Publications by authors named "Ariel Many"

111 Publications

Obstetrical outcomes of ART pregnancies in patients with male factor infertility.

J Assist Reprod Genet 2021 Jun 17. Epub 2021 Jun 17.

Department of Obstetrics and Gynecology, Lis Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel.

Purpose: Pregnancies conceived by in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are associated with an increased incidence of obstetrical and neonatal complications. With the growing rate of male factor infertility, which is unique by not involving the maternal milieu, we aimed to assess whether obstetrical outcomes differed between IVF/ICSI pregnancies due to male factor infertility and those not due to male factor infertility.

Methods: A retrospective cohort study of women receiving IVF/ICSI treatments at a single hospital over a five-year period was involved in the study. Inclusion criteria were women with a viable pregnancy that delivered at the same hospital. Pregnancies were divided into male factor only related and non-male factor-related infertility. The groups were compared for several maternal and neonatal complications.

Results: In total, 225 patients met the study criteria, with 94 and 131 pregnancies belonging to the male factor and non-male factor groups, respectively. Demographic and clinical characteristics were comparable, except for younger maternal age and higher incidence of twin pregnancies in the male factor group. A sub-analysis for singleton pregnancies revealed a less likelihood of cesarean delivery, preterm birth, and male gender offspring in the male factor group (p < 0.05). These differences were not observed in the sub-analysis for twin pregnancies. Other outcome measures were similar in both groups, both for singleton and twin pregnancies.

Conclusion: Singleton IVF pregnancies due to male factor infertility are associated with a reduced incidence of some adverse outcomes, likely due to lack of underlying maternal medical conditions or laboratory conditions related to ICSI. Our findings require validation by further studies on larger samples.
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http://dx.doi.org/10.1007/s10815-021-02259-1DOI Listing
June 2021

Predicting the need for blood transfusion requirement in postpartum hemorrhage.

J Matern Fetal Neonatal Med 2021 Jun 9:1-6. Epub 2021 Jun 9.

Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Objective: We aimed to assess the role of lactate and hemoglobin levels as predictors for the need for blood transfusion in post-partum hemorrhage (PPH).

Methods: A retrospective cohort study of women with PPH in a single university-affiliated tertiary medical center between August 2018 and June 2020. PPH was defined as an estimated excessive blood loss (of more than 500 ml following vaginal delivery and 1000 ml following a cesarean delivery) requiring at least one uterotonic drug and fluid resuscitation. Women were stratified by the need of requiring blood transfusion due to hemorrhage. The criteria for blood transfusion were: (1) clinically severe uncontrollable ongoing hemorrhage; (2) symptomatic anemia (maternal tachycardia >110 beats per minute, dizziness, syncope or presyncope) in the presence of Hb 7-8 g/dL or (3) postpartum Hb level < 7 g/dL regardless of maternal symptoms or signs of anemia. Demographic, labor characteristics as well as laboratory data were collected. For all women the Shock Index (SI: heart rate divided by systolic blood pressure) was calculated. Women without available data on immediate (more than 15 min from the bleeding initiation) hemoglobin (Hb) level and lactate concentrations were excluded.

Results: Overall, out of 22,241 deliveries during the study, 94 women were included, of them 26 (23.4%) required blood transfusion. The antepartum Hb level was lower in the transfused group (11.7 ± vs 12.4 ± 1.0 re/dL,  = .01). No significant differences were found in demographic and labor characteristics. In multivariate logistic regression analysis, a lower immediate postpartum Hb and a higher SI higher were associated with blood transfusion requirement (adjusted odds ratio (aOR) 3.45 [CI] 1.82-7.69,  < .001] and aOR 1.25 [CI 1.03-1.55,  = .03], respectively). The combination of SI, immediate postpartum Hb and lactate concentration provided the best integration, with an area under the curve of 0.86, sensitivity 92.65%, specificity 61.54%, positive and negative predictive values of 86.3% and 76.2%, respectively.

Conclusion: The combination of SI, immediate postpartum Hb and lactate levels is a good predictor for the need of blood requirement in PPH.
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http://dx.doi.org/10.1080/14767058.2021.1937992DOI Listing
June 2021

Efficient maternal to neonatal transfer of antibodies against SARS-CoV-2 and BNT162b2 mRNA COVID-19 vaccine.

J Clin Invest 2021 07;131(13)

Department Obstetrics and Gynecology, Wolfson Medical Center, Holon; affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

BACKGROUNDThe significant risks posed to mothers and fetuses by COVID-19 in pregnancy have sparked a worldwide debate surrounding the pros and cons of antenatal SARS-CoV-2 inoculation, as we lack sufficient evidence regarding vaccine effectiveness in pregnant women and their offspring. We aimed to provide substantial evidence for the effect of the BNT162b2 mRNA vaccine versus native infection on maternal humoral, as well as transplacentally acquired fetal immune response, potentially providing newborn protection.METHODSA multicenter study where parturients presenting for delivery were recruited at 8 medical centers across Israel and assigned to 3 study groups: vaccinated (n = 86); PCR-confirmed SARS-CoV-2 infected during pregnancy (n = 65), and unvaccinated noninfected controls (n = 62). Maternal and fetal blood samples were collected from parturients prior to delivery and from the umbilical cord following delivery, respectively. Sera IgG and IgM titers were measured using the Milliplex MAP SARS-CoV-2 Antigen Panel (for S1, S2, RBD, and N).RESULTSThe BNT162b2 mRNA vaccine elicits strong maternal humoral IgG response (anti-S and RBD) that crosses the placenta barrier and approaches maternal titers in the fetus within 15 days following the first dose. Maternal to neonatal anti-COVID-19 antibodies ratio did not differ when comparing sensitization (vaccine vs. infection). IgG transfer ratio at birth was significantly lower for third-trimester as compared with second trimester infection. Lastly, fetal IgM response was detected in 5 neonates, all in the infected group.CONCLUSIONAntenatal BNT162b2 mRNA vaccination induces a robust maternal humoral response that effectively transfers to the fetus, supporting the role of vaccination during pregnancy.FUNDINGIsrael Science Foundation and the Weizmann Institute Fondazione Henry Krenter.
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http://dx.doi.org/10.1172/JCI150319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245182PMC
July 2021

Prolonged exposure to meconium in cases of spontaneous premature rupture of membranes at term and pregnancy outcome.

J Matern Fetal Neonatal Med 2021 Apr 28:1-6. Epub 2021 Apr 28.

Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Objective: To evaluate the impact of prolonged exposure to meconium-stained amniotic fluid (MSAF), in women with term pre-labor spontaneous rupture of membranes (PROM), on pregnancy outcome.

Methods: A retrospective cohort study of women who gave birth in a single university-affiliated tertiary medical center (2011-2019). Eligibility was limited to singleton pregnancies at term who presented with PROM. Women with MSAF were immediately induced and were compared to low-risk pregnant women with clear amniotic fluid (CAF) at admission who underwent induction of labor 24 h after rupture of membranes. All women were stratified into 4-time frame groups from rupture of membranes to delivery: T0: 0-7 h, T1: 8-13 h, T2: 14-18 h, and T3: > 18 h for the MSAF group. The time frames for the CAF were: T0 - 24-31 h, T1: 32-38 h, T2: 40-44 h, and T3: > 44 h. The maternal adverse composite outcome included any of the following: intrapartum fever (IPF), prolonged second stage (PSS), need for manual removal of suspected retained placenta, postpartum hemorrhage, and readmission within 45 days after delivery. The adverse composite neonatal outcome included one or more of the following: meconium aspiration syndrome, neonatal asphyxia, need for respiratory support, and intracranial hemorrhage.

Results: Overall, 1631 women met the inclusion criteria (536 in the MSAF and 1095 in the CAF group). Both groups showed a gradual decrease in the rate of vaginal delivery over time, the vaginal delivery rate in the MSAF group was 75.7% at T0 in comparison to 61.6% at T3 ( < .001). In the CAF group, the vaginal delivery rate was 84.5% at T0 in comparison to 68.8% at T3 ( < .001). This decrease was in concomitance with an increase in the rates of prolonged second-stage and intrapartum fever. There were no significant differences in the rates of postpartum hemorrhage, suspected retained placenta, or readmission within 45 days between women with either MSAF or CAF. There was a significant gradual increase in the adverse composite neonatal outcome in the MSAF group (1.9% at T0, 5.2% at T1, 6.0% at T2, and 8.2% at T3.  = .038). No similar increase was found in the CAF group (2.5% at T0, 4.1% at T1, 2.6% at T2, and 4.1% at T3.  = .449).

Conclusion: Prolonged rupture of membranes in the presence of meconium does not affect maternal outcomes, however, prolonged exposure to meconium lead to an increased adverse neonatal outcome.
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http://dx.doi.org/10.1080/14767058.2021.1919077DOI Listing
April 2021

Cefazolin prophylaxis in minimally invasive gynecologic surgery - are dosage and timing appropriate? Prospective study using resampling simulation.

J Gynecol Obstet Hum Reprod 2021 Apr 24;50(9):102154. Epub 2021 Apr 24.

Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Objective: Cefazolin is a widely used antimicrobial prophylactic agent, however the appropriate dosage, timing, pharmacology and microbial coverage have not been well-established for gynecologic procedures. We aimed to describe serum concentrations and pharmacokinetics of Intravenous cefazolin given to women prior to scheduled minimally invasive gynecologic surgeries, and to determine whether appropriate antimicrobial coverage had been achieved in short time from prophylactic administration to surgical start time.

Methods: A prospective cohort analysis study, using a resampled dataset, of women undergoing scheduled gynecological surgeries in a university affiliated tertiary medical center. IV cefazolin (1 or 2 gr) was administered prior to incision to women weighing <80 kg (Group A) and ≥80 kg (Group B), respectively. Cefazolin serum levels were obtained at the time of skin incision (Time 0) and 30 min later (Time 30), measured by high-pressure liquid chromatography (HPLC). Appropriate antimicrobial coverage was defined when cefazolin serum levels were above minimal inhibitory concentrations (MIC) for Enterobacteriaceae.

Results: Overall, 21 women were included. The mean time interval between drug administration and incision did not differ between the two groups (18 ± 10 min vs. 11 ± 10 min, respectively, p = .0.25). A hierarchical mixed linear regression model, using a simulation of multiple random bootstrap resampling (n = 1,000), revealed that cefazolin serum levels exceeded MIC, regardless of the timing of administration in the sampling intervals. Mean cefazolin serum levels in time 0 and time 30 min were not affected by BMI in patients receiving 1 gr.

Conclusion: A single dose of IV cefazolin given shortly prior to skin incision provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled minimally invasive gynecologic surgery.
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http://dx.doi.org/10.1016/j.jogoh.2021.102154DOI Listing
April 2021

Length of the Second Stage of Labor in Women Delivering Twins.

Obstet Gynecol 2021 04;137(4):664-669

Departments of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Chaim Sheba Medical Center, Ramat-Gan, and Tel-Aviv University and Lis Maternity Hospital, Tel-Aviv, Israel, and Washington University in St. Louis School of Medicine, St. Louis, Missouri.

Objective: To evaluate the length of the second stage of labor in twin deliveries and to compare the length of the second stage in twin and singleton gestations.

Methods: This is a retrospective cohort study from three large hospitals in Israel. Clinical data were collected from the electronic medical record. The primary outcome was the length of the second stage (the time from documented 10-cm dilation until spontaneous vaginal delivery of the first twin). Multivariable linear regression was used to examine the association of clinical factors with the length of the second stage. The length of the second stage in twin and singleton pregnancies was compared.

Results: From 2011 to June, 2020, there were 2,009 twin deliveries and 135,217 singleton deliveries. Of the twin deliveries, 655 (32.6%) of the patients were nulliparous (95th percentile length of the second stage 3 hours and 51 minutes), 1,235 (61.5%) were parous (95th percentile 1 hour 56 minutes), and 119 (5.9%) were grand multiparous (five or more prior deliveries) (95th percentile 1 hour 24 minutes). In women delivering twins, epidural use was associated with a statistically significant increase in the length of the second stage of 40 minutes in nulliparous patients and 15 minutes in parous patients. In all groups, the length of the second stage was longer in patients delivering twins compared with singletons. Second-stage length longer than the 95th percentile in twins was associated with admission to the neonatal intensive care unit and need for phototherapy.

Conclusion: Second-stage labor is longer in twins than singletons and is associated with obstetric history. Normal ranges for the second stage may be useful in guiding clinical practice.
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http://dx.doi.org/10.1097/AOG.0000000000004308DOI Listing
April 2021

Early Preterm meconium stained amniotic fluid is an independent risk factor for peripartum maternal bacteremia.

Eur J Obstet Gynecol Reprod Biol 2021 Mar 31;258:75-79. Epub 2020 Dec 31.

Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To investigate the association of maternal peripartum bacteremia and meconium stained amniotic fluid in early preterm deliveries.

Methods: We conducted a single center retrospective study, in a tertiary university affiliated medical center. The study cohort included women with culture proven maternal bacteremia who had a preterm delivery between 24-34 weeks of gestation. The control group composed of women with similar gestational age at delivery without bacteremia. Maternal characteristics were compared between the groups.

Results: During the six-years study period there were 86,590 deliveries in our center. 2625 (3.03 %) women had early preterm deliveries (24-34 weeks), of them 22 (0.84 %) were diagnosed with peripartum bacteremia. The groups were similar with regard to obstetric and demographic characteristics. In the peripartum maternal bacteremia group, we found significantly higher rates of MSAF (6.86 % vs 22.73 %, p = 0.036). Logistic regression of multivariable analysis demonstrated that MSAF is an independent risk factor for maternal bacteremia adjusted for gestational age, intrapartum fever and leukocytosis (Odd Ratio 4.29, 95 % CI 1.26-12.56, p = 0.012) CONCLUSION: Preterm MSAF is an independent risk factor for maternal bacteremia among women with early preterm delivery. More studies are needed to determine the need for broad spectrum antibiotic prophylaxis therapy in preterm deliveries complicated by MSAF.
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http://dx.doi.org/10.1016/j.ejogrb.2020.12.052DOI Listing
March 2021

Maternal presentation and neonatal outcome in peripartum enterovirus infection.

Acta Paediatr 2021 05 9;110(5):1483-1489. Epub 2020 Dec 9.

Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Centre, Lis Maternity Hospital, Tel Aviv, Israel.

Aim: Enterovirus is a common pathogen. Although mostly asymptomatic, this infection has the potential to be life-threatening in neonates. This article aims to describe the early neonatal outcomes in peripartum infection.

Methods: We performed a retrospective cohort study in a tertiary hospital between 1/2014 and 5/2019. The enterovirus infection was established by real-time polymerase chain reaction analysis.

Results: Out of 161 neonates tested for the enterovirus infection 13 (8%) were positive. Maternal fever was the most common sign (n = 8, 66.7%). The mean gestational age at delivery was 36 + 5 (range 30 + 5 to 40 + 6 weeks). The mean time interval from birth to neonatal manifestations of infection was 5.2 (0-9) days. The most common presenting sign in the neonates was fever (n = 8, 61.5%). All neonates required the neonatal intensive care unit. The neonatal mortality rate was 3/13 (23%).

Conclusion: The neonatal morbidity and mortality from the enterovirus infection may have been associated with the severity of maternal presentation at the time of admission. Enterovirus real-time polymerase chain reaction analysis should be considered as part of the maternal evaluation in cases of maternal fever of unknown origin. Deferral of the induction of delivery for term pregnancies with confirmed enterovirus infections should be considered.
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http://dx.doi.org/10.1111/apa.15703DOI Listing
May 2021

The effects of time and temperature on umbilical cord gas analysis.

J Matern Fetal Neonatal Med 2020 Nov 22:1-7. Epub 2020 Nov 22.

Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.

Objective: Our objective was to evaluate the effects of time and temperature on umbilical-cord blood analysis.

Methods: This prospective study included the term spontaneous vaginal deliveries. One venous and seven arterial samples were drawn from each umbilical cord within 5 min from delivery. Three samples were immediately refrigerated (3 °C), while all other samples were stored at room temperature (23-26 °C). Samples were analyzed in pairs (refrigerated and room-temperature samples) at 0, 20, 40, and 60 min after delivery for pH and lactate levels. Repeated-measures analysis using a generalized linear model was used to compare the change in pH and lactate values over time.

Results: 518 samples from 74 women were analyzed. The mean gestational age was 39.1 ± 1.1 weeks. All neonates had an Apgar score of ≥9 in the 1st and 5th minutes. Mean arterial pH and lactate levels at delivery (time 0) were 7.32 ± 0.07 and 4.00 ± 1.36 mmol/L, respectively. Over time, a statistically significant decrease in pH and a reciprocal increase in lactate levels were observed. The mean change in arterial pH following 60 min was 0.021 ± 0.028 (room-temperature) and 0.016 ± 0.023 (refrigerated);  < 0.001. Compared to pH, a greater change was demonstrated in lactate levels over time; the mean change in lactate following 60 min was -0.896 ± 0.535 (room temperature) and -0.512 ± 0.450 mmol/L (refrigerated). Temperature significantly altered both pH and lactate levels, but lactate levels were altered at earlier time points.

Conclusion: Both time and temperature have significant effects on cord blood analysis. Yet, these changes are minor and may not have any clinical significance unless in extreme cases in which medicolegal aspects emerge.
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http://dx.doi.org/10.1080/14767058.2020.1849118DOI Listing
November 2020

Pregnancy outcome after cesarean section following a failed vacuum attempt.

J Matern Fetal Neonatal Med 2020 Nov 17:1-9. Epub 2020 Nov 17.

Lis Hospital for Women, Tel Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To compare the pregnancy outcome of women who underwent cesarean section in the second stage of labor, with or without a vacuum extraction attempt.

Methods: A retrospective cohort study of women who underwent a cesarean section during the second stage of labor in a single tertiary university-affiliated medical center (2012-2019). Pregnancy outcome was compared for women who underwent cesarean section following a failed vacuum extraction to women who had cesarean section during the second stage of labor with no vacuum extraction attempt. Neonatal outcomes included umbilical artery pH less than 7.1, Apgar at 5 min < 7, hypoxemic ischemic encephalopathy and NICU admission. Maternal outcomes included duration of hospitalization, need for blood transfusion and need for re-surgery in 45 days.

Results: Overall, 88,375 women delivered during the study period. Of them, 120 women had a cesarean section following a failed vacuum (study group). Another 551 women underwent a cesarean section in the second stage of labor without a VE attempt (control group). The groups were similar with regard to obstetrical and demographic characteristics. The rates of umbilical artery pH < 7.1 (17.50% vs 6.53%,  < .001), NICU admission (13.33% vs 2.90%,  < .001), hypoxemic ischemic encephalopathy (5.83% vs 0.18%,  < .001) and epicranial sub-aponeurotic hemorrhage (16.67% vs 2.18%,  < .001) were significantly higher in the study group. No significant differences were found in maternal outcomes. In a sub-analysis including only labor with reassuring fetal heart tracing, failed vacuum attempt was associated with higher rate of NICU admission and epicranial hemorrhage (16.67% vs 3.13%,  = .009, 27.78% vs. 3.41,  = .001, respectively).

