Liran Hiersch

Usefulness of brachial artery flow-mediated dilation to predict long-term cardiovascular events in subjects without heart disease.

Endothelial dysfunction is considered an important prognostic factor in atherosclerosis. To determine the long-term association of brachial artery flow-mediated dilation (FMD) and adverse cardiovascular (CV) events in healthy subjects, we prospectively assessed brachial FMD in 618 consecutive healthy subjects with no apparent heart disease, 387 men (63%), and mean age 54 ± 11 years. After overnight fasting and discontinuation of all medications for ≥12 hours, FMD was assessed using high-resolution linear array ultrasound. Subjects were divided into 2 groups: FMD ≤11.3% (n = 309) and >11.3% (n = 309), where 11.3% is the median FMD, and were comparable regarding CV risk factors, lipoproteins, fasting glucose, C-reactive protein, concomitant medications, and Framingham 10-year risk score. In a mean clinical follow-up of 4.6 ± 1.8 years, the composite CV events (all-cause mortality, nonfatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting, and percutaneous coronary interventions) were significantly more common in subjects with FMD ≤11.3% rather than >11.3% (15.2% vs 1.2%, p = 0.0001, respectively). Univariate analysis demonstrated that the median FMD significantly predicted CV events (odds ratio 2.78, 95% CI 1.35 to 5.71, p <0.001). Multivariate analysis, controlling for traditional CV risk factors, demonstrated that median FMD was the best independent predictor of long-term CV adverse events (odds ratio 2.93, 95% CI 1.28 to 6.68, p <0.001). In conclusion, brachial artery median FMD independently predicts long-term adverse CV events in healthy subjects with no apparent heart disease in addition to those derived from traditional risk factor assessment.

Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy

OBJECTIVEnTo determine the effectiveness and safety of uterine artery methotrexate (MTX) infusion and embolization combined with systemic MTX for treatment of non-tubal ectopic pregnancy.nnnSTUDY DESIGNnWe retrospectively reviewed the electronic files of all women admitted to a single tertiary, university-affiliated medical center with a diagnosis of non-tubal (cervical, interstitial or cesarean section scar) ectopic pregnancy, who were treated by a combination of uterine artery MTX infusion and embolization and systemic MTX between January 2001 and March 2014. The treatment protocol included a total of 4 MTX injections in doses of 1 mg/kg/day every other day (days 1, 3, 5, 7 of the protocol) alternating with folinic acid 0.1 mg/kg (days 2, 4, 6, 8). The first or second MTX dose was administered by transcatheter intra-arterial injection during the embolization procedure just before injecting Gelfoam for bilateral uterine artery occlusion, and the remaining doses were given intramuscularly.nnnRESULTSnDuring the study period, 25 women underwent uterine artery infusion and embolization combined with systemic MTX treatment for non-tubal ectopic pregnancy. Ten of the pregnancies were cervical, 9 were interstitial, and 6 were cesarean scar pregnancies. Mean gestational age and beta-human chorionic gonadotropin (β-HCG) level at admission were 68.6±12.9 days and 14,179 (range 436-61596) IU/L, respectively. Treatment was successful in 24 patients (96%) with mean β-HCG resolution time of 52.6 (6-147) days. Mild immediate side effects were reported including 8 cases (32%) of abdominal discomfort, 3 cases (12%) of groin or leg pain and 3 cases (12%) of puncture-site local skin infection. No serious immediate side effects such as internal vascular bleeding, sepsis or early liver or renal failure were observed. Among 12 women who stated that they tried to conceive and were more than a year from the treatment, 10 (83.3%) had subsequent pregnancy.nnnCONCLUSIONnA combination of uterine artery MTX infusion and embolization with systemic MTX seems to be an effective and safe treatment for non-tubal ectopic pregnancies in women who try to conceive.

The impact of isolated single umbilical artery on labor and delivery outcome

Data regarding the association between isolated single umbilical artery (SUA) and pregnancy outcome are inconsistent and mainly address the risk of pregnancy complications. Thus, we aimed to focus on the association between isolated SUA, and labor and delivery.

