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Lavie A, Aviram A, Hiersch L, Ashwal E, Yogev Y. 420: Uterine electrical activity, oxytocin & labor - translating electrical into mechanical. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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102
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Hiersch L, Krispin E, Linder N, Aviram A, Gabbay-Benziv R, Yogev Y, Ashwal E. Meconium-Stained Amniotic Fluid and Neonatal Morbidity in Low-Risk Pregnancies at Term: The Effect of Gestational Age. Am J Perinatol 2017; 34:183-190. [PMID: 27367282 DOI: 10.1055/s-0036-1585056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective To assess the association of gestational age at delivery with perinatal outcome in low-risk term deliveries complicated by meconium-stained amniotic fluid (MSAF). Methods We retrospectively analyzed all singleton deliveries that underwent a trial of labor in a single hospital (2007-2013). Exclusion criteria included pregnancy-related complications (e.g., hypertensive disorders, diabetes, oligohydramnios, and fetal anomalies). First, only deliveries with MSAF were analyzed. Perinatal outcome of deliveries at 370/7 to 386/7 weeks (early term) and 410/7 to 416/7 weeks (late term) were compared with those at 390/7 to 406/7 weeks of gestation (full term). Additionally, a gestational age based comparison was made between the risk for neonatal respiratory morbidity in deliveries with clear amniotic fluid and MSAF. Results During the study period, 28,248 deliveries were considered as low risk. Of them, 3,399 (12.0%) were diagnosed with MSAF and were divided to full term (n = 2,413), early term (n = 405), and late term (n = 581). In multivariate analysis, MSAF at early term was associated with neonatal jaundice, need for phototherapy, and neonatal sepsis. In a gestational age based stratification, when comparing between deliveries with clear amniotic fluid and those with MSAF, late term had the highest odds (4.2 vs. 0.5%; p < 0.001) for neonatal respiratory morbidity. Conclusion Gestational age was associated with specific complications in deliveries complicated by MSAF and otherwise low-risk deliveries.
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Affiliation(s)
- Liran Hiersch
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Nehama Linder
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Amir Aviram
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Rinat Gabbay-Benziv
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Yariv Yogev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Ashwal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Krispin E, Hiersch L, Katz A, Riter O, Aviram A, Hadar E, Wiznitzer A, Yogev Y, Ashwal E. 881: Progression from gestational hypertension to preeclampsia - what is the role of gestational age? Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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104
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Shmueli A, Nassie DI, Hiersch L, Ashwal E, Wiznitzer A, Yogev Y, Aviram A. 241: Prerecognition of large for gestational age (LGA) fetus and its consequences. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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105
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Shmueli A, Salman L, Nassie DI, Wiznitzer A, Chen R, Ashwal E, Hiersch L, Yogev Y, Aviram A. 949: The intriguing association between epidural anesthesia and mode of delivery among women in trial of labor after a previous cesarean delivery. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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106
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Abstract
PURPOSE To evaluate gender effect on induction of labor (IoL) failure rates stratified by indication to delivery. METHODS Retrospective cohort analysis of singleton pregnancies 34-42 weeks undergoing cervical ripening using controlled-release PGE2 vaginal insert. IoL Indications were divided into: (1) maternal; (2) hypertensive disorders; (3) premature rupture of membrane or (4) fetal (growth abnormalities, oligohydramnios, postdate, etc,). IoL failure was defined as: (1) Bishop-score ≤7 after 24 hours of PGE2; (2) cesarean delivery due to failed induction; (3) fetal distress followed by PGE2 removal and emergent cesarean. IoL failure rates were stratified by neonatal gender and indication to induction. Logistic regression analysis was utilized to control outcomes to potential confounders. RESULTS Overall, 1062 pregnancies were included - 521 (49%) had male fetuses. IoL indications did not differ by gender. IoL failure rate was 20.1% (213/1062) - 76% for unfavorable Bishop-score after PGE2 removal; 5.2% for failed induction and 18.8% for fetal-distress while on PGE2. Overall, 14.3% delivered by cesarean section. There were no differences in IoL failure as a group or by indications to induction stratified by fetal gender (21.7% vs. 18.5%, male vs. females, p < 0.05). CONCLUSIONS IoL failure rate is not affected by fetal gender regardless of indication to induction.
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Affiliation(s)
- Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eran Hadar
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Rony Chen
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Rinat Gabbay-Benziv
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
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107
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Hiersch L, Borovich A, Gabbay-Benziv R, Maimon-Cohen M, Aviram A, Yogev Y, Ashwal E. Can we predict successful cervical ripening with prostaglandin E2 vaginal inserts? Arch Gynecol Obstet 2016; 295:343-349. [DOI: 10.1007/s00404-016-4260-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
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108
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Hiersch L, Melamed N, Aviram A, Bardin R, Yogev Y, Ashwal E. Role of Cervical Length Measurement for Preterm Delivery Prediction in Women With Threatened Preterm Labor and Cervical Dilatation. J Ultrasound Med 2016; 35:2631-2640. [PMID: 27872420 DOI: 10.7863/ultra.15.12007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/25/2016] [Accepted: 03/05/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To compare the accuracy and cutoff points for cervical length for predicting preterm delivery in women with threatened preterm labor between those with a closed cervix and cervical dilatation. METHODS We conducted a retrospective cohort study of women with singleton pregnancies with threatened preterm labor before 34 weeks. The accuracy of cervical length for predicting preterm delivery was compared between women with cervical dilatation (0.5-3 cm) and those with a closed cervix. The predictive accuracy of cervical length for spontaneous preterm delivery was analyzed with several outcome-specific thresholds. RESULTS Overall, 1068 women with threatened preterm labor met the inclusion criteria; of them, 276 (25.8%) had cervical dilatation, and 792 (74.2%) had a closed cervix. The risk of preterm delivery before 37 weeks was significantly higher in the cervical dilatation group than the closed cervix group, as well as a shorter assessment-to-delivery interval of within 14 days (P = .001 and .004, respectively). On a multivariable analysis, cervical length was independently associated with the risk of preterm delivery in both groups. There was no significant difference between women with cervical dilatation and those with a closed cervix regarding the area under the receiver operating characteristic curves of cervical length for prediction of preterm delivery before 37 (0.674 versus 0.618; P = .18) and 34 (0.628 versus 0.640; P = .88) weeks and an assessment-to-delivery interval of 14 days (0.686 versus 0.660; P= .72). The negative predictive value of cervical length ranged from 77.4% to 95.7% depending on the different thresholds used. CONCLUSIONS Cervical length was significantly associated with the risk of preterm delivery in women presenting with threatened preterm labor and cervical dilatation of less than 3 cm. However, the predictive accuracy of cervical length as a single measure was relatively limited.
