Naama Steiner

Obstetric and neonatal outcome in patients with anxiety disorders

Abstract Objective: To investigate whether a diagnosis of anxiety disorder is a risk factor for adverse obstetric and neonatal outcome. Methods: A retrospective population-based study was conducted comparing obstetric and neonatal complications in patients with and without a diagnosis of anxiety. Multivariable analysis was performed to control for confounders. Results: During the study period 256 312 singleton deliveries have occurred, out of which 224 (0.09%) were in patients with a diagnosis of an anxiety disorder. Patients with anxiety disorders were older (32.17 ± 5.1 versus 28.56 ± 5.9), were more likely to be smokers (7.1% versus 1.1%) and had a higher rate of preterm deliveries (PTD; 15.2% versus 7.9%), as compared with the comparison group. Using a multiple logistic regression model, anxiety disorders were independently associated with advanced maternal age (OR 1.087; 95% CI 1.06–1.11; p = 0.001), smoking (OR 4.51; 95% CI 2.6–7.29; p = 0.001) and preterm labor (OR 1.92; 95% CI 1.32-–2.8; p = 0.001). In addition, having a diagnosis of an anxiety disorder was found to be an independent risk factor for cesarean section (adjusted OR 2.5; 95% CI 1.82–3.46; p < 0.001), using another multivariable model. No association was noted between anxiety disorders and adverse neonatal outcomes including small for gestational age, low Apgar scores and perinatal mortality. Conclusion: Anxiety disorders are independent risk factors for spontaneous preterm delivery and cesarean section, but in our population it is not associated with adverse perinatal outcome.

Clinical and microbiological characteristics of Bartholin gland abscesses.

OBJECTIVE: To examine the clinical course and causative microorganisms of Bartholin gland abscesses. METHODS: This was a retrospective study of all patients treated for Bartholin gland abscesses between the years 2006 and 2011 at the Soroka University Medical Center, a regional medical center in southern Israel. RESULTS: During the study period, 219 women were admitted as a result of an abscess of the Bartholin gland, 63% of which were primary abscesses and 37% recurrent abscesses (occurrence of a second clinical event). Pus cultures were positive in 126 (61.8%) of cases. Escherichia coli was the single most frequent pathogen found (43.7%) and 10 cases (7.9%) were polymicrobial. Culture-positive cases were significantly associated with fever (25% compared with 9.3%; P=.043), leukocytosis (50.4% compared with 33.8%; P=.027), and neutrophilia (17.9% compared with 5.9%; P=.021). The odds ratio of having any of these with a positive culture was 2.4 (95% confidence interval 1.3–4.3; P=.003). In the recurrent group, 81% recurred ipsilaterally and the mean time for recurrence was 32±50 months. Infection with E coli was significantly more common in recurrent infection compared with primary infections (56.8% compared with 37%; P=.033). Three cases of resistance to most beta-lactam antimicrobials (extended-spectrum beta-lactamase-producing [E coli] strains) were identified. CONCLUSION: A substantial proportion of patients with Bartholin gland abscess are culture-positive with E coli being the single most common pathogen. Microbiological findings coupled with their clinical correlates are important parameters in the management of patients with a Bartholin gland abscess and in the selection of empirical antimicrobial treatment during the primary diagnosis. LEVEL OF EVIDENCE: III

Postpartum uterine artery Doppler velocimetry among patients following a delivery complicated with preeclampsia

Objective: To evaluate postpartum uterine artery (UtA) velocimetry in patients following severe preeclampsia (PET) as compared with normotensive controls. Study Design: Postpartum UtA velocimetry was obtained prospectively during the early postpartum period. The right and left UtA pulsatility index (PI) was measured and the presence of an early diastolic notch was noted. For categorical variables, the χ2 test or Fisher exact was used as appropriate and for continuous variables the t-test was used. The p value <0.05 was considered statistically significant. Results: Thirty-one patients following severe PET and 52 normotensive controls were included in the study. Following severe PET, higher rates of intrauterine growth restriction, cesarean delivery, preterm delivery and accordingly lower neonatal birth weight were noted. Postpartum UtA velocimetry measurements were performed on average 51.2 h after delivery (range 8–169). Right and left UtA PI was comparable between patients following severe PET and controls. The presence of unilateral and bilateral early diastolic notches were significantly higher in patients following severe PET. Conclusions: The pathophysiology of uterine involution and the physiologic return of the uterine arteries to the non-pregnant state may be different following severe PET.

