Daniel S. Seidman

Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: A population-based study

Objective. The study was aimed to identify obstetric risk factors for early postpartum hemorrhage (PPH) in singleton gestations and to evaluate pregnancy outcome. Study design. A comparison between consecutive singleton deliveries with and without early PPH was performed. Deliveries occurred during the years 1988–2002 in a tertiary medical center. A multivariate logistic regression model was constructed in order to define independent risk factors for PPH. Results. Postpartum hemorrhage complicated 0.4% (n = 666) of all deliveries enrolled in the study (n = 154 311). Significant risk factors for PPH, identified using a multivariable analysis, were: retained placenta (OR 3.5, 95%CI 2.1–5.8), failure to progress during the second stage of labor (OR 3.4, 95%CI 2.4–4.7), placenta accreta (OR 3.3, 95%CI 1.7–6.4), lacerations (OR 2.4, 95%CI 2.0–2.8), instrumental delivery (OR 2.3, 95%CI 1.6–3.4), large for gestational age (LGA) newborn (OR 1.9, 95%CI 1.6–2.4), hypertensive disorders (OR 1.7, 95%CI 1.2–2.1), induction of labor (OR 1.4, 95%CI 1.1–1.7) and augmentation of labor with oxytocin (OR 1.4, 95%CI 1.2–1.7). Women were assigned into three different groups according to the assessed severity of PPH, assuming that the severe cases were handled by revision of the birth canal under anesthesia, and the most severe cases required in addition treatment with blood products. A significant linear association was found between the severity of bleeding and the following factors: vacuum extraction, oxytocin augmentation, hypertensive disorders as well as perinatal mortality, uterine rupture, peripartum hysterectomy and uterine or internal iliac artery ligation (p < 0.001 for all variables). Conclusion. Hypertensive disorder, failure to progress during the second stage of labor, oxytocin augmentation, vacuum extraction and LGA were found to be major risk factors for severe PPH. Special attention should be given after birth to hypertensive patients, and to patients who underwent induction of labor or instrumental delivery, as well as to those delivering LGA newborns.

Urinary tract endometriosis treated by laparoscopy

OBJECTIVE To evaluate the efficacy of the laparoscopic approach for the diagnosis and treatment of severe urinary tract endometriosis. DESIGN Retrospective review of 28 cases of severe urinary tract endometriosis. SETTING Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(S) Between October 1989 and September 1994, we treated 28 women who had deeply infiltrating urinary tract endometriosis (bladder, 7, ureter, 21). INTERVENTION(S) All procedures were performed laparoscopically. MAIN OUTCOME MEASURE(S) Postoperative urinary function, pain relief, and complications. RESULT(S) Those who had vesical endometriosis underwent partial cystectomy and primary repair. Partial ureteral obstruction was found in 17 women; 10 underwent ureterolysis and excision of endometriosis, and 7 had partial wall resection. Four patients with ureter involvement had complete obstruction. Three underwent partial resection and ureteroureterostomy, and one had ureteroneocystostomy. The rate of ureteral endometriosis in the present series is higher than that reported previously. CONCLUSION(S) Severe infiltrative endometriosis of the bladder and the ureter can present without specific symptoms and can cause silent compromise of renal function. We demonstrated that the laparoscopic approach is safe and effective in the diagnosis and treatment of this entity.

Recurrence rate after laparoscopic myomectomy

STUDY OBJECTIVE To determine the recurrence rate of myomas after laparoscopic myomectomy. DESIGN Retrospective review (Canadian Task Force classification II-2). SETTING Tertiary referral center. PATIENTS One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo). INTERVENTION Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.