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Affiliation(s)
- Liran Hiersch
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Melamed
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Aviram
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Bardin
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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109
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Hiersch L, Salzer L, Aviram A, Hadar E, Yogev Y, Ashwal E. Uterine electrical activity at labor: is there a correlation between labor stages? J Matern Fetal Neonatal Med 2016; 30:2620-2625. [DOI: 10.1080/14767058.2016.1259309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Liran Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Salzer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Aviram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eran Ashwal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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110
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Hiersch L, Eitan M, Ashwal E, Weisz B, Chayen B, Lipitz S, Yinon Y. Amniotic fluid discordance in monochorionic diamniotic twin pregnancies is associated with increased risk for twin anemia-polycythemia sequence. Prenat Diagn 2016; 36:1099-1103. [DOI: 10.1002/pd.4939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 09/05/2016] [Accepted: 09/29/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Liran Hiersch
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Mayan Eitan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Benny Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shlomo Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
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111
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Ashwal E, Shinar S, Wertheimer A, Reina L, Miremberg H, Aviram A, Yogev Y, Hiersch L. Presentation to delivery interval in women with early preterm delivery presenting with preterm labor: the effect of gestational age. J Matern Fetal Neonatal Med 2016; 30:2356-2361. [DOI: 10.1080/14767058.2016.1248934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Eran Ashwal
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
| | - Shiri Shinar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avital Wertheimer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
| | - Luciena Reina
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
| | - Hadas Miremberg
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
| | - Amir Aviram
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
| | - Yariv Yogev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Liran Hiersch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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112
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Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SJ, Romero R, Barrett J. Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations? Am J Obstet Gynecol 2016; 215:616.e1-616.e14. [PMID: 27365003 PMCID: PMC5086275 DOI: 10.1016/j.ajog.2016.06.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical length at midtrimester is a powerful predictor of preterm birth in twin gestations. However, given the fact that, in some cases, cervical shortening may become evident only later during the second trimester, it seems reasonable that serial monitoring of cervical length may improve the detection of preterm birth in women with twins. However, data in support of such a practice are limited and conflicting. The contradictory results may be related to the fact that in most of these studies, the analysis of the predictive value of serial measurements of cervical length was limited to data derived from only two sequential measurements of cervical length, while data on the predictive value of multiple (>2) measurements are scarce. OBJECTIVE We sought to determine whether serial measurements of cervical length can improve the prediction of preterm birth in asymptomatic women with twin gestations compared with a single measurement of cervical length at midgestation. STUDY DESIGN This was a retrospective cohort study of women with twin pregnancies followed up in a tertiary medical center from 2012 through 2014. All participants underwent routine measurement of cervical length at midgestation and every 2-3 weeks thereafter until 28-32 weeks. For each patient, cervical length was determined at the following time periods: 18+0 to 21+6 weeks (period 1, routine exam), 22+0 to 24+6 weeks (period 2), 25+0 to 27+6 weeks (period 3), and 28+0 to 32+0 weeks (period 4). Measurements of cervical length at periods 2-4 were analyzed in the form of either absolute length (in millimeters) or percent shortening relative to cervical length at period 1. The performance of a stepwise algorithm that incorporated serial measurements of cervical length for the prediction of preterm birth was compared to that achieved with a single measurement of cervical length at period 1. RESULTS Overall, 441 women with twin pregnancies who were eligible for the study underwent a total of 2374 cervical length measurements. The association of a short cervix (<10th percentile) with preterm birth at <32 weeks persisted in each of the 4 periods of gestation [odds ratio (95% confidence interval): 7.2 (3.1-16.5), 15.3 (6.4-36.7), 10.3 (4.4-24.3), and 23.1(8.3-64.1), respectively]. Compared with a single measurement of cervical length at midgestation (period 1), a stepwise algorithm integrating serial cervical length measurements from all 4 successive gestational age periods resulted in a significant increase in the area under the receiver operating characteristic curve (0.917 vs 0.613, P < .001). Similarly, when a target false-positive rate of 5% was used, the same stepwise algorithm was associated with a higher detection rate (69% vs 28%, P < .001), higher positive likelihood ratio (14.54 vs 5.12), and lower negative likelihood ratio (0.32 vs 0.76) for preterm birth at <32 weeks compared with a single measurement of cervical length at period 1. CONCLUSION Integration of serial measurements of cervical length using a stepwise algorithm in asymptomatic women with twin gestations can improve the detection of women at risk of preterm birth. Prospective studies are needed to validate these findings, and to investigate whether improved risk assessment performance is sufficient to offset the additional costs associated with serial cervical length measurements.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
| | - Alex Pittini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Steven J Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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113
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Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SS, Romero R, Barrett J. Serial cervical length determination in twin pregnancies reveals 4 distinct patterns with prognostic significance for preterm birth. Am J Obstet Gynecol 2016; 215:476.e1-476.e11. [PMID: 27207277 PMCID: PMC5045791 DOI: 10.1016/j.ajog.2016.05.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women with a twin gestation are at increased risk for preterm birth (PTB), and sonographic cervical length (CL) is a powerful predictor for spontaneous PTB. Obstetricians frequently monitor CL in multiple gestations; yet, the optimal method to integrate and interpret the results of serial sonographic CL has not been determined. OBJECTIVE We sought to determine whether there are different patterns of cervical shortening in twin gestations, and whether such patterns are related to the risk of PTB. STUDY DESIGN We conducted a retrospective study of all women with twins followed up in a single tertiary referral center during 2012 through 2014. All women underwent serial measurements of CL every 2-3 weeks starting from 14-18 weeks and until 28-32 weeks of gestation. Changes in CL were analyzed and classified into distinct patterns that were initially identified by visual inspection of all individual cases. Each pattern was then characterized by several parameters including information about when cervical shortening began, the rate of shortening, and whether a plateau was observed. Locally weighted regression mean profiles were generated to describe each pattern of CL over time. The association of these patterns with spontaneous PTB was determined. The specific characteristics of each pattern that further determined the risk of PTB were identified using multivariable logistic regression analysis. RESULTS We studied 441 women who had a total of 2826 measurements of CL done. Overall, 4 main patterns of change in CL were identified: pattern I, stable cervix (n = 196); pattern II, early and rapid shortening (n = 18); pattern III, late shortening (n = 109); and pattern IV, early shortening with a plateau (n = 118). The rate of PTB at <34 weeks was lowest in cases of pattern I (11.7%), followed by pattern IV (14.4%) and pattern III (20.2%), and was highest for women with pattern II (44.4%) (P < .001). In cases with pattern III (late shortening), the most important factors affecting the risk of PTB were the shortening rate, the gestational age at the onset of cervical shortening, and the initial plateau of CL. In the case of pattern IV (early shortening with a plateau), it was only the new plateau at which cervical shortening stopped that was associated with the risk of PTB. CONCLUSION Changes in sonographic CL over time in twin gestations can be classified into 4 patterns, each associated with a different risk of PTB.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
| | - Alex Pittini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven S Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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114
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Abstract
PURPOSE Maternal age is an important consideration for antenatal care, labor and delivery. We aimed to evaluate the induction of labor (IoL) failure rates among elderly nulliparous women. MATERIALS AND METHODS We conducted a retrospective analysis of all nulliparous women at 34 + 0 to 41 + 6 weeks, undergoing cervical ripening by prostaglandin E2 (PGE2) vaginal insert. Study group included elderly (≥35 years) nulliparous and control group included non-elderly (<35 years) nulliparous women. Primary outcome was IoL failure rate and secondary outcome was cesarean delivery rate. Outcomes were compared between the groups by univariate analysis followed by regression analysis to adjust results to potential confounders. RESULTS Of 537 women undergoing IoL, 69 (12.8%) were elderly. The univariate analysis demonstrated no difference in IoL failure rate (26.5% versus 34.8%, p = 0.502) between groups. However, elderly nulliparous women had higher rates of cesarean delivery (36.2% versus 21.4%, p = 0.009). This difference was no longer significant after adjustment for maternal body mass index, indication for delivery, birth weight and gestational age at delivery. CONCLUSION Among nulliparous women, older maternal age is not associated with higher rates of IoL failure or cesarean deliveries.