Conclusion: Failed vacuum attempt is associated with a significant increased neonatal morbidity, but not increased maternal morbidity.
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http://dx.doi.org/10.1080/14767058.2020.1849122DOI Listing
November 2020

Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment.

Placenta 2020 11 31;101:252-260. Epub 2020 Aug 31.

Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Introduction: Understanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI.

Methods: 34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location; number of bifurcations, generations and vessels diameters.

Results: Different vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings.

Discussion: This is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.
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http://dx.doi.org/10.1016/j.placenta.2020.08.001DOI Listing
November 2020

Calculating the appropriate prophylactic dose of cefazolin in women undergoing cesarean delivery.

J Matern Fetal Neonatal Med 2020 Jul 14:1-6. Epub 2020 Jul 14.

Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel.

Background And Objectives: Surgical site infection and other postoperative complications are relatively common in obstetrical procedures, and they are associated with morbidity, prolonged hospital stay, and readmissions. Appropriate levels of antimicrobial agents given directly before skin incision can prevent the establishment of surgical-related infection caused by endogenous microorganisms present on the woman's skin. We aimed to determine serum concentrations of cefazolin given to pregnant women prior to scheduled cesarean delivery and to compare their drug concentrations and pharmacokinetics in 2 weight groups.

Study Design: We conducted a prospective cohort analysis of the pharmacokinetics of cefazolin in women undergoing cesarean delivery (August 2017 to September 2018). One or two grams of intravenous cefazolin was administered within 30 min prior to skin incision to women weighing <80 kg and ≥80 kg, respectively. Maternal serum samples were obtained at skin incision and 30 min later. The serum concentration of cefazolin was measured by high-pressure liquid chromatography. Antimicrobial coverage was defined as being appropriate when the cefazolin levels were above the minimal inhibitory concentration. Pharmacokinetic parameters were estimated using a one-compartment model.

Results: A total of 61 women were enrolled, of whom 47 underwent cesarean delivery (study group). The mean time that had elapsed between drug administration to incision was 13 ± 6.9 min (95% confidence interval 10.6-16.2 min). The drug levels after 30 min in women who weighed >80 kg and in women who received 2 g cefazolin, after 30 min from incision differed significantly (87.0 ± 26.0 vs 55.4 ± 16.6 μg/ml, = .0001).

Conclusion: A single 1- or 2-g dose of cefazolin provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled cesarean delivery.
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http://dx.doi.org/10.1080/14767058.2020.1786529DOI Listing
July 2020

Clinical characteristics of preeclampsia in twin versus singleton pregnancies.

J Matern Fetal Neonatal Med 2020 Jun 29:1-5. Epub 2020 Jun 29.

Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

We aimed to compare features of preeclampsia between twin and singleton pregnancies. In this retrospective case-control study, women with twin pregnancies who were diagnosed with preeclampsia were matched to singleton pregnancies controls. Ninety-four women with twin gestation diagnosed with preeclampsia were compared to singleton pregnancies with preeclampsia. Twin pregnancies were diagnosed at an earlier mean gestational age (33.23 ± 7.32 vs 35.93 ± 3.52 weeks,  = .001), and had an earlier gestational age at delivery (35.05 ± 2.28 vs 36.31 ± 3.25 weeks,  = .002) in comparison to singleton pregnancies. Mean systolic blood pressure at diagnosis was lower (147.22 ± 14.62 vs 152.7 ± 15.22 mmHg,  = .013), and the rate of thrombocytopenia <100,000 platelets/microliter, (17.02% vs 7.45%,  = .045) was higher in the twin preeclampsia group. A subanalysis for diagnosis prior to 34 weeks of gestation revealed that the rate of chronic hypertension was lower (3.03% vs 26.32%,  = .020), and the gestational age at delivery was higher (32.83 ± 2.16 weeks vs 31.02 ± 2.49,  = .008) among the twin preeclampsia group. In the prior to 34 weeks gestation preeclampsia subanalysis, less women in the twin group were hospitalized due to maternal indications (hypertension, ominous signs for PE, disturbed laboratory tests and suspicion for intra-hepatic cholestasis of pregnancies) in comparison to the singleton preeclampsia group (63.64% vs 89.47%,  = .028), while non-maternal/fetal indications (active labor, premature rupture of membranes, cervical dynamics, latent phase or gastroenteritis) for hospitalization were more common in the twin preeclampsia group (30.30% vs 0.00%). Preeclampsia in women with twin pregnancies is diagnosed at an earlier gestational age with lower level of hypertension and a higher rate of thrombocytopenia in comparison to singleton pregnancies.
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http://dx.doi.org/10.1080/14767058.2020.1784872DOI Listing
June 2020

Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment.

Placenta 2020 07 19;96:34-43. Epub 2020 May 19.

Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Introduction: Understanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI.

Methods: 34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location, number of bifurcations, generations and vessels diameters.

Results: Different vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings.

Discussion: This is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.
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http://dx.doi.org/10.1016/j.placenta.2020.05.001DOI Listing
July 2020

Bypassing physiological puberty, a novel procedure of oocyte cryopreservation at age 7: a case report and review of the literature.

Fertil Steril 2020 08 5;114(2):374-378. Epub 2020 May 5.

Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel.

Objective: To report the first successful oocyte cryopreservation in a prepubertal girl.

Design: Case report and review of the literature.

Setting: Tertiary medical center.

Patient(s): A 7-year-old prepubertal girl with Turner syndrome mosaicism (45,X[37]/47,XXX[15]) who underwent a novel fertility preservation procedure after fertility preservation counseling and informed decision of the parents.

Intervention(s): Controlled ovarian hyperstimulation with daily administration of 100 IU recombinant human follicle-stimulating and 50 IU recombinant human luteinizing hormone per milliliter, injection of 250 μg human chorionic gonadotropin was given 36 hours before the follicular aspiration procedure, and oocytes retrieved by a transabdominal ultrasound guided approach.

Main Outcome Measure(s): Mature oocyte cryopreservation.

Result(s): The first cryopreservation cycle with use of a gonadotropin-releasing hormone agonist trigger failed to yield oocytes. The second cycle with human chorionic gonadotropin trigger was successful. Six oocytes were retrieved, and all were mature metaphase 2. The patient was discharged in good condition with no complications.

