Elad Mei-Dan

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 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.

Trans-cervical double balloon catheter with and without extra-amniotic saline infusion for cervical ripening: a prospective quasi-randomized trial

Abstract Objective: To compare the efficacy and safety of the trans-cervical double balloon catheter with and without extra-amniotic saline infusion (EASI) for cervical ripening. Methods: This is a secondary analysis of a prospective randomized study conducted between November 2007 and January 2011 evaluating different ripening methods. Women presenting for labor induction were assigned to receive the double balloon catheter with (study group) or without EASI (control group). Outcomes included time from device insertion to delivery, cesarean section rates, and adverse events. Results: One hundred and sixty women completed the study. Cesarean section rate (8.3% in study group, versus 20% in controls p = 0.07) and ripening success were comparable between the groups. Catheter insertion to delivery interval was significantly shorter and spontaneous catheter expulsion rate was significantly higher in the study group (14:19 hours versus 20:45 hours, p < 0.001, and 68.5% versus 51%, p = 0.04, respectively). Hospitalization length was significantly shorter in the study arm. There were no differences in other outcomes evaluated. A multivariable analysis found the EASI to be an independent predictor of a shorter insertion to delivery interval. Conclusions: The addition of EASI to the double balloon catheter for cervical ripening results in a shorter labor induction process without compromising its safety.

Spontaneous resolution of an umbilical cord arteriovenous fistula

Abstract An umbilical arteriovenous (AV) fistula is an extremely rare anomaly of the umbilical cord, with only one case being documented in the literature. The purpose of this report is to describe the prenatal sonographic characteristics of such a lesion and its potential complications. We report a case of an umbilical cord AV fistula detected at 24 weeks of gestation in one fetus of dichorionic-diamniotic twins. Color flow and spectral Doppler examinations showed a jet originating from one of the umbilical arteries entering the dilated umbilical vein. Serial ultrasounds revealed relative oligohydramnios and deep A waves in the ductus venosus for the affected twin. Upon performing fetal echocardiography assessment, mild cardiomegaly and dilatation of the inferior vena cava were detected. Chromosomal testing revealed a normal karyotype. The patient continued to be followed for close monitoring of fetal well-being and corticosteroids were administered. Cesarean section was planned for 28–30 weeks, but surprisingly, the oligohydramnios resolved, Doppler studies normalized, and no further intra-uterine growth restriction or fetal compromise was observed. Due to the recurrence of abnormal Doppler studies at 36 weeks of gestation, the patient was admitted for an induction of labor followed by a vaginal delivery of two healthy infants. Given the scarcity of reports regarding umbilical cord AV fistula, it is important to perform an extensive investigation of the affected fetus including karyotype and echocardiography. Furthermore, delivery timing should rely on close surveillance of fetal well-being to avoid the risk of fetal demise.