Doron Dukler

Elevated concentrations of interleukin-6 in intra-amniotic infection with Ureaplasma urealyticum in asymptomatic women during

BACKGROUNDnIntra-amniotic infection is an important cause of preterm delivery and interleukin-6 (IL-6) determination was recently applied for identification of microbial invasion of the amniotic cavity. Our aim was to determine the levels of IL-6 in culture-positive amniotic fluids at genetic amniocentesis and to evaluate their significance in relation to pregnancy outcome.nnnMETHODSnSeven culture-positive and 23 culture-negative amniotic fluids, obtained at 17-19 weeks of gestation, were analyzed for IL-6 levels by an immunoassay (ELISA). Pregnancy outcomes of all 30 women were obtained from the medical charts.nnnRESULTSnThe mean level of IL-6 in the culture-negative amniotic fluids was 78+/-206 pg/ml. Among the seven culture-positive, high levels of IL-6 were found only in three amniotic fluids that were culture-positive for Ureaplasma urealyticum (1834, 1342 and 2832 pg/ml). Low levels of IL-6, ranging from zero to 60 pg/ml, were found in four AFs that were culture-positive for Staphylococcus epidermidis (n=3) and Bacillus Gram-positive (n= 1). Adverse pregnancy outcome occurred in the three women who had intra-amniotic infection with U. urealyticum accompanied by high levels of IL-6 (two fetal loss and one preterm delivery at 28 weeks of gestation). The four women with culture-positive but IL-6 negative amniotic fluids, had normal pregnancy outcome and term delivery. Two of the 23 women with culture-negative had preterm delivery, one with high (1000 pg/ml) and one with low (80 pg/ml) levels of IL-6.nnnCONCLUSIONnHigh levels of IL-6 are suggestive of a genuine intra-amniotic infection with urea-plasmas resulting in adverse pregnancy outcome, while culture-positive amniotic fluids with normal IL-6 levels, may suggest a state of contamination.

Remote prognosis of primiparous women with preeclampsia

OBJECTIVEnTo describe the maternal characteristics of pregnancy and perinatal outcome of primiparous women with preeclampsia, to determine the recurrence rate and to define the maternal risk factors for preeclampsia in subsequent pregnancies.nnnMETHODSnA retrospective cohort study. Two groups of patients were defined: the study group consisted of 380 primiparous women with preeclampsia, and in a control group of 385 primiparous women without preeclampsia. The patients were followed during their consecutive deliveries. Multiple logistic regression analysis was used to determine the independent risk factors for the recurrence of preeclampsia in the second pregnancy.nnnRESULTSnIn the study and the control group there were a total of 1207 and 1293 deliveries, respectively. Of the 380 primiparous women in study group, 305 (80%) were identified as suffering from mild preeclampsia, 64 (17%) from severe preeclampsia, 10 (2.6%) from super imposed preeclampsia and only one (0.3%) had eclampsia. Primiparous with severe preeclampsia had a significantly higher rate of preterm delivery then those with mild preeclampsia (34 versus 11% respectively, P<0.0001). In addition, the study group had significantly higher rate of perinatal mortality (3.4 versus 0.3%, P=0.013) and perinatal complications. The recurrence rate of preeclampsia was significantly higher in the study group (25% versus 1.9%, P<0.0001). When adjusted for confounding variables, gestational diabetes was strongly associated with the recurrence of preeclampsia in the second pregnancy (OR 3.72 95% CI 1.45-9.53).nnnCONCLUSIONnPrimiparous women with preeclampsia are at an increased risk for recurrence in subsequent pregnancies. Gestational diabetes in primiparous women with preeclampsia is an independent risk factor for developing preeclampsia in the second pregnancy.

Preeclampsia in twin gestations: Association with IVF treatments, parity and maternal age

Objective.u2003To identify maternal factors that increase the risk of preeclampsia in twin gestations and to investigate whether twins conceived by in vitro fertilization (IVF) lead to an increased risk of preeclampsia development. Materials and methods.u2003A retrospective population-based cohort study of twin deliveries was performed. Maternal characteristics and perinatal outcomes were evaluated. Patients data were obtained from a computerized database and analyzed using SPSS statistical package. Results.u2003During the study period there were 2628 twin deliveries, and of these 3.1% had severe preeclampsia and 6.16% mild preeclampsia. Patients with severe preeclampsia were more likely to be primiparous, and to have significantly higher frequency of chronic hypertension, gestational diabetes mellitus (GDM), IVF treatments, cesarean delivery, preterm delivery and twin discordancy than in the normotensive patients. Chronic hypertension, pirimiparity, twin discordancy and maternal age were independent risk factors for the development of preeclampsia. In a multivariate regression model including IVF treatment, parity and maternal age as risk factors for preeclampsia, women younger than 35 years that conceived following IVF treatments had an independent risk factor for the development of preeclampsia. Conclusion.u2003IVF treatments in primiparous patients and age younger than 35 years are independent risk factors for preeclampsia. Twin discordancy is an additional independent risk factor for the occurrence of preeclampsia.

