Publications by authors named "Alon Shrim"

48 Publications

The Accuracy of Sonographic Fetal Head Circumference in Twin Pregnancies.

J Obstet Gynaecol Can 2021 Feb 20. Epub 2021 Feb 20.

Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Objective: To assess the accuracy of sonographic estimation of fetal head circumference in twin gestations.

Methods: A retrospective analysis of sonographic evaluations of twin gestations >34 weeks, performed within 7 days of delivery, in a single university-affiliated medical centre. Sonographic head circumference was compared with neonatal head circumference. Measures of accuracy included systematic error, random error, proportion of estimates within 5% of neonatal head circumference, and reliability analysis. Accuracy of sonographic head circumference was compared between the first and second twin.

Results: Overall, 103 twin gestations were evaluated at a median of 4 days before delivery. The majority of twins were dichorionic-diamniotic (83%). Median gestational age at delivery was 37 weeks, with a median birthweight of 2645 grams for the first twin and 2625 grams for the second twin. For all fetuses, median sonographic head circumference was lower than the neonatal head circumference (first twin: 317.5 vs. 330 mm; second twin: 318.4 vs. 330 mm, P > 0.05 for both). Measures of accuracy showed no significant difference between first and second twin. There was no difference in the number of sonographic head circumference evaluations that were within 5% of the neonatal head circumference between fetuses (64% for both twins). Cronbach α value was higher for the second twin (0.746 vs. 0.613), suggesting higher accuracy for head circumference measurement for the second twin.

Conclusion: In our cohort, sonographic head circumference underestimated postnatal head circumference. Accuracy measurements were not significantly different between the first and second twin.
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http://dx.doi.org/10.1016/j.jogc.2021.02.114DOI Listing
February 2021

It is about time. The advantage of transabdominal cervical length screening.

J Matern Fetal Neonatal Med 2020 Dec 20:1-6. Epub 2020 Dec 20.

Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel.

Purpose: Sonographic cervical length (CL) measurement has become a standard practice for identifying women at increased risk for preterm birth. We aimed to assess the time needed for CL measurement during fetal anatomy scan using either transabdominal or transvaginal ultrasound, and to provide a predictive value of the transabdominal CL measurements for reassuring transvaginal CL measurements of more than 25 mm.

Methods: In a prospective study we measured CL transabdominally, and transvaginally in all the anatomy scans performed at 18-25 weeks' gestation, from January 2017 until January 2018. CL and the duration of the examination were compared between the two approaches. Adjustments were made for, body mass index, previous cesarean sections and parity.

Results: Four hundred sixty-eight patients participated in the study. The time needed for the transabdominal CL measurement was significantly lower compare with the transvaginal CL measurement (0.46 ± 0.3 min versus 6.9 ± 1.38 min,  < 0.001). The CL measured transabdominally was significantly shorter than the CL measured transvaginally (36.7 ± 6.7 mm versus 41.9 ± 7.3 mm, respectively  < 0.001). All women with transabdominal CL measurements above 36 mm (64.2% of patients) had a transvaginal CL of more than 25 mm.

Conclusion: Transvaginal measurement of CL is a time-consuming procedure that prolong fetal anomaly scan by 25%. Transabdominal CL measurement of 36 mm is reassuring CL above 25 mm. Transabdominal ultrasound should be used as an initial tool for CL screening. Transvaginal measurements of CL should be reserved for high-risk women, for women with difficulties in demonstrating the cervix abdominally, and for women with transabdominal measurements of less than 36 mm.
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http://dx.doi.org/10.1080/14767058.2020.1864317DOI Listing
December 2020

Abdominal circumference discordance for prediction of small for gestational age at birth in twin pregnancies.

J Matern Fetal Neonatal Med 2020 Oct 12:1-6. Epub 2020 Oct 12.

Department of Obstetrics and Gynecology, The Rappaport Faculty of Medicine, Hillel Yaffe Medical Center, Hadera, Israel.

Objective: To evaluate whether single sonographic abdominal circumference (AC) discordancy estimation can predict small for gestational age (SGA) at birth in twin gestations.

Methods: A retrospective analysis of prospectively collected data. Cohort included all twin gestations delivered at one university-affiliated medical center between 2010 and 2018, with available sonographic evaluation from 22 gestational weeks to term. Pregnancies complicated by fetal chromosomal abnormalities, major anomalies or twin to twin transfusion syndrome were excluded. One sonographic evaluation per pregnancy was selected randomly. AC discordance was calculated as (large twin AC - small twin AC)/large twin AC*100. Prediction of SGA at birth for at least one newborn (<10% percentile for gestational age by gender-specific local curves for multiples) was evaluated using ROC statistics with calculation of Youden index to establish best AC discordance cutoff. AC discordance prediction performance was compared to estimated fetal weight discordance performance. Results were adjusted for confounders using logistic regression analysis.