Conclusion(s): This novel procedure bypasses the timely physiologic progression of pubertal maturation of the hypothalamic-pituitary-ovarian axis to directly target the ovaries and achieve mature ovarian follicles. This innovative approach offers a new treatment modality for prepubertal girls who need fertility preservation such as in Turner syndrome or in cases that ovarian tissue cryopreservation is contraindicated.
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http://dx.doi.org/10.1016/j.fertnstert.2020.03.009DOI Listing
August 2020

Perinatal outcomes of pregnancy in the fifth decade and beyond- a comparison of very advanced maternal age groups.

Sci Rep 2020 02 4;10(1):1809. Epub 2020 Feb 4.

Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada.

To study the effect of very advanced maternal age on perinatal outcomes. A retrospective cohort study of women aged 45 years and above, who delivered ≥22 weeks of gestation in a single tertiary center between 1/ 2011 and 12/ 2018. Maternal and neonatal outcomes were compared between women ≥50 years and women of 45-49 years at delivery. Of 83,661 parturients, 593 (0.7%) were 45-49 years old and 64 (0.07%) were ≥50 years old. Obstetrical characteristics were comparable, though the rate of chronic hypertension and preeclampsia with severe features were greater in women ≥50 years (6.2% vs 1.4%, p = 0.04, 15.6% vs 7.0%, p = 0.01, 95% CI 0.19-0.86, respectively). Elective cesarean deliveries were independently associated with advanced maternal age ≥50 (OR 2.63 95% CI 1.21-5.69). Neonatal outcomes were comparable for singletons, but rates of ventilatory support and composite severe neonatal outcomes were higher in twin pregnancies of women ≥50 years (42.8% vs 13.5%, p = 0.01, and 21.4% vs 4.0%, p = 0.03, respectively). Healthy women ≥50 have higher elective cesarean rates, despite similar maternal and neonatal characteristics.
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http://dx.doi.org/10.1038/s41598-020-58583-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000770PMC
February 2020

Length of labour in mothers and their daughters: A matched cohort study.

Eur J Obstet Gynecol Reprod Biol 2020 Feb 23;245:77-83. Epub 2019 Dec 23.

University of Central Lancashire, Preston, United Kingdom.

Objective: Physiological length of labour is highly variable and population norms have low sensitivity and specificity for individuals. The birth history of mothers may provide a basis for personalized assessment of labour progress in their nulliparous daughters. This study was designed to investigate the relationship between length of labour in nulliparous daughters and in their mother's first birth, as a basis for constructing individualised labour prediction models in future.

Study Design: A mother-daughter matched cohort study was conducted in two Israeli maternity hospitals. Recruitment took place between September 2014 and June 2015 via antenatal clinics. Inclusion criteria were nulliparous daughters with singleton pregnancies at ≥32 weeks' gestation and mothers of included daughters who had a first birth in hospital prior to 1997. Data were collected prospectively for daughters by questionnaire and from electronic hospital records, and through retrospective recall questionnaires for mothers. Mother-daughter length of labour data were analysed using parametric and non-parametric tests and logistic regression. Length of labour was categorized as ≤10 h and >10 h. Other factors influencing daughters' length of labour were also examined.

Results: Data from 323 mother-daughter pairs were analysed. Univariate logistic regression analysis showed that daughters of mothers who were in active labour for more than 10 h showed increased likelihood of having a longer labour [OR1.91 (95 % CI 1.19, 3.05, P = 0.007)]. Controlling for infant gender increased the effect size [OR3.23 (95 % CI 1.55, 6.74, P = 0.002)]. Multivariable logistic regression indicated that mothers' length of labour [OR1.88 (95 % CI 1.12, 3.17)] and daughters' age [OR1.08 (95 % CI 1.02, 1.14)], weight gain in pregnancy [OR1.10 (95 % CI 1.04, 1.16)] and use of anesthesia, were statistically significant factors for daughters' length of labour, with sensitivity, specificity, and positive and negative predictive values of 74 %, 56 %, 66 %, and 64 %, respectively.

Conclusions: A strong positive association between mother and daughter lengths of labour was found. A model that includes length of labour in their mother's first birth might be useful for labour progress prediction for nulliparous women. Practitioners could inquire about maternal first birth patterns as an additional heuristic to guide practice and increase precision in the clinical management of nullipara women's labour and delivery.
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http://dx.doi.org/10.1016/j.ejogrb.2019.12.007DOI Listing
February 2020

The Contribution of an Infectious Workup in Understanding Stillbirth.

Am J Perinatol 2021 03 10;38(4):377-382. Epub 2019 Oct 10.

Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.

Objective: This study was aimed to assess the utility of diagnostic tests of maternal and fetal infection in the evaluation of stillbirth.

Study Design: A single-center retrospective study from January 2011 to December 2016 of all women presenting to the hospital with intrauterine fetal death at or after 20 weeks of gestation. Standard evaluation included review of medical records, clinical and laboratory inflammatory workup, maternal serologies, fetal autopsy, placental pathology, and fetal and placental cultures. A suspected infectious etiology was defined as meeting at least two diagnostic criteria, and only after exclusion of any other identifiable stillbirth cause.

Results: During the 7-year study period, 228 cases of stillbirth were diagnosed at our center. An infectious etiology was the suspected cause of stillbirth in 35 cases (15.3%). The mean gestational age of infection-related stillbirth was 28 (range: 22-37) weeks, while for a noninfectious etiology, it was 34 (range: 25-38) weeks ( = 0.005). Placental histological findings diagnostic of overt chorioamnionitis and funisitis were observed in 31 (88.5%) cases. In 16 (45.7%) cases the placental and fetal cultures were positive for the same pathogen. Serology of acute infection was positive in three (8.5%) of the cases.

Conclusion: Maternal and fetal infectious workup is valuable in the investigation of stillbirth, particularly before 30 weeks of gestation and should be considered a part of standard evaluation.
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http://dx.doi.org/10.1055/s-0039-1697668DOI Listing
March 2021

Fetal gender and umbilical cord characteristics at birth.

J Matern Fetal Neonatal Med 2021 Aug 23;34(15):2454-2457. Epub 2019 Sep 23.

Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Lis Maternity Hospital, Tel Aviv University, Tel Aviv, Israel.

Objective: To determine fetal gender on umbilical cord parameters.

Methods: Umbilical cords were prospectively collected from uncomplicated, singleton, term pregnancies, which ended either by elective cesarean section or spontaneous vaginal delivery. Data regarding obstetrical history and pregnancy outcome were collected. Various cord parameters were examined including, length, number of coils, umbilical cord index (UCI), which demonstrate the ratio between number of coils and cord length, site of placental insertion, direction of coiling and the presence of true knots.