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Affiliation(s)
- Eran Hadar
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Rony Chen
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Arnon Wiznitzer
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Rinat Gabbay-Benziv
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach-Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
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Hiersch L, Krispin E, Aviram A, Mor-Shacham M, Gabbay-Benziv R, Yogev Y, Ashwal E. Predictors for prolonged interval from premature rupture of membranes to spontaneous onset of labor at term. J Matern Fetal Neonatal Med 2016; 30:1465-1470. [DOI: 10.1080/14767058.2016.1219992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Orbach-Zinger S, Ashwal E, Hazan L, Bracco D, Ioscovich A, Hiersch L, Khinchuck A, Aviram A, Eidelman LA. Risk Factors for Unintended Dural Puncture in Obstetric Patients: A Retrospective Cohort Study. Anesth Analg 2016; 123:972-6. [PMID: 27537928 DOI: 10.1213/ane.0000000000001510] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.
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Affiliation(s)
- Sharon Orbach-Zinger
- From the Departments of *Anesthesia and †Obstetrics and Gynecology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; and ‡Department of Anesthesia, Shaare Zedek Medical Center, Jerusalem, Israel
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Gabbay-Benziv R, Hadar E, Ashwal E, Chen R, Wiznitzer A, Hiersch L. Induction of labor: does indication matter? Arch Gynecol Obstet 2016; 294:1195-1201. [DOI: 10.1007/s00404-016-4171-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/03/2016] [Indexed: 12/01/2022]
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Shmueli A, Salman L, Ashwal E, Hiersch L, Gabbay-Benziv R, Yogev Y, Aviram A. Perinatal outcomes of vacuum assisted versus cesarean deliveries for prolonged second stage of delivery at term. J Matern Fetal Neonatal Med 2016; 30:886-889. [DOI: 10.1080/14767058.2016.1191066] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
OBJECTIVE To identify risk factors for mediolateral episiotomy, and evaluate the risk of obstetrical anal sphincter injury (OASI) among women with an episiotomy. METHODS A retrospective cohort study of all singletons vaginal deliveries at term between 2007 and 2014. Spontaneous and operative vaginal deliveries were compared separately, as well as nulliparous and multiparous women. RESULTS Overall, 41,347 women were included in the spontaneous vaginal delivery group: 12,585 (30.4%) nulliparous and 28,762 (69.6%) multiparous women. Risk factors for episiotomy (nulliparous) were maternal age (aOR 0.98), gestational age (GA, aOR 1.07), regional analgesia (RA, aOR 1.18), labor induction (aOR 1.17), meconium (aOR 1.37) and birth weight (BW, aOR 1.04). Episiotomy was associated with PPH (aOR 1.49). Among multiparous, risk factors were maternal age (aOR 1.04), previous vaginal delivery (aOR 0.38), GA (aOR 1.06), RA (aOR 1.22), meconium (aOR 1.22) and BW (aOR 1.05). Episiotomy was associated with 3rd degree perineal tear (aOR 2.26, 95% CI 1.03-4.97). Only birth weight (nulliparous) and previous vaginal deliveries (multiparous) were contributors for episiotomy in the OVD group. CONCLUSION Several risk factors for mediolateral episiotomy exist. Episiotomy does not protect nulliparous women, and may be associated with an increased risk for multiparous, for OASI. Therefore, the practice of routine episiotomy should be abandoned, and the practice of selective episiotomy reconsidered.
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Affiliation(s)
- Anat Shmueli
- a Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel
| | - Rinat Gabbay Benziv
- a Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel
| | - Liran Hiersch
- b Lis Maternity Hospital, The Tel-Aviv Sourasky Medical Center, Tel Aviv, The Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel , and
| | - Eran Ashwal
- b Lis Maternity Hospital, The Tel-Aviv Sourasky Medical Center, Tel Aviv, The Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel , and
| | - Rami Aviram
- c Department of Obstetrics and Gynecology , Meir Medical Center, Kfar Saba, The Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel
| | - Yariv Yogev
- b Lis Maternity Hospital, The Tel-Aviv Sourasky Medical Center, Tel Aviv, The Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel , and
| | - Amir Aviram
- b Lis Maternity Hospital, The Tel-Aviv Sourasky Medical Center, Tel Aviv, The Sackler Faculty of Medicine, Tel-Aviv University , Ramat-Aviv , Israel , and
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Gabbay-Benziv R, Aviram A, Bardin R, Ashwal E, Melamed N, Hiersch L, Wiznitzer A, Yogev Y, Hadar E. Prediction of Small for Gestational Age: Accuracy of Different Sonographic Fetal Weight Estimation Formulas. Fetal Diagn Ther 2016; 40:205-213. [DOI: 10.1159/000443881] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/28/2015] [Indexed: 11/19/2022]
Abstract
Objective: To compare the accuracy of various sonographic estimated fetal weight (sEFW) formulas for the prediction of small for gestational age (SGA) neonates. Methods: A retrospective analysis of 6,126 fetal biometrical measurements performed within 3 days of delivery. SGA prediction was evaluated for various sEFW formulas by calculating the sensitivity, specificity, positive/negative predictive value (PPV/NPV), likelihood ratio (+LR/-LR), overall accuracy and area under the receiver operating characteristic curve (AUC). Systematic error, random error, proportion of estimates >10% of birth weights, actual and absolute weight differences were compared between SGA and non-SGA neonates. Results: Overall, 638 (10.4%) neonates were SGA. There was considerable variation among formulas in sensitivity (mean ± SD, 62 ± 14.4%; range, 32.4-91.2), PPV (72.5 ± 10.7%; 45.8-95.6) and +LR (24.2 ± 10.9; 7.2-57.3), mild variation in specificity (96.6 ± 2.7%; 87.4-99.4), NPV (94.6 ± 5.3%; 72.2-98.9) and -LR (0.4 ± 0.1; 0.1-0.7) and minimal variation in AUC (mean, 0.93; range, 0.91-0.93). The majority of formulas had a lower accuracy for the SGA neonates, with systematic error and random error ranging from -4.2 to 14.3% and from 8.4 to 12.9% for SGA, and from -8.7 to 16.1% and from 7.2 to 10.5% for non-SGA, respectively. Conclusion: sEFW formulas differ in their accuracy for SGA prediction. In our population, the most accurate formula for SGA prediction was Hadlock's formula utilizing femur length, abdominal and head circumference.
