Asnat Walfisch

The unborn smoker: association between smoking during pregnancy and adverse perinatal outcomes.

Abstract Objective: To evaluate a possible dose-response relationship between active maternal smoking during pregnancy and adverse perinatal outcome. Design: Retrospective cohort study. Setting: Population-based in Montreal, Quebec, Canada. Population: Women who gave birth to a liveborn or stillborn infant during the period of January 2001 to December 2007. Methods: Active smokers of different daily cigarette consumption (n=1646) were identified through maternal self-reporting. The reference group comprised 19,292 non-smoking women who delivered during the same period. Main outcome measures: Birth weight, preterm delivery rate, fetal and neonatal mortality and morbidity, and congenital malformations. Results: Preterm delivery rate was significantly higher in the smoking group compared with controls (22.2% vs. 12.4%, P<0.05), as was intrauterine fetal demise (1.4% vs. 0.3%, P<0.05). Newborns of active smokers were more likely to weigh less (3150±759 g vs. 3377±604 g, P<0.05), suffer from respiratory distress syndrome (2.5% vs. 1.3%, P<0.05), suffer from a cardiac malformation (1.5% vs. 0.8%, P<0.05), and die (neonatal death 1.2% vs. 0.6%, P<0.05). A dose-response relationship was demonstrated between levels of daily cigarette smoking and several adverse outcomes. Using multiple regression models, smoking was found to be an independent predictor of preterm delivery (odds ratios (OR) 1.9, 95% confidence intervals (95%CI) 1.6–2), and intrauterine fetal demise (OR 2.4, 95%CI 1.4–4.2). Conclusion: Any amount of daily smoking appears to harm the fetus and newborn. As pregnancy may be a “window of opportunity” for behavioural changes, efforts to promote smoking cessation should be encouraged.

A rise in pain threshold during labor: A prospective clinical trial

Abstract To evaluate changes in pain threshold before, during and after labor in a prospective clinical trial. Forty pregnant women at term were included. Pain threshold in 18 specific pressure points was evaluated using a dolorimeter. Woman underwent pain threshold assessment at term before labor, during the active phase of labor and postpartum. Subjective pain intensity was assessed by the parturient using the Verbal Rating Scale (VRS). Pain threshold was significantly higher during active phase of labor. There was a significant decline in pain threshold after labor as compared to pain threshold during labor (2.507 ± 0.947 and 2.608 ± 1.023, respectively, p = 0.01). Pain intensity using the VRS score was higher during labor than before labor (4.8 ± 2.7 and 2.4 ± 2.6 p < 0.001). We found a significant rise in pain threshold during labor in term pregnancies. This rise may have an intended protective effect during the intense labor pain experience.

Gender differences and sex-specific manifestations associated with human immunodeficiency virus infection in women

The rapidly growing rates of human immunodeficiency virus (HIV) infection among women has prompted many challenging issues related to the management and consequences of HIV and its complications in this population. This paper reviews the current evidence with regard to various aspects of HIV infection in women. Special emphasis is placed on gender-differences as well as sex-specific manifestation of this disease, including epidemiology, viral load determination and disease progression, related morbidity, and anti-retroviral therapy. It is concluded that current advances in the understanding of HIV infection among women may lead to further refinement and optimization efforts in the management of HIV-infected women.

Early-term deliveries as an independent risk factor for long-term respiratory morbidity of the offspring

Newborns exhibit the lowest immediate respiratory morbidity rates when born following 39 completed weeks of gestation. We sought to determine whether early‐term delivery (37–38 + 6 weeks’ gestation) impacts on long‐term pediatric respiratory morbidity.

Surgical site infection following cesarean deliveries: trends and risk factors.