Effect of very advanced maternal age on pregnancy outcome and rate of cesarean delivery

Objective To determine outcomes of pregnancies in women at least 44 years of age and to determine factors predicting cesarean delivery in these patients. Methods Between January 1988 and December 1995, 109 women at least 44 years old delivered in our medical center. These women were matched to a group of 309 women 20–29 years of age. Multiple logistic regression analysis was used to evaluate the association between maternal age and outcome variables, controlling for possible confounding factors. Based on the logistic regression, a predictive model was calculated for cesarean delivery and validated prospectively in a separate group of 30 consecutive women at least 44 years old, who delivered during the first 8 months of 1996. Results Very advanced maternal age, compared with younger age, was associated with a significantly higher rate of medical complications (hypertensive disorder and diabetes) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5, 4.1; P < .001), instrument-assisted vaginal delivery (OR 7.5; 95% CI 2.2, 25.0; P < .004), and cesarean delivery (OR 7.3; 95% CI 2.2, 16.7; P < .001). The incidences of preterm labor, premature rupture of membranes, emergency cesarean delivery, meconium-stained amniotic fluid, small for gestational age newborns, and 5-minute Apgar scores of 7 or lower were not influenced by maternal age. The regression model showed an increased risk for cesarean delivery associated with age of at least 44 years (OR 7.3; 95% CI 2.2, 16.7), primiparity (OR 3.5; 95% CI 1.3, 9.8), infertility treatment (OR 3.6; 95% CI 1.5, 8.8), and egg donation (OR 19.5; 95% CI 6.1, 62.2), with positive and negative predictive values of 94 and 86%, respectively. Conclusion Maternal age of at least 44 years is associated with medical complications in pregnancy and more interventions during labor. However, overall pregnancy outcomes are favorable. Cesarean delivery can be predicted accurately based on maternal age, parity, and infertility treatment.

Heme oxygenase-1 induction may explain the antioxidant profile of aspirin

Aspirin is known to exert antioxidant effects by as yet unidentified mechanisms. In cultured endothelial cells derived from human umbilical vein, aspirin (30-300 microM) increased heme oxygenase-1 (HO-1) protein levels in a concentration-dependent fashion up to fivefold over basal levels. HO-1 induction was accompanied by a marked increase in catalytic activity of the enzyme as reflected by enhanced formation of both carbon monoxide and bilirubin. Pretreatment with aspirin or bilirubin at low micromolar concentrations protected endothelial cells from hydrogen peroxide-mediated toxicity. HO-1 induction and endothelial protection by aspirin were not mimicked by indomethacin, another inhibitor of cyclooxygenase. The nitric oxide (NO) synthase blocker L-NAME prevented aspirin-dependent HO-1 induction. These findings demonstrate that aspirin targets HO-1, presumably via NO-dependent pathways. Induction of HO-1 expression and activity may be a novel mechanism by which aspirin prevents cellular injury under inflammatory conditions and in cardiovascular disease.

Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy

OBJECTIVE To compare the outcome of pregnancy after operative laparoscopy or laparotomy for the management of adnexal pathology during pregnancy. DESIGN Retrospective comparative study. SETTING University tertiary care referral center for endoscopic surgery. PATIENT(S) Eighty-eight pregnant women who underwent 93 operations for suspected adnexal pathology at our institute. Laparoscopy was performed during the first trimester in 39 patients. The remaining 54 patients underwent laparotomy, 25 during the first trimester and 29 during the second trimester. INTERVENTION(S) Laparoscopy or laparotomy for the management of adnexal masses during pregnancy. MAIN OUTCOME MEASURE(S) Operative and postoperative maternal complications, miscarriage, congenital malformations, and newborn long-term outcome. RESULT(S) No operative or postoperative maternal complications occurred in the pregnant women who underwent laparoscopic surgery. In this group of 39 women, 5 women had a first-trimester miscarriage and 2 newborns had congenital malformations (hypospadias and cleft lip and palate). Two miscarriages occurred in the first-trimester laparotomy group, and 1 congenital malformation (transposition of the great vessels) was diagnosed in the second-trimester laparotomy group. CONCLUSION(S) Laparoscopic gynecologic surgery appears to be safe during pregnancy, although prospective controlled studies and national registries encompassing larger numbers of cases are needed.

