Induction of labor in term pregnancies with isolated polyhydramnios: Is it beneficial or harmful?

OBJECTIVE

To compare rates of adverse pregnancy outcomes in term pregnancies complicated by polyhydramnios between women who had induction of labor (IOB) versus women who had expectant management.

METHODS

This multicenter retrospective study included term pregnancies complicated by isolated polyhydramnios. Patients who underwent IOB were compared with those who had expectant management. The primary outcome was defined as a composite adverse maternal outcome, and secondary outcomes were various maternal and neonatal adverse outcomes. Univariate analyses were followed by multivariate logistic regression.

RESULTS

A total of 865 pregnancies with term isolated polyhydramnios were included: 169 patients underwent IOB (19.5%), while 696 had expectant management and developed spontaneous onset of labor (80.5%). Women who underwent IOB had significantly higher rates of composite adverse maternal outcome (23.1% vs 9.8%, P < 0.01), prolonged hospital stay, perineal tear grade 3/4, intrapartum cesarean, postpartum hemorrhage, blood products transfusion, and neonatal asphyxia compared with expectant management. While the perinatal fetal death rate was similar between the groups (0.6% vs 0.6%, P = 0.98), the timing of the loss was different. Four women in the expectant management group had a stillbirth, while in the induction group one case of intrapartum fetal death occurred due to uterine rupture. Multivariate analyses revealed that IOB was associated with a higher rate of composite adverse maternal outcome (adjusted odds ratio, 2.22 [95% CI, 1.28-3.83]; P < 0.01).

CONCLUSION

IOB in women with term isolated polyhydramnios is associated with higher rates of adverse maternal outcomes in comparison to expectant management. Further research is needed to determine the optimal approach for the management of isolated polyhydramnios at term.

Impact of prior use of topical hemostatic agents on trial of labor after cesarean: Insights from a multicenter cohort study

OBJECTIVE

To evaluate the association between a topical hemostatic agent used at the time of cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean (TOLAC).

METHODS

A multicenter retrospective cohort study was conducted (2005-2021). Parturients with a singleton pregnancy in whom a topical hemostatic agent was placed during the primary cesarean delivery were compared with patients in whom no such agent was placed. We assessed the uterine scar disruption rate after the subsequent TOLAC and the rate of adverse maternal outcomes. Univariate analyses were followed by multivariate analysis (adjusted odds ratio [aOR]; 95% confidence interval [CI]).

RESULTS

During the study period, 7199 women underwent a trial of labor and were eligible for the study; 430 (6.0%) had prior use of a hemostatic agent, 6769 (94.0%) did not. In univariate analysis, a history of topical hemostatic agent use was not found to be significantly associated with uterine scar rupture, dehiscence, or failed trial of labor. This was also confirmed on multivariate analysis for uterine rupture (aOR 1.91, 95% CI 0.66-5.54; P = 0.23), dehiscence of uterine scar (aOR 1.62, 95% CI 0.56-4.68; P = 0.37), and TOLAC failure (aOR 1.08, 95% CI 0.79-1.48; P = 0.61).

CONCLUSION

A history of hemostatic agent use is not associated with an increased risk for uterine scar disruption after subsequent TOLAC. Further prospective studies in other settings are needed to strengthen these findings.

Evaluating the validity of ChatGPT responses on common obstetric issues: Potential clinical applications and implications

OBJECTIVE

To evaluate the quality of ChatGPT responses to common issues in obstetrics and assess its ability to provide reliable responses to pregnant individuals. The study aimed to examine the responses based on expert opinions using predetermined criteria, including "accuracy," "completeness," and "safety."

METHODS

We curated 15 common and potentially clinically significant questions that pregnant women are asking. Two native English-speaking women were asked to reframe the questions in their own words, and we employed the ChatGPT language model to generate responses to the questions. To evaluate the accuracy, completeness, and safety of the ChatGPT's generated responses, we developed a questionnaire with a scale of 1 to 5 that obstetrics and gynecology experts from different countries were invited to rate accordingly. The ratings were analyzed to evaluate the average level of agreement and percentage of positive ratings (≥4) for each criterion.

RESULTS

Of the 42 experts invited, 20 responded to the questionnaire. The combined score for all responses yielded a mean rating of 4, with 75% of responses receiving a positive rating (≥4). While examining specific criteria, the ChatGPT responses were better for the accuracy criterion, with a mean rating of 4.2 and 80% of the questions received a positive rating. The responses scored less for the completeness criterion, with a mean rating of 3.8 and 46.7% of questions received a positive rating. For safety, the mean rating was 3.9 and 53.3% of questions received a positive rating. There was no response with an average negative rating below three.

CONCLUSION

This study demonstrates promising results regarding potential use of ChatGPT's in providing accurate responses to obstetric clinical questions posed by pregnant women. However, it is crucial to exercise caution when addressing inquiries concerning the safety of the fetus or the mother.

The association between discordant umbilical arterial resistance in growth-restricted fetuses and adverse outcomes

BACKGROUND

Assessing the umbilical artery pulsatility index via Doppler measurements plays a crucial role in evaluating fetal growth impairment.

OBJECTIVE

This study aimed to investigate perinatal outcomes associated with discordant pulsatility indices of umbilical arteries in fetuses with growth restriction.

STUDY DESIGN

In this retrospective cohort study, all singleton pregnancies were included if their estimated fetal weight and/or abdominal circumference fell below the 10th percentile for gestational age (2017-2022). Eligible cases included singleton pregnancies with concurrent sampling of both umbilical arteries within 14 days of birth at the ultrasound evaluation closest to delivery. The exclusion criteria included births before 22 weeks of gestation, evidence of absent or reverse end-diastolic flow in either umbilical artery, and known fetal genetic or structural anomalies. The study compared cases with discordant umbilical artery pulsatility index values (defined as 1 umbilical artery pulsatility index at ≤95th percentile and the other umbilical artery pulsatility index at >95th percentile for gestational age) to pregnancies where both umbilical artery pulsatility indices had normal pulsatility index values and those with both umbilical arteries displaying abnormal pulsatility index values. The primary outcome assessed was the occurrence of composite adverse neonatal outcomes. Multivariable logistic regressions were performed, adjusting for relevant covariates.

RESULTS

The study encompassed 1014 patients, including 194 patients (19.1%) with discordant umbilical artery pulsatility index values among those who had both umbilical arteries sampled close to delivery, 671 patients (66.2%) with both umbilical arteries having normal pulsatility index values, and 149 patients (14.7%) with both umbilical arteries exhibiting abnormal values. Pregnancies with discordant umbilical artery pulsatility index values displayed compromised sonographic parameters compared with those with both umbilical arteries showing normal pulsatility index values. Similarly, the number of abnormal umbilical artery pulsatility index values was associated with adverse perinatal outcomes in a dose-response manner. Cases with 1 abnormal (discordant) umbilical artery pulsatility index value showed favorable sonographic parameters and perinatal outcomes compared with cases with both abnormal umbilical artery pulsatility index values, and cases with both abnormal umbilical artery pulsatility index values showed worse sonographic parameters and perinatal outcomes compared with cases with discordant UA PI values. Multivariate analysis revealed that discordant umbilical artery pulsatility indices were significantly and independently associated with composite adverse perinatal outcomes, with an adjusted odds ratio of 1.75 (95% confidence interval, 1.24-2.47; P = .002).