DIC Score in Pregnant Women – A Population Based Modification of the International Society on Thrombosis and Hemostasis Score

Objectives The objectives of this study were: 1) To determine the component needed to generate a validated DIC score during pregnancy. 2) To validate such scoring system in the identification of patients with clinical diagnosis of DIC. Material and Methods This is a population based retrospective study, including all women who gave birth at the ‘Soroka University Medical Center’ during the study period, and have had blood coagulation tests including complete blood cell count, prothrombin time (PT)(seconds), partial thromboplastin time (aPTT), fibrinogen, and D-dimers. Nomograms for pregnancy were established, and DIC score was constructed based on ROC curve analyses. Results 1) maternal plasma fibrinogen concentrations increased during pregnancy; 2) maternal platelet count decreased gradually during gestation; 3) the PT and PTT values did not change with advancing gestation; 4) PT difference had an area under the curve (AUC) of 0.96 (p<0.001), and a PT difference ≥1.55 had an 87% sensitivity and 90% specificity for the diagnosis of DIC; 5) the platelet count had an AUC of 0.87 (p<0.001), an 86% sensitivity and 71% specificity for the diagnosis of DIC; 6) fibrinogen concentrations had an AUC of 0.95 (p<0.001) and a cutoff point ≤3.9 g/L had a sensitivity of 87% and a specificity of 92% for the development of DIC; and 7) The pregnancy adjusted DIC score had an AUC of 0.975 (p<0.001) and at a cutoff point of ≥26 had a sensitivity of 88%, a specificity of 96%, a LR(+) of 22 and a LR(−) of 0.125 for the diagnosis of DIC. Conclusion We could establish a sensitive and specific pregnancy adjusted DIC score. The positive likelihood ratio of this score suggests that a patient with a score of ≥26 has a high probability to have DIC.

Primiparity, assisted reproduction, and preterm birth in twin pregnancies: a population based study

ObjectiveTo determine the prevalence of pregnancy complications among primiparous patients with twin gestation in our population and to investigate the association between the increased rates of assisted reproduction (ART) in twin gestation and preterm birth (PTD).Material and methodsA retrospective population based cohort study was designed, including all twin deliveries after 24xa0weeks gestation (nxa0=xa02,601). The study group included 666 primiparous women and the comparison group 1,935 multiparous women. Maternal characteristics and perinatal outcome were evaluated. Women with fetal malformations were excluded. A multiple logistic regressions analysis for independent risk factors was performed including factors that were significantly different between the study groups in the univariate analysis. Patient’s data were obtained from computerized database and analyzed using SPSS statistical package.ResultsPrimiparous women had a significantly higher rate of preeclampsia, chronic hypertension, ART, prelabor rupture of membranes (PROM) preterm deliveries (PTD), labor dystocia, cesarean section (CS) and vacuum extraction of the first twin than the multiparous group. Primiparous patients had a significantly lower gestational age at delivery and neonatal birth weight of the first and second twin. In multiple logistic regressions analysis primiparity and ART were independent risk factors for PTD, (OR 1.45, 95% CI 1.18–1.78; OR 1.36, 95% CI 1.09–1.71, respectively).Conclusions(1) Primiparous patients with twin gestation represent a unique population with high rate of infertility and underlying diseases such as chronic hypertension in comparison to the multiparous women with twin gestation; (2) primiparity is an independent risk factor for prematurity in twin gestations; and (3) although primiparous women had an increased maternal complications, neonatal mortality rates were not significantly different from multiparous women.

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 (nu2009=u2009551) comprised the study group, while the rest of the deliveries (nu2009=u2009239u2009089) 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 (pu2009<u20090.001), recurrent abortions (pu2009=u20090.03), and previous placenta accreta [pu2009<u20090.001]. 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 37u2009weeks of gestation was more common among women with placenta accreta (pu2009<u20090.01), as was the rate of perinatal mortality (pu2009<u20090.001). Placenta accreta was an independent risk factor for perinatal mortality (adj. OR 8.2; 95% CI 6.4–10.4, pu2009<u20090.001) and late PTB (adj. OR 1.4; 95% CI 1.1–1.7, pu2009=u20090.002). Conclusion: Placenta accreta is an independent risk factor for late PTB and perinatal mortality.

