Amir Aviram

The association between isolated oligohydramnios at term and pregnancy outcome

AbstractPurposenAs conflicting data exist concerning the implications of isolated oligohydramnios on pregnancy outcome at term, we aimed to assess this association in low-risk pregnancies.MethodsA retrospective cohort study of term pregnancies with sonographic finding of isolated oligohydramnios (amniotic fluid index (AFI) <5xa0cm) between 2007 and 2012. Outcome was compared to a control group of pregnancies with normal AFI (5–25xa0cm). Pregnancies complicated by thrombophilia, hypertension, diabetes, deviant fetal growth or chromosomal/structural abnormalities were excluded. Composite adverse outcome included CS/operative delivery due to non-reassuring heart rate (NRFHR), low Apgar score, umbilical artery pHxa0<xa07.10, neonatal intensive care admission, meconium aspiration syndrome, intubation or hypoxic-ischemic encephalopathy.ResultsOverall, 987 pregnancies complicated by isolated oligohydramnios were compared to 22,280 low-risk pregnancies with normal AFI. Isolated oligohydramnios was associated with a higher rate of induction of labor (27.7 vs. 3.7xa0%, pxa0<xa00.001), CS due to NRFHR (2.3 vs. 1.1xa0%, pxa0<xa00.01) and composite adverse outcome (9.7 vs. 7.1xa0%, pxa0<xa00.01). However, after adjusting for potential confounders as induction of labor and nulliparity using multivariable logistic regression analysis, isolated oligohydramnios was not found to be independently associated with increased risk for composite adverse outcome (OR 1.01, 95xa0% CI 0.80–1.27, pxa0=xa00.93).ConclusionIsolated oligohydramnios at term by itself is not associated with increased obstetrical morbidity.

Risk factors for recurrence after Le Fort colpocleisis for severe pelvic organ prolapse in elderly women

INTRODUCTIONnWe investigated parameters associated with recurrence after partial (Le Fort) colpocleisis surgery for severe pelvic organ prolapse (POP) in elderly women.nnnMETHODSnA retrospective cohort study included all women who underwent partial colpocleisis in a single tertiary center from February 2007 through July 2013 for stage 3 or 4 triple compartment prolapse. Inclusion criteria were age over 60, sexually inactive, medical comorbidities, increased risk for comprehensive reconstructive pelvic surgery, and refusal or failure to use a pessary as a conservative non-surgical treatment. Exclusion criteria were post-menopausal bleeding, pelvic malignancy, and the desire to preserve coital function.nnnRESULTSnThe study group included 47 women of mean age 77.3 ± 8.2 (range 61-91 years). All had medical comorbidities. Fourteen patients (29.8%) had undergone previous hysterectomy. All patients underwent partial colpocleisis and perineorrhaphy. Seven women (14.9%) underwent mid-urethral sling for urinary incontinence. Mean follow-up was 14.8 ± 10.3 months (range, 2-37 months) and mean hospitalization, 3.5 ± 1.5 days (range, 2-9 days). There were no intraoperative complications. Postoperative complications comprised lower urinary tract infection (n = 2). Objective cure (according to vaginal examination) was 80.9% (38/47), and subjective (according to symptoms), 91.5% (43/47). No patient regretted the loss of sexual function. The main reasons for prolapse recurrence were statistically significant longer post-operative vaginal length and wider genital hiatus.nnnCONCLUSIONSnObjective and subjective cure rates of Le Fort colpocleisis for the treatment of severe POP were high with low morbidity. Parameters associated with prolapse recurrence were longer postoperative vaginal length and wider genital hiatus.

The significance of paracardiac lymph-node enlargement in patients with newly diagnosed stage IIIC ovarian cancer.

