Gali Garmi

Epidemiology, Etiology, Diagnosis, and Management of Placenta Accreta

Placenta accreta is a severe pregnancy complication and is currently the most common indication for peripartum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Main risk factor for placenta accreta is a previous cesarean delivery particularly when accompanied with a coexisting placenta previa. Antenatal diagnosis seems to be a key factor in optimizing maternal outcome. Diagnosis can be achieved by ultrasound in the majority of cases. Women with placenta accreta are usually delivered by a cesarean section. In order to avoid an emergency cesarean and to minimize complications of prematurity it is acceptable to schedule cesarean at 34 to 35 weeks. A multidisciplinary team approach and delivery at a center with adequate resources, including those for massive transfusion are both essential to reduce neonatal and maternal morbidity and mortality. The optimal management after delivery of the neonate is vague since randomized controlled trials and large cohort studies are lacking. Cesarean hysterectomy is probably the preferable treatment. In carefully selected cases, when fertility is desired, conservative management may be considered with caution. The current review discusses the epidemiology, predisposing factors, pathogenesis, diagnostic methods, clinical implications and management options of this condition.

Single-balloon compared with double-balloon catheters for induction of labor: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of a single-balloon catheter compared with a double-balloon catheter among women with unfavorable cervices undergoing induction of labor. METHODS: This prospective randomized study was conducted at a university teaching medical center between June 2008 and December 2010. Pregnant women admitted for induction of labor with a live singleton gestation in cephalic presentation with intact membranes and a Bishop score of 6 or less were randomly assigned for cervical ripening by a single-balloon catheter or a double-balloon catheter. The primary outcome was the length of time from catheter insertion until delivery. The secondary outcome was mode of delivery. RESULTS: Of 368 eligible women screened during the study period, 293 were included in the final analysis; 145 were randomly assigned to receive a single-balloon catheter and 148 received a double-balloon catheter. Demographic and obstetric parameters were comparable between the two groups. Length of time from catheter insertion until delivery was 19.4 (±6.0) and 19.1 (±6.8) hours among the single-balloon and the double-balloon catheter groups, respectively (P=.80). Length of time did not differ when primiparous women were analyzed separately. Incidence of cesarean delivery was 10.3% and 17.6% among the single-balloon and double-balloon catheter groups, respectively (P=.09). The incidence of either vacuum deliveries or cesarean deliveries was significantly lower among the single-balloon group (14.4%) compared with the double-balloon catheter group (25.7%; odds ratio 0.49, 95% confidence interval 0.26–0.92; P=.02). CONCLUSION: Both the single-balloon and double-balloon catheters are equally efficacious for inducing labor. The double-balloon catheter may be associated with more operative deliveries. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00690040. LEVEL OF EVIDENCE: I

Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial.

OBJECTIVE: To examine the effect of prophylactic balloon catheters on bleeding morbidity among women with a prenatal diagnosis of placenta accreta. METHODS: In a randomized trial, women with a prenatal diagnosis of placenta accreta were randomized to either preoperative prophylactic balloon catheters (intervention group) or to a control group. Other than placement of the prophylactic balloon catheters in the anterior division of the internal iliac arteries, the same multidisciplinary approach was used in both groups. The primary study outcome was the number of packed red blood cell (RBC) units transfused. To detect a mean reduction of three packed RBC units with the prophylactic balloon catheters, 12 women in each group were needed. RESULTS: Between January 2009 and March 2015, 27 women were randomized: 13 in the intervention group and 14 in the control group. Demographic and obstetric characteristics were similar between the groups. Six (46.2%) women in the intervention and seven (50.0%) in the control group underwent cesarean hysterectomy (P=.84). There were no significant differences between the intervention and control groups in the mean number of packed RBC units transfused, 5.2 (±6.2) and 4.1 (±3.8), respectively (P=.90), or in the calculated blood loss, 4,950 (±5,051) and 4,709 (±3,434) mL (P=.72). The number of women with blood loss greater than 2,500 mL, number of plasma products transfused, duration of surgery, peripartum complications, and hospitalization length did not differ significantly between the groups. Reversible adverse effects related probably to prophylactic balloon catheter insertion were noted in 2 of 13 (15.4%) women. CONCLUSION: In women with preoperative suspicion of placenta accreta, preoperative placement of prophylactic balloon catheters did not affect the number of packed RBC units transfused. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01373255. LEVEL OF EVIDENCE: I

The effects of decidual injury on the invasion potential of trophoblastic cells.