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Aviram A, Guy L, Ashwal E, Hiersch L, Yogev Y, Hadar E. Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth. Diabetes Res Clin Pract 2016; 113:198-203. [PMID: 26810272 DOI: 10.1016/j.diabres.2015.12.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 10/15/2015] [Accepted: 12/24/2015] [Indexed: 11/17/2022]
Abstract
AIM To assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering at the late preterm period. METHODS Retrospective observational cohort of all women with GDM who delivered a singleton fetus at the late preterm birth period (34+0/7 to 36+6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM. RESULTS 1849 women were included in the study, of whom 132 (7.1%) were diagnosed with GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal delivery (45.5% vs. 62.9%, p<0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%, p<0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24-2.66, p=0.002). Neonates of mothers with GDM had significant higher mean birth weight and birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity. CONCLUSION according to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications.
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Affiliation(s)
- Amir Aviram
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Liora Guy
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Eran Ashwal
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Liran Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Yariv Yogev
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel.
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Aviram A, Shmueli A, Hiersch L, Ashwal E, Wiznitzer A, Yogev Y, Hadar E. Pregnancy Outcome in Women with Decreased Sensation of Fetal Movements at Term According to Parity. Birth 2016; 43:42-8. [PMID: 26643600 DOI: 10.1111/birt.12205] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Decreased sensation of fetal movements (DFM) is a common maternal complaint. Thus, we aimed to evaluate the association between DFM and pregnancy outcome in singleton gestation at term according to parity. METHODS A retrospective cohort study of singleton pregnancies at term between 2008 and 2013. Eligibility was limited to women carrying a fetus with no known structural or chromosomal anomalies, at 37+0/7 to 42+0/7 weeks of gestation. Women presenting to the delivery ward with DFM were compared with women without similar complaints. RESULTS Overall, 12,564 nulliparous women and 25,292 multiparous women gave birth during the study period; of them, 300 nulliparous women (2.4%) and 525 multiparous women (2.1%) complained of DFM. For nulliparous women, after adjusting for potential confounders, DFM was associated with antepartum fetal death (aOR 4.6 [95% CI 1.1-19.8]), cesarean delivery (CD) (aOR 1.3 [95% CI 1.01-1.8]), 1-minute Apgar score less than 7 (aOR 2.3 [95% CI 1.5-3.5]) and neonatal seizures (aOR 3.2 [95% CI 1.3-8.2]). For multiparous women, DFM was associated with unscheduled CD (aOR 2.7 [95% CI 1.6-4.6]) and CD indicated by intermediate/abnormal fetal heart rate tracing (aOR 4.8 [95% CI 2.8-8.4]). CONCLUSIONS DFM carries different outcomes according to parity. Although for nulliparous women, DFM is associated with increased risk of CD and immediate adverse perinatal outcome, for multiparous women it is associated with increased risk for CD, with no immediate increased risk for adverse perinatal outcome.
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Affiliation(s)
- Amir Aviram
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Anat Shmueli
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Liran Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Eran Ashwal
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Arnon Wiznitzer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Yariv Yogev
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
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123
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Hiersch L, Krispin E, Aviram A, Wiznitzer A, Yogev Y, Ashwal E. Effect of Meconium-Stained Amniotic Fluid on Perinatal Complications in Low-Risk Pregnancies at Term. Am J Perinatol 2016; 33:378-84. [PMID: 26479168 DOI: 10.1055/s-0035-1565989] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study aims to determine the impact of meconium-stained amniotic fluid (MSAF) in low-risk pregnancies at term on pregnancy outcome. STUDY DESIGN A retrospective cohort study of women with MSAF during labor who delivered in a tertiary hospital at 37 to 41(+6) weeks of gestation (2007-2013). Exclusion criteria included: multiple gestations, noncephalic presentation, fetal structural/chromosomal anomalies, hypertensive disorders, diabetes, oligohydramnios, or small for gestational age. Pregnancy outcome of women with MSAF (N = 4,893) was compared with a control group of women without MSAF (N = 39,651). Neonatal respiratory morbidity was defined as the presence of any of the following: respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, or need for ventilatory support. RESULTS Overall, 10.9% of low-risk pregnancies at term were diagnosed with MSAF. Compared with the controls, women with MSAF had higher rates of nulliparity, gestational age at delivery ≥ 41 weeks, induction of labor, nonreassuring fetal heart rate, and operative deliveries. In multivariate analysis MSAF was associated with operative delivery (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.63-2.09; p < 0.001), cesarean section (OR, 1.48; 95% CI, 1.31-1.69; p < 0.001), respiratory morbidity (OR, 4.74; 95% CI, 3.87-5.82; p < 0.001), and increased risk for short-term neonatal morbidity. CONCLUSIONS MSAF is associated with a higher rate of adverse perinatal outcome even in low-risk pregnancies at term.