Results: After exclusion, 236 twin gestations entered analysis. Of them, 200/236 (84.7%) were dichorionic-diamniotic twins. Mean gestational age at ultrasound evaluation and at delivery were 30.9 ± 4.4 and 35.9 ± 2.4 weeks, respectively. In 28/236 (11.8%) pregnancies, at least one neonate was born SGA. AC discordance predicted SGA at birth as good as sonographic estimated fetal weight (sEFW) discordance: ROC-AUC 0.76, 95% CI 0.67-0.85 vs. 0.77 95% CI 0.66-0.87,  < .001 for all. Best AC discordance cutoff for prediction of SGA at birth was 7.1% (57% sensitivity, 87% specificity), ROC-AUC 0.72 (95% CI 0.61-0.84,  < .001). Results remained significant after adjustment for maternal age, nulliparity, chorionicity and ultrasound to delivery interval (aOR 1.21 95% CI 1.1-1.32,  < .001).

Conclusion: According to our results, AC discordance at single sonographic evaluation can predict SGA at birth in twin gestations as good as sEFW discordance. Best cutoff for SGA prediction was 7.1%.
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http://dx.doi.org/10.1080/14767058.2020.1832071DOI Listing
October 2020

The effect of endometrial thickness and pattern on the success of frozen embryo transfer cycles and gestational age accuracy.

Gynecol Endocrinol 2020 Sep 18:1-5. Epub 2020 Sep 18.

IVF Unit and Ultrasound Unit, Obstetric Gynecology Department, Hillel Yaffe Medical Center, Hadera, Israel.

Objective: To evaluate the relationship between endometrial thickness measured before embryo transfer, and pregnancy outcomes in frozen-thawed embryo transfer (FET).

Methods: We retrospectively analyzed outcomes of all consecutive FET cycles, from January 2012 to August 2018. Based on ROC analysis for endometrial thickness, we found 8 mm was a reliable cutoff point to predict pregnancy prior to embryo transfer. Accordingly, the cycles were divided into Group A: cycles with endometrial thickness ≤ 8 mm and Group B: > 8 mm.

Results: Group A included 485 FET cycles and group B included 626 cycles. Compared with group A, Group B had significantly higher chemical and clinical pregnancy rates (30.3 vs. 24.6%;  = .046, and 24.0 vs. 18.6%;  = .036), respectively. In multivariate analysis, endometrial thickness and the protocols used were the only parameters influencing the chance to achieve pregnancy, with odds ratio 1.54 (95%CI 1.07-2.22,  = .019) for the endometrium and odds ratio 1.95 (95%CI 1.31-2.9; = .001) to the protocol used. Endometrial thickness might predict crown-rump length (CRL) discordancy with odds ratio 4.61 ( = .001; 95% CI 1.42-14.92). Compared with group B, Group A had more cases of overt discordancy (13.3 vs. 4%;  = .016).

Conclusions: For patients undergoing FET cycles, endometrial thickness and treatment protocol may predict the chemical and clinical pregnancy rates, as well as CRL discordancy.

Summary: Endometrial thickness and preparation improved pregnancy rate in FET cycles and significantly greater crown-rump length discordancy was observed with thinner endometria.
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http://dx.doi.org/10.1080/09513590.2020.1821359DOI Listing
September 2020

Determination of reference values for third trimester amniotic fluid index: a retrospective analysis of a large cohort of pregnancies with comparison to previous nomograms.

J Matern Fetal Neonatal Med 2020 Jan 12:1-7. Epub 2020 Jan 12.

Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.

To establish a new set of reference values for third-trimester amniotic fluid index (AFI) and compare them to other previously published normograms. A retrospective cross-sectional cohort analysis of all singleton sonographic evaluations >22 gestational weeks in one university affiliated medical center between 2013 and 2017. Pregnancies complicated by rupture of membranes, major anomalies/chromosomal abnormalities were excluded. One evaluation per patient per pregnancy was randomly selected. Reference values were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age after normalization of variables and compared with previously published norms. A total of 7037 ultrasound evaluations entered the analysis. Correlation between AFI and gestational age was best represented by a first-degree polynomial equation. AFI decreased gradually from 16.4 at 22 weeks to 13.3 at 40 weeks (cm, median). The standard deviation increased with gestational age with AFI ranging from 12.9-20.2 at 22 weeks and 4.7-26.2 at 40 weeks (cm, 2.5-97.5 percentile). Compared to other curves, our reference values demonstrated a higher median AFI throughout all gestation. Reference values for the third trimester AFI were established. Curves should be correlated with perinatal outcome prior to wide clinical implementation.
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http://dx.doi.org/10.1080/14767058.2020.1712711DOI Listing
January 2020

New reference values for biometrical measurements and sonographic estimated fetal weight in twin gestations and comparison to previous normograms.

J Perinat Med 2019 Sep;47(7):757-764

Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.