OBJECTIVE: To investigate the effect of a decidual incision on trophoblastic invasion potential in vitro. METHODS: Human trophoblast cells were obtained from first-trimester legal terminations of pregnancy. Decidual tissue was retrieved from healthy, low-risk women who underwent an elective cesarean delivery at term. Each dissected decidual sample was divided into four similar-sized samples. The first slice was not treated, the second was incised with a surgical blade to mimic an in vivo injury, the third was incised and immediately repaired with medical adhesive material. This model was used to investigate trophoblastic invasion through a fully repaired decidua. The fourth slice was covered with medical adhesive material only, to exclude any effect of the adhesive material on the decidua. The percent of invasion was calculated as: absorbance of invaded cell×100=invasion index (%). Invasion was expressed as invasion index. The mean and standard deviation of the invasion index were then calculated. RESULTS: Eight decidual samples were retrieved from eight women. Incised decidua showed a significantly higher mean invasion index (83.3% [±8.1%], P=.012) than the other three models (intact decidua, 69.9% [±5.1%]; incised decidua repaired with adhesive, 66.6% [±8.2%]; intact decidua with adhesive, 58.3% [±11.3%]. There was no significant difference in the invasion index between the other models (P=.4). CONCLUSION: Induced decidual injury significantly increased the invasion potential of trophoblastic cells compared with intact decidua. Complete re-approximation of the incised edges reversed this effect in vitro.

Comparison between amniotomy, oxytocin or both for augmentation of labor in prolonged latent phase: a randomized controlled trial

BackgroundA prolonged latent phase is independently associated with an increased incidence of subsequent labor abnormalities. We aimed to compare between oxytocin augmentation, amniotomy and a combination of both on the duration of labor among women with a prolonged latent phase.MethodsWomen with a singleton fetus in cephalic presentation who have a prolonged latent phase, were randomly allocated to amniotomy (group 1), oxytocin (group 2) or both (group 3). A group of women who progressed spontaneously without intervention composed the control group (group 4). The primary outcome was the duration of time from initiation of augmentation until delivery.ResultsA total of 213 women were consented and randomized to group 1 (70 women), group 2 (72 women) and group 3 (71 women). Group 4 was composed from additional 70 women. A mean reduction of 120 minutes in labor duration was observed among group 3 compared to group 1 (p = 0.08) and 180 minutes compared to group 2 and 4 (p = 0.001). Women in group 3 had a shorter length of time from augmentation until the beginning of the active phase and a shorter first stage of labor than group 1 (p = 0.03), group 2 (p = 0.001) and group 4 (p = 0.001). Satisfaction was greater among group 3 and 4. Mode of delivery and neonatal outcome were comparable between the groups.ConclusionLabor augmentation by combined amniotomy and oxytocin among women with a prolonged latent phase at term seems superior compared to either of them alone.

Nifedipine compared with atosiban for treating preterm labor: a randomized controlled trial.

OBJECTIVE: To compare the tocolytic efficacy and tolerability of nifedipine with that of atosiban among pregnant women with preterm labor. METHODS: Pregnant women admitted with preterm labor and intact membranes between 24 and 33 weeks 6 days of gestation, between January 2008 and December 2011, were randomly assigned to either atosiban or nifedipine treatment. Assigned treatment was planned for up to 48 hours. If progress was determined after 1 hour or more, a crossover of the study drugs was performed. The primary outcome was to estimate the tocolytic efficacy and tolerability profile that was assessed in terms of the proportion of women who were not delivered and did not require an alternate tocolytic agent within 48 hours. Secondary outcomes were gestational age at delivery and neonatal morbidity. RESULTS: Seventy-five women in the nifedipine group and 70 in the atosiban group were included and analyzed. Baseline demographic and obstetric characteristics were comparable. Forty-eight (68.6%) women allocated to atosiban and 39 (52%) to nifedipine did not deliver and did not require an alternate agent at 48 hours respectively (P=.03). At 7 days from enrollment, 55 (78.6%) women allocated to atosiban and 67 (89.3%) to nifedipine remained undelivered with or without a rescue agent (P=.02). Mean gestational age at delivery was 35.2 (±3.0) and 36.4 (±2.8) weeks among the atosiban and nifedipine groups, respectively (P=.01). Mean birth weight and neonatal morbidity were comparable. CONCLUSIONS: Atosiban has fewer failures within 48 hours. Nifedipine may be associated with a longer postponement of delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00599898. LEVEL OF EVIDENCE: I

