Mordechai Dulitzki

Effect of very advanced maternal age on pregnancy outcome and rate of cesarean delivery

Objective To determine outcomes of pregnancies in women at least 44 years of age and to determine factors predicting cesarean delivery in these patients. Methods Between January 1988 and December 1995, 109 women at least 44 years old delivered in our medical center. These women were matched to a group of 309 women 20–29 years of age. Multiple logistic regression analysis was used to evaluate the association between maternal age and outcome variables, controlling for possible confounding factors. Based on the logistic regression, a predictive model was calculated for cesarean delivery and validated prospectively in a separate group of 30 consecutive women at least 44 years old, who delivered during the first 8 months of 1996. Results Very advanced maternal age, compared with younger age, was associated with a significantly higher rate of medical complications (hypertensive disorder and diabetes) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5, 4.1; P < .001), instrument-assisted vaginal delivery (OR 7.5; 95% CI 2.2, 25.0; P < .004), and cesarean delivery (OR 7.3; 95% CI 2.2, 16.7; P < .001). The incidences of preterm labor, premature rupture of membranes, emergency cesarean delivery, meconium-stained amniotic fluid, small for gestational age newborns, and 5-minute Apgar scores of 7 or lower were not influenced by maternal age. The regression model showed an increased risk for cesarean delivery associated with age of at least 44 years (OR 7.3; 95% CI 2.2, 16.7), primiparity (OR 3.5; 95% CI 1.3, 9.8), infertility treatment (OR 3.6; 95% CI 1.5, 8.8), and egg donation (OR 19.5; 95% CI 6.1, 62.2), with positive and negative predictive values of 94 and 86%, respectively. Conclusion Maternal age of at least 44 years is associated with medical complications in pregnancy and more interventions during labor. However, overall pregnancy outcomes are favorable. Cesarean delivery can be predicted accurately based on maternal age, parity, and infertility treatment.

A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage

Objective To determine the safety and efficacy of intramuscular oxytocin plus ergometrine compared to intravenous oxytocin for prevention of postpartum haemorrhage, and the significance of administration at the end of the second stage of labour compared with that after the third stage.

Male disadvantage for neonatal complications of term infants, especially in small-for-gestational age neonates

Abstract Objective: Sex differences in long and short-term outcomes for infants are observed. This has also been shown for several neonatal complications in preterm neonates. We aimed to evaluate whether sex impacts neonatal outcome among term neonates. Furthermore, we were interested in whether small-for-gestational age male and female neonates at term presented with different patterns of neonatal complications. Methods: Data on all term singleton deliveries and respective neonatal outcomes between 2004 and 2008 at a single tertiary medical center were utilized for this retrospective cohort study. Immediate neurological complications were defined as one or more of the following: intraventricular hemorrhage, convulsions, asphyxia and acidosis. Neonatal complications were compared between male and female term infants, as well as male and female term small-for-gestational age (SGA) neonates. Results: 37 342 singleton neonates were born ≥37 weeks’ gestation. 19 112 neonates were males. Birth weight, cesarean sections and operative deliveries were significantly higher for males. Neonatal hypoglycemia and immediate neurological complications were significantly more frequent in males. For term SGA’s, low 5-min apgar scores (<7) at 39–40 weeks were 2.65 times higher for males compared with females, as was hypoglycemia. Conclusions: Male infants at term, especially male SGA infants, are more likely to encounter complications during labor and require special neonatal care due to metabolic and/or neurological complications.

Outcome of pregnancy in three patients with primaryantiphospholipid syndrome after stroke

OBJECTIVE Ischemic stroke is the most common neurological manifestation in patients with antiphospholipid syndrome (APS). Pregnancy in APS patients markedly increases the risk of thrombosis. There is no data on pregnancy outcome in patients with APS with a history of an ischemic stroke. We report our experience with three APS patients with a history of stroke who had successful pregnancies and deliveries. PATIENTS Three patients with APS and previous stroke were treated with small doses of aspirin and anticoagulants during pregnancy. RESULTS The patients remained free of attacks of cerebral ischemia during their pregnancies and at follow-up periods of 1 to 4 years. CONCLUSIONS Successful pregnancy and delivery is possible in APS patients with a history of stroke, treated with low-dose aspirin and anticoagulants. A previous episode of cerebral ischemia should not be considered an absolute contraindication for an APS patient to become pregnant.

Abdominal computed tomography (CT) scan in the evaluation of refractory puerperal fever: impact on management

Abstract Introduction: Computed tomography (CT) imaging should be employed judiciously, given its cost, use of intravenous contrast, and ionizing radiation. The aim of this study was to determine the clinical benefit of a CT scan in the evaluation of refractory puerperal fever and to identify the appropriate candidates for its use. Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2007 to April 2017. Indications for CT scan were refractory postpartum fever of ≥3 days and/or ultrasound findings suggesting complex abdominal fluid collection. Primary outcome was defined as a change in the mode of treatment due to the CT findings. In addition, a multivariate analysis of risk factors for puerperal fever was performed to identify patients who would benefit from the CT scan evaluation. Results: There were 520 women that underwent an abdominal and pelvic CT scan during the study period, 238 (45.7%) met inclusion criteria, 94 (39.5%) had a normal CT scan, and 144 (60.5%) had abnormal findings including 32 (13.4%) cases with pelvic thrombophlebitis and 112 (47%) cases with pelvic fluid collections. Results of the CT changed clinical management in 93 (39.0%) patients, including: switching antibiotics in 24 (10%) patients, adding low molecular weight heparin for 28 (11.8%) patients, and surgical intervention (laparotomy or drainage insertion) in 41 (17.2%) patients. In the regression model, we didn’t find any significant risk factors associated with treatment change following the CT scan. Conclusions: Abdominal and pelvic CT scan in women with refractory puerperal fever has a high clinical yield and lead to a change in management in a substantial number of patients.