Abstract Objective: To identify trends and risk factors for early surgical site infection (SSI) following cesarean delivery (CD). Methods: A population-based study comparing characteristics of women who have and have not developed post cesarean SSI was conducted. Deliveries occurred between the years 1988 and 2013 in a tertiary medical center. A multivariable logistic regression model, with backwards elimination, was used to control for confounders. Results: Of the 41 375 cesarean deliveries performed during the study period, 1521 (3.7%) were complicated with SSI. SSI rates significantly deceased over the years, from 7.4% in 1988 to 1.5% in 2012. Using a multivariable regression model, the following independent risk factors for SSI were identified: obesity (OR 2.0; 95% CI, 1.6–2.5); previous CD (OR 1.8; 95% CI, 1.6–2.0); hypertensive disorders (OR 1.4; 95% CI, 1.2–1.6); premature rupture of membranes (OR 1.3; 95% CI, 1.1–1.6); gestational diabetes mellitus (GDM, OR 1.2; 95% CI, 1.1–1.4); and recurrent pregnancy losses (OR 1.2; 95% CI, 1.1–1.5). Conclusion: Independent risk factors for post-cesarean SSI include obesity, GDM, hypertensive disorders of pregnancy, premature rupture of membranes, and recurrent pregnancy losses. Information regarding higher rates of SSI and preventative measures should be provided to these high-risk women prior to surgery.

Fertility treatments and pediatric neoplasms of the offspring: results of a population-based cohort with a median follow-up of 10 years

Objective: Studies have questioned the long‐term health effects of offspring conceived after fertility treatments. Methods: We aimed to evaluate whether an association exists between mode of conception (in vitro fertilization, ovulation induction, or spontaneous pregnancy) and neoplasm risk (both benign and malignant tumors) among the offspring; we observed the offspring for up to 18 years. Study Design: A population‐based cohort analysis was performed that compared the risk for neoplasms among children (up to the age of 18 years) based on mode of conception. Neoplasm diagnoses were based on hospital records of the same single tertiary center in the region. All singletons born during from 1991–2013 and discharged alive were included in the study. Offspring with congenital malformations were excluded from the analysis. Kaplan‐Meier survival curves were constructed to compare cumulative neoplasms incidence; multivariable survival analyses were used to control for confounders that included gestational age, pregnancy complications, and maternal factors. Results: During the study period, 242,187 newborn infants met the inclusion criteria: 2603 (1.1%) were conceived after in vitro fertilization; 1721 (0.7%) were conceived after ovulation induction treatments, and 237,863 (98.3%) were conceived spontaneously. During the follow‐up period (median, 10.55 years), 1498 neoplasms(0.6%) were diagnosed. Incidence density rate for neoplasms was higher among children conceived either after in vitro fertilization (1.5/1000 person years) or ovulation induction treatments (1.0/1000 person years), as compared with naturally conceived children (0.59/1000 person years; Kaplan‐Meier log rank, P<.001). The association between in vitro fertilization and total pediatric neoplasms and the association between any fertility treatments and malignancies remained significant; we controlled for confounders such as gestational diabetes mellitus, hypertensive disorders, preterm birth, and maternal age (adjusted hazard ratio, 2.48; 95% confidence interval, 1.71–3.50; and adjusted hazard ratio, 1.96; 95% confidence interval, 1.14–3.36, for all neoplasms and all malignancies, respectively). Conclusion: Children conceived after fertility treatments are at an increased risk for pediatric neoplasms.

A rapidly progressive, life-threatening postpartum hemorrhage: successful treatment with anti-CD-20 monoclonal antibody.

BACKGROUND: Postpartum hemorrhage may be a life-threatening event and may result from coagulation defects. CASE: We report a case of a multigravida woman who developed rapidly progressive postpartum bleeding as a result of acquired factor VIII inhibitors. Repeated laparotomies and massive transfusions failed to achieve adequate control of bleeding. Laboratory studies revealed a prolonged activated partial thromboplastin time, and the presence of specific inhibitors was soon established. The patient responded only partially to steroids and immunotherapy. Upon administration of rituximab, an anti-CD-20 monoclonal antibody, control of bleeding was achieved. CONCLUSION: Early diagnosis of acquired hemophilia as a rare cause of postpartum hemorrhage is crucial, because specific therapy may be life saving.

Gestational diabetes mellitus is a significant risk factor for long-term ophthalmic morbidity

