Anat Hershko-Klement

Pregnancy-Associated Listeriosis: Clinical Characteristics and Geospatial Analysis of a 10-Year Period in Israel

BACKGROUND Listeria monocytogenes is a foodborne pathogen that causes life-threatening infections in elderly, immunocompromised, and pregnant women. In pregnancy it may cause fetal loss or a preterm delivery, and the neonate is prone to neonatal sepsis and death. METHODS We created a cohort of all L. monocytogenes cases during 10 years (1998-2007) in Israel, by a comprehensive review of cases in hospitals throughout the country and cases reported to the Ministry of Health. RESULTS One hundred sixty-six pregnancy-related listeriosis cases were identified, resulting in a yearly incidence of 5-25 cases per 100 000 births. Presentation associated with fetal demise was more common in the second trimester (55.3%), and preterm labor (52.3%) and abnormal fetal heart rate monitoring (22.2%) were more common in the third trimester (P = .001). Fetal viability was low in the second trimester (29.2%) and much higher (95.3%) in the third trimester. Each additional week of pregnancy increased the survival chance by 33% (odds ratio, 1.331 [95% confidence interval, 1.189-1.489]). A single case of maternal mortality was identified. Listeria monocytogenes serotype 4b was more common in pregnancy-related than in non-pregnancy-related cases (79.5% vs 61.3%, P = .011). Pulsed-field gel electrophoresis analysis suggested that 1 pulsotype is responsible for 35.7% of the pregnancy cases between 2001 and 2007. This clone is closely related to the Italian gastroenteritis-associated HPB2262 and the invasive US Scott A L. monocytogenes strains. CONCLUSIONS Our survey emphasizes the high rate of pregnancy-related listeriosis in Israel and shows that specific clones might account for this.

Is severe OHSS associated with adverse pregnancy outcomes? Evidence from a case-control study.

Ovarian hyperstimulation syndrome (OHSS) is a serious and potentially life-threatening complication of fertility treatment. This study evaluated pregnancy outcomes of women hospitalized for severe OHSS. A case-control study was performed of 125 women who were hospitalized due to severe OHSS compared with a control group, consisting of 156 women matched by age and aetiology of infertility, who conceived via IVF and did not develop OHSS. Among women with singleton pregnancies, patients with severe OHSS delivered significantly earlier (37.96 versus 39.11 weeks) and had smaller babies (2854 g versus 3142 g) compared with the matched controls. Similarly, rates of preterm delivery (<34 weeks of gestation: 8.9% versus 0%, P < 0.01; <37 weeks of gestation: 20.5% versus 5.1%, P < 0.01) were significantly increased among patients in the study group. There were no between-group differences in the rates of gestational diabetes, gestational hypertension and intrauterine growth restriction. In contrast, twin pregnancies following OHSS were not significantly different from matched control twins, with regard to the rates of delivery <34 weeks and <37 weeks of gestation, gestational diabetes, gestational hypertension and intrauterine growth restriction. In conclusion, severe OHSS at early gestation is associated with adverse pregnancy outcome only in singleton gestations.

Reduced versus nonreduced twin pregnancies: obstetric performance in a cohort of interventional conceptions

OBJECTIVE To describe the obstetric performance of a selected population of twin pregnancies, comparing reduced vs. nonreduced twin pregnancies after the successful completion of the 12th week. DESIGN Prospective cohort study. SETTING Outpatient fertility center. PATIENT(S) A cohort of 464 twin pregnancies including both ovulation induction and assisted reproductive technology pregnancies. INTERVENTION(S) Fetal reduction. MAIN OUTCOME MEASURE(S) Pregnancy outcome and prematurity rate. RESULT(S) The study group included a cohort of 464 twin pregnancies in a single outpatient fertility center: 70 cases of twin pregnancies after a reduction procedure (15.1%) and 394 cases of nonreduced twins (84.9%). Of the nonreduced twin pregnancies, 8.6% went through an abortion, as compared with 4.3% in the reduced group. Mean age at delivery was also comparable between the two groups (35.8 weeks in the reduced group, 35.6 weeks in the nonreduced group), as was the rate of severe prematurity (3.3% in the nonreduced group, 2.9% in the reduced group). CONCLUSION(S) Our work supports a lack of causative relationship between fetal reduction and pregnancy endpoint.

Nulliparity, fertility treatments and twins: a time for rethinking

OBJECTIVE To evaluate the risk that nulliparity poses to the outcome of twin pregnancies, an issue that gained importance due to the rise of twin gestations following assisted reproduction interventions. DESIGN A prospective cohort study. SETTING AND PATIENT(S) Between January 1, 2004, and January 7, 2008, we prospectively enrolled all pregnancies achieved by assisted reproduction techniques and including ovulation induction, which successfully completed the first trimester. Pregnancies achieved by egg donation were excluded. MAIN OUTCOME MEASURE(S) Second trimester abortion and severe prematurity (delivery before 32 weeks) rates and the number of live births. RESULT(S) Two-hundred-forty-three twin pregnancies were available for evaluation. Second trimester miscarriage rate was 9.3% in nulliparas and 2.4% in multiparas (P=0.061). Severe prematurity rate was 15.1% in nulliparas compared with 2.5% in multiparas (P=0.003). Better outcome of multiparas was also demonstrated by the calculated chance of taking home at least one baby: 97.6% for multiparas compared with 89.2% in nulliparas (P=0.024). CONCLUSION(S) Nulliparity is a risk factor for a poor outcome in twin pregnancies achieved by fertility treatments and is associated with an increased risk for severe prematurity and possibly late abortions. This information should be relayed to the patients undergoing fertility treatments and is a consideration regarding the number of fetuses in relation to parity.

Predictors of twin pregnancy after ovarian stimulation and intrauterine insemination in women with unexplained infertility

Abstract Multi-foetal gestation is a well-known, adverse outcome of infertility treatment. Maternal and obstetrical complications are more frequent in multiple pregnancies compared to singletons. The aim of this study was to determine parameters that affect the risk for multiple pregnancies after ovarian stimulation (OS) with intrauterine insemination (IUI). We retrospectively evaluated all cases of OS with IUI cycles that ended with successful clinical pregnancy. A total of 259 pregnancies were analysed (175 singletons, 63 twins and 21 triplets). Significant parameters predicting multiple pregnancies were gravidity and number of follicles at least 15 mm in diameter on day of hCG. A previous pregnancy increased the risk for multiple gestation by a factor of 1.86 (95% CI 1.03–3.37, p = 0.04). Each follicle ≥15 mm increased the odds ratio for multiple gestation by 1.3 (95% CI 1.03–1.65, p = 0.027). In conclusion, women with more than one previous pregnancy and three or more than three follicles ≥15 mm at hCG are at risk for multi-foetal pregnancy after OS and IUI.