Results: Overall, 154 umbilical cords were collected, of them 84 from male and 70 from female newborns. No differences were found regarding obstetrical history parameters or pregnancy outcome between the groups. The umbilical coiling index was significantly higher in female compared to male newborns (0.183 coils/cm versus 0.157 coils/cm, =.006) due to higher number of cord coils (12.25 ± 5.31 vs. 10.17 ± 3.96, =.007), with no difference in cord length (66.48 vs. 64.61 cm, =.372). These differences remained statistically significant even after correction for gravidity, parity and gestational age using multiple linear regression analysis.

Conclusion: Female newborns having higher umbilical cord index, compared to male as a result of more coils, with no length dissimilarity.
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http://dx.doi.org/10.1080/14767058.2019.1667328DOI Listing
August 2021

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions.

Am J Emerg Med 2020 06 17;38(6):1123-1128. Epub 2019 Aug 17.

Lis Maternity Hospital, Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center (affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel), Tel Aviv, Israel.

Introduction: Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions.

Methods: A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results.

Results: Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ± 5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%.

Conclusions: A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.
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http://dx.doi.org/10.1016/j.ajem.2019.158389DOI Listing
June 2020

Fertility outcomes in patients with tubo-ovarian abscesses after an oocyte retrieval: a longitudinal cohort analysis.

Arch Gynecol Obstet 2019 09 5;300(3):763-769. Epub 2019 Jul 5.

Department of Obstetrics and Gynecology, Affiliated to the Sackler School of Medicine, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, 6 Weizmann Street, 6423906, Tel Aviv, Israel.

Purpose: To determine the impact of pelvic inflammation caused by tubo-ovarian abscess (TOA) on ovarian response to stimulation.

Methods: This retrospective longitudinal cohort analysis that was carried out in a tertiary university-affiliated medical center included 15 women with TOA during in vitro fertilization (IVF) cycles. The ovarian response to stimulation and the pregnancy rate were compared in two subsequent cycles, the initial IVF cycle that was complicated by TOA after oocyte retrieval (first treatment cycle) and the following IVF treatment (second treatment cycle) that occurred within a period of a year from the first cycle.

Results: The mean number of retrieved oocytes was significantly higher in the first IVF cycle compared to the second cycle (8.1 ± 3.2 vs. 5.4 ± 2.5, P = .003], corresponding to a 30% reduction in ovarian response to gonadotropin stimulation. Fertilization rates were significantly lower in the second cycle (4.1 ± 2.9 vs. 2.9 ± 1.7, P = .015). Twelve women (80%) reached embryo transfer in the first cycle compared to 14 women (93.3%) in the second cycle. The mean number of transferred embryos was similar between the two cycles. There were no clinical pregnancies following the first cycle, and only one patient (6.6%) had a clinical pregnancy in the second treatment cycle.

Conclusions: TOA following fertility treatment has a detrimental effect on ovarian function. The pregnancy rate in the immediate period following TOA is poor. Current data for recommending the deferral of fertility treatment following a TOA episode are insufficient, calling for more studies to address these issues.
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http://dx.doi.org/10.1007/s00404-019-05230-9DOI Listing
September 2019

Risk factors for overt postpartum urinary retention-the effect of the number of catheterizations during labor.

Int Urogynecol J 2020 03 20;31(3):529-533. Epub 2019 Jun 20.

Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.

Introduction And Hypothesis: Our aim was to examine the effect of the number of catheterizations during labor on the development of overt postpartum urinary retention (PUR) in women who had a vaginal delivery with epidural anesthesia.

Methods: A single-center retrospective matched case-control study between 1 January 2015 and 31 December 2016. Women who developed overt PUR were compared with those who did not following a singleton vaginal delivery with epidural anesthesia. For each study two controls, matched for maternal age, gestational age at delivery, and parity, were selected. Each woman's controls were the immediate subsequent or previous delivery that met matching criteria.

Results: Two hundred parturients with overt PUR were matched with 400 parturients without overt PUR. In univariate analysis, women with PUR underwent significantly more catheterizations during labor, had an epidural for a longer period of time, and were more likely to have undergone a vacuum-assisted delivery and a mediolateral episiotomy (p < 0.01 for all). In multivariate analysis controlling for epidural duration, episiotomy, and vacuum-assisted delivery, the risk of PUR among women with at least two catheterizations was greater when fewer catheterizations were performed (OR = 0.78, 95% CI 0.61-0.99). When controlling for the number of catheterizations overall, episiotomy, and vacuum-assisted delivery, PUR risk significantly increased with a longer epidural duration (OR 1.23, 95% CI 1.17-1.29). Episiotomy and vacuum-assisted delivery had no significant effect on PUR.

Conclusions: The risk of PUR decreases as the number of catheterizations increases. Although longer epidural duration independently increases the risk of PUR, episiotomy and vacuum-assisted delivery do not.
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http://dx.doi.org/10.1007/s00192-019-04010-yDOI Listing
March 2020

Twin versus singleton pregnancy in women ≥ 45 years of age: comparison of maternal and neonatal outcomes.

J Matern Fetal Neonatal Med 2021 Jan 18;34(2):201-206. Epub 2019 Apr 18.

Department of Obstetrics & Gynecology, Lis Maternity & Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

