Shiri Shinar

Suspected Person-to-Person Transmission of Q Fever Among Hospitalized Pregnant Women

We report a case of suspected patient-to-patient transmission of Q fever among pregnant women in a high-risk pregnancy unit, presumably via aerosolization of vaginally excreted infectious placental particles. This case questions whether current infection control guidelines are sufficient for Q fever-infected women in similar settings.

Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery

PurposeSterilization via bilateral total salpingectomy is slowly replacing partial salpingectomy, as it is believed to decrease the incidence of ovarian cancer. Our objective was to compare short-term intra and post-operative complication rates of bilateral total salpingectomy versus partial salpingectomy performed during the course of a cesarean delivery.MethodsA large series of tubal sterilizations during cesarean sections were studied in a single tertiary medical center between 1/2014 and 8/2016 before and after a policy change was made, switching from partial salpingectomy to total salpingectomy. Patients who underwent bilateral partial salpingectomy using the modified Pomeroy technique were compared with those who underwent total salpingectomy. Operative length, estimated blood loss, postpartum fever, wound infection, need for re-laparotomy, hospitalization length, and blood transfusions were compared.ResultsDuring the study period, 149 women met inclusion criteria. Fifty parturients underwent bilateral total salpingectomy and 99 underwent partial salpingectomy in the course of the cesarean section. Demographic, obstetrical, and surgical characteristics were similar in both groups. Mean cesarean section duration was comparable for partial salpingectomy and total salpingectomy (a median of 35xa0min in both groups, Pu2009=u20090.92). Complications were rare in both groups with no significant differences in rates of postpartum fever, wound infection, re-laparotomy, hospitalization length, estimated blood loss, transfusions, and readmissions within 1-month postpartum.ConclusionRates of short-term complications are similar in patients undergoing bilateral partial salpingectomy and total salpingectomy during cesarean deliveries, making the latter a feasible alternative to the former.

The importance of declining insulin requirements during pregnancy in patients with pre-gestational gestational diabetes mellitus

OBJECTIVEnIn patients with pre-gestational and gestational diabetes mellitus (GDM), insulin requirements often increase during the third trimester of pregnancy in order to maintain proper glycemic control. However, a fraction of patients demonstrate a significant decrease in insulin requirements in late gestation. We aimed to evaluate the clinical significance of decreasing insulin requirements in patients with pre-gestational diabetes and GDM with respect to fetal wellbeing and pregnancy outcome.nnnSTUDY DESIGNnWe performed a retrospective cohort study in a single referral center for gestational diabetes between 1/2010 and 12/2014. Healthy pregnant women with pre-gestational diabetes and GDMA2 and a decrease of at least 30% in insulin requirements over a period of two weeks during the third trimester (group A) were compared to women with stable or increasing insulin requirements (group B). The primary outcome was a composite of situations associated with feto-placental dysfunction (fetal growth restriction, oligohydramnios and cesarean section due to category 2-3 monitor). Secondary outcomes were maternal oral glucose tolerance test (OGTT) results 6 weeks postpartum, neonatal intensive care unit (NICU) admission rates, Apgar scores ≤7 at 5min, arterial blood pH≤7.1, macrosomia, neonatal hypoglycemia and a composite adverse neonatal outcomes (defined as one or more of the following: respiratory morbidity, cerebral morbidity, phototherapy, need for blood transfusion, necrotizing enterocolitis or death).nnnRESULTSnGroup A consisted of 101 women and group B - of 203 women. There were no differences between the groups in demographic characteristics or diagnostic characteristics of diabetes. The frequency of conditions related to feto-placental dysfunction did not differ between the groups (7.9% vs. 8.4%, p=0.61). Secondary outcome measures also did not differ between the groups, regardless of insulin requirements.nnnCONCLUSIONnDecreasing insulin requirements during the third trimester are not associated with adverse perinatal outcome related to placental dysfunction.

How Long Is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study.

OBJECTIVEnThe aim of our study was to determine the optimal time for manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion. Risk factors for postpartum blood transfusions were studied.nnnMETHODSnComputerized data of all vaginal deliveries at our labor and delivery unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation up to 60 minutes into the third stage of labor were extracted for analysis. Patient demographics, obstetrical history, delivery course, and outcome were assessed as well as blood product requirements during the postpartum period. Receiver-operating curves (ROC) for prediction of blood transfusion during the third stage were calculated and risk factors were assessed.nnnRESULTSn31,226 vaginal deliveries occurred during the study period and 28,586 deliveries culminated with complete and spontaneous placental separation, 25,160 of which met inclusion criteria. Independent risk factors for blood transfusions were primiparity, longer second and third stage length, labor induction, and maternal intrapartum fever. ROC curves showed that the optimal cutoff for the prediction of blood transfusions was 17 minutes into the third stage of labor. Waiting more than 30 minutes for placental separation increases the risk for blood transfusion more than threefold.nnnCONCLUSIONSnA third stage longer than 17 minutes is associated with an increased risk for blood transfusion postpartum. After more than 30 minutes, the risk for blood transfusions increases more than threefold.

