Tali Silberstein

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.

Post-term pregnancy: should induction of labor be considered before 42 weeks?

Objective: To determine the occurrence of maternal and fetal complications in low-risk pregnancies beyond 39 weeks and to re-evaluate the acceptable cut-off (42 weeks) for induction of labor. Study design: A total of 36 160 low-risk pregnancies with reliable dating of gestational age (last menstrual period and early ultrasound examination) were evaluated retrospectively for fetal and maternal complications, including non-progressive labor, cervical tear, retained placenta, postpartum hemorrhage, vacuum delivery, Cesarean section, macrosomia, meconium-stained amniotic fluid, non-reassuring fetal heart rate monitoring and ante-, intra- and postpartum death. Pregnancy outcomes at different gestational ages were compared using univariate and multivariate analysis and receiver operator curves. Results: The rates of non-progressive labor stage I and II, retained placenta, vacuum delivery, Cesarean section, macrosomia, meconium-stained amniotic fluid and non-reassuring fetal heart rate monitoring were found to be significantly higher with increasing gestational age in the univariate analysis. These parameters were evaluated using multivariate analysis and the following were found to be significantly higher: non-progressive labor stage I and II, macrosomia, meconium-stained amniotic fluid and Cesarean section. Statistical analysis (receiver operator curves) showed that the most significant rise in the risk for non-progressive labor occurred after 42 completed weeks of gestation, and after 41 completed weeks for macrosomia, meconium-stained amniotic fluid and Cesarean section. Conclusions: The rates of non-progressive labor stage I and II, meconium-stained amniotic fluid, macrosomia and Cesarean section were significantly higher with increasing gestational age. In order to decrease the rate of macrosomia, meconium-stained amniotic fluid and Cesarean section, we suggest that induction of labor should be considered before 42 weeks.

The reduction of a nitroxide spin label as a probe of human blood antioxidant properties.

The kinetics of reduction of the radical R ”, 5-dimethylaminonaphthalene-1-sulfonyl-4-amino-2,2,6,6-tetramethyl-1-piperidine-oxyl, by blood and its components were studied using the EPR technique. The results demonstrate that R ” is adsorbed to the outer surface of the membrane and does not penetrate into the erythrocytes. A series of control experiments in PBS demonstrate that ascorbate is the only natural reducing agent that reacts with R ” . The observed first order rate of disappearance of the nitroxide radical, k , is: k blood > k eryth > k plasma and k blood ; k eryth + k plasma . The results demonstrate that: The erythrocytes catalyze the reduction of R ” by ascorbate. The rate of reduction of the radical is high though it does not penetrate the cells. In human erythrocytes there is an efficient electron transfer route through the cell membrane. The study points out that R ” is a suitable spin label for measuring the reduction kinetics and antioxidant capacity in blood as expressed by reduction by ascorbate.

Pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy

Objective. The study was designed to investigate obstetric risk factors and pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy (PUPPP). Methods. A population-based study comparing all pregnancies of women with and without PUPPP was conducted. Deliveries occurred during the years 1988–2002 at the Soroka University Medical Center. A multivariable logistic regression model was constructed in order to find independent risk factors associated with PUPPP. Results. During a 15-year period, 159 197 deliveries took place. PUPPP complicated 42 (0.03%) of all pregnancies. Using a multivariable analysis, the following conditions were significantly associated with PUPPP: multiple pregnancies (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7–14.1), hypertensive disorders (OR = 2.2, 95% CI 1.1–4.7), and induction of labor (OR = 7.6, 95% CI 4.0–14.5). Higher rates of 5-minute Apgar scores lower than 7 (OR = 8.0, 95% CI 4.4–14.9) and of cesarean deliveries (OR = 2.9, 95% CI 1.5–5.6) were noted in the PUPPP as compared to the comparison group. While investigating other perinatal outcome parameters such as oligohydramnios, intrauterine growth restriction, meconium-stained amniotic fluid and perinatal mortality, no significant differences were observed between the groups. Conclusion. Pruritic urticarial papules and plaques of pregnancy is a condition significantly associated with multiple pregnancies, hypertensive disorders, and induction of labor. Perinatal outcome is comparable to pregnancies without PUPPP.

Routine revision of uterine scar after cesarean section: Has it ever been necessary?

Although a trial of labor after cesarean section (VBAC) is successful and relatively safe, few studies have directly addressed the necessity of routine transcervical revision of uterine scar after prior cesarean section. We performed a longitudinal study of 3469 women who had VBAC. In all patients, uterine scar integrity was examined immediately after placental expulsion. The detection rate of uterine scar dehiscence or rupture was 0.23% (8/3469). Only one woman with complete uterine rupture needed immediate laparotomy for severe hemorrhage. Out of seven patients (0.2%), who had evidence of uterine dehiscence, three underwent explorative laparotomy. In conclusion, the potential benefit of routine examination of uterine scar after VBAC is doubtful. Transcervical revision should be performed only in symptomatic patients.

Comparing data mining and logistic regression for predicting IVF outcome

Design We utilized Quinlan’s C5.0 decision tree data mining algorithm to retrospectively investigate the predictive power of the 100 parameters that we track for each IVF cycle. The parameters investigated include patient demographics, stimulation regime, response properties, oocyte and embryo parameters and embryo transfer variables. To validate our findings from a statistical point of view we also constructed a statistical model based on logistic regression.