Remote prognosis after primary cesarean delivery: the association of VBACs and recurrent cesarean deliveries with maternal morbidity

Purpose To determine the effects of vaginal birth after cesarean (VBAC) versus repeated cesarean sections (RCS) after a primary cesarean section (CS), on the rate of intraoperative and postpartum maternal morbidity. Patients and methods This is a retrospective population-based cohort study. During the study period (1988–2005) there were 200,012 deliveries by 76,985 women at our medical center; 16,365 of them had a primary CS, of which 7429 women delivered a singleton infant after the primary CS, met the inclusion criteria, were included in our study, and were followed for four consecutive deliveries. Patients were divided into three study groups according to the outcome of their consecutive delivery after the primary CS: VBAC (n = 3622), elective CS (n = 1910), or an urgent CS (n = 1897). Survival analysis models were used to investigate the effect of the urgency of CS and the numbers of pregnancy predating the primary CS on peripartum complications. Results Women who failed a trial of labor had a higher rate of uterine rupture than those who had a VBAC. Patients who delivered by CS had a higher rate of endometritis than those giving birth vaginally. The rate of cesarean hysterectomy and transfer to other departments increased significantly at the fourth consecutive surgery (P = 0.02 and P = 0.003, respectively). VBAC was associated with a 55% reduction in the risk of intrapartum complications in comparison to a planned CS (hazard ratio [HR] 0.45; 95% confidence interval [CI]: 0.22–0.89. A greater maternal parity at the time of primary CS was associated with lower intrapartum and postpartum morbidities (HR 0.44; 95% CI: 0.24–0.79; HR 0.54; 95% CI: 0.47–0.62, respectively). Conclusions (1) A successful VBAC is associated with a reduction in the intrapartum complications; and (2) maternal morbidity increases substantially from the fourth consecutive cesarean delivery.

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

OBJECTIVEnThe 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.nnnSTUDY DESIGNnA 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).nnnRESULTSn(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.nnnCONCLUSIONnA 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.

Hydramnios and small for gestational age are independent risk factors for neonatal mortality and maternal morbidity

ObjectiveThe objective was to evaluate the contribution of hydramnios and small for gestational age (SGA) as a combined pathology to maternal and neonatal morbidity and mortality.MethodsThe study population consisted of 192 SGA neonates with hydramnios, 5,515 SGA neonates with a normal amount of amniotic fluids, 3,714 appropriate for gestational age (AGA) neonates with polyhydramnios and 83,763 AGA neonates with a normal amount of amniotic fluid. A cross-sectional population based study was designed between the four study groups. Multiple logistic regression analysis was used to assess the contribution of these abnormalities and different risk factors to maternal and perinatal complications.ResultsThe combination of hydramnios/SGA was found to be an independent risk factor for perinatal mortality (OR 20.55; CI 12.6–33.4). Congenital anomalies, prolapse of cord, hydramnios, SGA and grand multiparity were also independent risk factors for perinatal mortality. Independent risk factors for neonatal complications were prolapse of umbilical cord (OR 4.13; 95% CI 1.48–11.5), hydramnios/SGA (OR 2.72; 95% CI 1.81–4.07), chronic hypertension (OR 2.45; 95% CI 1.02–5.9), congenital malformations (OR 1.93; 95% CI 1.14–3.24) and SGA (OR 1.47; 95% CI 1.07–2). Significant independent risk factors for medical interventions during labor were fetal distress (OR 198.46; 95% CI 47.27–825.27), GDM Class B–R (OR 21.22; 95% CI 2.34–192.25), GDM class A (OR 4.64; 95% CI 2.62–8.21), severe pregnancy-induced hypertension (PIH; OR 7.74; 95% CI 2.35–25.42), hydramnios (OR 1.95; 95% CI 1.3–2.91), hydramnios/SGA (OR 1.84; 95% CI 1.12–3.02) and malpresentation (OR 1.56; 95% CI 1.32–1.84).ConclusionThe combination of hydramnios and SGA is an independent risk factor for perinatal mortality and maternal complications. We suggest that the growth restriction of these fetuses is responsible for the neonatal complications, while the hydramnios contributes mainly to maternal complications.

Can we find the perfect oil to protect the perineum? A randomized-controlled double-blind trial.

Abstract Objective: To determine whether perineal massage during the second stage of labor using oil enriched with vitamins, increases the chances of delivering with an intact perineum as compared to perineal massage using pure liquid wax. Method: A prospective, randomized, double-blind study was conducted. Women were assigned to liquid wax (jojoba oil) versus purified formula of almond and olive oil, enriched with vitamin B1, B2, B6, E and fatty acids. The caregivers used the oils during the second stage of labor. Results: A total of 164 women undergoing vaginal delivery were recruited. No significant differences regarding perineal lacerations, number of sutures and length of suturing were noted between the two groups. Likewise, while analyzing separately nulliparous and multiparous women, no significant differences were noted. Controlling for birth weight >4000u2009g, using the Mantel–Haenszel technique, no association was noted between perineal lacerations and the type of oil used (weighted ORu2009=u20090.9, 95% CI 0.3–2.4; pu2009=u20090.818). Conclusion: The type of the oil used during the second stage of labor for prevention of perineal tears has no effect on the integrity of the perineum. Accordingly, it seems that there is no perfect oil.