Batel Hamou

Placenta accreta is an independent risk factor for late pre-term birth and perinatal mortality

Abstract Objective: This study is aimed to identify the risk factors for the development of placenta accreta (PA) and characterize its effect on maternal and perinatal outcomes. Study design: This population-based retrospective cohort study included all deliveries at our medical center during the study period. Those with placenta accreta (n = 551) comprised the study group, while the rest of the deliveries (n = 239 089) served as a comparison group. Results: The prevalence of placenta accerta is 0.2%. Women with this complication had higher rates of ≥2 previous CS (p < 0.001), recurrent abortions (p = 0.03), and previous placenta accreta [p < 0.001]. The rates of placenta previa and peripartum hemorrhage necessitating blood transfusion were higher in women with placenta accreta than in the comparison group. PTB before 34 and 37 weeks of gestation was more common among women with placenta accreta (p < 0.01), as was the rate of perinatal mortality (p < 0.001). Placenta accreta was an independent risk factor for perinatal mortality (adj. OR 8.2; 95% CI 6.4–10.4, p < 0.001) and late PTB (adj. OR 1.4; 95% CI 1.1–1.7, p = 0.002). Conclusion: Placenta accreta is an independent risk factor for late PTB and perinatal mortality.

A prior placenta accreta is an independent risk factor for post-partum hemorrhage in subsequent gestations

OBJECTIVE The rate of placenta accreta, a life threatening condition, is constantly increasing, mainly due to the rise in the rates of cesarean sections. This study is aimed to determine the effect of a history of placenta accreta on subsequent pregnancies. STUDY DESIGN A population based retrospective cohort study was designed, including all women who delivered at our medical center during the study period. The study population was divided into two groups including pregnancies with: (1) a history of placenta accreta (n=514); and (2) control group without placenta accreta (n=239,126). RESULTS (1) A history of placenta accreta is an independent risk factor for postpartum hemorrhage (adjusted OR 4.1, 95% CI 1.5-11.5) as were placenta accreta (adjusted OR 22.0, 95% CI 14.0-36.0) and placenta previa (adjusted OR 7.6, 95% CI 4.4-13.2) in the current pregnancy, and a prior cesarean section (adjusted OR 1.7, 95% CI 1.3-2.2); (2) in addition, placenta accreta in a previous pregnancy is associated with a reduced rate of mild preeclampsia in future pregnancies (1.8% vs. 3.4%, RR 0.51, 95% CI 0.26-0.98); (3) however, in spite of the higher rate of neonatal deaths in the study group, a history of placenta accreta was not an independent risk factor for total perinatal mortality (adjusted OR 1.0, 95% CI 0.5-1.9) after adjusting for confounders. CONCLUSION A history of placenta accreta is an independent risk factor for postpartum hemorrhage. This should be taken into account in order to ensure a safety pregnancy and delivery of these patients.

Fetal heart rate monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis.

Abstract Objective: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2. Materials and methods: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders. Results: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis. Conclusion: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2.

Early onset preeclampsia and cerebral palsy: a double hit model?

BACKGROUND Cerebral palsy (CP) is a late sequel of pregnancy, and the role of preeclampsia is debatable. OBJECTIVE The aims of this study were to determine the association between preeclampsia and cerebral palsy and to determine the risk factors for the development of cerebral palsy in these patients. STUDY DESIGN A retrospective population-based cohort study was designed that included 229,192 singleton pregnancies. The study population was divided into 2 groups: (1) patients with preeclampsia (n = 9749) and (2) normotensive gestations (n = 219,443). Generalized Estimating Equation multiple logistic regression models were performed to study the associations among preeclampsia, small for gestational age, gestational age at delivery, and the risk factors for the development of cerebral palsy in neonates of women with preeclampsia. RESULTS The rate of cerebral palsy was double in patients with preeclampsia than in the normotensive group (0.2% vs 0.1%; P = .015); early onset preeclampsia and small for gestational age were independent risk factors for the subsequent development of cerebral palsy (odds ratio, 8.639 [95% confidence interval, 4.269-17.480]; odds ratio, 2.737 [95% confidence interval, 1.937-3.868], respectively). A second model was conducted to determine the risk factors for the development of cerebral palsy in women with preeclampsia. Birth asphyxia, complications of prematurity, and neonatal infectious morbidity, but not small for gestational age or gestational age at delivery, were independent risk factors for the development of cerebral palsy. CONCLUSION In a comparison with normal pregnant women, the rate of cerebral palsy is double among patients with preeclampsia, especially those with early-onset disease. Early-onset preeclampsia is an independent risk factor for cerebral palsy. Among women with preeclampsia, the presence of neonatal infectious morbidity, birth asphyxia, and complications of prematurity are independent risk factors for the development of cerebral palsy, which further supports the role of a multi-hit model in the pathogenesis of this syndrome.