Objective To construct new reference values for biometrical measurements and sonographic estimated fetal weight (sEFW) in twin gestations and compare them to previously published normograms. Methods A retrospective analysis of sEFW evaluations of twin gestations was performed between 2011 and 2016 in a single university-affiliated medical center. sEFW was calculated using the Hadlock 1985 formula. To avoid selection bias, one evaluation per pregnancy was randomly selected. Following mathematical transformation to obtain normality of values, normograms were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age (GA). Normograms were validated by applying all observations to ensure equal distribution at parallel percentiles. Our normograms were then compared to previously published sEFW normograms for twin gestations. Results A total of 864 sEFW evaluations were performed on 195 twin pregnancies at 22-39 gestational weeks. Of them, 390 entered the primary analysis. The rest were left for validation. Seventy percent of the cohort were dichorionic-diamniotic twins (136/195), 16% (32/195) were monochorionic-diamniotic twins and three (1.5%) were monochorionic-monoamniotic twins. Twenty-four fetuses lacked data on chorionicity. The rest were monochorionic twins or were of unknown chorionicity. Values corresponding to the 2.5th, 10th, 50th, 90th and 97.5th percentiles for sEFW are presented for every GA. Validation by applying all 864 evaluations on constructed normograms was achieved. Comparison to previously published twins' sEFW normograms demonstrated wide variation between curves. Conclusion New reference values for biometrical measurements and sEFW in twin gestations are presented for clinical and research use. Comparison to other curves demonstrates the wide variability and need for further investigation on twin's normal growth.
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http://dx.doi.org/10.1515/jpm-2019-0207DOI Listing
September 2019

Cesarean scar pregnancy managed with local and systemic methotrexate: A single center case series.

Eur J Obstet Gynecol Reprod Biol 2019 Jul 20;238:138-142. Epub 2019 May 20.

Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Rappaport Faculty of Medicine, The Technion Institute of Technology, Haifa, Israel.

Objective: To report the efficacy of combined systemic and local methotrexate treatment for cesarean scar pregnancy and review data from selected, similar case series.

Study Design: A retrospective case series of 12 patients with cesarean scar pregnancy treated in a university hospital between 2014 and 2018. The intervention was combined treatment of systemic and local methotrexate.

Results: Twelve patients were treated with combined systemic and local methotrexate. Clinical characteristics, clinical course and treatment efficacy were evaluated. Mean gestational age at diagnosis was 7.5 weeks (range 5.9-9.1). βhCG levels at diagnosis ranged from 1581 to 345,427 U/L with a mean of 77,795 U/L. All 12 patients were successfully treated without surgical intervention and with no significant side-effects. Mean hospitalization duration was 9 days (5.8-12.6) and mean time to normalization of βhCG levels was 98 days (63-132).

Conclusions: Treatment of cesarean scar pregnancy with a combination of systemic and local methotrexate was effective and safe. Although the treatment course tends to be longer than with other modalities, this protocol offers excellent success rates, with fertility preservation and few complications.
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http://dx.doi.org/10.1016/j.ejogrb.2019.05.014DOI Listing
July 2019

A novel differential diagnosis to nonobstructive diffuse and dilated bowel loops with polyhydramnios: Bartter syndrome.

J Clin Ultrasound 2019 Jan 23;47(1):42-43. Epub 2018 Sep 23.

Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel.

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http://dx.doi.org/10.1002/jcu.22642DOI Listing
January 2019

N 274 - Prise en charge de l'infection à la varicelle pendant la grossesse.

J Obstet Gynaecol Can 2018 08;40(8):e658-e664

Toronto (Ontario).

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http://dx.doi.org/10.1016/j.jogc.2018.05.035DOI Listing
August 2018

No. 274-Management of Varicella Infection (Chickenpox) in Pregnancy.

J Obstet Gynaecol Can 2018 08;40(8):e652-e657

Toronto, ON.

Objective: To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management .

Methods: The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae.

Evidence: Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010.

Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).

Recommendations:
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http://dx.doi.org/10.1016/j.jogc.2018.05.034DOI Listing
August 2018

Isolated aberrant right subclavian artery at 14-16 weeks of gestation and Down syndrome.

J Clin Ultrasound 2018 Jan 28;46(1):62-63. Epub 2017 Oct 28.

Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel.

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http://dx.doi.org/10.1002/jcu.22543DOI Listing
January 2018

Factors Associated with Compliance of Folic Acid Consumption among Pregnant Women.

Isr Med Assoc J 2017 Aug;19(8):494-498

Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.

Background: The prevalence of major malformations in the general population is estimated at 5% of all live births. Prenatal diagnosis is an important scientific tool that allows reliable consultation and improves pregnancy outcome. In 2008, congenital malformations were the leading cause of death in Muslim infants and the second cause of death in Jewish infants in Israel. It is known that folic acid consumption prior to pregnancy decreases the rate of several fetal malformations.

Objectives: To assess the folic acid consumption rate and to characterize variables associated with its use among pregnant women attending a rural medical center.

Methods: A cross-sectional observational study was conducted at our institution. Pregnant women in the second or third trimester of pregnancy or within 3 days postpartum were interviewed. The main variable measured was the use of folic acid. Demographic variables and the rate of prenatal testing were assessed. A secondary analysis of the population that reported no consumption of folic acid was carried out.