BIRTH WEIGHT, CURRENT BODY WEIGHT, AND BLOOD PRESSURE IN LATE ADOLESCENCE

Objective--To study the effect of birth weight and body weight on blood pressure in late adolescence. Design--Analysis of data on weight, height, and blood pressure at age 17 of subjects from the Jerusalem perinatal study, according to their birth weight. Data for men and women were analysed separately. Setting--Jerusalem, Israel. Subjects--32,580 subjects (19,734 men and 12,846 women) born in the three major hospitals in Jerusalem during 1964-71 and subsequently drafted in to the army. MAIN OUTCOME MEASURES--Correlations between birth weight and blood pressure at age 17 and weight and height at age 17 and blood pressure. Results--Diastolic and systolic blood pressures were associated with birth weight in both young men and young women, but the correlation coefficients were low. A high body weight at age 17 (greater than 66 kg for women, greater than 75 kg for men) rather than a low birth weight (less than 2500 g) was linked with higher systolic and diastolic blood pressures in both men and women (p less than 0.01). Conclusions--Intrauterine environment, as reflected by birth weight, has little effect on blood pressure in young men and women. Modification of factors which lead to excess weight during adolescence may have a major role in preventing hypertension in adults.

The cognitive outcome of full-term small for gestational age infants at late adolescence

Objective To assess the cognitive and academic performance of adolescents who were born small for gestational age (SGA) at term. Methods A 17-year historical prospective study was done by matching neonatal data of 1758 infants to the results of the medical and intelligence assessment performed at age 17 years at the army draft board medical examination in Israel. The results of children born SGA (weight at term birth below the third percentile) were compared to those of children who were born appropriate for gestational age (AGA). Results After adjustment by a multiple linear regression analysis, the mean (± standard error of the mean) intelligence test scores were 103.1 ± 2.9 versus 105.8 ± 1.5 (P = 0.3) for the males and 100.3 ± 2.5 versus 104.7 ± 1.6 (P < .03) for the females. Males born SGA at term were found to have lower educational achievements (having less than 12 years of schooling or attending a vocational school) compared with the AGA group. The odds ratio for this finding after adjustment by a logistic regression analysis was 2.40 (95% confidence interval 1.07–5.39; P < .03). Intranatal events were not found to have an effect on the measured neurodevelopmental outcome. Conclusion Infants born SGA at term have an increased risk for lower cognitive performance and schooling achievements than those born AGA; this result seems to be unrelated to their intranatal course.

Is low birth weight a risk factor for asthma during adolescence

The effect of low birth weight on the incidence of asthma by 17 years of age was investigated by studying medical draft examination records of 20,312 male subjects born in Jerusalem between January 1967 and December 1971. Additional information on birth weight and other demographic factors was abstracted from the Jerusalem Perinatal Study computerised database. A stepwise multiple logistic regression was used to estimate the odds ratios for developing asthma by 17 years of age in 500 g birthweight categories from less than 2000 g to 4500 g. The odds ratios were adjusted for the confounding effects of ethnic origin, social class (determined by area of residence), paternal education, maternal age, and birth order. The group with low birth weights (less than 2500 g, n = 1004) had a significantly increased risk of developing asthma by 17 years of age, with an adjusted odds ratio of 1.44 (95% confidence interval (CI) 0.79 to 2.66) for birthweight group less than 2000 g and 1.49 (95% CI 1.05 to 2.12) for birthweight group 2000-2499 g compared with the reference group of 3000-3499 g. We conclude that infants with birth weights of less than 2500 g may have a higher risk of asthma during childhood and adolescence than infants who were heavier at birth.

Accuracy of mothers' recall of birthweight and gestational age

Summary. Information on the birthweight and gestational age of previous siblings is usually dependent upon maternal recall. This information is of importance in assessing the current risk of perinatal morbidity and mortality. The validity of maternal recall of birthweight and gestational age of 880 children born to 97 multiparas was examined by comparison with hospital records. About 75% of all reported birthweights were accurate to within 100 g and a similar proportion of reported gestational ages was correct to within 1 week. Recall was most accurate for most recent births as well as for earliest births and was not related to maternal age or education. There was a tendency for the smallness of low birthweight infants to be exaggerated by mothers. We conclude that within defined limitations, maternal recall of birthweight and gestational age of previous children is sufficiently accurate for clinical and even for epidemiological use.