Postpartum uterine artery Doppler velocimetry among patients following a delivery complicated with preeclampsia

Objective: To evaluate postpartum uterine artery (UtA) velocimetry in patients following severe preeclampsia (PET) as compared with normotensive controls. Study Design: Postpartum UtA velocimetry was obtained prospectively during the early postpartum period. The right and left UtA pulsatility index (PI) was measured and the presence of an early diastolic notch was noted. For categorical variables, the χ2 test or Fisher exact was used as appropriate and for continuous variables the t-test was used. The p value <0.05 was considered statistically significant. Results: Thirty-one patients following severe PET and 52 normotensive controls were included in the study. Following severe PET, higher rates of intrauterine growth restriction, cesarean delivery, preterm delivery and accordingly lower neonatal birth weight were noted. Postpartum UtA velocimetry measurements were performed on average 51.2 h after delivery (range 8–169). Right and left UtA PI was comparable between patients following severe PET and controls. The presence of unilateral and bilateral early diastolic notches were significantly higher in patients following severe PET. Conclusions: The pathophysiology of uterine involution and the physiologic return of the uterine arteries to the non-pregnant state may be different following severe PET.

Antioxidants and Polyphenols: Concentrations and Relation to Male Infertility and Treatment Success

Oxidative stress is induced by reactive oxygen substances (ROS) that are known to affect male fertility. The aims of this study were to prospectively investigate and characterize total antioxidant and specifically polyphenols concentrations and their relations to sperm quality and fertility treatment success. During their infertility treatment, sixty-seven males were prospectively recruited to this study. After separation of the sperm from the semen sample, the semen fluid samples antioxidants and polyphenols concentrations were determined. Antioxidant concentration was significantly associated with sperm concentration and total motile count. Antioxidants concentration in the group of male with sperm concentration ≥ 15 × 106 was significantly higher than in the group of male with antioxidants concentration < 15 × 106 (830.3 ± 350 μM and 268.3 ± 220 μM, resp., p < 0.001). Polyphenols concentration did not differ between the groups of sperm concentration above and below 15 × 106 (178.7 ± 121 μM and 161.7 ± 61 μM, resp., p-NS). No difference was found between fertilization rates and antioxidants or polyphenols concentrations. This is the first study that reports on polyphenols concentration within semen fluid. More studies are needed in order to investigate polyphenols role in male fertility.

Induction of labor in twin gestation: lessons from a population based study.

Abstract Introduction: The route of delivery and the role of induction of labor in twin gestations are controversial. The aim of this study was to determine the efficacy of induction of labor in twin gestations. Methods: This retrospective population based cohort study included 4605 twin gestations divided into following groups: 1) spontaneous parturition (n = 2937, 63.78%); 2) induction of labor (n = 653, 14.2%) and 3) elective cesarean delivery (n = 1015, 22.04%). Results: The rate of vaginal delivery in the labor induction group was 81% (529/653). In comparison to the other study groups, induction of labor in twins was independently associated with a 77% reduction in the risk of cesarean delivery (OR 0.23; 95% CI 0.18–0.31) and a 78% reduction in the risk of postpartum death for the second twin (OR 0.22; 95% CI 0.05–0.94). The rate of nulliparity, term delivery and labor dystocia was higher in the induction of labor group (p < 0.001 in all comparisons). Conclusions: Our results suggest that induction of labor in twin gestation is successful and is independently associated with substantial reduction in the risk of cesarean delivery and postpartum death of the second twin.

