Doron Kabiri

Outcomes of subsequent pregnancies after conservative treatment for placenta accreta

To estimate the association between conservative treatment for placenta accreta and subsequent pregnancy outcomes.

Timing of Delivery After External Cephalic Version and the Risk for Cesarean Delivery

OBJECTIVE: To estimate the association between time of delivery after external cephalic version at term and the risk for cesarean delivery. METHODS: This retrospective cohort study included all successful external cephalic versions performed in a tertiary center between January 1997 and January 2010. Stepwise logistic regression was used to calculate the odds ratio (OR) for cesarean delivery. RESULTS: We included 483 external cephalic versions in this study, representing 53.1% of all external cephalic version attempts. The incidence of cesarean delivery for 139 women (29%) who gave birth less than 96 hours from external cephalic version was 16.5%; for 344 women (71%) who gave birth greater than 96 hours from external cephalic version, the incidence of cesarean delivery was 7.8% (P=.004). The adjusted OR for cesarean delivery was 2.541 (95% confidence interval 1.36–4.72). When stratified by parity, the risk for cesarean delivery when delivery occurred less than 96 hours after external cephalic version was 2.97 and 2.28 for nulliparous and multiparous women, respectively. CONCLUSION: Delivery at less than 96 hours after successful external cephalic version was associated with an increased risk for cesarean delivery. LEVEL OF EVIDENCE: III

The indication for induction of labor impacts the risk of cesarean delivery

Abstract Objective: The risk of cesarean delivery following labor induction has been clearly established. While numerous factors are known to impact this risk, the indication for induction has rarely been examined as a risk factor. This study aimed to examine the relationship between indication for induction and ultimate mode of delivery after labor induction. Methods: A retrospective cohort study was conducted examining all cases of labor induction in a tertiary center university teaching hospital over a one-year period. The primary outcome measure was mode of delivery (vaginal delivery versus cesarean delivery) and its relationship to the indication for induction. Secondary outcome measures were: parity, maternal age, birth week, cervical maturity, use of epidural anesthesia, fetal birth weight and fetal sex. Results: Seven hundred and ninety-six women met inclusion criteria, of which 17.1% ultimately underwent cesarean delivery. Using multivariate analysis, fetal indications for induction (including intra-uterine growth restriction, oligohydramnios, placental abruption, macrosomia and post-term pregnancy) were found to significantly increase the risk of cesarean delivery in nulliparous women. The other significant factor was birth after week 40u2009+u20090. Conclusions: The indication for labor induction impacts the risk of cesarean delivery. Specifically, induction of labor for fetal indications significantly increases the risk of cesarean delivery in nulliparous women.

Induction of labor at term following external cephalic version in nulliparous women is associated with an increased risk of cesarean delivery

PurposeTo determine whether induction of labor (IOL) after successful external cephalic version (ECV) is associated with an increased risk of cesarean delivery (CD) compared with IOL with spontaneous cephalic presentation.MethodsRetrospective case–control study. All women having IOL after successful ECV were eligible. Each woman in the study group was matched for parity, age and indication for induction with two consecutive controls having IOL and spontaneous cephalic presentation. The primary outcome measure was CD. Secondary outcomes measures were operative vaginal delivery, perineal tear/episiotomy and post-partum hemorrhage.Results79 women enrolled in the study group were matched with 158 controls. The overall incidence of CD was significantly higher in the study group compared with the control group (20.3 vs. 10.1xa0%; OR 2.25, 95xa0% CI 1.06–4.79, Pxa0=xa00.03). After dividing the groups according to parity, the difference in the CD rate remained statistically significant for nulliparous women (36.7 vs. 15xa0%; OR 3.28, 95xa0% CI 1.17–9.16, Pxa0=xa00.02), but not for multiparous women (10.2 vs. 7.1xa0%; OR 1.48, 95xa0% CI 0.44–4.92, Pxa0=xa00.53). There was no significant difference in adjusted odds ratios for secondary outcomes.ConclusionInduction of labor after successful ECV in nulliparous women increased the risk of CD compared with IOL with spontaneous cephalic presentation.

Re-laparotomy following cesarean delivery - risk factors and outcomes.