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Affiliation(s)
- Liran Hiersch
- Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Krispin
- Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Aviram
- Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Wiznitzer
- Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Ashwal
- Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bardin R, Aviram A, Meizner I, Ashwal E, Hiersch L, Yogev Y, Hadar E. Association of fetal biparietal diameter with mode of delivery and perinatal outcome. Ultrasound Obstet Gynecol 2016; 47:217-223. [PMID: 25728404 DOI: 10.1002/uog.14837] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To determine the association between sonographic assessment of fetal biparietal diameter (BPD) and pregnancy outcome. METHODS This was a retrospective cohort study of pregnancies at 37-42 weeks of gestation which had antepartum sonographic measurement of BPD within 7 days before delivery. Eligibility was limited to singleton pregnancies with neither known structural or chromosomal abnormalities nor prelabor Cesarean delivery (CD). The association of BPD with outcome was analyzed using multivariate logistic regression, receiver-operating characteristics curves and stratification according to BPD quartiles. RESULTS In total, 3229 women were eligible for analysis, of whom 2483 (76.9%) had a spontaneous vaginal delivery (SVD), 418 (12.9%) underwent operative vaginal delivery (OVD) and 328 (10.2%) underwent CD. The mean BPD in the obstetric intervention groups (OVD and CD) was significantly higher than that in the SVD group (P < 0.001). After adjusting for confounders, increased BPD was an independent risk factor such that higher values of BPD were associated with progressively higher risk of obstetric intervention (adjusted odds ratio, 1.05 for each 1-mm increase in BPD (95% CI, 1.02-1.09)), but no clear cut-off value for obstetric intervention was found. The fourth quartile group (BPD ≥ 97 mm) was associated with a significantly lower SVD rate (P < 0.001) and higher OVD rate (P = 0.04), relative to the first (BPD 88-90 mm) and second (BPD 91-93 mm) quartile groups, with no apparent adverse impact on immediate neonatal outcome. CONCLUSIONS Increased BPD within the week prior to delivery is an independent risk factor such that higher values of BPD are associated with progressively higher risk of obstetric intervention; however, in our experience, no adverse neonatal outcome resulted from such intervention. Thus, increased BPD should not discourage a trial of vaginal delivery.
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Affiliation(s)
- R Bardin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Aviram
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Meizner
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Ashwal
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Yogev
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hiersch L, Ashwal E, Topaz L, Porter A, Aviram A, Hadar E, Hod M, Yogev Y, Wiznitzer A. 784: Endothelial function assessment of women with gestational hypertensive disorders using a non-invasive peripheral artery tone plethysmography. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Aviram A, Gabbay-Benziv R, Hiersch L, Ashwal E, Hadar E, Wiznitzer A, Yogev Y. 686: Predictions of large for gestational age by various sonographic fetal weight estimation formulas--how accurate are we? Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ashwal E, Hiersch L, Melamed N, Berezowsky A, Aviram A, Wiznitzer A, Yogev Y. 676: Birthweight as a predictor of maternal and neonatal morbidity. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Aviram A, Hadar E, Hiersch L, Ashwal E, Gabbay-Benziv R, Wiznitzer A, Yogev Y. 225: Is it safe to perform vacuum extraction in neonates under 2500 grams? Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ashwal E, Hiersch L, Aviram A, Hadar E, Calderon I, Wiznitzer A, Yogev Y. 487: A new approach for intrapartum fetal heart rate tracing. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ashwal E, Hiersch L, Aviram A, Gabbay-Benziv R, Hadar E, Wiznitzer A, Yogev Y. 813: Prepregnancy body mass index and gestational weight gain and the risk for adverse perinatal outcome in non-diabetic gravidas. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gabbay-Benziv R, Aviram A, Ashwal E, Hiersch L, Melamed N, Hadar E, Yogev Y. 673: Sonographic prediction of small for gestational age--which formula is more accurate? Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Aviram A, Borovich A, Hadar E, Gabbay-Benziv R, Hiersch L, Ashwal E, Wiznitzer A, Yogev Y. 382: Delivery versus expectant management for women attempting trial of labor after previous single cesarean delivery (CD) at term -Stratification of pregnancy outcomes by gestational age. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hiersch L, Ashwal E, Asher D, Aviram A, Hadar E, Gabbay-Benziv R, Wiznitzer A, Yogev Y. 521: Risk factors for post-partum hemorrhage following vacuum extraction. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Krissi H, Aviram A, Hiersch L, Ashwal E, Eitan R, Peled Y. Structured hands-on workshop decreases the over-detection rate of obstetrical anal sphincter injuries. Int J Colorectal Dis 2016; 31:45-50. [PMID: 26293790 DOI: 10.1007/s00384-015-2365-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to assess the effect of a structured hands-on workshop on the detection rate of obstetric anal sphincter injuries. METHODS All physicians attending the delivery ward in our institution participated in a structured obstetric anal sphincter injury hands-on workshop developed by Dr. Ranee Thakar and Dr. Abdul Sultan which demonstrated proper identification and techniques for obstetric anal sphincter injury detection and repair. We retrospectively reviewed the electronic records of all singleton-pregnancy women who delivered vaginally (vertex presentation) during the 2 years prior to and 1 year following the workshop to assess the workshop's effect on the rate of detection of obstetric anal sphincter injuries. RESULTS Overall, 20,484 women met the inclusion criteria during the study period and were eligible for final analysis. There were no significant differences in patient's characteristics between the groups. Women in the pre-workshop group had a higher rate of obstetric anal sphincter injuries than the post-workshop group (0.4 vs. 0.2 %, p = 0.005). On multivariate analysis, factors independently associated with a decreased risk for obstetric anal sphincter injuries were deliveries in the post-workshop period (odds ratio 0.43, 95 % confidence interval 0.24-0.79, p = 0.006), parity (odds ratio 0.37, 95 % confidence interval 0.25-0.54, p < 0.001), and spontaneous vaginal delivery (odds ratio 0.43, 95 % confidence interval 0.26-0.71, p = 0.001). CONCLUSIONS A proper detection of obstetric anal sphincter injuries may depend on the experience of the assessor. A structured hands-on workshop is important to avoid over diagnosis third-degree perineal tears.
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Affiliation(s)
- Haim Krissi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel.
| | - Amir Aviram
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Ram Eitan
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Yoav Peled
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
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Krissi H, Hiersch L, Aviram A, Ashwal E, Goldschmit C, Peled Y. Factors Affecting Adnexal Torsion Direction: A Retrospective Cohort Study. Gynecol Obstet Invest 2015; 81:405-10. [PMID: 26670007 DOI: 10.1159/000441789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022]
Abstract
AIMS To investigate a trend for adnexal torsion direction and factors that may be associated with direction. METHODS We retrospectively reviewed the medical files of all women who underwent exploratory laparoscopy for suspected ovarian torsion in our center from August 2010 to December 2012. RESULTS Fifty-five women had laparoscopically proven torsion. Medial rotation, defined as clockwise rotation of the left adnexa or counterclockwise rotation of the right adnexa, with the proximal (lateral) segment of the infundibulopelvic ligament serving as the referral point was noted in most cases (n = 47, 85.5%). There was no statistically significant difference between the medial and lateral rotation groups. However, the proportion of pregnant women and mean parity were significantly higher in the lateral compared to the medial rotation group: 62.5 vs. 19.1%, p = 0.009 and 1.1 ± 1.2 vs. 0.1 ± 0.4, p < 0.001. Medial torsion was present in 64.3% of pregnant women vs. 92.7% of nonpregnant women, p = 0.009. CONCLUSION The direction of ovarian or adnexal torsion is usually medially rotated, opposite to the psoas muscles and the great blood vessels on the same side. However, surgeons should be aware of an increased rate of lateral rotation among pregnant women.