CONCLUSION

Evaluating the resistance indices of both umbilical arteries may provide useful data and assist in assessing adverse perinatal outcomes among fetuses with growth restriction.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BACKGROUND

An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth.

OBJECTIVE

We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery.

STUDY DESIGN

We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity.

RESULTS

A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42).

CONCLUSION

Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.

Operative delivery in the second stage of labor and preterm birth in a subsequent pregnancy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy.

DATA SOURCES

MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023.

STUDY ELIGIBILITY CRITERIA

All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included.

METHODS

Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool.

RESULTS

After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57-2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries.

CONCLUSION

Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution.

Labor Induction in Women with Isolated Polyhydramnios at Term: A Multicenter Retrospective Cohort Analysis

Background: With the increasing popularity of elective induction after 39 + 0 weeks, the question of whether induction of labor (IOL) is safe in women with isolated polyhydramnios has become more relevant. We aimed to evaluate the pregnancy outcomes associated with IOL among women with and without isolated polyhydramnios. Methods: This was a multicenter retrospective cohort that included women who underwent induction of labor at term. The study compared women who underwent IOL due to isolated polyhydramnios to low-risk women who underwent elective IOL due to gestational age only. The main outcome measure was a composite adverse maternal outcome, while the secondary outcomes included maternal and neonatal adverse pregnancy outcomes. Results: During the study period, 1004 women underwent IOL at term and met inclusion and exclusion criteria; 162 had isolated polyhydramnios, and 842 had a normal amount of amniotic fluid. Women who had isolated polyhydramnios had higher rates of the composite adverse maternal outcome (28.7% vs. 20.4%, p = 0.02), prolonged hospital stay, perineal tear grade 3/4, postpartum hemorrhage, and neonatal hypoglycemia. Multivariate analyses revealed that among women with IOL, polyhydramnios was significantly associated with adverse composite maternal outcome [aOR 1.98 (1.27-3.10), p < 0.01]. Conclusions: IOL in women with isolated polyhydramnios at term was associated with worse perinatal outcomes compared to low-risk women who underwent elective IOL. Our findings suggest that the management of women with polyhydramnios cannot be extrapolated from studies of low-risk populations and that clinical decision-making should take into account the individual patient's risk factors and preferences.

Impacted fetal head extraction methods at second stage cesarean and subsequent preterm delivery: A multicenter study

OBJECTIVE

Second-stage cesarean delivery (CD) is associated with subsequent preterm birth (PTB). It has been suggested that an increased risk of PTB after second-stage cesarean delivery could be linked to a higher chance of cervical injury due to the extension of the uterine incision. Previous studies have shown that reverse breech extraction is associated with lower rates of uterine incision extensions compared to the "push" method. We aimed to investigate the association between the method of fetal extraction during second-stage CD and the rate of spontaneous PTB (sPTB), as well as other maternal and neonatal outcomes during the subsequent pregnancy.

METHODS

This was a multicenter retrospective cohort study. The study population included women in their first subsequent singleton delivery following a second-stage CD between 2004 and 2021. The main exposure of interest was the method of fetal extraction in the index CD ("push" method vs. reverse breech extraction). The primary outcome of this study was sPTB <37 weeks in the subsequent pregnancy. Secondary outcomes were overall PTB, trial of labor, and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling.

RESULTS

During the study period, 2969 index CD during second stage were performed, of those 583 met the inclusion criteria, of whom 234 (40.1%) had fetal extraction using the reverse breech extraction method, while 349 (59.9%) had the "push" method for extraction. In univariate analysis, women in those two groups had statistically similar rates of sPTB (3.7% vs. 3.0%; odds ratio [OR] 1.25, 95% CI: 0.49-3.19) and overall PTB (<37, <34 and <32 weeks), as well as other maternal, neonatal, and trial of labor outcomes. This was confirmed by multivariate analyses with an adjusted OR of 1.27 (95% CI: 0.43-3.71) for sPTB.

CONCLUSION

Among women with a previous second-stage CD, no significant difference was observed in PTB rates in the subsequent pregnancies following the "push" method compared to the reverse breech extraction method.

Is a pregnancy following a second trimester uterine evacuation associated with increased adverse maternal and neonatal outcomes?

OBJECTIVE

To evaluate maternal and neonatal outcomes of pregnancies following a uterine evacuation in the second trimester, in comparison to a first trimester spontaneous pregnancy loss.

STUDY DESIGN

A retrospective analysis of data of women who conceived ≤6 months following a uterine evacuation due to a spontaneous pregnancy loss and subsequently delivered in a single tertiary medical center between 2016 and 2021. Maternal and neonatal outcomes were compared between women with second trimester (14-23 weeks) and first trimester (<14 weeks) pregnancy loss. The primary outcome of this study was the preterm delivery (<37 weeks) rate. Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95 % confidence intervals (CIs) were calculated.

RESULTS

During the study period, 1365 women met the inclusion criteria. Of those, 272 (19.9 %) women gave birth following a second trimester uterine evacuation and 1093 (80.1 %) women following a first trimester uterine evacuation. There were no demographic differences between the two groups. No difference was found in the preterm delivery rate in the subsequent pregnancy (5.1 % vs. 5.3 %, p = 0.91), further confirmed in the multivariate analysis [aOR 1.02 (0.53-1.94), p = 0.96]. No differences were identified with respect to other maternal and neonatal parameters examined, including hypertension disorders of pregnancy, third stage placental complications, mode of delivery and neonatal birth weight.

CONCLUSION

Pregnancy conceived shortly after second trimester uterine evacuation as compared to first trimester, confers no additional risk for preterm delivery or other adverse perinatal outcomes. Further studies to strengthen these findings are needed.

The Correlation between Fetal Monitor Decelerations Area and Neonatal Cord pH among Preeclamptic parturient: an Automated Approach to a Clinical Challenge

OBJECTIVE

 To examine whether a correlation exists between electronic fetal monitoring (EFM) in the final 120 minute prior to delivery and neonatal cord blood pH among parturients with preeclampsia.

STUDY DESIGN

 A retrospective cohort study of parturients with term and near-term preeclampsia who delivered at Soroka University Medical Center between 2013 and 2020 was conducted. EFM tracings, demographical data, and obstetrical outcomes were retrieved from the patients' electronic medical records. Using MATLAB program, area under the curve (AUC) measurements were applied. Correlation was calculated using the Spearman's correlation coefficient.