Results: Out of 382 women who participated in the study, 270 (71%) reported consumption of folic acid. Using a multivariate analysis model, we found that maternal education, planning of pregnancy, and low parity were independent predictors of folic acid consumption. Women who were not consuming folic acid tended to perform fewer prenatal tests during pregnancy.

Conclusions: High maternal educational level, planning of pregnancy, and low parity are related to high consumption rates of folic acid. Women who were not taking folic acid performed fewer prenatal tests during pregnancy.
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August 2017

Trends in Continuity of Pregnancy in Women with Positive Cytomegalovirus IgM during the First Trimester, 2008-2009.

Isr Med Assoc J 2017 Aug;19(8):484-488

Maccabi HMO, Medical services, Israel.

Background: Cytomegalovirus (CMV) infection during pregnancy is the most common cause of intrauterine infection, and is a common cause of sensorineural hearing loss and mental retardation.

Objectives: To evaluate trends in amniocentesis and pregnancy outcome in women with suspected cytomegalovirus (CMV) infection during the first trimester.

Methods: All blood tests for CMV immunoglobulin M (IgM) done between 2008 and 2009 on pregnant women who were enrolled in the Maccabi Healthcare Services were retrieved from laboratory database. Immunoglobulin G (IgG) avidity was measured and women were classified according to the risk of acquiring CMV infection. For each patient, performance of amniocentesis and whether pregnancy came to term were recorded.

Results: Of 109,439 pregnant women evaluated during the study period, 76,712 (70.1%) were tested for CMV IgM, and 792 (1.03%) were found to be positive. Among women with positive IgM, only 205 (25.9%) underwent amniocentesis. When compared with women with negative CMV IgM, the rate of pregnancy cessation was doubled in women with positive CMV IgM (28.3% vs. 14.3%, P < 0.05) and mostly elevated in women with a high risk of acquiring CMV (42.3% pregnancy cessation). Among women with positive CMV IgM, those who did not undergo amniocentesis were more likely to abort than those who performed amniocentesis (35.6% vs. 7.3%, P < 0.05).

Conclusions: More women with suspected CMV infection during the first trimester of pregnancy aborted before all means of detection were utilized to rule out or confirm fetal infection with CMV.
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August 2017

Prise en charge de l'infection à la varicelle pendant la grossesse.

J Obstet Gynaecol Can 2016 Dec 4;38(12S):S34-S40. Epub 2017 Jan 4.

Torono (Ont.).

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http://dx.doi.org/10.1016/j.jogc.2016.09.018DOI Listing
December 2016

Prenatal diagnosis of 17q12 deletion syndrome: from fetal hyperechogenic kidneys to high risk for autism.

Prenat Diagn 2016 Nov 25;36(11):1027-1032. Epub 2016 Oct 25.

Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel HaShomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: The linkage between 17q12 microdeletions, renal anomalies, and higher risk for neurodevelopmental disorders is well described in the literature. The current study presents prenatal diagnosis of normal-sized fetal hyperechogenic kidneys leading to the diagnosis of 17q12 deletion syndrome and autism spectrum disorder.

Methods: Over a period of 9 years in a single referral center, seven fetuses were diagnosed with hyperechogenic renal parenchyma and were followed up prospectively. Amniocentesis for molecular diagnosis was performed in all cases, and subsequently, five fetuses were found to harbor a 17q12 deletion by chromosomal microarray analysis. Postnatal evaluation was carried out by a developmental neurologist.

Results: Five of the seven fetuses had molecular diagnosis of 17q12 deletion. One patient elected termination of pregnancy. On long-term follow-up, all of the four children showed symptoms consistent with neurodevelopmental disorders. The two fetuses with no deletion have a normal follow-up with regression of the renal hyperechogenicity.

Conclusions: We report a strikingly high correlation between prenatal hyperechogenic kidneys, 17q12 microdeletion, and autism spectrum disorder with the advantage of optimal prenatal counseling as well as early diagnosis and intervention. © 2016 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/pd.4926DOI Listing
November 2016

Maternal characteristics of pregnancies with intrauterine fetal demise.

J Perinat Med 2016 Oct;44(7):779-784

Objective: To identify maternal characteristics independently associated with pregnancies resulting in intrauterine fetal demise (IUFD).

Study Design: This was a population-based cohort study of all births taking place at the McGill University Health Centre in Montreal, Canada, between 2001 and 2007, using the McGill University Obstetrics and Neonatal Database. Maternal characteristics were compared between pregnancies that resulted in IUFD and control pregnancies resulting in live newborns. A logistic regression analysis was constructed to identify parameters independently associated with IUFD.