OBJECTIVEnExtra-abdominal metastases in epithelial ovarian cancer (EOC) are relatively rare. Interpreting computed tomography (CT) scans, during initial work-up, little attention is focused on enlargement of paracardiac lymph nodes (PCLN) and their significance is not clear. We aimed to examine whether the presence of PCLN during initial diagnosis of EOC influences prognosis.nnnMETHODSnA retrospective study comparing patients with stage 3 EOC who were diagnosed with PCLN on CT scan during initial evaluation to stage 3C patients without PCLN. Scans were reviewed by a single radiologist for peritoneal involvement, distal metastases and presence of PCLN. Disease status at diagnosis, results of surgery, chemotherapy and response, disease-free interval (DFI) and overall survival (OS) were recorded.nnnRESULTSnThirty one patients with stage 3C EOC with PCLN on initial CT scan were included and compared with 41 controls. There was no significant difference between groups in abdominal optimal cytoreduction rate. Lower rates of complete response (CR) to initial treatment were detected in the study group (45.2% vs. 78.0%, p=.004). In survival analysis, the DFI for patients with PCLN was shorter (median 9.0 vs. 24.0 months, p=.0097) and overall survival was shorter (median 31.7 vs. 61.3 months, p=.001). Multivariate analysis showed that PCLN was significantly associated with a lower rate of CR, a shorter DFI and a shorter OS.nnnCONCLUSIONnThe presence of enlarged PCLN at presentation appears to be associated with poor prognosis in stage 3C EOC. Further attention should be given to detection and follow-up of such findings when considering treatment.

Structured hands-on workshop decreases the over-detection rate of obstetrical anal sphincter injuries.

PurposeThe purpose of this study was to assess the effect of a structured hands-on workshop on the detection rate of obstetric anal sphincter injuries.MethodsAll physicians attending the delivery ward in our institution participated in a structured obstetric anal sphincter injury hands-on workshop developed by Dr. Ranee Thakar and Dr. Abdul Sultan which demonstrated proper identification and techniques for obstetric anal sphincter injury detection and repair. We retrospectively reviewed the electronic records of all singleton-pregnancy women who delivered vaginally (vertex presentation) during the 2xa0years prior to and 1xa0year following the workshop to assess the workshop’s effect on the rate of detection of obstetric anal sphincter injuries.ResultsOverall, 20,484 women met the inclusion criteria during the study period and were eligible for final analysis. There were no significant differences in patient’s characteristics between the groups. Women in the pre-workshop group had a higher rate of obstetric anal sphincter injuries than the post-workshop group (0.4 vs. 0.2xa0%, pu2009=u20090.005). On multivariate analysis, factors independently associated with a decreased risk for obstetric anal sphincter injuries were deliveries in the post-workshop period (odds ratio 0.43, 95xa0% confidence interval 0.24–0.79, pu2009=u20090.006), parity (odds ratio 0.37, 95xa0% confidence interval 0.25–0.54, pu2009<u20090.001), and spontaneous vaginal delivery (odds ratio 0.43, 95xa0% confidence interval 0.26–0.71, pu2009=u20090.001).ConclusionsA proper detection of obstetric anal sphincter injuries may depend on the experience of the assessor. A structured hands-on workshop is important to avoid over diagnosis third-degree perineal tears.

Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth

AIMnTo assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering at the late preterm period.nnnMETHODSnRetrospective observational cohort of all women with GDM who delivered a singleton fetus at the late preterm birth period (34+0/7 to 36+6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.nnnRESULTSn1849 women were included in the study, of whom 132 (7.1%) were diagnosed with GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal delivery (45.5% vs. 62.9%, p<0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%, p<0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24-2.66, p=0.002). Neonates of mothers with GDM had significant higher mean birth weight and birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity.nnnCONCLUSIONnaccording to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications.

Association between sonographic measurement of fetal head circumference and labor outcome

To evaluate the association between sonographically measured head circumference (HC) and labor outcome.

Anatomical diversity of the female external genitalia and its association to sexual function.

OBJECTIVEnTo provide data on the anatomical dimensions of adult female genitalia and to investigate the possible association of vulvar morphology and sexual function.nnnSTUDY DESIGNnThis cross-sectional prospective cohort study, using measurements of the external genitalia was performed in a day-care unit of a tertiary, university-affiliated medical center from 2013 to 2014. Thirty-two premenopausal women aged 20-51 years, undergoing gynecological procedures under general anesthesia (not involving the external genitalia) were asked to respond to both a local general data questionnaire and a validated sexual function questionnaire (PISQ-12). Based on reported orgasmic performance during sexual intercourse, patients were divided into two groups, and the measured genital features were compared.nnnRESULTSnAge, body mass index, parity and sexual activity history were recorded. A wide range of values was noted for each measurement. There was no statistically significant association between external genitalia measurements and age, parity or sexual activity. There was no statistically significant difference in any of the external genitalia measurements between the groups.nnnCONCLUSIONnWide variability exists in the appearance of female external genitalia. Sexual function does not appear to be associated with genital dimensions. This information is important for both women and surgeons when considering cosmetic vulvar surgery.