The aim of the study is to compare the effect of very advanced maternal age (≥45 years) on maternal and neonatal outcomes of twin and singleton pregnancies. This retrospective cohort study included women ≥ 45 years of age who gave birth to twins. Each was randomly matched to two women ≥ 45 years of age who gave birth to singletons within 7 days of the study subject. Data on maternal age, gravidity, parity, background medical information, body mass index at conception, number of fetuses, mode of conception (either spontaneous or assisted reproductive technology [ART]), mode of delivery, and gestational age at delivery were extracted from a real-time computerized database. The data of 75 twin pregnancies of women aged ≥ 45 years were compared with those of 150 singleton pregnancies matched for maternal age. There were significantly more cases of hypertensive complications among the twin pregnancies compared to the singleton pregnancies (41.33 versus 14.00%, respectively, OR = 3.33, 95% CI = 2.26-8.30,  = .000) and more cases of preeclamptic toxemia (29.33 versus 12.00%, respectively, OR = 3.04, 95% CI = 1.51-6.13,  = .001). The duration of twin pregnancies was much shorter compared to singleton pregnancies, with a higher incidence of deliveries prior to 37 weeks' gestation (56.00 versus 8.00%, respectively, OR = 14.64, 95% CI = 6.94-30.85,  = .000), and deliveries prior to 34 weeks' gestation (22.67 versus 2.00%, respectively, OR = 14.36, 95% CI = 4.06-50.86,  = .000). More infants of twin pregnancies had a low birth weight (68.00 versus 10.00%, respectively, OR = 19.13, 95% CI = 10.14-36.06,  = .000), and many had a very low birth weight (10.67 versus 0.67%, respectively, OR = 17.79, 95% CI = 2.33-135.97,  = .000). The infants of twin pregnancies also included more cases of intubation (10.00 versus 0.00%, respectively,  = .000), more cases of hypoglycemia (12.67 versus 5.33%, respectively, OR = 2.57, 95% CI = 1.09-6.08,  = .026), and were admitted much more often to the neonatal intensive care unit (36.00 versus 8.00%, respectively, OR = 6.47,  = .00, CI = 3.29-12.74). Women ≥ 45 years of age with twin pregnancies and their neonates sustain more severe adverse outcome compared to matched pairs of singleton pregnancies. It is recommended that a single embryo transfer should be offered in preference to multiple embryos when those women are undergoing ART.
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http://dx.doi.org/10.1080/14767058.2019.1602115DOI Listing
January 2021

The effect of maternal obstructive sleep apnea on the placenta.

Sleep 2019 06;42(6)

Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Study Objectives: Obstructive sleep apnea (OSA) during pregnancy has been associated with adverse maternal outcomes. However, the effect of maternal OSA on fetal growth is less clear. The placenta is a critical organ for fetal growth and development and the principal determinant of birthweight. We aimed to investigate the effect of maternal OSA on placental growth and function.

Methods: Placentas of women recruited to a prospective longitudinal study were consecutively obtained immediately after delivery. Each placenta was measured for length, width, and thickness. Total RNA was isolated for gene expression analysis of VEGF, VEGF receptor, PIGF, and leptin. Histological and morphometric evaluations of the placenta were performed.

Results: A total of 53 placentas were investigated. Ten women (19%) had OSA, and the weight of their placentas was significantly higher compared with the placentas of the controls (526.1 ± 83.9 vs. 425.7 ± 95.5 g, p = 0.004). There was a significant positive correlation between placental weight and the log apnea-hypopnea index even after controlling for maternal body mass index (BMI; r = 0.31, p = 0.04). The birthweight/placental weight ratio was significantly lower in women with OSA compared with controls (p = 0.03). Placental weight and newborn triceps adiposity thickness correlated positively after controlling for maternal BMI (r = 0.29, p = 0.04). Leptin expression was 1.8-fold higher in placentas of women with OSA compared with controls (p = 0.02). No histological differences were found between the groups.

Conclusions: Maternal OSA is associated with increased placental weight that correlated with OSA severity and neonatal adiposity independently of maternal BMI. Placental leptin overexpression may mediate/underlie the above findings.Trial Registration: Clinical Trials NCT00931099.
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http://dx.doi.org/10.1093/sleep/zsz072DOI Listing
June 2019

Comparison of pregnancy outcome between immigrant women in couples with same ethnicity to mixed ethnicity couples.

J Matern Fetal Neonatal Med 2020 Nov 22;33(21):3666-3669. Epub 2019 Feb 22.

Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Lis Maternity and Women's Hospital, Tel Aviv University, Tel Aviv, Israel.

To compare the pregnancy outcome of immigrant women who became pregnant to the same ethnicity partner versus a partner from a different ethnicity. A retrospective cohort study on all singleton pregnancies of immigrant women who delivered between the years 2011-2015 in a single tertiary University Affiliated Hospital. Demographic and obstetrical data were collected. Same ethnicity couples and mixed couples were compared using the Pearson chi-square test for dichotomous variables, and Student's -test for normally distributed continuous variables. Overall, 443 immigrant women delivered during the study period, of them, 294 (66.37%) had the same ethnicity spouse and 149 (33.63%) were part of a mixed couple. Women of same ethnicity couples were significantly younger (32.7 versus 35.05 years,  < .0001) and more likely to be nulliparous (48 versus 32%,  = .001), compared to women of mixed couples. The rate of episiotomy was significantly higher among women with the same ethnicity spouse in comparison to women of mixed couples (37.22 versus 23.85%,  = .01). There was no significant difference in all other obstetrical or perinatal outcomes tested. Maternal component is the main factor for perinatal outcomes among immigrant mothers.
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http://dx.doi.org/10.1080/14767058.2019.1582634DOI Listing
November 2020

Is There a Benefit to Culturing Intra-Uterine Devices in Pelvic Inflammatory Disease?

Gynecol Obstet Invest 2019 25;84(1):20-26. Epub 2018 Jul 25.

Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Aims: The study aimed to compare the clinical course and disease severity between culture positive and culture negative patients with intra-uterine devices (IUD)-associated pelvic inflammatory disease (PID).

Methods: A retrospective study of all IUD-associated PID patients admitted to tertiary medical center between 2010 and 2015. All patients received standard empiric antibiotic therapy upon admission. The study cohort was divided into 2: patients with culture positive IUDs and patients with negative cultures. Electronic medical records and culture results were analyzed from the time of admission.

Results: During the study period, 480 hospitalized patients were diagnosed with PID. Of these, 94 patients had IUD-associated PID, 59 with positive cultures and 35 with negative cultures. While fever was more common in the latter (p = 0.01), no significant differences were found in disease severity in patient outcomes (i.e., length of stay, rates of invasive treatment, and total abdominal hysterectomies). In a sub-analysis of patients with IUD cultures of established PID pathogens only, there were no differences in disease severity and outcome in patients with antibiotic susceptible or resistant strains.

Conclusions: IUD removal for culture in PID patients is probably unnecessary. Alteration of treatment according to the culture results may have little impact on disease course and outcome.
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http://dx.doi.org/10.1159/000490666DOI Listing
March 2019

Mild Maternal Obstructive Sleep Apnea in Non-obese Pregnant Women and Accelerated Fetal Growth.

Sci Rep 2018 Jul 17;8(1):10768. Epub 2018 Jul 17.

Sleep Disorders Center, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.

