondary outcomes: fetal death or delivery ≤28+0 weeks; development of abnormal umbilical artery Doppler velocimetry; slow fetal growth.MethodsWomen with singleton pregnancies (n=142, estimated fetal weights [EFWs] rdcentile, ResultsThe most discriminative model for fetal or neonatal death included EFW z-score (Hadlock 3 formula/Marsal chart), gestational age and umbilical artery Doppler category (AUC 0.91, 95%CI 0.86-0.97) but was less well calibrated than the model containing only EFW z-score (Hadlock3/Marsal). The most discriminative model for fetal death or delivery ≤28+0 weeks included maternal serum placental growth factor (PlGF) concentration and umbilical artery Doppler category (AUC 0.89, 95%CI 0.83-0.94).ConclusionUltrasound measurements and maternal serum PlGF concentration at diagnosis of severe early-onset FGR predict pregnancy outcomes of importance to patients and clinicians.Trial registrationClinicalTrials.govNCT02097667FundingEuropean Union, Rosetrees Trust, Mitchell Charitable Trust.

Objective: The objective of this study is to assess the delivery outcomes of neonates with congenital heart defects (CHD), and to explore the effect of prenatal diagnosis on these outcomes. Methods: A retrospective study including singleton deliveries between 2011 and 2020. All singleton neonates delivered at >24 weeks of gestation were included in this study. Fetuses with known prenatal anomalies other than CHD were excluded from this study. Pregnancy and neonatal outcomes were analyzed. A comparison was made between pregnancies with CHD and controls; and between pregnancies with prenatal diagnosis of CHD and postnatal diagnosis of CHD. Results: A total of 1598 neonates with CHD (688, 43.1% diagnosed prenatally) comprised the study group, compared to 85,576 singleton controls. Pregnancies with CHD had significantly increased BMI before pregnancy, suffered more from diabetes and chronic hypertension, had more inductions of labor, and had more cesarean deliveries (CD) including both elective CD and urgent CD due to non-reassuring fetal monitor (NRFHR) (OR = 1.75; 95%CI 1.45–2.14). Prenatal diagnosis of CHD is associated with a significant increased rate of induction of labor compared to postnatal diagnosis of CHD (OR = 1.59; 95% CI 1.15–2.22), but did not affect the mode of delivery including the rate of CD and CD due to non-reassuring fetal heart rate (NRFHR). Gestational age at birth and birthweight were significantly lower in pregnancies with CHD compared to controls, with no difference between prenatal to postnatal diagnosis of the anomaly. Neonates with CHD had a higher incidence of hypoxic ischemic encephalopathy and seizures compared to controls without any impact by prenatal diagnosis. Conclusion: Prenatal diagnosis of CHD is associated with an increased rate of induction of labor, with no increased rate of CD and CD due to NRFHR. The 5-min Apgar score is lower in pregnancies with postnatal diagnosis of CHD.

Abnormal fetal tongue size is a phenotypic feature of various syndromes including Beckwith-Wiedemann, Pierre-Robin, oromandibular limb hypoplasia, chromosomal aberrations, etc. Current data regarding normal fetal tongue size are limited. Hence, micro/macroglossia are subjectively determined. The aim of the study was to construct a contemporary fetal tongue nomogram and to assess its clinical contribution.A prospective cross-sectional study was performed in well dated, low risk, singleton pregnancies. Fetal tongues were measured by 5 trained sonographers. Highest quality images were selected. Intra- and interobserver variability was assessed. Tongue length, width, area, and circumference 1st to 99th centiles were calculated for each gestational week. Based on the normal tongue size charts, we created a Tongue Centile Calculator.Over 18 months, 664 tongue measurements were performed. A cubic polynomial regression model best described the correlation between tongue size and gestational age. The correlation coefficient (rWe present novel fetal tongue size charts from 13 to 40 weeks of gestation. Clinical application of these nomograms may be beneficial in the prenatal diagnosis of syndromes or malformations associated with abnormal fetal tongue size.