Pregnancy Outcome in Women with Decreased Sensation of Fetal Movements at Term According to Parity

BACKGROUNDnDecreased sensation of fetal movements (DFM) is a common maternal complaint. Thus, we aimed to evaluate the association between DFM and pregnancy outcome in singleton gestation at term according to parity.nnnMETHODSnA retrospective cohort study of singleton pregnancies at term between 2008 and 2013. Eligibility was limited to women carrying a fetus with no known structural or chromosomal anomalies, at 37+0/7 to 42+0/7xa0weeks of gestation. Women presenting to the delivery ward with DFM were compared with women without similar complaints.nnnRESULTSnOverall, 12,564 nulliparous women and 25,292 multiparous women gave birth during the study period; of them, 300 nulliparous women (2.4%) and 525 multiparous women (2.1%) complained of DFM. For nulliparous women, after adjusting for potential confounders, DFM was associated with antepartum fetal death (aOR 4.6 [95% CI 1.1-19.8]), cesarean delivery (CD) (aOR 1.3 [95% CI 1.01-1.8]), 1-minute Apgar score less thanxa07 (aOR 2.3 [95% CI 1.5-3.5]) and neonatal seizures (aOR 3.2 [95% CI 1.3-8.2]). For multiparous women, DFM was associated with unscheduled CD (aOR 2.7 [95% CI 1.6-4.6]) and CD indicated by intermediate/abnormal fetal heart rate tracing (aOR 4.8 [95% CI 2.8-8.4]).nnnCONCLUSIONSnDFM carries different outcomes according to parity. Although for nulliparous women, DFM is associated with increased risk of CD and immediate adverse perinatal outcome, for multiparous women it is associated with increased risk for CD, with no immediate increased risk for adverse perinatal outcome.

Delivery outcomes of large‐for‐gestational‐age newborns stratified by the presence or absence of gestational diabetes mellitus

To evaluate separate and combined contributions of gestational diabetes mellitus (GDM) and large‐for‐gestational age (LGA) on delivery outcomes.

Can we predict successful cervical ripening with prostaglandin E2 vaginal inserts

PurposePrevious studies have suggested that a variety of maternal and obstetrical characteristics may predict successful prostaglandin E2 (PGE2) cervical ripening. However, in most studies women were administered vaginal tablets or gel so scarce is known regarding potential predictors in women administrated slow-release vaginal inserts. We aimed to characterize the response of cervical ripening for labor induction using slow-release PGE2 vaginal insert and to identify predictors for success.MethodsA retrospective cohort study in a single center (2013–2015). The association between maternal characteristics at admission and cervical ripening success/failure were explored. Cervical ripening failure was defined as a Bishop’s score <7 following 24xa0h from cervical ripening or the need for cesarean delivery (CS) due to arrest of dilatation at cervical dilatation ≤5xa0cm. Cases with major fetal anomalies, multiple gestations, non-vertex presentation or any contraindication for vaginal delivery were excluded.ResultsOf 15,564 deliveries during the study period, 986 (6.3%) women met inclusion criteria, of them, 774 (78.56%) succeeded and 212 (21.5%) failed cervical ripening. Cervical ripening success was associated with (OR, 95% CI): nulliparity (0.42, 0.22–0.81, pxa0=xa00.009, i.e., nulliparity was negatively associated with successful ripening), gestational age (GA) at delivery (1.29, 1.02–1.61, pxa0<xa00.03), and cervical dilation at admission (4.58, 2.57–8.17, pxa0<xa00.001). The indications for labor induction were not associated with cervical ripening success. A prediction model which included the abovementioned characteristics had an AUC of 0.792 (95% CI 0.743–0.840).ConclusionsOverall, basic parameters, such as parity, cervical dilatation at admission and gestational age can predict successful cervical ripening PGE2 vaginal inserts.