PurposeTo investigate whether patients with a history of gestational diabetes mellitus (GDM) have an increased risk for long-term ophthalmic morbidity.MethodsDesign a population-based study compared the incidence of long-term maternal ophthalmic morbidity in a cohort of women with and without a history of GDM. Setting Soroka University Medical Center. Participants: All singleton pregnancies of women who delivered between 1988 and 2013. Main outcome measure(s) Diagnosis of ophthalmic morbidity. Analyses A Kaplan–Meier survival curve was used to estimate cumulative incidence of ophthalmic morbidity. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HR) for ophthalmic morbidity.ResultsDuring the study period, 104,751 deliveries met the inclusion criteria; 9.4% (n = 9888) of which occurred in patients with a diagnosis of GDM during at least one of their pregnancies. Patients with GDM had a significantly higher incidence of ophthalmic morbidity such as glaucoma, diabetic retinopathy, and retinal detachment compared with controls (0.1 vs. 0.02%, p < 0.001; 0.2 vs. 0.04%, p < 0.001; 0.2 vs. 0.1%, p < 0.001, respectively). Patients with concurrent GDM and preeclampsia had a significantly higher incidence of total ophthalmic complications compared to patients with GDM only (1 vs. 0.6%, respectively, p < 0.001). Using Kaplan–Meier survival curve, patients with a previous diagnosis of GDM had significantly higher cumulative incidence of ophthalmic morbidity (p < 0.001, log-rank test). In the Cox proportional hazards model, a history of GDM remained independently associated with ophthalmic morbidity (adjusted HR 2.0; 95% CI 1.5–2.8; p < 0.001).ConclusionsGDM is an independent risk factor for long-term maternal ophthalmic morbidity.

Isolated Oligohydramnios at Term as an Indication for Labor Induction: A Systematic Review and Meta-Analysis.

Objective: To investigate whether isolated oligohydramnios at term is associated with increased rates of perinatal morbidity and mortality and whether induction of labor in term pregnancies with isolated oligohydramnios is superior to conservative management in reducing perinatal morbidity and mortality. Study Design: We searched databases from inception to May 2015. We included studies that evaluated isolated oligohydramnios at term and perinatal outcome. Each outcome was analyzed separately, performing a comparative analysis between the study and control groups. Results: Twelve studies were included with 35,999 women: 2,414 (6.7%) with isolated oligohydramnios and 33,585 (93.29%) with normal amniotic fluid index. Patients with isolated oligohydramnios had significantly higher rates of labor induction [odds ratio (OR) 7.56, confidence interval (CI) 4.58-12.48] and Cesarean sections (OR 2.07, CI 1.77-2.41). There were higher rates of an Apgar score <7 at 1 and 5 min (OR 1.53, CI 1.03-2.26, and OR 2.01, CI 1.3-3.09, respectively) and admission to the neonatal intensive care unit (OR 1.47, CI 1.17-1.84). There were no significant differences in cord pH <7.1 and meconium-stained amniotic fluid. In the single randomized trial comparing induction of labor with expectant management, no differences were found in any significant maternal or neonatal outcomes. Conclusion: Isolated oligohydramnios at term is associated with significantly higher rates of labor induction, Cesarean sections, and short-term neonatal morbidity.

Pediatric Cardiovascular Morbidity of the Early Term Newborn

Objective To determine whether early term delivery (at 370/7‐386/7 weeks of gestation) is associated with long‐term pediatric cardiovascular morbidity of the offspring. Study design A population‐based cohort analysis was performed including all term deliveries occurring between 1991 and 2014 at a single tertiary medical center. Gestational age at delivery was subdivided into early term (370/7‐386/7), full term (390/7‐406/7), late term (410/7‐416/7) and post term (≥420/7) delivery. Hospitalizations of children up to the age of 18 years involving cardiovascular morbidity were evaluated, including structural valvular disease, hypertension, arrhythmias, rheumatic fever, ischemic heart disease, pulmonary heart disease, perimyoendocarditis, congestive heart failure, and others. Kaplan‐Meier survival curves were used to compare cumulative hospitalization incidence between groups. A multivariable Weibull parametric model was used to control for confounders. Results During the study period, 223 242 term singleton deliveries met the inclusion criteria. Of them, 24% (n = 53 501) occurred at early term. Hospitalizations involving cardiovascular morbidity were significantly more common in children delivered at early term (0.7%) as compared with those born at full (0.6%), late (0.6%), or post term (0.5%; P = .01). The survival curve demonstrated a significantly higher cumulative incidence of cardiovascular‐related hospitalizations in the early term group (log‐rank P < .001). In the Weibull model, early term delivery was found to be an independent risk factor for cardiovascular‐related hospitalization as compared with full term delivery (adjusted HR, 1.16; 95% CI, 1.01‐1.32; P = .02). Conclusion Early term delivery is independently associated with pediatric cardiovascular morbidity of the offspring as compared with offspring born at full term.