ObjectiveTo quantify the risks of mortality, morbidity and postnatal characteristics associated with extreme preterm fetal growth restriction (EP-FGR).DesignThe EVERREST (Doesvascular endothelial growth factor gene therapy safely improve outcome in severeearly-onset fetal growth restriction?) prospective multicentre study of women diagnosed with EP-FGR (singleton, estimated fetal weight (EFW) +0–26+6weeks of gestation). The UK subgroup of EP-FGR infants (SettingFour tertiary perinatal units (UK, Germany, Spain, Sweden).Main outcomesAntenatal and postnatal mortality, bronchopulmonary dysplasia (BPD), sepsis, surgically treated necrotising enterocolitis (NEC), treated retinopathy of prematurity (ROP).ResultsOf 135 mothers recruited with EP-FGR, 42 had a stillbirth or termination of pregnancy (31%) and 93 had live births (69%). Postnatal genetic abnormalities were identified in 7/93 (8%) live births. Mean gestational age at birth was 31.4 weeks (SD 4.6). 54 UK-born preterm EP-FGR infants (ConclusionsMortality following diagnosis of EP-FGR is high. Survivors experience increased neonatal morbidity compared with AGA preterm infants.Trial registration numberNCT02097667.

Esophageal atresia is a major anomaly of varying severity. The complexity of surgical correction depends on the presence of a distal fistula.This study aimed to determine the feasibility and accuracy of prenatal ultrasound detection of the distal fistula in fetuses diagnosed with esophageal atresia.This was an observational study conducted at a single tertiary care center between 2019 and 2021. Included were pregnant patients carrying a fetus prenatally diagnosed with esophageal atresia that was confirmed postnatally during corrective surgery or at postmortem autopsy. During the scan, the performing investigator determined the presence or absence of a distal fistula by scanning the location of the lower esophagus during fetal breathing. Cases in which the lower esophagus was observed distending with amniotic fluid during breathing were deemed "fistula present," and the remaining cases "fistula absent." Test feasibility and performance indices, including sensitivity, specificity, and positive and negative predictive value were calculated. The offline clips and images were reviewed by 2 investigators for the assessment of interoperator agreement using Cohen's Kappa formula.Included were 16 fetuses with esophageal atresia scanned between 2019 and 2021. All fetuses were successfully scanned with sufficient resolution of the area of interest during at least 3 cycles of breathing. It took a median of 8.5 minutes to determine the presence or absence of a distal fistula. The feasibility of the test was 100% (16/16). The test's sensitivity, specificity, and positive and negative predictive values were 80% (95% confidence interval, 55-100), 100% (95% confidence interval, 60-100), 100% (95% confidence interval, 65-100), and 75% (95% confidence interval, 45-100), respectively. The Cohen's Kappa for interoperator agreement was calculated to be 1, P.001, corresponding to a "perfect" level of agreement.Distal fistulas in esophageal atresia can be demonstrated prenatally by targeted scanning using appropriate technique. The method provided is feasible, reproducible, and has excellent performance indices. This novel technique and observations may improve the prenatal diagnosis and counseling of esophageal atresia.

True knot of the umbilical cord (TKUC) is found in 0.3-2.1% of pregnancies and is associated with an increased risk of adverse perinatal outcomes.A retrospective cohort study including all singleton pregnancies delivered from 2011 to 2019 was performed. Diagnosis of TKUC was made postnatally, immediately after delivery of the baby. Comparison was made between pregnancies with and without TKUC regarding maternal, fetal and neonatal adverse outcome.Overall, 867/85,541 (1%) pregnancies were diagnosed with TKUC. Maternal age, BMI, gravidity and parity were significantly higher in pregnancies with TKUC as well as higher rate of induction of labor, meconium-stained amniotic fluid, and delivery prior to 37 weeks. The rate of cesarean deliveries due to non-reassuring-fetal monitor was significantly higher in pregnancies with TKUC. Overall, there were 2.5% IUFD in pregnancies with TKUC vs. 1% in pregnancies without TKUC (p 0.001). Importantly, the rate of IUFD prior to 37 weeks of gestation was not significantly higher in the group with TKUC, however, the rate of IUFD after 37 weeks of gestation was 10 folds higher in fetuses with TKUC, 0.9% vs. 0.08% (p 0.001). Significantly, more neonates with TKUC needed phototherapy or suffered from hypoglycemia. There were no differences in the 5 min Apgar scores, admission to the NICU and number of days of hospitalization.Pregnancies complicated with TKUC are associated with a tenfold higher risk of IUFD beyond 37 weeks of gestation. To the results of this study suggest that it would be prudent to induce labor around 37 weeks of gestation in pregnancies with prenatal diagnosis of TKUC. It may be warranted to use continuous fetal monitoring during labor and delivery in those cases were antenatal diagnosis of TKUC is made.