NKp44 and NKp30 splice variant profiles in decidua and tumor tissues: a comparative viewpoint

NKp44 and NKp30 splice variant profiles have been shown to promote diverse cellular functions. Moreover, microenvironment factors such as TGF-β, IL-15 and IL-18 are able to influence both NKp44 and NKp30 splice variant profiles, leading to cytokine-associated profiles. Placenta and cancerous tissues have many similarities; both are immunologically privileged sites and both share immune tolerance mechanisms to support tissue development. Therefore, we studied the profiles of NKp44 and NKp30 splice variants in these states by comparing (i) decidua from pregnancy disorder and healthy gestation and (ii) matched normal and cancer tissue. Decidua samples had high incidence of both NKp44 and NKp30. In cancerous state it was different; while NKp30 expression was evident in most cancerous and matched normal tissues, NKp44 incidence was lower and was mostly associated with the cancerous tissues. A NKp44-1dominant inhibitory profile predominated in healthy pregnancy gestation. Interestingly, the NKp44-2/3 activation profile becomes the leading profile in spontaneous abortions, whereas balanced NKp44 profiles were observed in preeclampsia. In contrast, a clear preference for the NKp30a/b profile was evident in the 1st trimester decidua, yet no significant differences were observed for NKp30 profiles between healthy gestation and spontaneous abortions/preeclampsia. Both cancerous and matched normal tissues manifested balanced NKp30c inhibitory and NKp30a/b activation profiles with a NKp44-1dominant profile. However, a shift in NKp30 profiles between matched normal and cancer tissue was observed in half of the cases. To summarize, NKp44 and NKp30 splice variants profiles are tissue/condition specific and demonstrate similarity between placenta and cancerous tissues.

Pregnancy outcomes among patients with recurrent pregnancy loss and uterine anatomic abnormalities

Abstract Background: Different etiologies for recurrent pregnancy loss have been identified, among them are: anatomical, endocrine, genetic, chromosomal and thrombophilia pathologies. Aims: To assess medical and obstetric characteristics, and pregnancy outcomes, among women with uterine abnormalities and recurrent pregnancy loss (RPL). This study also aims to assess the impact of uterine anatomic surgical correction on pregnancy outcomes. Methods: A retrospective case control study of 313 patients with two or more consecutive pregnancy losses followed by a subsequent (index) pregnancy. Anatomic abnormalities were detected in 80 patients. All patients were evaluated and treated in the RPL clinic at Soroka University Medical Center. Out of 80 patients with uterine anatomic abnormalities, 19 underwent surgical correction, 32 did not and 29 had no clear record of surgical intervention, and thus were excluded from this study. Results: Women with anatomic abnormalities had a higher rate of previous cesarean section (18.8% vs. 8.6%, P=0.022), tended to have a lower number of previous live births (1.05 vs. 1.37, P=0.07), and a higher rate of preterm delivery (22.9% vs. 10%, P=0.037). Using multivariate logistic regression analysis, anatomic abnormality was identified as an independent risk factor for RPL in patients with previous cesarean section after controlling for place of residence, positive genetic/autoimmune/endocrine workup, and fertility problems (OR 7.22; 95% CI 1.17–44.54, P=0.03). Women suffering from anatomic abnormalities tended to have a higher rate of pregnancy loss compared to those without anatomic abnormalities (40% vs. 30.9%, P=0.2). The difference in pregnancy loss rate among women who underwent surgical correction compared to those who did not was not statistically significant. Conclusion: In patients with previous cesarean section, uterine abnormality is an independent risk factor for pregnancy loss. Surgical correction of uterine abnormalities among RPL patients might have the potential to improve live birth rate.

