Reli Hershkovitz

Gender Does Matter in Perinatal Medicine

Objective: To investigate complications and outcome of pregnancies with male and female fetuses. Methods: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. We compared pregnancies with male vs. female fetuses. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses with the Mantel-Haenszel technique and multiple logistic regression models were performed to control for confounders. Results: During the study period there were 55,891 deliveries of male and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01–1.12; p = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8–2.1; p < 0.001), failure to progress during the first and second stages of labor (OR = 1.2; 95% CI 1.1–1.3; p < 0.001 and OR = 1.4; 95% CI 1.3–1.5; p < 0.001, respectively), cord prolapse (OR = 1.3; 95% CI 1.1–1.6; p = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1–1.2; p < 0.001) and true umbilical cord knots (OR = 1.5; 95% CI 1.3–1.7; p < 0.001). Higher rates of CS were found among male compared with female neonates (8.7 vs. 7.9%; OR = 1.1; 95% CI 1.06–1.16; p < 0.001). Using three multivariate logistic regression models and controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring fetal heart rate patterns (OR = 1.5; 95% CI 1.4–1.6; p < 0.001), low Apgar scores at 5 min (OR = 1.5; 95% CI 1.3–1.8; p < 0.001) and CS (OR = 1.2; 95%CI 1.2–1.3; p < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, nonprogressive labor, fetal macrosomia, nuchal cord and true umbilical cord knots using the Mantel-Haenszel technique did not change the significant association between male gender and CS. Conclusion: Male gender is an independent risk factor for adverse pregnancy outcome.

Risk factors associated with true knots of the umbilical cord

OBJECTIVE To determine obstetrical risk factors and pregnancy outcome of fetuses with true knot of the umbilical cord. METHODS Study population included 69,139 singleton deliveries occurring between the years 1990-1997. Data were retrieved from the database of the Soroka University Medical Center. Fetuses with malformations were excluded. RESULTS The incidence of true knots was 1.2% (841/69,139). In a multivariate analysis the following factors were found to be significantly associated with true knot of cord: grandmultiparity, chronic hypertension, hydramnios, patients who undergone genetic amniocentesis, male gender and cord problems (prolapse of cord and cord around the neck). The incidence of fetal distress and meconium stained amniotic fluid was significantly higher among patients with true knots of cord (7% versus 3.6%, P<0.001 and 22% versus 16%, respectively, P<0.0001). Moreover, there was a four-fold higher rate of antepartum fetal death among those fetuses (1.9% versus 0.5%, P<0.0001). In addition, fetuses with true knots of the umbilical cord were more often delivered by a cesarean section (130/841 versus 711/68,298, P<0.0001). The following obstetrical factors were found to be significantly correlated to true knots of the umbilical cord in a multiple logistic regression model: gestational diabetes, hydramnios, patients undergoing genetic amniocentesis, male fetuses. CONCLUSIONS Patients with hydramnios, who underwent genetic amniocentesis and those carrying male fetuses are at an increased risk for having true knots of the umbilical cord. Thus, careful sonographic and Doppler examinations should be seriously performed in these patients for detection of the complication of the umbilical cord.

Lipoic acid prevention of neural tube defects in offspring of rats with streptozocin-induced diabetes

OBJECTIVE Increased oxidant stress has been suggested to play a role in the pathogenesis of disturbed embryogenesis in diabetic pregnancies. The present study was conducted to determine whether administration of lipoic acid, a naturally occurring antioxidant, would reduce the incidence of diabetic embryopathy in the streptozocin-induced diabetic rat model. STUDY DESIGN After conception, rats were randomly distributed to 5 groups. From day 1, rats were daily injected intraperitoneally with either lipoic acid, 30 mg/kg, or vehicle. At day 6, rats from groups 3, 4, and 5 were made diabetic by a single intraperitoneal injection of streptozocin. Group 4 rats were injected with lipoic acid from day 1 to day 6, after vehicle treatment until day 17. At day 17 of gestation, rats were killed. The fetuses were released from the yolk sacs and surrounding decidua and were examined for size, resorption rate, and neural tube defects. RESULTS Pregnant diabetic rats treated with vehicle lost weight during pregnancy (-3.2 +/- 1.9 g/d), as opposed to normal pregnancy-related weight gain (3.5 +/- 0.5 g/d). Treatment with lipoic acid protected against diabetes-induced weight loss, without a measurable effect on fed-state glucose concentrations. Daily treatment with lipoic acid (pregnancy days 1 to 17) was efficient in reducing the resorption rate from 24.0% +/- 9.5% in vehicle-treated diabetic rats to 10.2% +/- 4.8% in lipoic acid-treated diabetic rats (P <.05). The rate of neural tube defects in diabetic rats treated with lipoic acid throughout the pregnancy was reduced from 26.0% +/- 7.0% to 10.2% +/- 3.2% (P <.05). In rats treated only during pregnancy days 1 to 5 (before diabetes induction), lipoic acid failed to exert its protective effects against neural tube defects, which emphasizes the importance of the presence of lipoic acid during the organogenesis period. The atherosis of placental vasculature demonstrated in the vehicle-treated diabetic rats was absent from placentas obtained from lipoic acid-treated diabetic animals. CONCLUSIONS Our data demonstrate a protective effect of lipoic acid against diabetic embryopathy, fetal losses, and ultrastructural alteration of diabetic placentas.