Trace element concentrations in follicular fluid of small follicles differ from those in blood serum, and may represent long-term exposure

OBJECTIVE To determine the levels of elements in follicular fluid (FF) of patients undergoing IVF and evaluate the relationship between the concentration of elements in FF, follicular volume, and blood. DESIGN Prospective blinded study. SETTING University-based IVF center. PATIENT(S) Follicular fluid/blood samples from 6/3 patients, respectively, undergoing IVF. INTERVENTION(S) Single follicular aspirations of 33 follicles were performed. Blood samples ( approximately 5 mL) were drawn at the time of oocyte retrieval from 3/6 patients only. The concentrations 26 elements were measured by inductively coupled plasma mass spectroscopy. MAIN OUTCOME MEASURE(S) Trace elements concentrations in follicular fluid and blood. RESULT(S) [1] Calcium and magnesium were the most abundant, followed by Cu, Zn, Fe, Cr, Rb. The elements V, Sr, Se, B, As, Pb, Al, Mo, Mn, and Cs were found in trace amounts. The elements Li, Be, Ag, Cd, Ba, Ti, Bi, U were not detected. [2] Element concentrations in small follicles frequently differed from those of large follicles. [3] Element concentrations in large follicles more closely resembled those in blood. CONCLUSION(S) Concentrations of elements in FF of small follicles can differ from those of large follicles in the same woman and from those of blood serum. When follicles grow they become filled with fluid of an elemental composition similar to blood. Concentrations of elements in small follicles may represent longer term element exposure, whereas those of growing follicles represents the coincident blood concentrations.

Elements in maternal blood and amniotic fluid determined by ICP-MS

Abstract Objective: Knowledge about levels of toxic and non-toxic elements in amniotic fluid is limited. The aims of this study were: (1) to measure levels of trace elements Cu, Fe, Zn, B, Sr and Co in amniotic fluid and maternal serum during second trimester of pregnancy; and (2) to determine what correlations exists between elements levels in amniotic fluid and maternal serum. Methods: The levels of, iron, copper, zinc, cobalt, strontium and boron were measured in blood and amniotic fluid during genetic amniocentesis using inductively coupled plasma mass spectrometry (ICP-MS). Results: Concentrations of the elements: Fe, Cu, Zn, Co, Sr and B in amniotic fluid were significantly lower than in maternal blood. For iron, zinc, cobalt, strontium and boron there was a linear correlation between levels in amniotic fluid and maternal serum. Conclusions: The concentration of trace elements in amniotic fluid was found to be lower than maternal serum and linearly correlated to its level.

Aplasia cutis congenita: clinical management and a new classification system.

Background: Aplasia cutis congenita is a rare, congenital disorder. In its severe phenotype, it is potentially life threatening. Its management and the timing of surgery remain controversial because of the risks involved with both conservative and surgical approaches. Most literature is based on case reports and very small case series because of the rarity of the disorder. The authors present their experience treating newborns with aplasia cutis congenita and its progressive development. Methods: Using a hospital registry, the authors found all cases of newborns diagnosed with aplasia cutis congenita during the years 2000 to 2013. Clinical data were gathered from hospital and clinic records, and photographs were obtained by the plastic surgery team. Results: Twenty-two cases of aplasia cutis congenita were included in this study: 21 on the scalp and one on the foot heel. Eleven patients were male and 11 were female. Defect size ranged from 1 to 150 cm2 (average, 29 cm2). Three patients died as a result of uncontrollable hemorrhage. Six patients underwent emergency coverage, one with allografts later replaced by split-thickness skin grafts and five by immediate split-thickness skin grafting. All of the patients who underwent immediate skin grafting survived and thrived. Conclusions: The authors emphasize the role of emergency split-thickness skin grafting in the treatment of large aplasia cutis congenita or ones with large veins or sagittal sinus exposure. The authors also present a practical, treatment-oriented classification that could assist physicians in estimating the severity and therefore prognosis of the disease and offer a treatment guideline. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Gestational diabetes complicated by hydramnios was not associated with increased risk of perinatal morbidity and mortality.

OBJECTIVE To determine whether gestational diabetes (GDM) complicated with hydramnios is associated with higher rates of perinatal morbidity and mortality than those with normal amniotic fluid (AFI). STUDY DESIGN A case control study of 368 pregnant women with GDM was conducted between January 1995 and December 1996. The study group consisted of 184 women with hydramnios (AFI>25 cm) that were matched for maternal age, parity, and gestational age to 184 women with gestational diabetes and normal AFI. A Students t-test, McNemar test and logistic regression test were used to compare the two groups. RESULTS Both groups were under strict metabolic control; mean glucose levels of 5.2+/-2.4 mmol/l in the study group and 5.5+/-2.4 mmol/l in the controls (P>0.05). There were no significant differences between groups in the rates of severe preeclampsia, premature rupture of membranes (PROM), cesarean section rate, intrauterine growth restriction (IUGR), antepartum fetal death, fetal distress, prolapse of umbilical cord and placenta abruption. Even though the prevalence of large for gestational age (LGA) and birth weight were significantly higher in the study group (31 versus 19% and 3441+/-477 versus 3232+/-554 g, respectively), the prevalence of neonatal trauma was the same in both groups (2.6%). There was no significant difference in the Apgar scores (1 and 5 min), newborn hypoglycemia, metabolic acidosis and hyperbilirubinemia. CONCLUSIONS Hydramnios in women with GDM was not associated with increased risk of perinatal morbidity and mortality.