Results: We identified 20,744 births during the study period, 87 of which were complicated by IUFD. Mothers with IUFD were more likely to be younger, with less formal education, higher rates of smoking during pregnancy, and more fetal anomalies (42.5% vs. 7.5%, P<0.001). After exclusion of pregnancies with congenital and/or chromosomal abnormalities, less formal education (7 vs. 13.6 school years, P<0.001) and smoking during pregnancy (24% vs. 7.7%, P<0.001) remained significantly more common in pregnancies resulting in IUFD. In the multivariable regression analysis both smoking and number of maternal school years were independently associated with IUFD pregnancies (OR 2.22 for smoking, P=0.007 and OR 0.865 for number of school years, P<0.001).

Conclusion: Lower levels of education and smoking during pregnancy are independent predictors of IUFD.
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http://dx.doi.org/10.1515/jpm-2015-0135DOI Listing
October 2016

Prolonged second stage of labour and the risk for subsequent preterm birth.

J Obstet Gynaecol Can 2015 Apr;37(4):324-329

McGill University Health Centre, Montreal QC; Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Royal Victoria Hospital, McGill University, Montreal QC.

Objective: To assess whether prolonged second stage of labour influences the gestational age at the subsequent delivery.

Methods: We performed a retrospective cohort study. Clinical information was retrieved from the McGill Obstetrical and Neonatal Database for the period of January 2001 to February 2008. We evaluated primiparous women with term singleton pregnancies who reached the second stage of labour. Women were divided into two groups, according to the duration of the second stage: delivery after more than three hours of full cervical dilatation, or delivery within three hours. The primary outcome measured was the incidence of spontaneous preterm births at the subsequent delivery.

Results: Among 1818 women whose records were available for analysis, 416 women (22.9%) had a prolonged second stage of labour in their first delivery. Women with a prolonged second stage in their first delivery did not deliver prematurely more often in the successive delivery than those women whose second stage was not prolonged (rate of preterm birth 4.3% in the prolonged second stage group and 5.5% in the normal second stage group; P = 0.3).

Conclusion: In our population of primiparous women with a singleton term delivery, a prolonged second stage of labour lasting more than three hours was not associated with preterm birth at their subsequent delivery.
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http://dx.doi.org/10.1016/S1701-2163(15)30282-6DOI Listing
April 2015

Maternal predictors of RBC folate levels in an urban Canadian population.

Reprod Toxicol 2015 Jun 27;53:127-30. Epub 2015 Apr 27.

Department of Obstetrics and Gynecology, McGill University Health Centre, McGill University, Montreal, Canada.

Objective: To assess factors associated with low Red Blood Cell folate (RBCf) levels in an obstetric population in a tertiary centre.

Methods: Cross-sectional study. Three hundred and fifty women completed a questionnaire detailing use of folic acid supplementation, and had their RBCf levels measured. Values ≥ 906 nmol/L were considered optimal. Factors associated with optimal RBCf were assessed, individually and in a logistic regression model.

Results: Median RBCf was 1282 nmol/L. Thirty-five women (10%) had suboptimal levels. Predictors of suboptimal RBCf were non-Caucasian ethnicity, non-consumption of folic acid supplementations, and inadequate health care provider information regarding the benefits of folic acid consumption.

Conclusion: Although, in our population, a high proportion of women achieved optimal levels of RBCf, some women remain at risk due to inadequate folate consumption. Patient and health care provider education regarding folate can still be improved, particularly in the groups identified to be at greater risk.
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http://dx.doi.org/10.1016/j.reprotox.2015.04.009DOI Listing
June 2015

Can the practice of nonclosure of visceral and parietal peritoneum during cesarean delivery be justified? Reply.

Am J Obstet Gynecol 2015 Apr 12;212(4):550-1. Epub 2014 Dec 12.

Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; Bruce and Ruth Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.

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http://dx.doi.org/10.1016/j.ajog.2014.12.009DOI Listing
April 2015

The unborn smoker: association between smoking during pregnancy and adverse perinatal outcomes.

J Perinat Med 2015 Sep;43(5):553-8

Objective: To evaluate a possible dose-response relationship between active maternal smoking during pregnancy and adverse perinatal outcome.

Design: Retrospective cohort study.

Setting: Population-based in Montreal, Quebec, Canada.

Population: Women who gave birth to a liveborn or stillborn infant during the period of January 2001 to December 2007.

Methods: Active smokers of different daily cigarette consumption (n=1646) were identified through maternal self-reporting. The reference group comprised 19,292 non-smoking women who delivered during the same period.

Main Outcome Measures: Birth weight, preterm delivery rate, fetal and neonatal mortality and morbidity, and congenital malformations.

Results: Preterm delivery rate was significantly higher in the smoking group compared with controls (22.2% vs. 12.4%, P<0.05), as was intrauterine fetal demise (1.4% vs. 0.3%, P<0.05). Newborns of active smokers were more likely to weigh less (3150±759 g vs. 3377±604 g, P<0.05), suffer from respiratory distress syndrome (2.5% vs. 1.3%, P<0.05), suffer from a cardiac malformation (1.5% vs. 0.8%, P<0.05), and die (neonatal death 1.2% vs. 0.6%, P<0.05). A dose-response relationship was demonstrated between levels of daily cigarette smoking and several adverse outcomes. Using multiple regression models, smoking was found to be an independent predictor of preterm delivery (odds ratios (OR) 1.9, 95% confidence intervals (95%CI) 1.6-2), and intrauterine fetal demise (OR 2.4, 95%CI 1.4-4.2).