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Affiliation(s)
- Haim Krissi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
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Ashwal E, Aviram A, Wertheimer A, Krispin E, Kaplan B, Hiersch L. The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial. J Matern Fetal Neonatal Med 2015; 29:3024-9. [PMID: 26669965 DOI: 10.3109/14767058.2015.1114079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity. METHODS Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4 cm dilation). The primary measured outcome was the length of second stage of labor. RESULTS Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery. CONCLUSION Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.
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Affiliation(s)
- Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Avital Wertheimer
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Eyal Krispin
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Boris Kaplan
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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Ashwal E, Krissi H, Hiersch L, Less S, Eitan R, Peled Y. Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls. J Pediatr Adolesc Gynecol 2015; 28:526-9. [PMID: 26168769 DOI: 10.1016/j.jpag.2015.03.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 03/13/2015] [Accepted: 03/19/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To describe the clinical characteristics and treatment of ovarian torsion in premenarchal girls with surgically verified ovarian torsion. DESIGN AND PARTICIPANTS A retrospective cohort study design was used. The medical charts of all premenarchal girls with surgically verified ovarian torsion treated in a university-affiliated tertiary medical center from 1997 to 2012 were reviewed for clinical, treatment, and outcome data. RESULTS Thirty-two premenarchal girls were identified. Their median age was 9 years. There were 7 recurrences during the study period (17.9%), for a total of 39 cases. The main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Physical examination revealed abdominal tenderness in 25 cases (64.1%). Abdominal ultrasound, performed in 31 patients (38 cases), yielded pathologic findings in 28 (73.7%), mainly an enlarged ovary (11 cases, 28.9%). Doppler flow studies were abnormal in 15 cases. In 26 cases (68.4%), the tentative preoperative working diagnosis was ovarian torsion. Laparoscopy was performed in 26 cases, laparotomy in 10, and laparoscopy converted to laparotomy in 3 cases. Conservative management, mainly with additional cyst drainage or cystectomy, was used in 37 cases (95.2%) with oophoropexy in 5 cases. Two patients required oophorectomy because of a suspected neoplasm and severe ovarian necrosis. Pathologic examination demonstrated 5 simple cysts, 1 necrotic ovary, and 1 mature cystic teratoma. CONCLUSIONS Ovarian torsion in premenarchal girls is associated with nonspecific signs and symptoms. Abdominal ultrasound and Doppler imaging may assist in the diagnosis. Laparoscopy with conservative management is preferred. Owing to the high recurrence rate, oophoropexy may be considered.
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Affiliation(s)
- Eran Ashwal
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Krissi
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Saharon Less
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ram Eitan
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Peled
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Ashwal E, Wertheimer A, Aviram A, Orbach-Zinger S, Yogev Y, Hiersch L. Maternal hemoglobin decline following 'uneventful' cesarean delivery. J Matern Fetal Neonatal Med 2015; 29:3061-5. [PMID: 26514072 DOI: 10.3109/14767058.2015.1114086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess hemoglobin (Hb) decline following elective and non-elective uneventful cesarean section (CS). METHODS A retrospective cohort study of all women with singleton pregnancy who underwent uneventful CS defined as clinical estimation of intra-operative bleeding < 1000 ml. Hemoglobin decline (pre- and post-CS levels difference) of women with non-elective CS (during labor/delivery process) were compared to those who underwent elective CS (no labor). Cases complicated by placenta previa/abruption were excluded. RESULTS Overall 2767 women underwent uneventful CS, of them, 954 (34.5%) were non-elective and 1813 (65.5%) were elective. Hemoglobin decline was higher in the non-elective group (1.5 ± 1.3 versus 1.0 ± 1.2 g/dL, p < 0.001). This was also observed in the nulliparous patients as well as in those with previous single CS subgroups. The rate of Hb decline ≥3 g/dL and the rate of post-CS Hb < 7 g/dL were higher in the non-elective group (8.9% versus 3.1%, p < 0.001 and 2.3% versus 0.4%, p = 0.001, respectively). On multivariable analysis, non-elective CS was found to be significantly associated with Hb decline of ≥3 g/dl after surgery (aOR = 2.10, 95% CI 1.36-3.23, p = 0.001) and need for blood products transfusion (aOR = 2.24, 95% CI 1.04-4.83, p = 0.03). CONCLUSION Non-elective CS was associated with an increased risk of Hb decline and blood product transfusion even in an apparent uneventful operation.
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Affiliation(s)
- Eran Ashwal
- a Helen Schneider Hospital for Women , Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Avital Wertheimer
- a Helen Schneider Hospital for Women , Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Amir Aviram
- a Helen Schneider Hospital for Women , Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Sharon Orbach-Zinger
- a Helen Schneider Hospital for Women , Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Yariv Yogev
- a Helen Schneider Hospital for Women , Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women , Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
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Aviram A, Hiersch L, Ashwal E, Yogev Y, Hadar E. The association between myometrial electrical activity and time to delivery in threatened preterm labor. J Matern Fetal Neonatal Med 2015; 29:2897-903. [PMID: 26493342 DOI: 10.3109/14767058.2015.1110571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the association between myometrial electrical activity and time-to-delivery in preterm labor using uterine electromyography. METHODS Myometrial electrical activity was measured via the electrical uterine monitor (EUM) device. Data was prospectively collected among women admitted due to suspected preterm labor, prior to 34 weeks of gestation. EUM-Index was defined as the mean electrical activity of the uterine muscle over a period of 10 minutes measured in units of microjoule (μJ, microwatt second). The association between the EUM-Index at admission to time-to-delivery and delivery prior to 34 weeks of gestation was calculated. RESULTS Overall, 45 women were included in the study. EUM-Index combined with cervical dilatation, demonstrated significant correlation to time-to-delivery (R(2 )= 0.49, p = 0.005), which was strengthened for women presenting prior to 28 weeks of gestation. EUM-Index above the median (>3.05 MJ) was significantly associated with a shorter latency period for delivery (36.0 ± 19.4 vs. 50.2 ± 25.9 days, p = 0.04). For delivery prior to 34 weeks, the EUM-Index showed an AUC = 0.65 (95% CI 0.48-0.82), and a cutoff of 2.5 MJ provided 91.7% sensitivity and 93.3% negative predictive value. CONCLUSION EUM-Index at time of admission due to suspected preterm labor is inversely correlated with time-to-delivery and may effectively rule out preterm delivery prior to 34 weeks.