Abstract Introduction: Re-laparotomy following caesarean delivery (CD) is a rare yet serious complication. The aim of this study was to identify risk factors, diagnostic features and outcomes following re-laparotomy. Materials and methods: This retrospective cohort study reviewed cases of re-laparotomy following CD performed at Hadassah-Hebrew University Medical Center. Occurrences were identified via the electronic medical record database. Results: During the study period, 17u2009213 women underwent CD, of which 55 (0.3%) underwent re-laparotomy during the same hospitalization. Main indications for re-laparotomy were intra-peritoneal bleeding (62%) and wound infection/dehiscence (22%). During re-laparotomy, the bleeding source was found and ligated in 85% of the cases. Age, parity, previous CD, induction of labor, anesthesia type and operative duration were significant risk factors for re-laparotomy. In a selected group of patients, trial of conservative treatment was made. However, in 76% of these women a re-laparotomy was required. Discussion: Risk factors for re-laparotomy following CD should be identified, thus enabling more intensified monitoring of patients considered at risk for this complication. When intra-peritoneal bleeding following CD is suspected, conservative management has a high failure rate and should be reserved for a selected group of stable patients.

Antepartum Membrane Stripping in GBS Carriers, Is It Safe? (The STRIP-G Study).

Objective Stripping of the membranes is an established and widely utilized obstetric procedure associated with higher spontaneous vaginal delivery rates, reduced need for formal induction of labor and a lower likelihood of post-term pregnancy. Due to the theoretical concern of bacterial seeding during the procedure many practitioners choose not to sweep the membranes in Group B Streptococcus (GBS) colonized patients. We conducted ‘the STRIP-G study’ in order to determine whether maternal and neonatal outcomes are affected by GBS carrier status in women undergoing membrane stripping. Study design We conducted a prospective study in a tertiary referral center, comparing maternal and neonatal outcomes following membrane stripping among GBS-positive, GBS-negative, and GBS-unknown patients. We compared the incidence of composite adverse neonatal outcomes (primary outcome) among the three study groups, while secondary outcome measure was composite adverse maternal outcomes. Results A total of 542 women were included in the study, of which 135 were GBS-positive, 361 GBS-negative, and 46 GBS-unknown status. Demographic, obstetric, and intra-partum characteristics were similar for all groups. Adverse neonatal outcomes were observed in 8 (5.9%), 31 (8.6%), and 2 (4.3%) in the GBS-positive, GBS-negative, and unknown groups, respectively (P = 0.530), (Odds Ratio between GBS-Positive vs. GBS-Negative groups 0.67 (95%, CI = 0.30–1.50)); while composite adverse maternal outcomes occurred in 9 (6.66%), 31 (8.59%), and 5 (10.87%) in the GBS-positive, GBS-negative, and unknown groups, respectively (P = 0.617). Conclusions Antepartum membrane stripping in GBS carriers appears to be a safe obstetrical procedure that does not adversely affect maternal or neonatal outcomes.

Preliminary evaluation of novel skin closure of Pfannenstiel incisions using cold helium plasma and chitosan films

Abstract Objective: To assess the safety and performance of a new energy-based skin closure system (BioWeld1TM) for the surgical Pfannenstiel incision in patients scheduled for elective cesarean section. Methods: This prospective, single center, non-randomized study included 20 patients who were scheduled for elective cesarean section. The BioWeld1 system was performed after suturing the internal layers of the cesarean section incision. A clinical evaluation of safety and efficacy was performed for 1, 2, 4–7, 21, and 45u2009d after the procedure. The Vancouver Scar Scale (VSS) was used to evaluate scarring. Results: Up to 21u2009d after the procedure, no safety device-related adverse events were reported. All patients had full closure of the epidermis, a very low total VSS score, and no evidence of discharge, redness, edema, or thermal damage. None of the patients exhibited more than a mild degree of encrustation. Conclusion: The BioWeld1 System has been shown to be safe and effective for skin closure in cesarean section.