RESULTS

 EFM of 88 parturients with preeclampsia were assessed. A significant negative correlation was demonstrated between cord blood pH and the decelerations AUC, total decelerations duration, and deceleration depth. No correlation was demonstrated between area over the curve (acceleration) and cord blood pH. In a multivariate linear regression, total deceleration AUC was found independently negatively associated with cord blood pH (beta = -0.264, p = 0.011) controlling for second stage of labor duration and induction of labor.

CONCLUSION

 Among parturients with preeclampsia, EFM indices may assist in the diagnosis of fetal acidemia. Further studies are needed to strengthen and establish the use of electronic EFM in the management of labor and delivery.

KEY POINTS

· A negative correlation was demonstrated between cord blood pH and the decelerations AUC.. · Total deceleration AUC was found independently negatively associated.. · Among parturients with preeclampsia, EFM indices may assist in the diagnosis of fetal acidemia..

Erratum: Management of Pregnancy in Women of Advanced Maternal Age: Improving Outcomes for Mother and Baby [Corrigendum]

[This corrects the article DOI: 10.2147/IJWH.S283216.].

Failed vacuum and preterm delivery risk in the subsequent pregnancy: a multicenter retrospective cohort study

BACKGROUND

Second-stage cesarean delivery is associated with subsequent preterm delivery. Failed vacuum-assisted delivery is a subgroup of second-stage cesarean delivery in which the fetal head is engaged deeper in the pelvis and, thus, is associated with an increased risk of short-term maternal complications.

OBJECTIVE

This study aimed to investigate the maternal and neonatal outcomes of women at their subsequent delivery after a second-stage cesarean delivery with failed vacuum-assisted extraction vs after a second-stage cesarean delivery without a trial of vacuum-assisted extraction.

STUDY DESIGN

This was a multicenter retrospective cohort study. The study population included all women in their subsequent pregnancy after a second-stage cesarean delivery who delivered in all university-affiliated obstetrical centers (n=4) in a single geographic area between 2003 and 2021. Maternal and neonatal outcomes of women who had second-stage cesarean delivery after a failed vacuum-assisted delivery were compared with women who had second-stage cesarean delivery without a trial of vacuum-assisted delivery. The primary outcome of this study was preterm delivery at <37 weeks of gestation. The secondary outcomes were vaginal birth rate and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling.

RESULTS

During the study period, 1313 women met the inclusion criteria, of whom 215 (16.4%) had a history of failed vacuum-assisted delivery at the previous delivery and 1098 (83.6%) did not. In univariate analysis, women with previously failed vacuum-assisted delivery had similar preterm delivery rates (<37, <34, <32, and <28 weeks of gestation), a successful trial of labor after cesarean delivery rates, uterine rupture, and hysterectomy. However, multivariable analyses controlling for confounders showed that a history of failed vacuum-assisted delivery is associated with a higher risk of preterm delivery at <37 weeks of gestation (adjusted odds ratio, 2.05; 95% confidence interval, 1.11-3.79; P=.02), but not with preterm delivery at <34 or <32 weeks of gestation.

CONCLUSION

Among women with a previous second-stage cesarean delivery, previously failed vacuum-assisted delivery was associated with an increased risk of preterm delivery at <37 weeks of gestation in the subsequent birth.

Covid-19 third vaccination during pregnancy: maternal and neonatal outcomes-a retrospective study

PURPOSE

To evaluate the impact of Covid-19 (Pfizer-BioNTech BNT162b2) third booster dose vaccination during pregnancy on maternal and neonatal outcomes.

METHODS

This is a multicenter, retrospective computerized database study. Parturients who delivered in Israel between August and December 2021 with full records of Covid-19 disease and vaccination status were included. Those who received third booster during pregnancy were compared to those who received two doses of vaccine during pregnancy and to unvaccinated parturients. Various adverse maternal and neonatal outcomes were evaluated. Parturients who were previously positive with Covid-19 PCR swabs during pregnancy or before pregnancy were excluded. Univariate analysis was followed by multivariate analysis.

RESULTS

A total of 2583 women were included in the analysis; 626 received the third booster dose of the BNT162b2 Covid-19 vaccine, 1094 received two doses of the vaccine, and 863 unvaccinated women. Maternal and neonatal outcomes were comparable between the study groups. An adjusted multivariable logistic regression analysis demonstrated that receiving the third booster was not associated with an increase in neither composite adverse maternal or neonatal outcome (aOR 0.9; 95% CI [0.65-1.22], p = 0.47; aOR 0.7; 95% CI [0.53-1.035], p= 0.09, respectively) when compared to those who received two doses of the vaccine. However, administration of the third booster dose during pregnancy was associated with a reduced composite adverse neonatal outcome when compared to unvaccinated women (aOR 0.6; 95% CI [0.42-0.86], p = 0.01).

CONCLUSION

Receiving the third booster dose of the BNT162b2 Covid-19 vaccine during pregnancy is not associated with an increased risk of any adverse maternal outcomes and may be beneficial for the neonates.

Trial of labor following cesarean in patients with bicornuate uterus: a multicenter retrospective study

OBJECTIVE

This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus.

METHODS

A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses.

RESULTS

Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC.

CONCLUSIONS

This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients.

The Impact of Advanced Maternal Age on Pregnancy Outcomes: A Retrospective Multicenter Study

The aim of this multicenter retrospective cohort study was to examine the impact of maternal age on perinatal outcomes in multiparas, stratified according to maternal age in one- and two-year increments. The analysis involved 302,484 multiparas who delivered between the years 2003 and 2021 in four university-affiliated obstetrics departments. Maternal age was considered both as a continuous variable and in two-year intervals, as compared with a comparison group of parturients aged 25-30 years. The study focused on cesarean delivery and neonatal intensive care unit (NICU) admission as primary outcomes. The findings revealed that cesarean delivery rates increased as maternal age advanced, with rates ranging from 6.7% among 25-30 year olds, rising continuously from 13.5% to 19.9% between the age strata of 31 and 42, to exceeding 20% among those aged ≥ 43 years (p < 0.01 for each stratum when compared to 25-30 year old group). Similarly, NICU admission rates rose from 2.7% in the comparison group to 6% in parturients aged 45-46 years (p < 0.01 for each stratum when compared to 25-30 year old group). The study highlights the association between incrementally advanced maternal age and increased rates of maternal and neonatal complications, necessitating global awareness of these implications for family planning decisions and maternal care.

Unintended lower-segment hysterotomy extension at cesarean delivery and the risk for uterine rupture during a subsequent trial of labor

OBJECTIVE

To evaluate the association between unintended uterine extension in cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean delivery (TOLAC).

METHODS

This is a multicenter retrospective cohort study (2005-2021). Parturients with a singleton pregnancy who had unintended lower-segment uterine extension during the primary cesarean delivery (excluding T and J vertical extensions) were compared with patients who did not have an unintended uterine extension. We assessed the subsequent uterine scar disruption rate following the subsequent TOLAC and the rate of adverse maternal outcome.