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Affiliation(s)
- Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center, Israel and the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center, Israel and the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center, Israel and the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Yariv Yogev
- a Helen Schneider Hospital for Women, Rabin Medical Center, Israel and the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eran Hadar
- a Helen Schneider Hospital for Women, Rabin Medical Center, Israel and the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
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Ashwal E, Wertheimer A, Aviram A, Wiznitzer A, Yogev Y, Hiersch L. Prediction of successful trial of labor after cesarean - the benefit of prior vaginal delivery. J Matern Fetal Neonatal Med 2015; 29:2665-70. [PMID: 26399162 DOI: 10.3109/14767058.2015.1099156] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine predictive factors for vaginal birth after cesarean section (VBAC). METHODS A retrospective cohort study of all women with singleton pregnancies and a prior single low transverse cesarean section (CS) who attempted vaginal delivery in a tertiary hospital (2010-2014). Pregnancy outcome of women with VBAC was compared to those who failed vaginal delivery. Sub-analysis for women with no prior vaginal deliveries was performed. Pregnancies with non-cephalic presentation, estimated fetal weight >4000 g and any contraindications for vaginal delivery were excluded. RESULTS Of the 40 714 deliveries, 1767 women met inclusion criteria. Among them 1563 (88.5%) had a VBAC and 204 (11.5%) failed. There was no significant difference between the groups regarding maternal age, comorbidities and pregnancy complications. Predictors for VBAC were (odds ratio, 95% confidence interval) interval from prior CS (1.13, 1.04-1.22, p=0.004), previous VBAC (2.77, 1.60-4.78, p < 0.001), prior vaginal delivery prior to the CS (3.05, 1.73-5.39, p < 0.001) and induction of labor (0.62, 0.40-0.97, p = 0.03). For women with no prior vaginal birth, only birthweight was associated with VBAC (0.99, 0.99-1.00, p = 0.02). CONCLUSION While different variables may influence the rate of VBAC, the predictive ability of VBAC for women with no previous vaginal deliveries remains poor.
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Affiliation(s)
- Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Avital Wertheimer
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Arnon Wiznitzer
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Yariv Yogev
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
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Hiersch L, Yeoshoua E, Miremberg H, Krissi H, Aviram A, Yogev Y, Ashwal E. The association between Mullerian anomalies and short-term pregnancy outcome. J Matern Fetal Neonatal Med 2015; 29:2573-8. [PMID: 26395238 DOI: 10.3109/14767058.2015.1098613] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the association between Mullerian anomalies (MuAs) and short-term perinatal outcome. STUDY DESIGN A retrospective cohort study, comparing pregnancy outcome in women with and without MuAs matched by age, number of fetuses and parity in a 1:2 ratio. RESULTS Among 243 women with MuAs, 156 (64.2%) had bicornuate uterus, 38 (15.6%) had septate uterus, 27 (11.1%) had unicornuate uterus and 22 (9.1%) had didelphic uterus. Compared to controls (n = 486), women with MuAs had higher rates of previous preterm deliveries (PTDs) (20.2 versus 5.9%, p < 0.001) and previous cesarean section (CS) (50.6% versus 12.5%, p < 0.001). Women with MuAs had higher rates of PTDs <37 weeks (25.1% versus 6.1%, p < 0.001) and <32 weeks (4.1% versus 0.6%, p = 0.001), preterm premature rupture of membranes (PPROM) (12.8% versus 2.7%, p < 0.001) and small for gestational age (SGA) infants (12.3 versus 6.8%, p = 0.01). There was higher rate of CS in the MuA group (82.3 versus 22.1%, p < 0.001), mainly due to higher rates of malpresentation and previous CS. In multivariate analysis, MuA was associated with SGA (2.04, 1.15-3.63), PTDs <37 weeks (3.72, 1.79-7.73), PTDs <32 weeks (7.40, 1.54-35.56), PPROM (6.31, 3.04-13.12), malpresentation (21.62, 12.49-37.45) and retained placenta (4.13, 1.73-9.86). No increased risk was observed in the rate of in-labor CS (0.52, 0.21-1.30, p = 0.16). When the rate of adverse outcomes was stratified according to MuAs subtypes, women with unicornuate uterus had the highest rate of breech presentation at delivery (55.6%) and women with didelphy uterine had the highest proportion of PTDs <37 weeks (40.9%). CONCLUSION Women with MuAs are at increased risk for adverse pregnancy outcome, mainly PTDs + and PPROM, SGA infants and CS due to malpresentation. However, the risk of in-labor CS is not increased compared to the general population.
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Affiliation(s)
- Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Effi Yeoshoua
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Hadas Miremberg
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Haim Krissi
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Yariv Yogev
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah Tikva , Israel and.,b Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
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Aviram A, Yogev Y, Bardin R, Hiersch L, Wiznitzer A, Hadar E. Association between sonographic measurement of fetal head circumference and labor outcome. Int J Gynaecol Obstet 2015; 132:72-6. [PMID: 26433468 DOI: 10.1016/j.ijgo.2015.06.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 05/29/2015] [Accepted: 09/10/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the association between sonographically measured head circumference (HC) and labor outcome. METHODS In a retrospective study at a tertiary medical center in Israel, data were reviewed for all term singleton deliveries between July 2007 and December 2012 with HC measurements up to 7days before delivery. HC was compared between women with operative vaginal delivery (OVD) or cesarean delivery for prolonged second stage and those with normal vaginal delivery. The impact of HC above the 75th percentile on pregnancy outcome was analyzed. RESULTS The study included 2351 women, of whom 2045 (87.0%) had a normal vaginal delivery, 259 (11.0%) underwent OVD, and 47 (2.0%) cesarean. Each 10mm increase in HC was associated with increased risk for obstetric intervention because of a prolonged second stage (adjusted odds ratio [aOR] 1.26; 95% confidence interval [CI] 1.08-1.46). HC above the 75th percentile was independently associated with increased odds of OVD (aOR 1.77; 95% CI 1.30-2.41), 1-minute Apgar score less than 7 (aOR 2.91; 95% CI 1.50-5.66), and neonatal asphyxia (aOR 2.19; 95% CI 1.02-4.71). CONCLUSION Term HC above the 75th percentile was associated with increased rates of obstetric interventions because of a prolonged second stage and might be associated with neonatal asphyxia.