Sonographic large fetal head circumference and risk of cesarean delivery

BACKGROUND: Persistently high rates of cesarean deliveries are cause for concern for physicians, patients, and health systems. Prelabor assessment might be refined by identifying factors that help predict an individual patients risk of cesarean delivery. Such factors may contribute to patient safety and satisfaction as well as health system planning and resource allocation. In an earlier study, neonatal head circumference was shown to be more strongly associated with delivery mode and other outcome measures than neonatal birthweight. OBJECTIVE: In the present study we aimed to evaluate the association of sonographically measured fetal head circumference measured within 1 week of delivery with delivery mode. STUDY DESIGN: This was a multicenter electronic medical record‐based study of birth outcomes of primiparous women with term (37‐42 weeks) singleton fetuses presenting for ultrasound with fetal biometry within 1 week of delivery. Fetal head circumference and estimated fetal weight were correlated with maternal background, obstetric, and neonatal outcome parameters. Elective cesarean deliveries were excluded. Multinomial regression analysis provided adjusted odds ratios for instrumental delivery and unplanned cesarean delivery when the fetal head circumference was ≥35 cm or estimated fetal weight ≥3900 g, while controlling for possible confounders. RESULTS: In all, 11,500 cases were collected; 906 elective cesarean deliveries were excluded. A fetal head circumference ≥35 cm increased the risk for unplanned cesarean delivery: 174 fetuses with fetal head circumference ≥35 cm (32%) were delivered by cesarean, vs 1712 (17%) when fetal head circumference <35 cm (odds ratio, 2.49; 95% confidence interval, 2.04–3.03). A fetal head circumference ≥35 cm increased the risk of instrumental delivery (odds ratio, 1.48; 95% confidence interval, 1.16–1.88), while estimated fetal weight ≥3900 g tended to reduce it (nonsignificant). Multinomial regression analysis showed that fetal head circumference ≥35 cm increased the risk of unplanned cesarean delivery by an adjusted odds ratio of 1.75 (95% confidence interval, 1.4–2.18) controlling for gestational age, fetal gender, and epidural anesthesia. The rate of prolonged second stage of labor was significantly increased when either the fetal head circumference was ≥35 cm or the estimated fetal weight ≥3900 g, from 22.7% in the total cohort to 31.0%. A fetal head circumference ≥35 cm was associated with a higher rate of 5‐minute Apgar score ≤7: 9 (1.7%) vs 63 (0.6%) of infants with fetal head circumference <35 cm (P = .01). The rate among fetuses with an estimated fetal weight ≥3900 g was not significantly increased. The rate of admission to the neonatal intensive care unit did not differ among the groups. CONCLUSION: Sonographic fetal head circumference ≥35 cm, measured within 1 week of delivery, is an independent risk factor for unplanned cesarean delivery but not instrumental delivery. Both fetal head circumference ≥35 cm and estimated fetal weight ≥3900 g significantly increased the risk of a prolonged second stage of labor. Fetal head circumference measurement in the last days before delivery may be an important adjunct to estimated fetal weight in labor management.

OC13.02: Fetal head circumference to predict delivery mode: a pilot study

Objectives: Fetal macrosomia is a perennial obstetric management problem. Macrosomia assessment is based mostly on clinically or sonographically EFW. We explored the impact of head circumference (HC) on obstetric outcomes including delivery mode and maternal and neonatal complications, as compared to birth weight, in order to improve the management of ‘‘big babies.’’ Methods: In several parallel cohort studies based on over 120,000 term singleton deliveries we analysed the association of HC with unplanned Caesarean delivery [UCD] and vacuum extraction (VE), failed vacuum, prolonged second stage of labour (PSSL), persistent occiput posterior (OP) position at delivery, levator ani avulsion, and neonatal outcomes including Apgar<7, umbilical artery pH≤7.1, and NICU admission. Results: When HC≥95th centile, the risks of PSSL, UCD, VE, failed vacuum, and neonatal complications, are significantly increased. Risk of levator ani avulsion is increased when HC≥90th centile. Results (OR and 95% CI) as compared with high birthweight are summarised in table 1. Conclusions: In several studies we have observed that large HC (≥90th or 95th centile) impacts on length of second stage, delivery mode, maternal pelvic floor trauma, and neonatal complications. OP position at delivery intensifies the effect of large HC. We propose that prelabour counselling and obstetric management take into account head circumference, along with other fetal and maternal parameters.

Higher Rates of Operative Delivery and Maternal and Neonatal Complications in Persistent Occiput Posterior Position with a Large Head Circumference: A Retrospective Cohort Study

Introduction: We investigated whether large head circumference (HC) combined with persistent occiput posterior (OP) position is associated with higher rates of operative delivery and obstetric and neonatal complications than OP deliveries without large HC or in occiput anterior (OA) position. Materials and Methods: Term singleton deliveries in our centers from January 2010 to December 2014, delivered in cephalic OA (n = 41,038) or OP position (n = 1,740), were assessed. We compared delivery modes, maternal and neonatal complications in OA versus OP deliveries, and HC ≥90th centile versus HC <90th centile in persistent OP position. Results: Persistent OP position combined with HC ≥90th centile was associated with higher rates of vacuum extraction and unplanned cesarean delivery than HC <90th centile in OP position (20.1 vs. 17.2%, OR 1.53 [95% CI 0.99-2.36], and 23.4 vs. 9.2%, OR 3.326 [95% CI 2.17-5.11], respectively). Rates of prolonged second stage of labor and neonatal intensive care unit admission were also increased compared to those in either OA position with HC ≥90th centile or OP position with HC <90th centile. Discussion: Large HC combined with OP position is associated with higher rates of operative delivery and prolonged second stage of labor compared to OP delivery with HC <90th centile. HC might be included with other measures to assess women in labor, as it is associated with fetal outcomes in OP deliveries.