The association between isolated oligohydramnios at term and pregnancy outcome

AbstractPurposenAs conflicting data exist concerning the implications of isolated oligohydramnios on pregnancy outcome at term, we aimed to assess this association in low-risk pregnancies.MethodsA retrospective cohort study of term pregnancies with sonographic finding of isolated oligohydramnios (amniotic fluid index (AFI) <5xa0cm) between 2007 and 2012. Outcome was compared to a control group of pregnancies with normal AFI (5–25xa0cm). Pregnancies complicated by thrombophilia, hypertension, diabetes, deviant fetal growth or chromosomal/structural abnormalities were excluded. Composite adverse outcome included CS/operative delivery due to non-reassuring heart rate (NRFHR), low Apgar score, umbilical artery pHxa0<xa07.10, neonatal intensive care admission, meconium aspiration syndrome, intubation or hypoxic-ischemic encephalopathy.ResultsOverall, 987 pregnancies complicated by isolated oligohydramnios were compared to 22,280 low-risk pregnancies with normal AFI. Isolated oligohydramnios was associated with a higher rate of induction of labor (27.7 vs. 3.7xa0%, pxa0<xa00.001), CS due to NRFHR (2.3 vs. 1.1xa0%, pxa0<xa00.01) and composite adverse outcome (9.7 vs. 7.1xa0%, pxa0<xa00.01). However, after adjusting for potential confounders as induction of labor and nulliparity using multivariable logistic regression analysis, isolated oligohydramnios was not found to be independently associated with increased risk for composite adverse outcome (OR 1.01, 95xa0% CI 0.80–1.27, pxa0=xa00.93).ConclusionIsolated oligohydramnios at term by itself is not associated with increased obstetrical morbidity.

Serial cervical length determination in twin pregnancies reveals 4 distinct patterns with prognostic significance for preterm birth

BACKGROUNDnWomen with a twin gestation are at increased risk for preterm birth (PTB), and sonographic cervical length (CL) is a powerful predictor for spontaneous PTB. Obstetricians frequently monitor CL in multiple gestations; yet, the optimal method to integrate and interpret the results of serial sonographic CL has not been determined.nnnOBJECTIVEnWe sought to determine whether there are different patterns of cervical shortening in twin gestations, and whether such patterns are related to the risk of PTB.nnnSTUDY DESIGNnWe conducted a retrospective study of all women with twins followed up in a single tertiary referral center during 2012 through 2014. All women underwent serial measurements of CL every 2-3 weeks starting from 14-18 weeks and until 28-32 weeks of gestation. Changes in CL were analyzed and classified into distinct patterns that were initially identified by visual inspection of all individual cases. Each pattern was then characterized by several parameters including information about when cervical shortening began, the rate of shortening, and whether a plateau was observed. Locally weighted regression mean profiles were generated to describe each pattern of CL over time. The association of these patterns with spontaneous PTB was determined. The specific characteristics of each pattern that further determined the risk of PTB were identified using multivariable logistic regression analysis.nnnRESULTSnWe studied 441 women who had a total of 2826 measurements of CL done. Overall, 4 main patterns of change in CL were identified: pattern I, stable cervix (nxa0= 196); pattern II, early and rapid shortening (nxa0= 18); pattern III, late shortening (nxa0= 109); and pattern IV, early shortening with a plateau (nxa0= 118). The rate of PTB at <34 weeks was lowest in cases of pattern I (11.7%), followed by pattern IV (14.4%) and pattern III (20.2%), and was highest for women with pattern II (44.4%) (P < .001). In cases with pattern III (late shortening), the most important factors affecting the risk of PTB were the shortening rate, the gestational age at the onset of cervical shortening, and the initial plateau of CL. In the case of pattern IV (early shortening with a plateau), it was only the new plateau at which cervical shortening stopped that was associated with the risk of PTB.nnnCONCLUSIONnChanges in sonographic CL over time in twin gestations can be classified into 4 patterns, each associated with a different risk of PTB.

Post-term pregnancy is an independent risk factor for neonatal morbidity even in low-risk singleton pregnancies