RESULTS

During the study period, 7199 patients underwent a trial of labor and were eligible for the study, of whom 1245 (17.3%) had a previous unintended uterine extension and 5954 (82.7%) did not. In univariate analysis, previous unintended uterine extension during the primary cesarean delivery was not significantly associated with uterine scar rupture in the following subsequent TOLAC. Nevertheless, it was associated with uterine scar dehiscence, higher rates of TOLAC failure, and a composite adverse maternal outcome. In multivariate analyses, only the association between previous unintended uterine extension and higher rates of TOLAC failure was confirmed.

CONCLUSION

A history of unintended lower-segment uterine extension is not associated with an increased risk for uterine scar disruption following subsequent TOLAC.

Perinatal outcomes in nulliparous women with a history of multiple pregnancy losses according to number of previous pregnancy losses

BACKGROUND

While it is widely acknowledged that pregnancy losses can lead to negative outcomes for both mothers and fetuses, there is limited information available on the specific levels of risk associated with each additional pregnancy loss.

OBJECTIVE

This study aimed to investigate the effect of number of previous pregnancy losses among nulliparous women on maternal and neonatal adverse outcomes.

STUDY DESIGN

This was a multicenter retrospective cohort study. The study population included all nulliparous women with singleton pregnancies who delivered in all university-affiliated obstetrical centers in a single geographic area between 2003 and 2021. Maternal and neonatal outcomes of women who delivered at our medical centers and had varying numbers of previous pregnancy losses were compared with women who had no previous pregnancy loss. The primary outcome of this study was preterm delivery rate at <37 weeks of gestation. The secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was performed using multiple logistic regression modeling.

RESULTS

During the study period, 97,904 nulliparous women met the inclusion and exclusion criteria. Of those women, 84,245 (86%) had no previous pregnancy losses (reference group), 10,724 (11%) had 1 previous pregnancy loss, 2150 (2.2%) had 2 previous pregnancy losses, 516 (0.5%) had 3 previous pregnancy losses, 160 (0.2%) had 4 previous pregnancy losses, and 99 (0.1%) had ≥5 previous pregnancy losses. Women who had previous pregnancy losses had significantly higher rates of preterm delivery, hypertensive disorders of pregnancy, diabetes mellitus (pregestational and gestational), unplanned cesarean delivery, perinatal death, neonatal intensive care unit admissions, and neonatal hypoglycemia. The risks of preterm delivery and most other adverse obstetrical outcomes correlated with the number of previous pregnancy losses. Multivariate analyses showed that each previous pregnancy loss was associated with an additional, significant, increased risk of preterm delivery of 14% at <37 weeks of gestation, 37% at <34 weeks of gestation, 45% at <32 weeks of gestation, and 77% at <28 weeks of gestation.

CONCLUSION

A history of previous pregnancy losses increased the risk of preterm delivery and other perinatal outcomes in a dose-dependent manner. To minimize perinatal complications, obstetricians should be aware of the risks and complications in this unique population, consider close monitoring of the cervical length, and maintain high vigilance in case of complications with special attention to other potentially modifiable risks.

Association between One Abnormal Value on 3-Hour Oral Glucose Tolerance Test and Adverse Perinatal Outcomes in Twin Gestation

AIM

To investigate whether women with twin gestation and one abnormal value on the diagnostic 3-hour oral glucose tolerance test (OGTT) are at an increased risk of adverse perinatal outcomes.

METHODS

This was a retrospective multicenter study of women with twin gestation, comparing four groups: (1) normal 50-g screening, (2) normal 100-g 3-hour OGTT, (3) one abnormal value on the 3-hour OGTT, and (4) GDM. Multivariable logistic regressions adjusted for maternal age, gravidity, parity, previous CDs, fertility treatments, smoking, obesity and chorionicity were used.

RESULTS

The study included 2,597 women with twin gestations, of which 79.7% had a normal screen, and 6.2% had one abnormal value on the OGTT. In adjusted analyses, women with one abnormal value were found to have higher rates of preterm delivery <32 weeks, large for gestational age neonates, and composite neonatal morbidity of at least one fetus, however, similar maternal outcomes as those with a normal screen.

CONCLUSION

Our study provides evidence that women with twin gestation and one abnormal value on the 3-hour OGTT are at an increased risk of unfavorable neonatal outcomes. This was confirmed by multivariable logistic regressions. Further research is needed to determine whether interventions such as nutritional counseling, blood glucose monitoring, and treatment with diet and medication would improve perinatal outcomes in this population.

A Scoring System Developed by a Machine Learning Algorithm to Better Predict Adnexal Torsion

STUDY OBJECTIVE

To establish a clinically relevant prediction score for the diagnosis of adnexal torsion (AT) in women who were operated on for suspected AT.

DESIGN

A retrospective cohort study conducted between 2014 and 2021.

SETTING

A large tertiary teaching medical center.

PATIENTS

Women who underwent urgent laparoscopy for suspected AT.

INTERVENTIONS

Analyses included univariate and multivariate models combined with the machine learning (ML) Random Forest model, which included all information available about the women and reported the accuracy of the model and the importance of each variable. Based on this model, we created a predictive score and evaluated its accuracy by receiver operating characteristic (ROC) curve.

MEASUREMENTS AND MAIN RESULTS

A total of 503 women were included in our study, 244 (49%) of whom were diagnosed with AT during the surgery, and 44 (8.8%) cases of necrotic ovary were found. Based on the Random Forrest and multivariate models, the most important preoperative clinical predictive variables for AT were vomiting, left-side complaints, and concurrent pregnancy; cervical tenderness and urinary symptoms decreased the likelihood of surgically confirmed AT. The most important sonographic findings that predicted increased risk of surgically confirmed AT were ovarian edema and decreased vascular flow; in contrast, hemorrhagic corpus luteum decreased the likelihood of surgically confirmed AT. The accuracy of the Random Forest model was 71% for the training set and 68% for the testing set, and the area under the curve for the multivariate model was 0.75 (95% confidence interval [CI] 0.69-0.80). Based on these models, we created a predictive score with a total score that ranges from 4 to 12. The area under the curve for this score was 0.72 (95% CI 0.67-0.76), and the best cutoff for the final score was >5, with a sensitivity, specificity, positive predictive value, and negative predictive value of 64%, 73%, 70%, and 67%, respectively.

CONCLUSION

Clinical characteristics and ultrasound findings may be incorporated into the emergency room workup of women with suspected AT. ML in this setting has no diagnostic/predictive advantage over the performance of logistic regression methods. Additional prospective studies are needed to confirm the accuracy of this model.