The use of sonographic cervical length assessment for the prediction of time from induction to delivery

Abstract Objective: The objective of this study is to investigate the role of trans-vaginal cervical length measurement in the prediction of the interval to successful vaginal delivery after induction of labor with balloon catheter. Methods: In this prospective study of cervical length measurement before induction of labor, singleton pregnancies that underwent induction of labor between 37 and 42 weeks of gestation were included. The data collected included trans-vaginal sonographic cervical measurements followed by digital cervical assessment. Bishop score was used to quantify digital assessment (before induction of labor). Results: During the study period, 71 patients were included in the study. A statistically significant linear correlation was found between sonographic cervical length prior to induction of labor and the time of delivery (Pearson correlation 0.335; p values 0.005). Of the 57 vaginal deliveries, 27 patients had a cervical length of less than 28 mm. Patients with a cervical length of less than 28 mm had a significantly shorter time to delivery compared to patients with more than 28 mm length (20.4 versus 28.7, respectively; p value = 0.019). Cervical length of 28 mm remained significantly correlated even after performing several logistic regression models in order to control for confounders such as parity and age. In addition, a correlation was found between Bishop scores of above 7 to the time to delivery. Conclusions: Cervical length is correlated linearly to the time interval between induction of labor and delivery. A cervical length of less than 28 mm was found to be statistically significant in predicting a shorter time to delivery.

Pregnancy outcomes among patients with recurrent pregnancy loss and chromosomal aberration (CA) without PGD

Abstract Background: Recurrent pregnancy loss (RPL) is defined by two or more failed clinical pregnancies. Three to four percent of the couples with RPL have chromosomal aberrations (CA) in at least one partner. The parent’s structural chromosomal abnormalities may cause an unbalanced karyotype in the conceptus which could lead to implantation failure, early or late pregnancy loss, or delivery of a child with severe physical and/or mental disabilities. Objective: To compare live birth rates of couples with CA to couples with normal karyotypes and to investigate medical and obstetric characteristics and pregnancy outcomes of couples with CA and RPL who attend an RPL clinic at a tertiary hospital. Methods: A retrospective cohort study, including 349 patients with two or more consecutive pregnancy losses. The study group consisted of 52 patients with CA, and the control group consisted of 297 couples with normal karyotype. All patients were evaluated and treated in the RPL clinic at Soroka University Medical Center and had at least one subsequent spontaneous pregnancy. Results: The demographic and clinical characteristics were not found to be statistically different between the two groups. The group of carriers of CA had 28/52 (53.8%) live births in their index pregnancy vs. the normal 202/297 (68%) (P=0.067, CI 95%) in the control group. No statistically significant etiology was found between the study group and the control group. A statistically significant difference in live birth rates was found when comparing the total amount of pregnancies [index pregnancy (IP)+post index pregnancy (PIP)] between the study group and the control group (54.16% vs. 67.82%, respectively, P=0.0328). Conclusion: Patients with RPL and CA who have spontaneous pregnancies, have a good prognosis (63.4%) of a successful pregnancy with at least one of the pregnancies (index or post index) resulting in a live birth.

Small for gestational age as an independent risk factor for long-term pediatric gastrointestinal morbidity of the offspring

