Shlomi Barak

Maternal complications associated with multiple cesarean deliveries.

OBJECTIVE: The claim that a planned repeat cesarean delivery is safer than a trial of labor after cesarean may not be applicable to women who desire larger families. The aim of this study was to assess maternal complications after multiple cesarean deliveries. METHODS: The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group). RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004). CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number. LEVEL OF EVIDENCE: II-2

Common oral manifestations during pregnancy: a review.

Pregnancy has far-reaching systemic effects extending beyond the reproductive system. Oral and masticatory changes during pregnancy have been documented for many years; however, their magnitude and frequency have not been stressed. This review highlights the major oral complications during pregnancy. Pregnancy gingivitis and pregnancy tumor are described and presented, and possible preventive strategies are suggested. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to summarize the major oral complications during pregnancy, to outline the etiologic factors associated with each of these conditions, and to explain the role of dental treatment during pregnancy.

Results of a well-defined protocol for a trial of labor after prior cesarean delivery.

OBJECTIVE: It has been claimed that a trial of labor after cesarean carries higher maternal and fetal risks than planned cesarean delivery. Because the management of such patients in our department differs from that described in some studies, and is perhaps more cautious, we hypothesized that the outcome may be better. METHODS: We identified women with 1 previous low uterine segment cesarean who had delivered a cephalic singleton infant at gestational age 34 weeks or more from January 2000 through May 2005. Our policy is to encourage such women to undergo a trial of labor unless cesarean delivery is indicated. Unless otherwise indicated, our policy is to wait for spontaneous labor. We do not use prostaglandins, and recommend cesarean delivery if the cervix is unripe.(Bishop score < 6). We compared the outcome between women who underwent a trial of labor and women who underwent planned cesarean delivery. RESULTS: A trial of labor was attempted by 841 women (80% successful), and 467 underwent planned cesarean delivery. Uterine rupture was observed in 1 woman 18 hours after vaginal delivery. There was no difference in major or minor maternal morbidity. There was no serious neonatal morbidity. Among the planned cesarean patients, hospital stay was longer, and there were more admissions to the neonatal intensive care unit. CONCLUSION: With our well-defined protocol, a trial of labor after cesarean seems to be as safe for the mother and infant as planned cesarean delivery, and the hospital stay is shorter. LEVEL OF EVIDENCE: II-2

Primary ovarian ectopic pregnancy misdiagnosed as first-trimester missed abortion.

Primary ovarian ectopic pregnancy is an uncommon ectopic gestation. It accounts for 0.5% to 1% of all ectopic gestations, and its incidence ranges from 1 in 7000 to 1 in 40,000 deliveries. 1 , 2 The clinical appearance varies. It is known to mimic an ovarian tumor or a tubal ectopic pregnancy 3 - 8 but to be misdiagnosed as an asymptomatic 8-week missed abortion is uncommon and makes this an interesting case. In the literature, there have been sparse case reports of primary ovarian ectopic pregnancy mistaken for intrauterine gestation, some of which progressed to the third trimester. 9 - 1 2 We present this case as an example of a misdiagnosed missed abortion and discuss sonographic examination methods to diagnose ovarian ectopic pregnancy.

Fetal heart rate patterns and neurodevelopmental outcome in very low birth weight infants

Background. To evaluate the validity of fetal heart rate monitoring during the last hour prior to birth, as a predictor of long term neurodevelopmental outcome of very low birth weight infants. Methods. A total of 111 very low birth weight infants were included in the study. Fetal heart rate tracings were obtained during the last hour prior to delivery. A perinatologist, blinded to the neonatal outcome, evaluated the tracings and divided them into three groups: reassuring, nonreassuring, and pathological. Neurodevelopmental status was evaluated at age 2 years. The relationship between fetal heart rate monitoring results and the neurodevelopmental outcome at 2 years of age was assessed with a chi‐square test and the Students t‐test. Results. At 2 years of age 97 (87.4%) of the children had normal neurodevelopmental function, while 14 (12.6%) had variable degrees of neurodevelopmental impairment. The fetal heart rate monitoring results were classified as reassuring (normal) in 35 cases (31.5%), nonreassuring in 56 cases (50.5%), and pathological in 20 cases (18.0%). Both normal and pathological fetal heart rate patterns were associated with similar incidence of abnormal neurodevelopmental outcome, 14.3% and 15.0% of cases, respectively (p=0.778). Pathological fetal heart rate patterns as a predictor of neurodevelopmental outcome had a sensitivity of 27%, specificity of 74%, positive predictive value of 15%, and negative predictive value of 86%. Conclusion. Electronic fetal heart rate monitoring prior to delivery is not a reliable tool for the prediction of neurodevelopmental impairment in premature infants of very low birth weight, at 2 years of age.

Fetal Escape From the Amniotic Sac Follow-up From First Trimester to Delivery

upture of the amniotic membrane with its subsequent disintegration may cause the fetus to appear in the chorionic cavity. This has been described previously as occurring after amniocentesis and fetal surgical procedures1–3; however, the spontaneous escape of the fetus through a defect in the amniotic membrane in the early second trimester is an extremely rare event. In this report, such an “amniotic escape” is presented with its sonographic follow-up and postpartum findings. The clinical importance of this peculiar disorder is discussed.

Subcutaneous Implantation of Pure Crystalline Estradiol Pellets for Conception Control

Objectives: Assessment of the contraceptive effectiveness of pure estradiol pellets implanted annually under the skin, thus avoiding the ‘first passage phenomenon’ through the liver, using a modification of Emperaire and Greenblatt’s method. Study Design: 228 women wishing birth control for 1 year or more were included. 5 pellets of estradiol (25 mg each) were implanted initially. At each subsequent annual treatment, 4 pellets were implanted. Withdrawal bleeding was induced monthly with oral norethindrone acetate 5 mg taken for 7 days. Our experience encompassed 8,136 cycles, or 678 women years. The study obtained approval of the local Ethical Committee. Results: Annual continuation rates were 51 per 100 women in the second year, 65 in the third, 72 in the fourth and 84 ± 10.1 annually over the next 6 years. Through 12 years of our study, 2 accidental pregnancies occurred. The annual net cumulative pregnancy rates were 0.44 and 0.48 per 100 women at 1 and 2 years, and reduced to 0.29 at the end of 10 years. Return of fecundity after discontinuing treatment was 53% after 12 months, 81% after 24 months and 89% after 36 months. The mean estradiol levels were 1,413 ± 161 pmol/l one week following the pellet installation. The mean serum estradiol level of the 43 women who were assayed arbitrarily or a year following last insertion was 1,207 pmol/l (range 462–2,904 pmol/l); 22% had serum estradiol levels <1,000 pmol/l and 6.3% (3 women) had levels >1,750 pmol/l. A total of 28 endometrial biopsies were obtained –19 were proliferative, 6 showed slight simple hyperplasia, and three, benign cystic glandular hyperplasia. Conclusion: Subcutaneous implantation of pure estradiol pellets offers excellent birth control, has minimal untoward effects, is simple to insert and can serve as a possible alternative for conception control. It could be considered for 3 indications: for women who have completed family planning; for women in older age group (above 35 years) who are approaching the climacteric; and for women at any age, who need prolonged periods of contraception.