Intrapartum cervical lacerations and their impact on future pregnancy outcome

Abstract Objective: To investigate the significance of intrapartum cervical lacerations on subsequent pregnancies. Study design: A retrospective cohort analysis was conducted, comparing outcomes of subsequent singleton pregnancies, in women with and without a history of cervical lacerations in a previous delivery. Deliveries occurred between the years 1991–2014 at the Soroka University Medical Center. Multiple logistic regression models were constructed to control for clinically significant confounders. Results: During the study period 187,162 deliveries met the inclusion criteria. Of them, 429 (0.2%) occurred in women with a history of cervical lacerations in the previous pregnancy (study group). The study group exhibited significantly higher rates of recurrent cervical lacerations (21/429, 4.9% versus 275/187 162,0.1%, p value = .001), cerclage (13/429, 3% versus 260/187 162, 0.1% p value = .001), cervical incompetence (8/429, 1.9% versus 609/187 162, 0.3% p value = .001) cesarean delivery (CD) (97/429, 22.6% versus 26 280/187 162,14%, p value = .001), severe perineal tears (third or fourth degree; 2/429, 0.5%, versus 164/187 162, 0.1%, p value = .056) and blood transfusion (11/429, 2.6% versus 2448/187 162, 1.3%, p value = .022) as compared with the comparison group. Using a multivariable logistic regression model, history of cervical laceration in a previous pregnancy was found to be an independent risk factor for subsequent CD (OR 1.4, 95% CI 1.1–1.9), recurrent cervical laceration (OR 29.3, 95% CI 17.7–48.5), severe perineal lacerations (OR 11.7, 95% CI 5.1–27.2), and preterm delivery (OR 1.8, 95% CI 1.1–2.8) in the subsequent pregnancy. Conclusions: A history of intrapartum cervical laceration is an independent risk factor for recurrent cervical lacerations, CD, preterm delivery, and severe perineal lacerations in the subsequent pregnancy.

Once episiotomy, always episiotomy?

ObjectiveTo investigate the association between episiotomy and perineal damage in the subsequent delivery.Study designA retrospective cohort study was conducted, comparing outcome of subsequent singleton deliveries of women with and without episiotomy in their first (index) delivery. Deliveries occurred between the years 1991–2015 in a tertiary medical center. Traumatic vaginal tears, multiple pregnancies, and cesarean deliveries (CD) in the index pregnancy were excluded from the analysis. Multiple logistic regression models were used to control for confounders.ResultsDuring the study period, 43,066 women met the inclusion criteria; of them, 50.4% (n = 21,711) had subsequent delivery after episiotomy and 49.6% (n = 21,355) had subsequent delivery without episiotomy in the index pregnancy. Patients with episiotomy in the index birth higher rates of subsequent episiotomy (17.5 vs. 3.1%; P < 0.001; OR 1.9; 95% CI). In addition, the rates of the first and second degree perineal tears as well as the third and fourth degree perineal tears were significantly higher in patients following episiotomy (33.6 vs. 17.8%; P < 0.001, and 0.2 vs. 0.1%; P = 0.002, respectively). Nevertheless, there was no significant difference at the rates of CD and instrumental deliveries, between the groups. While adjusting for maternal age, ethnicity, birth weight, and vacuum delivery—the previous episiotomy was noted as an independent risk factor for recurrent episiotomy in the subsequent delivery (adjusted OR 6.7; 95% CI 6.2–7.3, P < 0.001). The results remained significant for term (adjusted OR 6.8; 95% CI 6.2–7.4, P < 0.001) as well as preterm deliveries (adjusted OR 4.5; 95% CI 3.3–6.3, P < 0.001) in two different models.ConclusionEpisiotomy is an independent risk factor for recurrent episiotomy in the subsequent delivery.

OP09.10: Early postpartum uterine artery Doppler velocimetry among patients with severe pre-eclampsia compared to normotensive controls

Objectives: Uterine Doppler is used in screening for placentaassociated diseases, such as pre-eclampsia and intrauterine growth restriction of the fetus (IUGR). The aim of this study was to examine the predictive value of second trimester uterine Doppler in pregnancies complicated by systemic lupus eritematosus (SLE). Methods: Observational study on 55 pregnancies in women with SLE treated at our Unit from 2000 to 2008. The Doppler examination was performed between 23+0 and 25+6 weeks of gestation. The mean uterine artery pulsatility index (UtA PI) was calculated. Results: The median (interquartile range, IQR) UtA PI was 1.00 (0.90–1.20). Three patients had a mean uterine artery PI above the 95th centile for gestational age. All these patients developed pre-eclampsia and IUGR. No cases of pre-eclampsia or IUGR were observed in patients with the mean uterine artery PI below the 95th centile for gestational age. The sensitivity was 100% (95% CI 0.44–1.00), specificity was 100% (95% CI 0.93–1.00). Conclusions: In our series, the mean uterine artery PI was an excellent predictor for pre-eclampsia and IUGR in women with SLE.