Conclusion: Any amount of daily smoking appears to harm the fetus and newborn. As pregnancy may be a "window of opportunity" for behavioural changes, efforts to promote smoking cessation should be encouraged.
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http://dx.doi.org/10.1515/jpm-2014-0299DOI Listing
September 2015

Adhesion prevention after cesarean delivery: evidence, and lack of it.

Am J Obstet Gynecol 2014 Nov 22;211(5):446-52. Epub 2014 May 22.

Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Bruce and Ruth Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery.
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http://dx.doi.org/10.1016/j.ajog.2014.05.027DOI Listing
November 2014

Sonographic assessment of fetal secondary palate between 12 and 16 weeks of gestation using three-dimensional ultrasound.

Prenat Diagn 2013 Dec 10;33(13):1256-9. Epub 2013 Oct 10.

Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel.

Objective: To evaluate fetal secondary palate in fetuses at 12 to 16 weeks' gestation by three-dimensional ultrasound.

Methods: Between June 2006 and July 2008, volumes of palate were prospectively acquired in fetuses at gestational age of 12 to 16 weeks. Acquisition was performed when the fetus was facing the transducer with head extended at an angle of 30° to 40° to the ultrasound beam. Secondary palate was assessed off-line.

Results: Secondary palate was assessed in 45 fetuses with normal face anatomy and 4 fetuses with malformations of the face (one with retrognathia, one with retrognathia and micrognathia, one with cleft lip and one with cleft lip and primary palate). The secondary palate was visualized in 19/49 (38.7%) fetuses: in 2/49, only hard palate was demonstrated; in 6/49, only soft palate and in 11/49, both hard and soft palate were fully demonstrated.

Conclusion: Information concerning evenness of secondary palate may be provided by three-dimensional ultrasound in 38.7% of examined fetuses at 12 to 16 weeks of gestation. This examination should be offered in pregnancies at high risk for cleft palate.
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http://dx.doi.org/10.1002/pd.4242DOI Listing
December 2013

Three-dimensional ultrasound demonstration of the fetal palate in high-risk patients: the accuracy of prenatal visualization.

Prenat Diagn 2013 May 12;33(5):436-41. Epub 2013 Mar 12.

Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel.

Objective: The aim of this research was to evaluate the ability of three-dimensional (3D) ultrasound for demonstrating the palate of fetuses at high risk for cleft palate.

Method: Fifty-seven fetuses at high risk for cleft palate were referred for specialist ultrasound at 12-40 weeks' gestation. A detailed assessment of palate was made using both two-dimensional and 3D ultrasounds on the axial plane. Antenatal diagnoses were compared with postnatal findings.

Results: Cleft palate was suspected in 13 (22.8%); a normal palate was demonstrated in 38 (67%), and in six (10.2%), the palate view could not be obtained. Mean gestational age at the first visit was 27 weeks 6 days (range of 12-40 weeks 3 days). Examination after delivery revealed that one of the 38 fetuses with presumed normal palate had a cleft hard palate, and one had a cleft soft palate (false negative 5%). Among the 13 fetuses with suspected cleft palate, three had an intact palate (false-positive 23%). Sensitivity, specificity, positive predictive value, and negative predictive value of detection of palatal clefts were 71.4%, 91.9%, 62.5%, and 94.4%, respectively.

Conclusion: Using 3D technology, we diagnosed a cleft palate in 83% of high-risk cases, with 5% false negative. 3D technology might produce some technical artifacts resulting in a 23% false-positive rate.
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http://dx.doi.org/10.1002/pd.4083DOI Listing
May 2013

Does multi-fetal pregnancy reduction adversely influence intra-uterine growth?

Acta Obstet Gynecol Scand 2013 Mar;92(3):342-5

Department of Maternal Fetal Medicine, McGill University, Montreal, Canada.

Multi-fetal pregnancy reduction (MFPR) is offered in the management of higher-order multiple gestations to reduce the risks associated with such pregnancies. Pregnancy outcomes, including birthweight, following MFPR have been examined with variable findings. However, little attention has been paid to in utero growth in such pregnancies. This study examines whether the intra-uterine growth performance of a twin pregnancy resulting from MFPR differs from that of an unreduced twin pregnancy. This was a retrospective analysis comparing the intrauterine growth of 20 higher order multiple pregnancies that underwent MFPR with resulting di-chorionic twin gestations with 293 unreduced di-chorionic twin gestations. Biometric nomograms were derived for the unreduced twin population and the biometric parameters for the reduced pregnancies were compared with these. There was a difference with respect to femur length in the period 20-28 weeks (p = 0.003) but no other significant differences were observed. MFPR does not itself adversely influence intra-uterine fetal growth.
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http://dx.doi.org/10.1111/aogs.12076DOI Listing
March 2013

Can discordance in CRL at the first trimester predict birth weight discordance in twin pregnancies?