Abstract Objective: The concept of neonatal programming has begun to emerge as an important component of adult health. Scarce data exist regarding perinatal risk factors for long-term gastrointestinal (GI) morbidity of the offspring. We aimed to evaluate the association between birthweight (BW) at term and long-term pediatric GI morbidity. Study design: A population-based cohort analysis was performed, comparing the risk of long-term GI morbidity (up to the age of 18 years) in children delivered at term according to their BW. The study included all term deliveries occurring between 1991 and 2014 at a single regional tertiary medical center. Multiple gestations and fetuses with congenital malformations were excluded. BW was subdivided into: small for gestational age (small for gestational age (SGA) – BW ≤ 5th centile), appropriate for gestational age (AGA −5th centile < BW < 95th centile), and large for gestational age (LGA – BW ≥95th centile). Hospitalizations up to the age of 18 years involving GI morbidity were evaluated, using a predefined set of ICD-9 codes, as recorded in the hospital files. A Kaplan–Meier survival curve was used to compare cumulative GI morbidity incidence. A Cox proportional hazards model was constructed to control for confounders. Results: During the study period, 225,600 term singleton deliveries met the inclusion criteria. Of them, 4.6% (n = 10,415) were SGA and 4.3% (n = 9796) were LGA. During the 18-years follow-up period, 11,791 (5.2%) children were hospitalized with GI morbidity. Hospitalizations were significantly more common in the SGA group, as compared with the AGA and LGA groups (6.6 versus 5.2 versus 4.5%, respectively, p < .001) Specifically, inflammatory bowel disease, celiac, hernia, hepatitis, and cholecystitis, were more common in the SGA group. The Kaplan–Meier survival curve demonstrated a significantly higher cumulative incidence of gastrointestinal morbidity in the SGA group (log rank p < .001). In the Cox proportional hazards model, controlled for relevant clinical confounders, SGA BW was found to be an independent risk factor for long-term GI morbidity (adjusted HR = 1.23, 95%CI 1.14–1.33, p < .001). Conclusions: SGA offspring are at an increased and independent risk for long-term pediatric GI morbidity.

The unfavorable slope from mild preeclampsia through severe preeclampsia, to eclampsia

OBJECTIVE To compare the risk factors as well as maternal and perinatal outcomes between women with eclampsia to those with mild and severe preeclampsia. METHODS A retrospective study comparing pregnancy outcomes of women with preeclampsia (mild and severe) with those who were complicated with eclampsia was conducted. Statistical analysis included chi-square test for trend (the linear-by-linear association test). RESULTS The study population consisted of 10,018 women, 0.5% (n=52) suffered from eclampsia, 24% (n=2,409) had severe preeclampsia and 75.4% (n=7,557) had mild preeclampsia. A significant linear association was noted between the three groups (eclampsia, severe preeclampsia and mild preeclampsia) and risk factors such as nulliparity, young maternal age and oligohydramnios. A significant linear association was also documented between the three groups and adverse obstetric and perinatal outcomes such as post-partum hemorrhage, the need for blood transfusion, non reassuring fetal heart rate (NRFHR) patterns, low Apgar score at 5min and perinatal mortality. CONCLUSIONS An unfavorable slope was noted in the rate of certain risk factors and adverse perinatal outcomes between women with eclampsia through patients with severe preeclampsia to those with mild preeclampsia.

P08.09: Umbilical artery peak systolic velocity in IUGR fetuses

was to determine the performance of screening for PE in singleton pregnancies during routine clinical practice. Methods: Between 2011–2012 measurements of UtA-PI were performed at 11–13+6 weeks, and mean pulsatility index (PI) was calculated. Doppler, maternal history and biometry variables (age, ethnic origin, method of conception, BMI, parity, smoking, family or personal history of hypertension or PE, blood pressure) were combined with first trimester PAPP-A to assess the risk of PE. Astraia Software 2.3.2 was used in risk calculation. Results: 2552 women were recruited after informed consent to the study, and outcome data were available in 950 (37.2%) cases. PE occurred in 36 (3.8%) patients. The overall detection rate of early and late PE was 44.4% (16/36) with a false positive rate (FPR) of 12.3% (112/914). There were only 2 cases with early PE, the detection rate was 50% (1/2), with a FPR of 18.7% (178/948). The detection rate of the late PE (delivery at 34th weeks or after) was 44.1% (15/34), with a FPR of 9.5% (87/914). Conclusions: Combining risk factors in the mother’s history with UtA-PI allows calculation of patient-specific risk for the development of PE. Because of the small number of early PE cases in our study population our detection rate can not be taken into consideration. The detection rate (44%) of late PE in our study is comparable with the published retrospective data (60%). The Astraia software used only serum PAPP-A for risk calculation. Further biochemical markers might improve the detection rate. Follow-up of our recruited cases is still going on.