Short Interpregnancy Interval Following a Multifetal Pregnancy: Maternal and Neonatal Outcomes

Objective: To evaluate the maternal and neonatal outcomes of women with short interpregnancy intervals (IPI < 6 months) following a multifetal pregnancy. Study design: A multicenter retrospective cohort study of women with an index multifetal delivery and a subsequent singleton gestation between 2005 and 2021. The obstetrical outcomes of pregnancies following short IPI (<6 months) were compared to those with an IPI of 18–48 months. Additional analyses were also conducted for the other IPI groups: 7–17 months, and longer than 49 months, while women with an IPI of 18–48 months served as the reference group. The primary outcome was preterm birth (<37 weeks) rate. Secondary outcomes were other adverse maternal and neonatal outcomes. Univariate and multiple logistic regression analyses were performed. Results: Overall, 2514 women had a primary multifetal delivery with a subsequent singleton gestation at our medical centers; 160 (6.4%) had a short IPI, and 1142 (45.4%) had an optimal IPI. Women with a singleton gestation following a short IPI were younger, with lower rates of previous cesarean and fertility treatments. Women in the short IPI group had significantly higher rates of preterm birth <37 weeks, anemia (Hb < 11 gr%) on admission to the delivery room, and placental abruption. Multivariable logistic regression analysis demonstrated that short IPI is associated with an increased risk for preterm birth (aOR 2.39, 95% CI 1.12–5.11, p = 0.03). Conclusion: Short IPI following a multifetal gestation is associated with an increased risk for preterm birth in subsequent singleton pregnancy.

Repeat low order caesarean delivery, risk factors for complications: A retrospective, longitudinal study

One-third of cesarean deliveries (CDs) are repeat operations, of which the majority are low-order, second (CD2) and third (CD3). The study objectives were to identify risk factors for a complicated maternal CD among women undergoing a repeat low-order CD and to develop a predictive model for at-risk women. A retrospective longitudinal follow-up study was conducted in a single medical center, during 2005-2016. Women who underwent both CD2 and CD3 at the site were included. Those with placenta accreta or a caesarean hysterectomy were excluded. A composite complicated maternal CD was defined by either uterine rupture/dehiscence, blood transfusion, relaparotomy, admission to the intensive care unit or prolonged operative time >90th percentile. Data was analyzed comparing between CD2 to CD3, each woman served as her own control. Univariate analysis followed by a multivariate logistic regression modeling were performed with an OR of 95% CI defining significance. The study group comprised of 1,331 women. A complicated CD occurred in 159 (12%) vs. 226 (17%) of CD2 vs. CD3 respectively, (p<0.001). Women with a complicated CD2 were at higher risk for complications in CD3, aOR 2.3 (95% CI 1.5, 3.3). Sub-Saharan African origin and preterm delivery at CD3 were both risk factors for a complicated CD3, aOR 3.7 (95% CI 1.9, 7.3) and aOR 1.7 (95% CI 1.1, 2.7), respectively. The multivariate regression model included 1328 cases, was statistically significant, χ2(7) = 50.760, p <0.001, explained 6.3% of the variance of composite complicated maternal CD3 and correctly classified 82.9% of cases. Although a complicated CD2, Sub-Saharan African origin and preterm delivery are risk factors for maternal complications in CD3, it is hard to predict which specific women will experience complications. Sensitivity, specificity, positive and negative predictive value of a complicated CD2 for detecting complications in CD3 were 21%, 90%, 30% and 85% respectively.

Use of antibiotics in women undergoing correction of an obstetric anal sphincter injury: Results from a national Israeli survey

OBJECTIVE

Obstetric anal sphincter injures (OASIS) have long-term implications on women's health. Administration of antibiotic prophylaxis and treatment following OASIS repair is controversial. We conducted a national survey to provide data about practice routines regarding antibiotic prophylaxis and treatment following OASIS repair in Israeli labor and delivery units.

METHODS

A national survey was performed among obstetricians and gynecologists from 24 university-affiliated delivery centers within the jurisdiction of the Israeli Ministry of Health during 2020. Representatives from each center completed the "Google form" electronic survey. For each questionnaire item, the most common answer was chosen to represent the center's answer.

RESULTS

The number of physicians who responded per center varied from 1 to 14 (median, 3.5). Preoperative and postoperative antibiotic treatment was given in 75% and 92% of the centers, respectively. While most centers (58.3%) recommend pelvic floor physical therapy on release, recommendations about functional radiologic tests vary. In all centers, there is a designated clinic for postpartum follow-up of OASIS. Most centers (83%) allow trial of vaginal delivery in the subsequent pregnancy, on an individual basis.

CONCLUSION

Heterogeneity exists in managing OASIS in Israel, particularly regarding administration of antibiotics. Further studies are needed to examine the consequences of different management protocols.

Factors Associated With Operatively Confirmed Adnexal Torsion Among Pregnant Women - A Multicenter Cohort Study

PURPOSE

 The aim of this study was to investigate the association of clinical, laboratory, and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy.

MATERIALS AND METHODS

 A multicenter retrospective study of pregnant women who underwent urgent laparoscopy for suspected adnexal torsion during 2004-2019 in three tertiary medical centers.

RESULTS

 Adnexal torsion was found in 143/208 (68.8 %) cases. Women with adnexal torsion had lower parity and lower rates of previous cesarean section, but higher rates of fertility treatments and multiple gestations, and were more likely to report right lower abdominal pain, with shorter duration of symptoms (< 24 hrs) and vomiting but not nausea. Women with adnexal torsion were found to have higher rates of sonographic findings suggestive of ovarian edema, while normal-appearing ovaries on ultrasound were more common in women without torsion. A multivariate logistic regression analysis showed that complaints of right abdominal pain were positively associated with adnexal torsion (aOR [95 % CI] 5.03 (1.45-17.49), while previous cesarean delivery and ultrasound findings of normal-appearing ovaries were negatively associated with adnexal torsion (aOR of 0.17 (0.05-0.52) and 0.10 (0.02-0.43), respectively).

CONCLUSION

 Clinical characteristics and ultrasound findings may be incorporated into the emergency room workup of pregnant women with suspected adnexal torsion.

Trial of labor following cesarean in preterm deliveries: success rates and maternal and neonatal outcomes: a multicenter retrospective study

PURPOSE

To evaluate the rates of vaginal birth after cesarean (VBAC) among parturients attempting preterm trial of labor following a cesarean delivery (TOLAC) vs. term TOLAC.

METHODS

A multicenter historic cohort study was conducted at two university-affiliated centers between August 2005 and March 2021. Parturients in their second delivery, attempting TOLAC after a single low segment transverse cesarean delivery were included. We retrospectively examined computerized medical records of all preterm (< 37 weeks) and term (37-42 weeks) births. Multifetal gestations and postterm deliveries (≥ 42 weeks) were excluded. A univariate analysis was conducted, followed by a multivariate analysis.

RESULTS

4865 second deliveries following previous cesarean were identified: 212 (4.4%) preterm and 4653 (95.6%) term. Hypertensive disorders, diabetes and fertility treatments were significantly more prevalent in the preterm group. VBAC rate was significantly lower in preterm group (57.5 vs 79.7%., p < 0.01), including both spontaneous and vaginal-assisted deliveries. In multivariate analysis, preterm TOLAC was independently associated with TOLAC failure [adjusted odds ratio 2.24, [95% confidence interval 1.62-3.09]. Overall, maternal outcomes were favorable. Rates of uterine rupture, re-laparotomy and postpartum hemorrhage were comparable between groups. Neonatal outcomes were less favorable among the preterm group; however, preterm vs. term TOLAC was not associated with low 5 min Apgar score (aOR 1.76, 95% CI 0.92-3.40).