To correlate the duration of Category II cardiotocograms (CTG) with adverse neonatal outcomes associated with perinatal asphyxia and determine the duration before fetal compromise.This retrospective, observational study used electronic medical record data from a cohort of 271 patients, delivered by C-section due to non-reassuring fetal heart rate, at a tertiary medical center, from 2015 through 2017. Duration of Category II CTG, variability, tachycardia and deceleration frequency were analyzed and correlated to immediate postnatal outcomes. including cord pH ≤ 7, cord base excess12, 1- and 5-min Apgar scores ≤7, need for ventilation, need for chest compressions, NICU admission, hypoglycemia and convulsions. Intrapartum fever and meconium stained amniotic fluid were correlated to the same outcomes. Categorical and continuous variables were analyzed using chi-square and t-tests, respectively. P 0.05 was considered significant.The mean duration of Category II CTG was 146 min (range 17-553). Longer duration did not result in increased rates of adverse neonatal outcomes. In contrast, reduced fetal heart rate (FHR) variability, fetal tachycardia and intrapartum fever did show increased rates of adverse neonatal outcomes, as follows: patients exhibiting reduced vs. normal (FHR) variability had 12.9% vs. 1.4% cord pH ≤ 7, P = 0.006 and 12.5% vs. 1.3% cord BE 12, P = 0.004: patients with fetal tachycardia vs. normal baseline FHR exhibited 48% vs. 17.9% 1-minute Apgar score ≤7, P = 0.0004; 8% vs. 0.8% 5-minute Apgar score ≤7, P = 0.04; and 48% vs. 18.7% ventilation support, P 0.001; patients with intrapartum fever vs. normal temperature, cord BE 12 was seen in 9.7% vs. 1.7%, P = 0.035; 1-minute Apgar score was ≤7 in 35.5% vs. 18.7%, P = 0.03; 5-minute Apgar score ≤7 in 9.7% vs. 0.4%, P = 0.005; need for ventilation in 35.5% vs. 19.6%, P = 0.042; need for chest compressions in 6.45% vs. none, P = 0.013; and NICU admission in 12.9% vs. 2.5%, P = 0.018.Our results suggest that the duration of Category II CTG alone does not appear to predict perinatal asphyxia. Parameters associated with perinatal asphyxia are reduced FHR variability, fetal tachycardia and intrapartum fever. Therefore, when contemplating intervention during labor to avoid fetal asphyxia, these parameters should be strongly considered.

To improve choice of vacuum-assisted delivery (VAD) system, we compared outcomes of Kiwi handheld system and Mityvac M-style conventional system (both use disposable plastic cups).Retrospective observational study with data collection from electronic medical records. The study was conducted at a tertiary medical center, with approximately 7000 deliveries annually. Categorical and continuous variables were analyzed using chi-square test and t-test, respectively. p value 0.05 considered significant. The main outcomes assessed were the overall failure rate of each system, failure rates for occipito-anterior (OA) vs. occipito-transverse/occipito-anterior (OT/OP) positions, +1 vs. +2 fetal stations, and early maternal/neonatal outcomes.During a 10-month period, there were 507 (8.4%) attempted VADs, 36 failed (7.1%) and 8 (1.5%) converted to cesarean section. Of these, 364 were Kiwi-assisted and 143 Mityvac-assisted. Background characteristics were similar. The handheld system had more failures overall (9.6 vs. 0.7%), at OA (7.6 vs. 0.9%) and non-OA positions (17.3% vs. none), at + 1 (13.25 vs. 0.96%) and at + 2/3 stations (6.1% vs. none), than the conventional system did, respectively. There was a higher rate of early post-partum hemorrhage (15.3 vs. 7.4%) in the conventional group. Both systems had similar rates of third/fourth degree perineal tears, shoulder dystocia and adverse neonatal outcomes.Our results suggest more failures with Kiwi compared to Mityvac, overall and at any fetal position/station, without a significant difference in adverse outcome profile.