Postcesarean wound infection: prevalence, impact, prevention, and management challenges

Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.

Comparison of intrapartum outcome among immigrant women from Ethiopia and the general obstetric population in Israel

To compare intrapartum outcome between ethnic Ethiopian women and the general obstetric population in Israel.

Are there modifiable risk factors that may predict the occurrence of brachial plexus injury

Objective:To identify risk factors, particularly modifiable, associated with brachial plexus injury.Study Design:A retrospective case–control study conducted at a single hospital between the years 1993 and 2012. All neonates who were diagnosed of brachial plexus injury were included. A control group matched at a ratio of 1:2 was randomly selected. Demographic and obstetric data were obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. All medical files were manually checked and validated. A stepwise logistic regression model was performed to identify independent predictors for brachial plexus injury before delivery among those found significant in the univariate analysis.Results:Of all 83 806 deliveries that took place during this period, 144 cases of brachial plexus injury were identified (1.7/1000 deliveries). Overall, 142 cases and 286 controls had available data. Among the study group, 41 (28.9%) had documented shoulder dystocia compared with 1 (0.4%) among the controls (P<0.0001). Logistic regression analysis revealed that maternal age above 35 years (P=0.01; odds ratio (OR) 2.7; 95% confidence interval (CI) 1.3 to 5.7), estimated fetal weight before delivery (P<0.0001; OR 2.5; 95% CI 1.7 to 3.8, for each 500 g increase), vaginal birth after cesarean (P=0.02; OR 3.3; 95% CI 1.2 to 8.8) and vacuum extraction (P=0.02; OR 3.6; 95% CI 1.2 to 10.3) were all found to be independent predictors for developing brachial plexus injury. When stratifying the analysis according to parity, vacuum delivery was found to be an independent risk factor only among primiparous women (OR 6.0; 95% CI 1.7 to 21.6).Conclusions:The findings suggest that very few factors contributing to brachial plexus injury are modifiable. For that reason, it remains an unpredictable and probably an unavoidable event.

Correlation between Clinical, Placental Histology and Microbiological Findings in Spontaneous Preterm Births

Aims: To examine the occurrence of chorioamnionitis and abruption among women who had a spontaneous preterm birth (SPTB), the correlation between clinical and placental findings, and the impact of these complications on neonatal outcome after delivery. Methods: This was a retrospective case-control study conducted between 2008 and 2012 at a single teaching hospital. The study group included all women who had an SPTB (23-36 weeks). Placentas were cultured and underwent histological examination. Results: A total of 478 women were included. The mean gestational age at delivery was 32.6 ± 3.1 weeks. Overall, 260 (54.4%) women had either clinical and/or histological abruption or chorioamnionitis. Clinical chorioamnionitis was diagnosed before birth in 14 (2.9%) women, while histological chorioamnionitis (HCA) in 84 (17.4%). Overall, 38 neonates had infection. Placental cultures were negative in 65.8% (25/38) of these neonates, and in 77.1% (27/38), HCA was ruled out. Logistic regression analysis revealed that neonatal morbidity and mortality were correlated with gestational age at delivery (p = 0.02), not with placental pathology (p = 0.08). Conclusions: Half of the women with PTB had clinical or histological abruption, chorioamnionitis or both. A partial correlation was found between clinical and placental findings. The main determinant of neonatal outcome was gestational age at delivery and not placental findings.