Alina Weissmann-Brenner

Maternal and neonatal outcomes of large for gestational age pregnancies.

Objective. To compare maternal and neonatal outcomes of term large for gestational age (LGA) pregnancies and adequate for gestational age (AGA) pregnancies. Design. Retrospective analysis. Setting. Large university research medical center. Population. All term singleton LGA (birthweight ≥90th percentile) and AGA pregnancies (birthweight 10.1–89.9th percentile) delivering between 2004 and 2008. Methods. Data collected included maternal age, gestational age at delivery, mode of delivery, birthweight, fetal sex, and maternal and neonatal complications. Birthweight percentiles were determined according to locally derived gender‐specific birthweight tables. Main outcome measures. Comparisons between LGA and AGA pregnancies and between LGA 90–94.9th, 95–98.9th and ≥99th percentile. Results. The study population comprised 34 685 pregnancies; 3900 neonates matched the definition of term LGA. Maternal age and gestational age at delivery were significantly higher for LGA neonates. Significantly more LGA neonates were born by cesarean section, and significantly more LGA pregnancies were complicated by postpartum hemorrhage (PPH), shoulder dystocia or neonatal hypoglycemia, and had a longer hospitalization period. Maternal and neonatal risks increased as birthweight increased from the 90–94.9th to 95–98.9th to ≥99th percentile. Specifically, the risks of shoulder dystocia (odds ratio 2.61, 3.35 and 5.11, respectively), PPH (odds ratio 1.81, 2.12 and 3.92, respectively) and neonatal hypoglycemia (odds ratio 2.53, 3.8 and 5.19, respectively) all increased linearly with birthweight percentile. Conclusions. Large for gestational age pregnancies are associated with an increased rate of cesarean section, PPH, shoulder dystocia and neonatal hypoglycemia, as well as longer hospitalization. These risks increase as the birth percentile rises. These risks need to be emphasized in pre‐delivery counseling.

Aortic dissection in pregnancy.

BACKGROUND: Aortic dissection is a rare but life-threatening disease. The most common predisposing cause is chronic hypertension. CASE: A 38-year-old multipara with chronic hypertension was admitted at 38 weeks of gestation reporting new-onset severe chest pain. Cardiac enzymes, blood gases, electrocardiogram, and chest radiograph were normal. The chest pain and the hypertension worsened despite treatment with narcotics. Bedside transesophageal echocardiography revealed aortic dissection. Uneventful cesarean delivery was followed by surgical repair of the aorta. CONCLUSION: Aortic dissection should be considered when a pregnant woman presents with preeclampsia superimposed on chronic hypertension and intractable chest pain.

Isolated fetal umbilical vein varix—prenatal sonographic diagnosis and suggested management

To present our experience with fetuses with umbilical vein varix (UVV), to investigate possible risk factors and to suggest a management scheme of evaluation.

Maternal and neonatal outcomes of macrosomic pregnancies

Summary Background To compare maternal and neonatal outcomes of term macrosomic and adequate for gestational age (AGA) pregnancies. Material/Methods A retrospective analysis was performed on all term singleton macrosomic (birth weight ≥4000 g) and AGA (birth weight >10th percentile and <4000 g) pregnancies delivered at our hospital between 2004 and 2008. Data collected included maternal age, gestational age at delivery, mode of delivery, birth weight, fetal gender, maternal and neonatal complications. Comparisons were made between macrosomic and AGA pregnancies and between different severities of macrosomia (4000–4250 g, 4250–4500 g and ≥4500 g). Results The study population comprised of 34,685 pregnancies. 2077 neonates had birth weight ≥4000 g. Maternal age and gestational age at delivery were significantly higher for macrosomic neonates. Significantly more macrosomic neonates were born by cesarean section, and were complicated with shoulder dystocia, neonatal hypoglycemia, and had longer hospitalization period (both in vaginal and cesarean deliveries). Specifically, the odds ratio (OR) relative to AGA pregnancies for each macrosomic category (4000–4250 g, 4250–4500 g and ≥4500 g) of shoulder dystocia was 2.37, 2.24, 7.61, respectively, and for neonatal hypoglycemia 4.24, 4.41, 4.15, respectively. The risk of post partum hemorrhage was statistically increased when birth weight was >4500 g (OR=5.23) but not for birth weight between 4000–4500 g. No differences were found in the rates of extensive perineal lacerations between AGA and the different macrosomic groups. Conclusions Macrosomia is associated with increased rate of cesarean section, shoulder dystocia, neonatal hypoglycemia, and longer hospitalization, but not associated with excessive perineal tears. Increased risk of PPH was found in the >4500g group.