CONCLUSION

In our study, VBAC rates were lower in preterm compared to term deliveries. Maternal outcomes were comparable. Neonatal outcomes were less favorable in the preterm group, more likely due to prematurity than delivery mode.

Factors Associated with Failed Trial of Labor after Cesarean, among Women with Twin Gestation-A Multicenter Retrospective Cohort Study

Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40−0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36−19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65−1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01−20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery.

Mode of preterm delivery and risk of recurrent preterm delivery, a multicenter retrospective study

OBJECTIVE

To examine whether mode of preterm delivery is associated with the risk of recurrent preterm delivery in subsequent pregnancy.

STUDY DESIGN

A multicenter retrospective study. Women with the first two consecutive singleton deliveries at two university-affiliated medical centers between August 2005-March 2021, with first delivery occurring spontaneously < 37 weeks of gestation were included. Excluded were women with multifetal pregnancies in either pregnancy and those with an indicated first preterm delivery. A univariate analysis was followed by a multivariate analysis.

RESULTS

A total of 1,019 women with spontaneous preterm first delivery were included. Of those, 141 (13.8 %) underwent cesarean delivery in their first preterm delivery, while 878 (86.2 %) had a vaginal delivery. Univariate analysis revealed that women who underwent cesarean delivery in their first delivery had, during the subsequent delivery: longer mean gestational age at delivery (37.8 ± 3.3 vs 36.8 ± 3.7 weeks; p < 0.01), but statistically similar rates of recurrent preterm delivery both < 37 weeks and < 34 weeks (23.4 % vs 27.2 % and 7.1 % vs 10.6 %; p = 0.34 and p = 0.20, respectively). Multivariate analysis revealed that mode of delivery- cesarean - in the preterm delivery was not associated with recurrent pre-term delivery (0.66 (0.41-1.04), p = 0.07).

CONCLUSION

Mode of delivery in first preterm delivery is not associated with higher or lower rates of recurrent preterm delivery.

Parity-Adjusted Term Neonatal Growth Chart Modifies Neonatal Morbidity and Mortality Risk Stratification

Objective: To investigate the impact of parity-customized versus population-based birth weight charts on the identification of neonatal risk for adverse outcomes in small (SGA) or large for gestational age (LGA) infants compared to appropriate for gestational age (AGA) infants. Study design: Observational, retrospective, cohort study based on electronic medical birth records at a single center between 2006 and 2017. Neonates were categorized by birth weight (BW) as SGA, LGA, or AGA, with the 10th and 90th centiles as boundaries for AGA in a standard population-based model adjusted for gestational age and gender only (POP) and a customized model adjusted for gestational age, gender, and parity (CUST). Neonates defined as SGA or LGA by one standard and not overlapping the other, are SGA/LGA CUST/POP ONLY. Analyses used a reference group of BW between the 25th and 75th centile for the population. Results: Overall 132,815 singleton, live, term neonates born to mothers with uncomplicated pregnancies were included. The customized model identified 53% more neonates as SGA-CUST ONLY who had significantly higher rates of morbidity and mortality compared to the reference group (OR = 1.33 95% CI [1.16−1.53]; p < 0.0001). Neonates defined as LGA by the customized model (LGA-CUST) and AGA by the population-based model LGA-CUST ONLY had a significantly higher risk for morbidity compared to the reference (OR = 1.36 95% CI [1.09−1.71]; p = 0.007) or the LGA POP group. Neonatal mortality only occurred in the SGA and AGA groups. Conclusions: The application of a parity-customized only birth weight chart in a population of singleton, term neonates is a simple platform to better identify birth weight related neonatal risk for morbidity and mortality.

Maternal and Neonatal Outcomes of Women Conceived Less Than 6 Months after First Trimester Dilation and Curettage

Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single tertiary medical center between 2016 and 2021. The maternal and neonatal outcomes of women who had D&C were compared to those of women who had non-medical or spontaneous miscarriages. The primary outcome of this study was the rate of preterm birth (<37 weeks). Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: During the study period, 1773 women met the inclusion criteria; of those, 1087 (61.3%) women gave birth following D&C. We found no differences between the study groups in any maternal or neonatal parameter examined including preterm birth (PTB), miscarriage to pregnancy interval, fertility treatments, hypertension disorders of pregnancy, placental complications, mode of delivery and neonatal birth weights. This was confirmed on a multivariate analysis as well [aOR 1.74 (0.89−3.40), p = 0.11] for preterm birth. Conclusion: Watchful waiting or the medical treatment of a first trimester missed abortion present no more risks than D&C to pregnancies conceived within six months of the index miscarriage. Further studies in other settings to strengthen these findings are needed.

Outcomes of attempted vaginal births after previous recurrent operative vaginal deliveries: An individual cumulative risk analysis

BACKGROUND

Data about the risk of recurrence of vacuum extraction (VE) in multiple consecutive deliveries are scarce. We aimed to evaluate the pattern and individual cumulative risk of recurrence of VE in consecutive term deliveries.

STUDY DESIGN

A retrospective cohort study based on a validated electronic database at a single center between 2005 and 2019. For the purpose of the study, we focused on consecutive term deliveries of all primiparas (P1) that had a record of at least one additional delivery during the study period. We identified P1 VE deliveries (reference group) and calculated the individual cumulative risk of repeated VE for three consecutive deliveries. Multivariate analysis was conducted adjusting for potential confounders.

RESULTS

We identified 35 113 primiparas that met inclusion criteria. The overall VE rate for P1 was 17.9% (6969 parturient). The cumulative rates of repeated VEs at the 2nd, 3rd, and 4th deliveries were 8.6%, 26.8%, and 25.0%, respectively. The risk of recurrent VE for each of the consecutive deliveries was confirmed after adjustment for confounders (aOR [95% CI]: 5.8 [4.76-7.04], 34.2 [18.59-62.81], and 113.9 [9.77-1328.69] for the 2nd, 3rd, and 4th consecutive deliveries, respectively).

CONCLUSION

Women with VE at the first and second deliveries have a substantially increased risk of VE in their following deliveries; this finding may influence woman's preference when choosing future mode of delivery.

Primary risk stratification for neonatal jaundice among term neonates using machine learning algorithm

BACKGROUND

Neonatal jaundice occurs in approximately 60% of term newborns. Although risk factors for neonatal jaundice have been studied, all the suggested strategies are based on various newborn tests for bilirubin levels. We aim to stratify neonates into risk groups for clinically significant neonatal jaundice using a combined data analysis approach, without serum bilirubin evaluation.