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Affiliation(s)
- Amir Aviram
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.
| | - Yariv Yogev
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Ron Bardin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Liran Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Arnon Wiznitzer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
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Ashwal E, Wertheimer A, Aviram A, Pauzner H, Wiznitzer A, Yogev Y, Hiersch L. The association between fetal head position prior to vacuum extraction and pregnancy outcome. Arch Gynecol Obstet 2015; 293:567-73. [DOI: 10.1007/s00404-015-3884-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 09/04/2015] [Indexed: 11/29/2022]
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Melamed N, Hiersch L, Gabbay-Benziv R, Bardin R, Meizner I, Wiznitzer A, Yogev Y. Predictive value of cervical length in women with twin pregnancy presenting with threatened preterm labor. Ultrasound Obstet Gynecol 2015; 46:73-81. [PMID: 25251479 DOI: 10.1002/uog.14665] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/08/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess the accuracy and determine the optimal threshold of sonographic cervical length (CL) for the prediction of preterm delivery (PTD) in women with twin pregnancies presenting with threatened preterm labor (PTL). METHODS This was a retrospective study of women with twin pregnancies who presented with threatened PTL and underwent sonographic measurement of CL in a tertiary center. The accuracy of CL in predicting PTD in women with twin pregnancies was compared with that in a control group of women with singleton pregnancies. RESULTS Overall, 218 women with a twin pregnancy and 1077 women with a singleton pregnancy, who presented with PTL, were included in the study. The performance of CL as a predictive test for PTD was similar in twins and singletons, as reflected by the similar correlation between CL and the examination-to-delivery interval (r, 0.30 vs 0.29; P = 0.9), the similar association of CL with risk of PTD, and the similar areas under the receiver-operating characteristics curves for differing delivery outcomes (range, 0.653-0.724 vs 0.620-0.682, respectively; P = 0.3). The optimal threshold of CL for any given target sensitivity or specificity was lower in twin than in singleton pregnancies. However, in order to achieve a negative predictive value of 95%, a higher threshold (28-30 mm) should be used in twin pregnancies. Using this twin-specific CL threshold, women with twins who present with PTL are more likely to have a positive CL test, and therefore to require subsequent interventions, than are women with singleton pregnancies with PTL (55% vs 4.2%, respectively). CONCLUSION In women with PTL, the performance of CL as a test for the prediction of PTD is similar in twin and singleton pregnancies. However, the optimal threshold of CL for the prediction of PTD appears to be higher in twin pregnancies, mainly owing to the higher baseline risk for PTD in these pregnancies.
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Affiliation(s)
- N Melamed
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L Hiersch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Gabbay-Benziv
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Bardin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Meizner
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Wiznitzer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Yogev
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hiersch L, Ashwal E, Aviram A, Rayman S, Wiznitzer A, Yogev Y. The association between previous single first trimester abortion and pregnancy outcome in nulliparous women. J Matern Fetal Neonatal Med 2015; 29:1457-61. [DOI: 10.3109/14767058.2015.1051022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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146
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Aviram A, Ashwal E, Hiersch L, Hadar E, Wiznitzer A, Yogev Y. The effect of intrapartum dental support use among nulliparous during the second stage of labor - a randomized controlled study. J Matern Fetal Neonatal Med 2015; 29:868-71. [PMID: 25777794 DOI: 10.3109/14767058.2015.1024648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We aimed to determine the effect of a dental support device (DSD) use on the course of labor and delivery in nulliparous women. METHODS A randomized, controlled, open-label study of nulliparous (at 37 + 0/7 and 41 + 3/7 weeks of gestation) in a single tertiary university-affiliated medical center. Exclusion criteria included maternal chronic diseases, multi-fetal gestation and fetal chromosomal or structural anomalies. Outcomes were analyzed according to the actual use of the DSD, and satisfaction questionnaires following delivery. RESULTS Overall, 191 women were randomized (93in the study group and 98 in the control group). The median duration of the second stage was similar between the groups (100.0 ± 91.0 versus 98.0 ± 128.8 min, p = 0.97) and the maximal VAS score was significantly higher in the DSD group (4.0 ± 8.5 versus 3.0 ± 6.8, p = 0.04). The rate of obstetrical interventions such as operative vaginal delivery or cesarean section during the second stage was significantly higher in the control group than in the study group (28.2% versus 12.3% and 6.4% versus 1.2%, respectively, p = 0.004), mainly due to prolonged second stage of labor (24.5% versus 8.6%, p = 0.005). Of the DSD group, 50.6% rated the use of the DSD as comfortable, 32.2% rated its effect on pain relief as high, 55.6% would recommend its use to their peers and 51.9% would like to use it in their consecutive delivery. CONCLUSION The use of a DSD among nulliparous women appears to decrease the need for obstetrical intervention due to prolonged second stage of labor, with fair satisfaction of patients.
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Affiliation(s)
- Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah-Tikva , Israel and.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah-Tikva , Israel and.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah-Tikva , Israel and.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Eran Hadar
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah-Tikva , Israel and.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Arnnon Wiznitzer
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah-Tikva , Israel and.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Yariv Yogev
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petah-Tikva , Israel and.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
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Hiersch L, Yogev Y. Management of diabetes and pregnancy – When to start and what pharmacological agent to choose? Best Pract Res Clin Obstet Gynaecol 2015; 29:225-36. [DOI: 10.1016/j.bpobgyn.2014.04.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 04/13/2014] [Indexed: 12/16/2022]
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148
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Hiersch L, Ashwal E, Aviram A, Salzer L, Hadar E, Wiznitzer A, Yogev Y. 502: Myometrial electrical activity at labor – Is there a correlation between labor stages? Am J Obstet Gynecol 2015. [DOI: 10.1016/j.ajog.2014.10.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hiersch L, Ashwal E, Aviram A, Miremberg H, Wiznitzer A, Yogev Y. 352: Are mullerian anomalies associated with increased risk for adverse pregnancy outcome? Am J Obstet Gynecol 2015. [DOI: 10.1016/j.ajog.2014.10.398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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150
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Aviram A, Ashwal E, Hiersch L, Hadar E, Wiznitzer A, Yogev Y. 125: Decreased perception of fetal movements at term among nulliparous women – old complaint, new insights? Am J Obstet Gynecol 2015. [DOI: 10.1016/j.ajog.2014.10.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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