Distribution of Third-Stage Length and Risk Factors for Its Prolongation.

Introductionu2003The aim of our study was to demonstrate the distribution of an uncomplicated third stage and to determine the optimal time for manual intervention. Risk factors for a prolonged third stage were studied. Materials and Methodsu2003Computerized data of all vaginal deliveries at our L&D unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation were extracted for further analysis. Cases necessitating manual removal of the placenta due to immediate postpartum hemorrhage (PPH) were also excluded. Patient demographics, obstetrical history, course of delivery, and delivery outcome were assessed, and risk factors for a prolonged third stage were analyzed. Resultsu2003There were 31,226 vaginal deliveries during the study period. Of these, 25,160 deliveries met inclusion criteria. The median third-stage length was 12 minutes. Within 30 minutes 97% of the placentas separated spontaneously. Independent risk factors for a third stageu2009>u200930 minutes included older maternal age, primiparity, history of abortions, twin gestation, and intrapartum fever. Conclusionu2003The average time for third stage isu2009<u200915 minutes with 97% occurring by 30 minutes and 100% by 60 minutes. In the absence of PPH, it is clinically prudent to perform manual removal after 30 minutes.

Redefining normal hemoglobin and anemia in singleton and twin pregnancies

To assess the benefit of a hemoglobin cutoff of 105 g/L as a trigger for anemia evaluation during the second trimester of pregnancy.

Birthweight and large for gestational age trends in non-diabetic women with three consecutive term deliveries

ObjectiveIncreased birthweight is a risk factor for early neonatal complications, as well as cardiovascular and metabolic disease later in adulthood. We aimed to assess birthweight trends and the rate of large for gestational age newborns in women in their third delivery according to birthweight in the first and second deliveries.Study designA retrospective cohort study of all women who delivered their first three consecutive deliveries in a single medical center (1994–2013). Only non-diabetic women with term (≥u200937xa0weeks) singleton deliveries in all three deliveries were included. BW centile (according to local gender- and gestational age-specific birth curves) trends between deliveries was assessed. In addition, the risk for large for gestational age (≥u200990th centile) infants in the third delivery was assessed according to the presence or absence of large for gestational age in previous deliveries. Pregnancies complicated by multiple gestations, preeclampsia, chronic or gestational hypertension or fetal anomalies were excluded.ResultsOf the 121,728 deliveries during the study period, 3521 women (10,563 deliveries [8.6%]) met inclusion criteria. Mean birthweight centile in the first, second and third deliveries were 47.2u2009±u200926.3, 58.3u2009±u200925.8 and 61.5u2009±u200924.7, respectively (pu2009<u20090.001). While 45.9% women had their maximal birthweight centile in the third delivery, only 16.5% had it in the first delivery (pu2009<u20090.001). In multivariate analysis, adjusted for maternal age, gestational age at delivery and neonatal gender, the rate of large for gestational age infants in the third delivery was increased as the number of previous large for gestational age deliveries increased in a dose-dependent pattern (aORu2009=u20094.37, CIu2009u20092.89–6.61 for women with large for gestational age infant only in the first delivery, aORu2009=u20095.31, CIu2009 u20094.15–6.79 for women with large for gestational age infants only in the second delivery, aORu2009=u200910.62, CIu2009u20096.89–16.38 for women with large for gestational infants age in the first and second deliveries; women with no large for gestational age infants in both the first and second delivery served as reference group).ConclusionIn women with repeated term deliveries, birthweight centile is frequently increased in the third delivery compared to the previous two deliveries. Moreover, the number and order of previous large for gestational age deliveries in the first two deliveries are major risk factors for large for gestational age in the third delivery.