STUDY DESIGN

Term (gestational week 37-42) neonates born in a single medical center, 2005-2018 were identified. Anonymized data were analyzed using machine learning. Thresholds for stratification into risk groups were established. Associations were evaluated statistically using neonates with and without clinically significant neonatal jaundice from the study population.

RESULTS

A total of 147,667 consecutive term live neonates were included. The machine learning diagnostic ability to evaluate the risk for neonatal jaundice was 0.748; 95% CI 0.743-0.754 (AUC). The most important factors were (in order of importance) maternal blood type, maternal age, gestational age at delivery, estimated birth weight, parity, CBC at admission, and maternal blood pressure at admission. Neonates were then stratified by risk: 61% (n = 90,140) were classed as low-risk, 39% (n = 57,527) as higher-risk. Prevalence of jaundice was 4.14% in the full cohort, and 1.47% and 8.29% in the low- and high-risk cohorts, respectively; OR 6.06 (CI: 5.7-6.45) for neonatal jaundice in high-risk group.

CONCLUSION

A population tailored "first step" screening policy using machine learning model presents potential of neonatal jaundice risk stratification for term neonates. Future development and validation of this computational model are warranted.

Duration of the second stage of labour and risk of subsequent spontaneous preterm birth

OBJECTIVES

To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

POPULATION

Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded.

METHODS

Charts from 2007 to 2019 were reviewed.

MAIN OUTCOME MEASURES

Rate of sPTB (<37 weeks of gestation) in the second delivery.

RESULTS

Of 13 958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180 min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96-1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71-4.12; p < 0.001), with a more pronounced risk in those with second-stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94-5.94; p < 0.001).

CONCLUSION

Second-stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage caesarean section, particularly if performed after a prolonged second stage.

Post-cesarean ileus: An assessment of incidence, risk factors and outcomes

OBJECTIVE

To estimate the frequency of post cesarean paralytic ileus and to identify associated risk factors and outcomes.

STUDY DESIGN

A retrospective cohort study of woman who underwent cesarean delivery between 2005 and 2019. All parturients who had cesarean delivery were stratified and compared according to whether or not they were diagnosed with a paralytic ileus. Women were excluded if they had an intestinal injury or repair during the cesarean or if they suffered from a post cesarean mechanical bowel obstruction diagnosed during re-laparotomy. Basic demographics, obstetric history, current delivery characteristics, re-suturing indications and outcomes were obtained and analyzed. Univariate analyses were followed by a multivariate analysis (adjusted Odds Ratio (aORs) ; [95% Confidence Interval]).

RESULTS

A total of 23,486 women met the inclusion and exclusion criteria of which 135 (0.6%) were diagnosed with paralytic ileus whilst 23,347 (99.4%) did not and served as the control group. Multivariate analysis revealed that an estimated intra-operative blood loss ≥ 1000 ml was the most significant risk factor for post cesarean paralytic ileus (aOR 2.27 (1.18-4.36)), followed by multifetal gestation (aOR 2.08 (1.24-3.51)), corporeal uterine incision (aOR 1.97 (1.07-3.63)), use of topical hemostatic agents (aOR 1.78 (1.19-2.66)) and increasing maternal age (aOR 1.78 (1.19-2.66)). Regarding maternal outcomes, post cesarean paralytic ileus was associated with higher rates of postpartum hemorrhage (44.4% vs. 13.4%, p < 0.01), transfusion of blood products (23.7% vs. 3.9%, p < 0.01), post-cesarean exploratory laparotomy (4.4% vs. 0.1%, p < 0.01) and prolonged hospital stay (32.6% vs. 5.2%, p < 0.01).

CONCLUSION

In our population, whilst post cesarean paralytic ileus is infrequent, when it occurs it is associated with increased short-term maternal morbidity.

The association between primary cesarean delivery in primipara and subsequent mode of conception, a retrospective study

OBJECTIVE

To examine the association between primary cesarean delivery and the mode of conception in the subsequent delivery among women without a history of infertility.

METHODS

A retrospective study. Women with the first two consecutive deliveries in our medical center were included. Excluded were women who conceived following fertility treatments or were older than 35 years at their first delivery.

RESULTS

Twenty-three thousand four hundred and twenty-seven women were included in the study. Of those, 2215 (9.5%) underwent cesarean delivery in their first delivery, while 21,212 (90.5%) delivered vaginally. Univariate analysis revealed that women with primary cesarean delivery compared to women how delivered vaginally had higher rates of fertility treatments at the subsequent delivery (2.5 vs. 0.8%; p < .01). Those who had fertility treatments were significantly older during both the first and second deliveries, had higher rates of diabetic disorders of pregnancy (pregestational and gestational) at both the first and second deliveries, obesity and morbid obesity at the second delivery, and higher incidence of repeat cesarean delivery. Multivariate analysis revealed that the only factor that correlated significantly with the use of fertility treatments at the second delivery was maternal age at second delivery [aOR 1.2 (1.1-1.3), p < .01].

CONCLUSION

Among women without a history of infertility, cesarean delivery in the first delivery is not independently associated with fertility treatments in the subsequent delivery.

Maternal and Neonatal Outcomes in Twin Deliveries with Prolonged Second-Stage Duration of the Presenting Twin: a Retrospective Cohort Study

To assess the risk of adverse maternal and neonatal outcomes as a function of the presenting twin second-stage duration. A retrospective cohort study of deliveries taking place in an academic medical center between 2005 and 2019. The study group included women with twin pregnancies with the first fetus in vertex presentation, who attempted vaginal delivery with epidural analgesia and attained the second stage of labor. Prolonged second stage (PSS) was defined as when exceeding the 95th percentile of presenting twin second-stage duration recorded among all parturients who achieved spontaneous vaginal deliveries in our center during the study period, stratified by parity: 3 h in nulliparas and 1 h in multiparas. Women with and without PSS were compared. The primary outcome was a composite of adverse maternal outcomes. A univariate analysis was conducted and followed by multivariate analysis. During the study period, 1,337 parturients (36% of twin deliveries) met study criteria, of these 22% (298) were nulliparous and 78% (1,039) were multiparous. The second stage of labor of the presenting twin was prolonged in 41 (13.8%) of the nulliparas and 64 (6.2%) multiparas. Prolonged second stage was associated with episiotomy, chorioamnionitis, endometritis, and blood product transfusion, as well as vacuum deliveries of the first and second twin, second-stage cesarean, and a higher rate of composite adverse maternal outcome in nulliparous (41.5% vs. 20.2%, p<0.01) and with higher rates of episiotomy, postpartum hemorrhage, and vacuum deliveries of the first and second twin, but a similar rate of composite adverse maternal outcome in multiparous women (7.8% vs. 9.3%, p=0.68); moreover, the composite adverse neonatal outcome was not increased in nulliparous (36.6% vs. 38.5%, p=0.81) nor in multiparous women (21.9% vs. 23.6%, p=0.75). Prolonged second stage of labor of the presenting twin was associated with an adverse composite maternal outcome in nulliparous and with postpartum hemorrhage in multiparous. Further larger studies are warranted to reinforce our findings.