J Perinat Med 2012 May 13;40(5):489-93. Epub 2012 May 13.

Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel HaShomer, Israel.

Objective: To examine the correlation between measurements of crown rump length (CRL), nuchal translucency (NT), and birth weight in dichorionic (DC) and monochorionic (MC) twin pregnancies.

Methods: A retrospective analysis was performed on all twin term pregnancies delivered between 2001 and 2007 at the McGill University Health Center. Data collected included maternal age, CRL and NT measurement, results of glucose challenge test, birth weight and length, gestational age at delivery, and fetal gender.

Results: The study population comprised 792 fetuses: 94 MC/DA and 698 DC/DA. Maternal age, gestational age at delivery, birth weight, and birth length were all significantly higher for the DC group. Male fetuses had significantly higher NT and higher birth weight than female fetuses. Discordance in CRL was found to correlate with discordance in birth weight in the entire study population (P<0.0001, R=0.25), in the DC twins (P<0.0001, R=0.275), but not in MC twins (R=0.10, P=0.33). CRL discordance above the 90th percentile (>12%) predicted 14/40 pregnancies with birth weight discordance above the 90th percentile (>24%) [P<0.001, LR=4.1 (2.6-6.2)]. CRL discordance above the 95th percentile (>16%) predicted 5/21 pregnancies with birth weight discordance above the 95th percentile (>30%) [P<0.001, LR=5.5 (2.6-10.4)]. NT discordance was correlated with CRL discordance (R=0.15, P<0.0001), but not with birth weight, regardless of chorionicity or gender.

Conclusion: In twin pregnancies, CRL discordance in first trimester can predict discordance of more than 25% in neonatal birth weight.
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http://dx.doi.org/10.1515/jpm-2011-0250DOI Listing
May 2012

Computed tomographic diagnosis of traumatic fetal subdural hematoma.

Emerg Radiol 2013 Apr 14;20(2):169-72. Epub 2012 Aug 14.

Department of Radiology, Hillel Yaffe Medical Center, P.O.B. 169, Hadera 38100, Israel.

Intrauterine subdural hematoma (SDH) is a rare event; maternal trauma, especially during the last trimester of pregnancy, is the best documented cause of fetal SDH. We report an extremely rare case of fetal SDH due to maternal trauma diagnosed by multidetector computed tomography. We also discuss the clinical and imaging features of fetal SDH which can be used to assist in diagnosis with emphasis on CT criteria.
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http://dx.doi.org/10.1007/s10140-012-1067-7DOI Listing
April 2013

Rhinosinusitis-related quality of life during pregnancy.

Am J Rhinol Allergy 2012 Jul-Aug;26(4):283-6

Otolaryngology, Head and Neck Surgery Unit, Ziv Medical Center, Zefat, Israel.

Background: Pregnancy rhinitis manifests as nasal congestion, with resolution of symptoms after delivery. Eighteen to 30% of pregnant patients report symptoms of rhinitis. Pregnancy rhinitis may have an adverse effect on quality of life (QOL) and may cause obstructive sleep apnea (OSA), which in turn may adversely affect the outcome of pregnancy. Previous examinations of the prevalence of pregnancy rhinitis during different stages of pregnancy have been inconclusive. This study aimed to determine rhinosinusitis-specific QOL during different stages of pregnancy.

Methods: A cross-sectional observation study of patients in the second and third trimesters of pregnancy using the 22-item Sino-Nasal Outcome Test (SNOT-22) was conducted in the obstetric clinic at McGill University Health Center in Montreal, Canada. Seventy-six low- risk pregnant patients were included in the study. Thirty-two patients were in the second trimester of pregnancy and 44 patients were in the third trimester.

Results: Average item scores for the entire questionnaire were significantly higher (p = 0.041), indicating more severe impairment of QOL, in the third trimester in comparison with the second trimester. A comparison between women with and without preexisting allergic rhinitis, in both the second and the third trimesters, shows significantly higher SNOT-22 scores for the allergic group (p = 0.007). QOL was lower in the third trimester than in nonrhinosinusitis patients (p = 0.011).

Conclusion: Rhinosinusitis-specific QOL is lower in the third trimester of pregnancy in comparison with the second trimester and also in comparison with nonrhinosinusitis patients. Increased awareness may enhance the QOL of pregnant patients, prevent OSA, and thereby positively influence the outcome of pregnancy.
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http://dx.doi.org/10.2500/ajra.2012.26.3776DOI Listing
December 2012

Management of varicella infection (chickenpox) in pregnancy.

J Obstet Gynaecol Can 2012 Mar;34(3):287-292

Toronto ON.

Objective: To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management.

Methods: The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae.

Evidence: Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010.

Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).