The prevalence of obstructive sleep apnea (OSA) during pregnancy is rising. OSA during pregnancy has been associated with hypertensive disorders of pregnancy and gestational diabetes. The effect of maternal OSA on the fetus, particularly on fetal growth, is less apparent. Most of the currently available human data is based on non-objective assessment of OSA and includes heterogeneous populations with inadequate control on confounders, such as maternal obesity and pregnancy complications. Using objective tools in non-obese women with uncomplicated pregnancies, we aimed to investigate the association between maternal OSA and fetal growth. A total of 155 non-obese pregnant women were recruited. Birth-weight percentile of the newborns of women with mild OSA was significantly higher compared with the newborns of non-OSA controls (72% vs. 57%, respectively, P < 0.01). Birth-length and triceps thickness measurements were significantly higher among the newborns of women with OSA compared with controls (P = 0.02 for both). The proportion of large for gestational age (LGA) newborns was higher among women with OSA compared with controls (28% vs. 8%, respectively, P = 0.04). Our results suggest that maternal OSA during the third trimester of pregnancy - even in a mild form -is associated with accelerated fetal growth.
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http://dx.doi.org/10.1038/s41598-018-29052-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050232PMC
July 2018

Maternal cardiovascular hemodynamics in normotensive versus preeclamptic pregnancies: a prospective longitudinal study using a noninvasive cardiac system (NICaS™).

BMC Pregnancy Childbirth 2018 Jun 14;18(1):229. Epub 2018 Jun 14.

Department of Obstetrics and Gynecology, Lis Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, 6423906, Tel Aviv, Israel.

Background: Preeclampsia is among the most common medical complications of pregnancy. The clinical utility of invasive hemodynamic monitoring in preeclampsia (e.g., Swan-Ganz catheter) is controversial. Thoracic impedance cardiography (TIC) and Doppler echocardiography are noninvasive techniques but they both have important limitations. NICaS™ (NI Medical, PetachTikva, Israel) is a noninvasive cardiac system for determining cardiac output (CO) that utilizes regional impedance cardiography (RIC) by noninvasively measuring the impedance signal in the periphery. It outperformed any other impedance cardiographic technology and was twice as accurate as TIC.

Methods: We used the NICaS™ system to compare the hemodynamic parameters of women with severe preeclampsia (PET group, n = 17) to a cohort of healthy normotensive pregnant women with a singleton pregnancy at term (control group, n = 62) (1/2015-6/2015). Heart rate (HR), stroke volume (SV), CO, total peripheral resistance (TPR) and mean arterial pressure (MAP) were measured 15-30 min before CS initiation, immediately after administering spinal anesthesia, immediately after delivery of the fetus and placenta, at the abdominal fascia closure and within 24-36 and 48-72 h postpartum.

Results: The COs before and during the CS were significantly higher in the control group compared to the PET group (P < .05), but reached equivalent values within 24-36 h postpartum. CO peaked at delivery of the newborn and the placenta and started to decline afterwards in both groups. The MAP and TPR values were significantly higher in the PET group at all points of assessment except at 48-72 h postpartum when it was still significantly higher for MAP while the TPR only exhibited a higher trend but not statistically significant. The NICaS™ device noninvasively demonstrated low CO and high TPR profiles in the PET group compared to controls.

Conclusions: The immediate postpartum period is accompanied by the most dramatic hemodynamic changes and fluid shifts, during which the parturient should be closely monitored. The NICaS™ device may help the clinician to customize the most optimal management for individual parturients. Our findings require validation by further studies on larger samples.
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http://dx.doi.org/10.1186/s12884-018-1861-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6001131PMC
June 2018

Maternal and neonatal hyponatremia during labor: a case series.

J Matern Fetal Neonatal Med 2019 Aug 12;32(16):2711-2715. Epub 2018 Mar 12.

a Department of Obstetrics and Gynecology , Lis Maternity Hospital, Sourasky Medical Center , Tel Aviv , Israel.

Background: Hyponatremia during labor and delivery may result in severe maternal and neonatal sequelae. Our aim was to describe the direct effect of hyponatremia in labor on pregnancy outcome.

Methods: A case series of parturients diagnosed with hyponatremia during labor and their neonates. Clinical presentation, laboratory workup, and maternal and neonatal outcomes are presented.

Results: Four parturients and their corresponding six neonates were diagnosed with hyponatremia. Of these, two cases were caused by water intoxication and two were preeclampsia induced. While two were identified due to maternal or neonatal symptoms, two were diagnosed by routine laboratory testing. In all cases, low maternal sodium resulted in similarly low neonatal sodium. Neonatal symptoms included respiratory distress syndrome (RDS), lethargy, and jaundice.

Conclusion: Psychogenic drinking during labor and preeclampsia may predispose to maternal hyponatremia, resulting in neonatal hyponatremia. Early recognition and treatment can prevent further maternal deterioration and adverse neonatal sequelae.
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http://dx.doi.org/10.1080/14767058.2018.1446517DOI Listing
August 2019

Maternal hemodynamics in late gestation and immediate postpartum in singletons vs. twin pregnancies.

Arch Gynecol Obstet 2018 02 30;297(2):353-363. Epub 2017 Nov 30.

Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Purpose: Differences in hemodynamic changes during a cesarean section (CS) between twin and singleton pregnancies are poorly defined. The Non-Invasive Cardiac System (NICaS) is an impedance device that measures cardiac output (CO) and its derivatives. We compared maternal cardiac parameters using NICaS™ in singleton and twins before and during delivery, as well at the early puerperium in healthy women undergoing CS at term.

Methods: This prospective longitudinal study included women with twin (n = 27) or singleton pregnancies (n = 62) whose hemodynamic parameters were assessed by NICaS before an elective CS, after spinal anesthesia, immediately after delivery, after fascia closure, and within 24-36 and 48-72 h postpartum.

Results: By 24-36 h postpartum, the mean arterial pressure and the total peripheral resistance equaled preoperative values in both groups. The CO increased throughout the CS and peaked immediately after delivery in the singleton group (P < 0.0001), after which it abruptly began to decline until reaching a nadir 24-36 h after delivery (P < 0.0001), while it remained steady throughout the CS and then dropped until 24-36 h after delivery in the twin group (P < 0.05). None of the studied parameters differed significantly between the groups for the 24-36 and 48-72 h postpartum measurements.

Conclusions: Hemodynamic parameters immediately before, during and shortly after CS in singleton and twin pregnancies are equivalent. Further evaluations of the value of NICaS™ in assessing cardiovascular-related pregnancy complications are warranted.
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http://dx.doi.org/10.1007/s00404-017-4601-8DOI Listing
February 2018