Trial of labor after cesarean in primiparous women with fetal macrosomia

KEY MESSAGE

Spontaneous labor onset, epidural anesthesia and prior cesarean for non-arrest disorders are strong predictors of successful vaginal birth after cesarean in women delivering a macrosomic fetus.

PURPOSE

Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women with fetal macrosomia.

METHODS

A retrospective cohort study conducted during 2005-2019 at two university hospitals, including all primiparous women delivering a singleton fetus weighing ≥ 4000 g, after cesarean delivery at their first delivery. A multivariate analysis was performed to evaluate the characteristics associated with TOLAC success (primary outcome).

RESULTS

Of 551 primiparous women who met the inclusion criteria, 50.1% (n = 276) attempted a TOLAC and 174 (63.0%) successfully delivered vaginally. In a multivariate analysis, spontaneous onset of labor (aOR [95% CI] 3.68 (2.05, 6.61), P < 0.001), epidural anesthesia (aOR [95% CI] 2.38 (1.35, 4.20), P = 0.003) and history of cesarean delivery due to non-arrest disorder (aOR [95% CI] 2.25 (1.32, 3.85), P = 0.003) were the only independent factors associated with TOLAC success. Successful TOLAC was achieved in 82.0% (82/100) in the presence of all three favorable factors, 61.3% (65/106) in the presence of two factors and 38.6% (27/70) in the presence of one or less of these three factors (P < 0.001).

CONCLUSION

Spontaneous onset of labor, epidural anesthesia and prior cesarean delivery due to non-arrest disorders were independently associated with higher vaginal birth after cesarean rate among women with fetal macrosomia, with an overall favorable success rate in the presence of these factors. These findings should be implemented in patient counseling in those contemplating a vaginal birth in this setting.

Factors associated with the development of neonatal hypoglycemia after antenatal corticosteroid administration: It's all about timing

OBJECTIVE

To determine the factors associated with neonatal hypoglycemia among neonates exposed to antenatal corticosteroid (ACS).

METHODS

A retrospective study conducted during 2017-2019 at a tertiary-care center including all neonates delivered between 24 and 34 weeks of gestation after ACS administration. The primary outcome was neonatal hypoglycemia (<40 mg/dl).

RESULTS

Overall, 362 early preterm neonates, including 205 singletons and 157 twins, were exposed to ACS before delivery and constituted the study group. Of them, 275 (76.0%) were exposed to a single ACS course and 87 (24.0%) to an additional rescue ACS course. Neonatal hypoglycemia occurred in 84 (23.2%) neonates. The incidence of neonatal hypoglycemia was significantly higher in those delivered between 24 and 48 h after ACS administration compared with those delivered outside this time interval (10/25, 40.0% vs 74/337, 21.9%; P = 0.049). In multivariate analysis, after adjusting for neonatal birth weight and gestational age, delivery within 24-48 h after ACS administration was the only independent risk factor associated with neonatal hypoglycemia (adjusted odds ratio 2.41, 95% confidence interval 1.03-5.68; P = 0.044).

CONCLUSION

Neonatal hypoglycemia occurred in over one-fifth of those exposed to ACS, and was independently associated with delivery between 24 and 48 h after ACS administration.

Covid-19 vaccination during the third trimester of pregnancy: rate of vaccination and maternal and neonatal outcomes, a multicentre retrospective cohort study

Objective

To evaluate the impact of Covid‐19 vaccination (Pfizer–BioNTech BNT162b2) during the third trimester of pregnancy on maternal and neonatal outcomes.

Design

A multicentre, retrospective computerised database.

Population

Women who gave birth at >24 weeks of gestation in Israel, between January and April 2021, with full records of Covid‐19 disease and vaccination status.

Methods

Women who received two doses of the vaccine were compared with unvaccinated women. Women who were recorded as having disease or a positive Covid‐19 polymerase chain reaction (PCR) swab during pregnancy or delivery were excluded from both study groups. Univariate analysis was followed by multivariate logistic regression.

Main outcome measures

Composite adverse maternal outcomes. Secondary outcomes were vaccination rate and composite adverse neonatal outcomes.

Results

The overall uptake of one or both vaccines was 40.2%; 712 women who received two doses of the Covid‐19 vaccine were compared with 1063 unvaccinated women. Maternal composite outcomes were comparable between the groups; however, women who received the vaccine had higher rates of elective caesarean deliveries (CDs) and lower rates of vacuum deliveries. An adjusted multivariable logistic regression analysis demonstrated that Covid‐19 vaccination was not associated with maternal composite adverse outcome (aOR 0.8, 95% CI 0.61–1.03); a significant reduction in the risk for neonatal composite adverse outcomes was observed (aOR 0.5, 95% CI 0.36–0.74).

Conclusions

In a motivated population covered by a National Health Insurance Plan, we found a 40.2% rate of vaccination for the Covid‐19 vaccine during the third trimester of pregnancy, which was not associated with adverse maternal outcomes and, moreover, decreased the risk for neonatal adverse outcomes.

Tweetable abstract

Covid‐19 vaccine during pregnancy is safe for both mother and fetus.

Covid‐19 vaccine during pregnancy is safe for both mother and fetus.

Mild gestational thrombocytopenia in primiparous women, does it affect risk of early postpartum hemorrhage? A retrospective cohort study

PURPOSE

To assess whether women with mild gestational thrombocytopenia have a higher risk of postpartum hemorrhage.

METHODS

A retrospective computerized database. Primiparous women that delivered at our center (2005-2019) were included; we excluded women with possible etiologies for thrombocytopenia such as systemic lupus or coagulation disorders, and hypertensive disorder of pregnancy. Demographics, obstetric characteristics, and maternal as well as neonatal data were compared between groups. The exposure measure of the study was mild thrombocytopenia (100,000-150,000) versus normal thrombocyte count (>150,000) at admission for labor. Postpartum hemorrhage (PPH) is defined as a clinical estimated blood loss of > 500 mL and/or a hemoglobin drop of ≥ 3 g/dl.

RESULTS

Overall, 39,886 primiparous met the study's criteria, 5,209 (13.1%) had mild gestational thrombocytopenia (mean platelet count of 132.4 ± 13.2, study group) while 34,677 (86.9%) had normal platelet count at admission (mean of 221.6 ± 50.6, comparison group.) PPH occurred in 17.6% of the study group as opposed to 14% in the comparison group (p < .001). Similarly, all measures of increased bleeding were more common in the study group as compared to the comparison group, including rates of hemoglobin drop greater than 4 and 5 gram/dl, parenteral iron infusion, and blood products transfusion. On multivariable analysis, the aOR for PPH among women in the study group was 1.23 [1.11-1.36].

CONCLUSION

Primiparous women with mild gestational thrombocytopenia are at increased risk of peripartum hemorrhage, this should be considered a risk factor when assessing parturients' risk of PPH.