The Hemodynamics of Labor in Women Undergoing Vaginal and Cesarean Deliveries as Determined by Whole Body Bioimpedance

Objective The objective of this study was to assess the hemodynamics of labor, delivery, and 48 hours postpartum in women undergoing vaginal and cesarean deliveries by utilizing a whole body bioimpedance‐based device. Materials and Methods A prospective longitudinal single‐center observational study was performed between September 2014 and September 2015. The hemodynamics of low‐risk women undergoing spontaneous vaginal delivery were compared with those undergoing elective cesarean sections. Cardiac index (CI), stroke index, total peripheral resistance index (TPRI), and mean arterial pressure (MAP) were assessed at different time points during delivery and in the immediate postpartum period (1, 24, and 48 hours postpartum). Results Eighty‐seven women were evaluated, 63 parturients in the vaginal delivery group and 24 in the cesarean delivery group. Normal vaginal delivery was characterized by a reduction in MAP and CI after epidural anesthesia, whereas elective cesarean sections were characterized by a rise in MAP and CI after spinal anesthesia. As labor progressed, CI increased reaching its peak during the second stage. Immediately following delivery, TPRI declined to its nadir with no significant change in CI. As opposed to vaginal delivery, in cesarean delivery, TPRI peaked within 1‐hour postpartum resulting in a significant decline in CI. Conclusion Whole body bioimpedance can be used effectively to assess the hemodynamics of vaginal and cesarean deliveries.

A novel modality for intrapartum fetal heart rate monitoring

Abstract Background: Intrapartum fetal heart rate (FHR) monitoring is well recommended during labor to assess fetal wellbeing. Though commonly used, the external Doppler and fetal scalp electrode monitor have significant shortcomings. Lately, non-invasive technologies were developed as possible alternatives. Objective: The objective of this study is to compare the accuracy of FHR trace using novel Electronic Uterine Monitoring (EUM) to that of external Doppler and fetal scalp electrode monitor. Material and methods: A comparative study conducted in a single tertiary medical center. Intrapartum FHR trace was recorded simultaneously using three different methods: internal fetal scalp electrode, external Doppler, and EUM. The latter, a multichannel electromyogram (EMG) device acquires a uterine signal and maternal and fetal electrocardiograms. FHR traces obtained from all devices during the first and second stages of labor were analyzed. Positive percent of agreement (PPA) and accuracy (by measuring root means square error between observed and predicted values) of EUM and external Doppler were both compared to internal scalp electrode monitoring. A Bland–Altman agreement plot was used to compare the differences in FHR trace between all modalities. For momentary recordings of fetal heart rate <110 bpm or >160 bpm level of agreement, sensitivity, and specificity were also evaluated. Results: Overall, 712,800 FHR momentary recordings were obtained from 33 parturients. Although both EUM and external Doppler highly correlated with internal scalp electrode monitoring (r2u2009=u20090.98, pu2009<u2009.001 for both methods), the accuracy of EUM was significantly higher than external Doppler (99.0% versus 96.6%, pu2009<u2009.001). In addition, for fetal heart rate <110 bpm or >160 bpm, the PPA, sensitivity, and specificity of EUM as compared with internal fetal scalp electrode, were significantly greater than those of external Doppler (pu2009<u2009.001). Conclusion: Intrapartum FHR using EUM is both valid and accurate, yielding higher correlations with internal scalp electrode monitoring than external Doppler. As such, it may provide a good framework for non-invasive evaluation of intrapartum FHR.

Is There a Role for Placental Cultures in Cases of Clinical Chorioamnionitis Complicating Preterm Premature Rupture of Membranes

Objective To assess the role of placental cultures in cases of preterm premature rupture of membranes (PPROM) complicated by chorioamnionitis and to determine the effect of positive cultures on short‐term neonatal outcomes. Design A retrospective single‐center study. The medical records of all women with PPROM between January 1, 2011, and December 31, 2015, were reviewed. Cases were divided into placental culture positive (group A) and placental culture negative (group B) groups. Maternal and pregnancy characteristics as well as short‐term neonatal outcomes were compared between groups. Results During the 5‐year study period, 61 cases of clinical chorioamnionitis complicating PPROM were diagnosed: 25 cases were culture positive (group A) and 36 were culture negative (group B). Neonatal outcome measures, including Apgar score at 5 minutes (p = 0.028; odds ratio [OR]: 5.27; confidence interval [CI]: 1.19‐23.34), respiratory distress syndrome (p = 0.026; OR: 4.11; CI: 1.18‐14.25), and neonatal infection (p < 0.0001; OR: 11.59; CI: 3.37‐39.87) were significantly more common in group A newborns, regardless of gestational age at delivery as was the composite neonatal outcome (p = 0.017; OR: 7.35: CI: 1.42‐37.79). Placental isolates were primarily Streptococci and Escherichia coli. Conclusion Placental cultures may be an essential predictor of neonatal morbidity in PPROM and may contribute to the modification of neonatal treatment.