Male disadvantage for neonatal complications of term infants, especially in small-for-gestational age neonates

Abstract Objective: Sex differences in long and short-term outcomes for infants are observed. This has also been shown for several neonatal complications in preterm neonates. We aimed to evaluate whether sex impacts neonatal outcome among term neonates. Furthermore, we were interested in whether small-for-gestational age male and female neonates at term presented with different patterns of neonatal complications. Methods: Data on all term singleton deliveries and respective neonatal outcomes between 2004 and 2008 at a single tertiary medical center were utilized for this retrospective cohort study. Immediate neurological complications were defined as one or more of the following: intraventricular hemorrhage, convulsions, asphyxia and acidosis. Neonatal complications were compared between male and female term infants, as well as male and female term small-for-gestational age (SGA) neonates. Results: 37 342 singleton neonates were born ≥37 weeks’ gestation. 19 112 neonates were males. Birth weight, cesarean sections and operative deliveries were significantly higher for males. Neonatal hypoglycemia and immediate neurological complications were significantly more frequent in males. For term SGA’s, low 5-min apgar scores (<7) at 39–40 weeks were 2.65 times higher for males compared with females, as was hypoglycemia. Conclusions: Male infants at term, especially male SGA infants, are more likely to encounter complications during labor and require special neonatal care due to metabolic and/or neurological complications.

Umbilical vein anomaly in fetuses with Down syndrome

To describe the prevalence of abnormal umbilical vein (UV) anatomy in fetuses with Down syndrome.

Rituximab associated neutropenia: Description of three cases and an insight into the underlying pathogenesis

Summary Background To describe Rituximab associated neutropenia (RAN), and to explore its underlying mechanism. Case Report We describe three patients with RAN. The effect of patient’s plasma on colony forming unit, Granulocyte-Monocyte (CFU-GM) was measured by the addition of plasma to the culture of a healthy bone-marrow. Repeated tests were performed after recovery of white count. In the leukopenic period the patient’s plasma inhibited CFU growth completely. Control plasma did not have such an effect. Addition of patient’s cell supernatant to bone marrow cells did not change the number of CFU. The same effect was demonstrated in normal control. After recovery the patient’s plasma did not inhibit colony formation, similar to control. Conclusions RAN is a clinically significant side effect. It may take place during treatment or several months afterwards. Circulating antibodies in the plasma may be responsible for this unique BM toxicity.

Nucleated red blood cells in uncomplicated prolonged pregnancy

OBJECTIVE: Elevated counts of nucleated red blood cells (NRBCs), as well as prolongation of pregnancy, have been suggested as predictors of adverse perinatal outcome. However, the association between these 2 variables has received only minimal attention. We sought to evaluate fetal NRBCs in prolonged pregnancies. METHODS: Umbilical cord blood was prospectively collected at delivery from 75 prolonged (at or beyond 287 days) pregnancies. One hundred and fifty term deliveries (260–286 days) served as controls. All pregnancies were accurately dated with the use of first-trimester sonography. Fetal biophysical profile testing was initiated at 40 weeks of gestation. Patients were delivered if they were in spontaneous labor or the biophysical profile was nonreassuring or by 42 weeks of gestation. Nucleated red blood cell counts were expressed per 100 white blood cells (WBC). Umbilical artery pH studies, as well as other demographic and clinical variables, were obtained. RESULTS: Prolonged pregnancy was associated with a significantly increased incidence of induction of labor and a greater birth weight. There were no other differences between the study group and controls. The median NRBCs per 100 WBCs in prolonged pregnancy was not significantly elevated over the term values (median 3, range 0–35 versus median 3, range 0–34, respectively; P = .25). Neonatal outcome was also comparable between groups. The univariate regression analysis demonstrated a significant association between elevated NRBC counts and low arterial cord blood pH (P < .008, R = 0.175), elevated base excess (P = .02, R = 0.149), low platelet counts (P = .046, R = 0.134), and male gender (P = .028). Stepwise regression analysis revealed that low arterial cord blood pH and male gender were the only independent variables predicting elevated NRBC counts at birth. CONCLUSION: The findings of this study suggest that elevated NRBC counts are associated with specific pregnancy complications rather than uncomplicated prolonged pregnancies in general. LEVEL OF EVIDENCE: II-2

Combined Effect of Fetal Sex and Advanced Maternal Age on Pregnancy Outcomes

Background Fetal sex and maternal age are each known to affect outcomes of pregnancies. The objective of the present study was to investigate the influence of the combination of maternal age and fetal sex on pregnancy outcomes in term and post-term singleton pregnancies. Material/Methods This was a retrospective study on term singleton pregnancies delivered between 2004 and 2008 at the Chaim Sheba Medical Center. Data collected included maternal age, fetal sex, and maternal and neonatal complications. The combined effect of fetal sex and maternal age on complications of pregnancy was assessed by multivariable logistic regression models. Results The study population comprised 37,327 pregnancies. The risk of operative deliveries increased with maternal age ≥40 and in pregnancies with male fetuses. The risk of maternal diabetes and of longer hospitalization increased as maternal age increased, and in women <40 carrying male fetuses. The risk of hypertensive disorders increased in pregnancies with males as maternal age advanced. The risk of shoulder dystocia and neonatal respiratory complications increased in male neonates born to women<40. The risk of neonatal hypoglycemia increased in males for all maternal ages. Conclusions Risk assessment for fetal sex and advanced maternal age were given for different pregnancy complications. Knowledge of fetal sex adds value to the risk assessment of pregnancies as maternal age increases.

Three‐dimensional ultrasound demonstration of the fetal palate in high‐risk patients: the accuracy of prenatal visualization

The aim of this research was to evaluate the ability of three‐dimensional (3D) ultrasound for demonstrating the palate of fetuses at high risk for cleft palate.