Objective To determine the independent association of post-term pregnancy with neonatal outcome in low-risk newborns. Design Retrospective cohort. Setting Tertiary university-affiliated medical centre. Patients All newborns of low-risk singleton pregnancies born at 39+0 to 44+0u2005weeks’ gestation over a 5-year period. Exclusion criteria: multiple gestation, maternal hypertensive disorder, diabetes or cholestasis, placental abruption or intrapartum fever (>38°C), small for gestational age (<10th centile) and major congenital or chromosomal anomalies. Interventions None. Outcome measures Admission to the neonatal intensive care unit (NICU), hospital length of stay, 5-min Apgar score, birth trauma, respiratory, neurological, metabolic and infectious morbidities and neonatal mortality. The adverse outcome rate was compared among three groups based on gestational age at birth: post-term (≥42+0u2005weeks), late term (41+0 to 41+6u2005weeks) and full term (39+0 to 40+6u2005weeks). Results Of the 23u2005524 eligible neonates, 747 (3.2%) were born post-term, 4632 (19.7%) late term and 18u2005145 (77.1%) full term. Women in the post-term group versus the late-term group had a significantly higher rate of caesarean section (8.9% vs 5.6%, p<0.001) and operative vaginal delivery (9.6% vs 7.4%, p=0.024). Post-term pregnancy versus full-term pregnancy was associated with an increased risk of NICU admission (OR 2.0, 95% CI 1.4 to 2.8), respiratory morbidity (OR 2.2, 95% CI 1.3 to 3.8) and infectious morbidity (OR 1.88, 95% CI 1.32 to 2.69). Post-term pregnancy versus late-term pregnancy was similarly associated with an increased risk of NICU admission (OR 2.0, 95% CI 1.4 to 2.9), respiratory morbidity (OR 2.7, 95% CI 1.5 to 5.0) and infectious morbidity (OR 1.8, 95% CI 1.2 to 2.7) and with hypoglycaemia (OR 2.6, 95% CI 1.2 to 5.4). Post-term delivery was not associated with neonatal mortality. Conclusions Post-term pregnancy is an independent risk factor for neonatal morbidity even in low-risk singleton pregnancies.

Structured hands-on workshop decreases the over-detection rate of obstetrical anal sphincter injuries.

PurposeThe purpose of this study was to assess the effect of a structured hands-on workshop on the detection rate of obstetric anal sphincter injuries.MethodsAll physicians attending the delivery ward in our institution participated in a structured obstetric anal sphincter injury hands-on workshop developed by Dr. Ranee Thakar and Dr. Abdul Sultan which demonstrated proper identification and techniques for obstetric anal sphincter injury detection and repair. We retrospectively reviewed the electronic records of all singleton-pregnancy women who delivered vaginally (vertex presentation) during the 2xa0years prior to and 1xa0year following the workshop to assess the workshop’s effect on the rate of detection of obstetric anal sphincter injuries.ResultsOverall, 20,484 women met the inclusion criteria during the study period and were eligible for final analysis. There were no significant differences in patient’s characteristics between the groups. Women in the pre-workshop group had a higher rate of obstetric anal sphincter injuries than the post-workshop group (0.4 vs. 0.2xa0%, pu2009=u20090.005). On multivariate analysis, factors independently associated with a decreased risk for obstetric anal sphincter injuries were deliveries in the post-workshop period (odds ratio 0.43, 95xa0% confidence interval 0.24–0.79, pu2009=u20090.006), parity (odds ratio 0.37, 95xa0% confidence interval 0.25–0.54, pu2009<u20090.001), and spontaneous vaginal delivery (odds ratio 0.43, 95xa0% confidence interval 0.26–0.71, pu2009=u20090.001).ConclusionsA proper detection of obstetric anal sphincter injuries may depend on the experience of the assessor. A structured hands-on workshop is important to avoid over diagnosis third-degree perineal tears.

Management of diabetes and pregnancy – When to start and what pharmacological agent to choose?

Gestational diabetes mellitus (GDM) complicates 3-15% of pregnancies depending upon the geographic location and ethnic groups, and its incidence is estimated to increase even further due to the increasing rates of obesity in the general population and the trend towards advanced maternal age in pregnancy. GDM is associated with adverse pregnancy outcome such as an increased rate of fetal macrosomia, neonatal metabolic disturbances, and maternal injuries. It has been shown that there is an inverse relation between maternal glycemic control and the risk of complications. When diet and exercise therapy fail in achieving good glycemic control, pharmacological intervention is warranted. This chapter deals with the evidence regarding the various pharmacological interventions for glycemic control in women with GDM, when to start, and what pharmacological agent to use.

Effectiveness of medical treatment with methotrexate for interstitial pregnancy

In the last three decades, systemic methotrexate (MTX) has become widely accepted as the primary treatment for unruptured tubal pregnancy. This has prompted investigations into the use of MTX in the management of interstitial pregnancy.

Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth

AIMnTo assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering at the late preterm period.nnnMETHODSnRetrospective observational cohort of all women with GDM who delivered a singleton fetus at the late preterm birth period (34+0/7 to 36+6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.nnnRESULTSn1849 women were included in the study, of whom 132 (7.1%) were diagnosed with GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal delivery (45.5% vs. 62.9%, p<0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%, p<0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24-2.66, p=0.002). Neonates of mothers with GDM had significant higher mean birth weight and birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity.nnnCONCLUSIONnaccording to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications.