Amir Aviram

Maternal obesity: Implications for pregnancy outcome and long-term risks–a link to maternal nutrition

As obesity becomes a worldwide epidemic, its prevalence during reproductive age is also increased. Alarming reports state that two‐thirds of adults in the USA are overweight or obese, with half of them in the latter category, and the rate of obese pregnant women is estimated at 18–38%. These women are of major concern to womens health providers because they encounter numerous pregnancy‐related complications. Obesity‐related reproductive health complications range from infertility to a wide spectrum of diseases such as hypertensive disorders, coagulopathies, gestational diabetes mellitus, respiratory complications, and fetal complications such as large‐for‐gestational‐age infants, congenital malformations, stillbirth, and shoulder dystocia. Recent reports suggest that obesity during pregnancy can be a risk factor for developing obesity, diabetes, and cardiovascular diseases in the newborn later in life. This review will address the implication of obesity on pregnancy and child health, and explore recent literature on obesity during pregnancy.

Pregnancy course and outcome following blunt trauma

Objective: To investigate short- and long-term outcome following blunt trauma in pregnancy, and to identify risk factors for adverse pregnancy outcome in these cases. Methods: A retrospective cohort study of all pregnant women who were admitted following blunt trauma (N = 411). Women who experienced immediate complications (N = 13) were compared with those who did not (N = 398). Pregnancy outcome of women who experienced trauma during pregnancy and did not deliver during the trauma admission (N = 303) were compared with a control group of women matched to by maternal age and parity in a 3:1 ratio (N = 909). Results: The overall rate of immediate complications was 3.2%, with the most common complications being preterm labor (2.0%) and placental abruption (1.7%). Independent risk factors for immediate complications were higher severity of trauma, multiple gestation, vaginal bleeding and uterine contractions at admission. Patients who experienced trauma were at increased risk for long-term adverse outcome including preterm labor, placental abruption, and perinatal morbidity. Increased trauma severity (ISS ≥ 5) and the need for laparotomy during the trauma hospitalization were independently associated with long-term adverse pregnancy outcome. Conclusion: Trauma during pregnancy is associated with both immediate and long-term adverse pregnancy outcome. Women who experience trauma should be followed more closely throughout pregnancy.

The association between Mullerian anomalies and short-term pregnancy outcome.

Abstract Objective: To determine the association between Mullerian anomalies (MuAs) and short-term perinatal outcome. Study design: 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. Results: 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%, p < 0.001) and previous cesarean section (CS) (50.6% versus 12.5%, p < 0.001). Women with MuAs had higher rates of PTDs <37 weeks (25.1% versus 6.1%, p < 0.001) and <32 weeks (4.1% versus 0.6%, p = 0.001), preterm premature rupture of membranes (PPROM) (12.8% versus 2.7%, p < 0.001) 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%, p < 0.001), 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%). Conclusion: 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.

Association of isolated polyhydramnios at or beyond 34 weeks of gestation and pregnancy outcome.

OBJECTIVE: To evaluate pregnancy outcome among women with isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation. METHODS: Retrospective cohort study at a tertiary medical center between 2007 and 2012. Isolated polyhydramnios was defined as amniotic fluid index (AFI) greater than 25 cm at admission in the absence of gestational or pregestational diabetes mellitus or fetal structural or chromosomal anomalies. Women with isolated polyhydramnios were compared with women with a normal AFI (5–25 cm). RESULTS: Overall, 31,376 women were eligible for analysis, of whom 215 (0.7%) had isolated polyhydramnios and 31,161 normal AFI. Women with isolated polyhydramnios had higher rates of labor induction (7.9% compared with 4.8%, P=.04) and cesarean delivery (12.1% compared with 5.1%, P<.001). They also had higher rates of placental abruption (0.9% compared with 0.2%, P=.02), abnormal or intermediate fetal heart rate (FHR) tracings (7.0% compared with 3.2%, P=.002), and prolonged first stage of delivery (6.0% compared with 1.4%, P<.001). Isolated polyhydramnios was also associated with higher rates of shoulder dystocia (1.9% compared with 0.3%, P<.001) and respiratory distress syndrome (0.5% compared with 0.03%, P=.001). On a multiple logistic regression model, isolated polyhydramnios was an independent risk factor for labor induction (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.01–2.8), cesarean delivery (adjusted OR 2.6, 95% CI 1.7–4.0), prolonged first stage of delivery (adjusted OR 3.6, 95% CI 1.97–6.7), abnormal or intermediate FHR tracings (adjusted OR 2.6, 95% CI 1.6–4.5), placental abruption (adjusted OR 8.4, 95% CI 2.00–35.4), shoulder dystocia (adjusted OR 3.4, 95% CI 1.2–9.7), and respiratory distress syndrome (adjusted OR 38.9, 95% CI 4.6–332.6). Mild isolated polyhydramnios (AFI 25.1–30.0) was independently associated with cesarean delivery, prolonged first stage of delivery, placental abruption, abnormal or intermediate FHR tracings, and shoulder dystocia. CONCLUSION: Isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation is associated with adverse obstetric and neonatal outcomes. LEVEL OF EVIDENCE: II

Maternal nutrition and offspring's adulthood NCD's: a review.

Overnutrition and undernutrition during pregnancy are closely related to pregnancy outcome as well as neonatal and perinatal outcomes. This and more, from various published data it seems that the effect of maternal nutrition during fetal life stretches far beyond the neonatal period, and influences health issues in adulthood, from cardiovascular and metabolic disorders through mental illnesses. The purpose of this review is to update about overnutrition and undernutrition during pregnancy and their effect on noncommunicable adulthood diseases, and about leading theories on the subject.

Effect of Prostaglandin E2 on Myometrial Electrical Activity in Women Undergoing Induction of Labor

OBJECTIVE To investigate the effect of prostaglandin E2 (PGE2) on electrical uterine activity using a novel uterine muscle electromyography device in patients undergoing induction of labor. STUDY DESIGN Electrical uterine myography (EUM) was prospectively measured using a noninvasive nine channels recorder in 31 women undergoing induction of labor with vaginal PGE2 tablets. Women were monitored before and up to 12 hours after vaginal PGE2 application. EUM index was defined as mean electrical activity of the uterine muscle over a period of 10 minutes measured in units of microjoule (µJ, µWs). RESULTS The EUM index was not increased significantly during the first 2 hours following PGE2 application (overall increase of 5.3 ± 60.1%, p = 0.7). Peak EUM activity was observed during 2 to 8 hours following PGE2 application, which represented a statistically significant increase compared with the EUM index before PGE2 application (3.3 ± 0.5 µJ vs. 2.5 ± 0.95 µJ, p = 0.01), and with the EUM index 0 to 2 hours following PGE2 application (3.3 ± 0.5 µJ vs. 2.3 ± 0.9 µJ, p = 0.004). CONCLUSION The data suggests that in women undergoing labor induction with PGE2, uterine activity peaks 2 to 8 hours following PGE2 application. This information may provide more insight into the mechanism of PGE2 action.

Effect of Meconium-Stained Amniotic Fluid on Perinatal Complications in Low-Risk Pregnancies at Term.

OBJECTIVE This study aims to determine the impact of meconium-stained amniotic fluid (MSAF) in low-risk pregnancies at term on pregnancy outcome. STUDY DESIGN A retrospective cohort study of women with MSAF during labor who delivered in a tertiary hospital at 37 to 41(+6) weeks of gestation (2007-2013). Exclusion criteria included: multiple gestations, noncephalic presentation, fetal structural/chromosomal anomalies, hypertensive disorders, diabetes, oligohydramnios, or small for gestational age. Pregnancy outcome of women with MSAF (N = 4,893) was compared with a control group of women without MSAF (N = 39,651). Neonatal respiratory morbidity was defined as the presence of any of the following: respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, or need for ventilatory support. RESULTS Overall, 10.9% of low-risk pregnancies at term were diagnosed with MSAF. Compared with the controls, women with MSAF had higher rates of nulliparity, gestational age at delivery ≥ 41 weeks, induction of labor, nonreassuring fetal heart rate, and operative deliveries. In multivariate analysis MSAF was associated with operative delivery (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.63-2.09; p < 0.001), cesarean section (OR, 1.48; 95% CI, 1.31-1.69; p < 0.001), respiratory morbidity (OR, 4.74; 95% CI, 3.87-5.82; p < 0.001), and increased risk for short-term neonatal morbidity. CONCLUSIONS MSAF is associated with a higher rate of adverse perinatal outcome even in low-risk pregnancies at term.

Does artificial rupturing of membranes in the active phase of labor enhance myometrial electrical activity

Abstract Objective: To determine whether artificial rupture of membranes (AROM) during active phase of labor augments uterine contractility using Electrical Uterine Myography (EUM). Study design: A prospective study of 31 women with term singleton pregnancy during active phase of labor. Using a non-invasive EUM technique, electrical uterine activity was recorded in the 30 min preceding AROM and in the immediate 30 min thereafter. Augmentation was defined as >5% increase in EUM index between the basal and post-AROM states, representing the mean EUM increase of the entire cohort. Low basal uterine contraction was defined as EUM index of less than the entire cohort median result prior AROM (3.5 micro-Watt-Second (mWS)). Results: Mean dilatation in which AROM was preformed was 5.5 ± 1.8 cm. There was a significant increase in mean EUM measurement in the post-AROM compared to the basal state (3.59 ± 0.39 versus 3.42 ± 0.47 mWS, p < 0.001). In multivariate analysis, low BMI and low basal uterine contractions were the only significant predictors for augmentation following AROM (OR 0.69, 95% C.I 0.45–0.97, p = 0.009 and OR 16.03, 95% CI 1.90–134.69, p = 0.003, respectively). Conclusion: Myometrial electrical activity was significantly enhanced following AROM. Augmentation was mostly pronounced in patients with lower BMI and initial lower basal uterine contraction.

The association between young maternal age and pregnancy outcome

Abstract Objective: We aimed to determine the association between young maternal age at delivery with adverse pregnancy outcome in a single, tertiary, university-affiliated medical center. Methods: A retrospective, cohort, matched control study using the first percentile distribution of maternal age at delivery (21 years old, n = 461) as the study group, and four control groups by maternal age matched by parity in a 2:1 ratio (22–25, 26–30, 31–35 and 36–40 years; n = 922 each). Results: Women aged ≤21 years were found to have lower rates of chronic hypertension [compared with women aged 36–40 years old (0.0% versus 1.3%, p < 0.05)], lower rates of gestational diabetes mellitus (GDM) (1.3% versus 3.7%, p = 0.007), higher rates of perineal lacerations [compared with women aged 31–35 and 36–40 years old, 41% versus 31.8% and 31.1%, respectively, p < 0.01)], higher rates of postpartum hemorrhage (4.6% versus 1.5%, p < 0.0001) and higher rates of low 5-min Apgar score (2.2% versus 0.8%, p = 0.004). No significant differences were found in terms gestational age at delivery, birth weight, fetal sex, intrapartum or antepartum mortality. Conclusion: Young maternal age at delivery is associated with increased risk of short-term complications after delivery.

Prediction of Small for Gestational Age: Accuracy of Different Sonographic Fetal Weight Estimation Formulas.

Objective: To compare the accuracy of various sonographic estimated fetal weight (sEFW) formulas for the prediction of small for gestational age (SGA) neonates. Methods: A retrospective analysis of 6,126 fetal biometrical measurements performed within 3 days of delivery. SGA prediction was evaluated for various sEFW formulas by calculating the sensitivity, specificity, positive/negative predictive value (PPV/NPV), likelihood ratio (+LR/-LR), overall accuracy and area under the receiver operating characteristic curve (AUC). Systematic error, random error, proportion of estimates >10% of birth weights, actual and absolute weight differences were compared between SGA and non-SGA neonates. Results: Overall, 638 (10.4%) neonates were SGA. There was considerable variation among formulas in sensitivity (mean ± SD, 62 ± 14.4%; range, 32.4-91.2), PPV (72.5 ± 10.7%; 45.8-95.6) and +LR (24.2 ± 10.9; 7.2-57.3), mild variation in specificity (96.6 ± 2.7%; 87.4-99.4), NPV (94.6 ± 5.3%; 72.2-98.9) and -LR (0.4 ± 0.1; 0.1-0.7) and minimal variation in AUC (mean, 0.93; range, 0.91-0.93). The majority of formulas had a lower accuracy for the SGA neonates, with systematic error and random error ranging from -4.2 to 14.3% and from 8.4 to 12.9% for SGA, and from -8.7 to 16.1% and from 7.2 to 10.5% for non-SGA, respectively. Conclusion: sEFW formulas differ in their accuracy for SGA prediction. In our population, the most accurate formula for SGA prediction was Hadlocks formula utilizing femur length, abdominal and head circumference.