Recommendations: 1. Varicella immunization is recommended for all non-immune women as part of pre-pregnancy and postpartum care. (II-3B) 2. Varicella vaccination should not be administered in pregnancy. However, termination of pregnancy should not be advised because of inadvertent vaccination during pregnancy. (II-3D) 3. The antenatal varicella immunity status of all pregnant women should be documented by history of previous infection, varicella vaccination, or varicella zoster immunoglobulin G serology. (III-C) 4. All non-immune pregnant women should be informed of the risk of varicella infection to themselves and their fetuses. They should be instructed to seek medical help following any contact with a person who may have been contagious. (II-3B) 5. In the case of a possible exposure to varicella in a pregnant woman with unknown immune status, serum testing should be performed. If the serum results are negative or unavailable within 96 hours from exposure, varicella zoster immunoglobulin should be administered. (III-C) 6. Women who develop varicella infection in pregnancy need to be made aware of the potential adverse maternal and fetal sequelae, the risk of transmission to the fetus, and the options available for prenatal diagnosis. (II-3C) 7. Detailed ultrasound and appropriate follow-up is recommended for all women who develop varicella in pregnancy to screen for fetal consequences of infection. (III-B) 8. Women with significant (e.g., pneumonitis) varicella infection in pregnancy should be treated with oral antiviral agents (e.g., acyclovir 800 mg 5 times daily). In cases of progression to varicella pneumonitis, maternal admission to hospital should be seriously considered. Intravenous acyclovir can be considered for severe complications in pregnancy (oral forms have poor bioavailability). The dose is usually 10 to 15 mg/kg of BW or 500 mg/m² IV every 8 h for 5 to 10 days for varicella pneumonitis, and it should be started within 24 to 72 h of the onset of rash. (III-C) 9. Neonatal health care providers should be informed of peripartum varicella exposure in order to optimize early neonatal care with varicella zoster immunoglobulin and immunization. (III-C) Varicella zoster immunoglobulin should be administered to neonates whenever the onset of maternal disease is between 5 days before and 2 days after delivery. (III-C).
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http://dx.doi.org/10.1016/S1701-2163(16)35190-8DOI Listing
March 2012

Pregnancies in young adolescent mothers: a population-based study on 37 million births.

J Pediatr Adolesc Gynecol 2012 Apr 16;25(2):98-102. Epub 2011 Nov 16.

Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. Electronic address:

Objectives: Pregnancy in young adolescents is often understudied. The objective of our study was to evaluate the effect of young maternal age on adverse obstetrical and neonatal outcomes.

Methods: We conducted a population-based cohort study using the Center for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all births in the US between 1995 and 2004. We excluded all births of gestational age under 24 weeks and those with reported congenital malformations or chromosomal abnormalities. Maternal age was obtained from the birth certificate and relative risks estimating its effect on obstetrical and neonatal outcomes were computed using unconditional logistic regression analysis.

Results: 37,504,230 births met study criteria of which 300,627 were in women aged <15 years with decreasing rates from 11/1,000 to 6/1,000 over a 10-year period. As compared to women 15 years and older, women <15 were more likely to be black and Hispanic, less likely to have adequate prenatal care, and more likely to not have had any prenatal care. In adjusted analysis, births to women <15 were more likely to be IUGR, born under 28, 32, and 37 weeks' gestation and to result in stillbirths and infant deaths. Prenatal care was protective against infant deaths in women < 15 years of age.

Conclusion: Although public health initiatives have been successful in decreasing rates of young adolescent pregnancies, these remain high risk pregnancies that may benefit from centers capable of ensuring adequate prenatal care.
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http://dx.doi.org/10.1016/j.jpag.2011.09.004DOI Listing
April 2012

Perinatal outcome of monochorionic twins with selective IUGR compared with uncomplicated monochorionic twins.

Twin Res Hum Genet 2011 Oct;14(5):457-62

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.

Objective: To evaluate the perinatal outcome of MC twins with selective IUGR (sIUGR).

Study Design: A prospective study, which included three groups of MC twins: Group A, uncomplicated MC twin pregnancies (n = 91); group B, sIUGR with normal umbilical artery Doppler (n = 19); and group C, sIUGR with abnormal (absence or reversed EDV) umbilical artery Doppler (n = 18). The latter were routinely hospitalized in the high-risk ward under strict surveillance.

Results: Neonatal outcome of fetuses complicated with sIUGR and normal Doppler was similar to controls. Neonates born to pregnancies complicated by sIUGR and abnormal Doppler had significantly increased incidence of CNS findings, RDS, NEC, sepsis, and neonatal death compared to controls. Adverse outcome in this group was independently associated only with gestational age at birth.

Conclusion: The perinatal outcomes of MC twins complicated with sIUGR and normal Doppler are similar to uncomplicated MC pregnancies. MC twins with sIUGR and abnormal Doppler have reasonable outcomes, yet significantly more neonatal complications compared to non-complicated MC twins.
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http://dx.doi.org/10.1375/twin.14.5.457DOI Listing
October 2011