Ultrasound in obstetrics: a review of safety.

The data available to data suggest that diagnostic US has no adverse effect on embryogenesis or fetal growth. However, although B and M mode are safe during the first trimester, color, pulsed or power Doppler should be performed with caution. The US effects are mainly due to cavitation. However, this Mechanism has been determined mainly in animal models. Thermal effect, which was thought to be hazardous, probably does not influence fetal development.

Intraamniotic infection in patients with preterm labor and twin pregnancies

Background. Microbial invasion of the amniotic cavity plays a major role in the pathogenesis of preterm labor and delivery in singleton pregnancy. Nevertheless, this association is not well established among patients with multiple gestations. The purpose of our study was to explore the role of intraamniotic infection in the setting of twin pregnancies.

Maternal Hypertensive Disorders Are an Independent Risk Factor for the Development of Necrotizing Enterocolitis in Very Low Birth Weight Infants

Objective: The purpose of this study was to compare complications and outcome of preterm neonates weighing ≤1,500 g who developed necrotizing enterocolitis (NEC) to neonates without NEC. Study Design: During January, 1995 to December, 1998, 211 live preterm neonates were born with birth weight ≤1,500 g. A cross sectional prospective study was designed and two groups were defined: 17 neonates who developed NEC and 194 without NEC. Multiple logistic regression analysis was performed to determine independent risk factors for the development of NEC. Results: The prevalence of NEC was 8% (17/211). The following complications were found to be significantly higher among mothers of neonates with NEC: mild pre-eclampsia (11.8 vs. 2.6%, p = 0.04); severe pre-eclampsia (35.5 vs. 12.9%, p = 0.01); chronic hypertension (29.4 vs. 5.7%, p < 0.001) and low birth weight (968 ± 233 vs. 1,123 ± 257 g, p = 0.02). In contrast, mean maternal age, mean gestational age at delivery and parity were not significantly different between the groups. A multivariate analysis including the following factors: maternal hypertensive disorders, pregestational diabetes mellitus, birth weight and gestational age at delivery, found only maternal hypertensive disorders to be independent risk factors for NEC (OR = 5.21, 95% CI 1.64–16.58). Conclusions: Maternal hypertension is an independent risk factor for the development of NEC in preterm neonates weighing <1,500 g. Thus, maternal vascular disorders may play an important role in the pathophysiology of NEC.

Prenatal Diagnosis of Congenital Lobar Emphysema: Case Report and Review of the Literature

Congenital lobar emphysema (CLE) is a rare developmental anomaly of the lower respiratory tract, which is characterized by hyperinflation of 1 or more of the pulmonary lobes. The routine use of prenatal sonography has resulted in early identification and serial evaluation of congenital lung lesions. 1 Prenatal diagnosis of CLE is rarely reported in the literature. 2 Here we report a case of a fetus with an echogenic lung presenting in the second trimester suspected of CLE. A discussion of the causes and natural course of CLE is presented.

Prenatal diagnosis of isolated abnormal number of ribs

To determine the incidence of prenatal isolated abnormal number of ribs, using three‐dimensional (3D) ultrasound.

Obstetric risk factors for failure to progress in the first versus the second stage of labor.

Objective: To compare obstetric risk factors for failure of labor to progress in the first versus the second stage. Study design: A comparison was performed of all singleton, vertex and term deliveries with an unscarred uterus, complicated with non-progressive labor during the first and the second stages. Deliveries occurred between the years 1988 and 1999 in a tertiary university medical center. Results: Patients with non-progressive labor in the first stage (n = 1197) were significantly older, of higher birth order, and were more likely to have complications such as gestational diabetes, hypertensive disorders, premature rupture of membranes, meconium-stained amniotic fluid, hydramnios and oligohydramnios (p < 0.001 for all variables) as compared to patients with non-progressive labor in the second stage (n = 1545). In addition, pregnancies complicated with non-progressive labor in the first stage had a significantly higher rate of fetal macrosomia as compared to patients with non-progressive labor in the second stage (11.6% vs. 8.8%; p < 0.001). Conclusions: Higher rates of fetal macrosomia and high-risk pregnancies were noted among pregnancies complicated with non-progressive labor during the first vs. the second stage. The significant increase in Cesarean deliveries during the first stage of labor among high-risk pregnancies might reflect exaggerated concern of caregivers. This concern may influence an overall conservative attitude leading to the seemingly simpler mode of direct intervention by Cesarean delivery.

A new autosomal recessive congenital contractural syndrome in an Israeli Bedouin kindred.

We describe 23 cases with a syndrome of congenital contractures belonging to a large, inbred Israeli‐Bedouin kindred. The phenotype described is similar to the Finnish type lethal congenital contracture syndrome yet differs in the following ways: by some additional craniofacial/ocular findings, by the lack of hydrops, multiple pterygia, and fractures, and by the normal duration of pregnancy. The major unique and previously undescribed clinical feature in our patients is a markedly distended urinary bladder as well as other urinary abnormalities. The vast majority of the cases died shortly after birth. Sonographic prenatal diagnosis was possible as early as 15 weeks gestation by demonstrating fetal akinesia, limb contractures, hydramnios, and distended urinary bladder. Linkage to 5q and 9q34 loci has been excluded.