Publications by authors named "Aya Mohr-Sasson"

23 Publications

  • Page 1 of 1

Prediction score for recurrent adnexal torsion in women with a previous adnexal torsion.

Int J Gynaecol Obstet 2021 Feb 24. Epub 2021 Feb 24.

Department of Obstetrics and Gynecology, Hadassah Medical Center, Jerusalem, Israel.

Objective: To develop a risk score for preoperative prediction of recurrent adnexal torsion (rAT) among women with a history of previous adnexal torsion (AT).

Methods: A retrospective cohort study. We included women with a history of AT, presenting with suspected rAT who underwent diagnostic laparoscopy between March 2011 and March 2020. We compared women with rAT to those without. We constructed a prediction score and validated it in a prospectively collected cohort between April 2020 and June 2020.

Results: One hundred and fifteen women composed the study cohort. Recurrent AT was confirmed laparoscopically in 86 (74.8%) cases. A risk score for rAT was developed, based on three associated factors: enlarged ovary, no previous oophoropexy and current IVF treatment. In the construction cohort, the rate of torsion was 44.4%, 67.9%, 82.9% and 100% if none, one, two, or three risk factors were present, respectively. In the prospective validation of the risk score, the prediction of one and two risk factors was 60.0% and 100% respectively.

Conclusion: Enlarged ovary is independently associated with preoperative rAT diagnosis. Coupled with information regarding the previous surgical approach in previous AT and current IVF use, these factors could be used to efficiently predict rAT among women with a previous AT.
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http://dx.doi.org/10.1002/ijgo.13660DOI Listing
February 2021

Pregnancy and neonatal outcomes of twin pregnancies - the role of maternal age.

J Perinat Med 2021 Feb 17. Epub 2021 Feb 17.

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

Objectives: We aim to study the association of maternal age with maternal and neonatal complications in twin pregnancies.

Methods: A retrospective cohort study of dichorionic-diamniotic twin pregnancies stratified into three groups according to maternal age ("A" <25, "B" 25-34 and "C" 35-44 years old). Outcome measures included pregnancy, delivery and neonatal complications. A sub-analysis of fertilization pregnancies only was conducted.

Results: Compared with younger women (groups A [n=65] and B [n=783]), older women [group C (n=392)] demonstrated significantly higher rates of gestational diabetes mellitus (B 6.6% vs. A 0%, p =0.027, C 10.2% vs. B 6.6%, p =0.032), were more likely to undergo cesarean deliveries (C 66.6%, B 57.6%, A 52.3%, p =0.007), and were at increased risk of having more than 20% difference in weight between the twins (C 24.5%, B 17.4%, A 16.9%, p =0.013). Other outcomes, including preeclampsia, did not differ between the groups. A sub-analysis of the fertilization only pregnancies was performed. Compared with younger women (groups A [n=18] and B [n=388]), older women (group C [n=230]) underwent more cesarean deliveries (p=0.004), and had more than 20% difference in weight between the twins (p<0.004). Other outcomes, including gestational diabetes mellitus rates and preeclampsia, did not differ between the groups.

Conclusions: Women at advanced maternal age with dichorionic twin pregnancies had significantly higher rates of gestational diabetes mellitus, cesarean deliveries and fetal weight discordancy as compared with younger women. In contrast, the incidence of preeclampsia was not affected by maternal age.
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http://dx.doi.org/10.1515/jpm-2020-0386DOI Listing
February 2021

Placenta accreta spectrum in subsequent pregnancy following myomectomy.

J Matern Fetal Neonatal Med 2020 Nov 25:1-8. Epub 2020 Nov 25.

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

Purpose: To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy.

Methods: A retrospective cohort study, including all women after myomectomy that gave birth in a single tertiary care center from February 2011 to January 2019. Data was collected from the patients' medical files and completed by telephone questionnaire. Patients were stratified to 3 groups, according to the mode of operative myomectomy (laparotomy, laparoscopy, hysteroscopy). Groups were compared for women demographics, fibroid's characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery.

Results: Two hundred forty one women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of whom 82, 89, and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no in-between groups differences in women's age, BMI, and gravidity. Disruption of the endometrial cavity during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) cases, respectively ( = .21). During the subsequent pregnancy following myomectomy, placenta accreta spectrum disorder was suspected in only one woman in each of the study groups ( = .63). Placenta previa was low and comparable between groups. Vaginal delivery rate was significantly higher in the hysteroscopy group, as compared to the laparoscopy or the laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%);  = .001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%);  = .01] and further interventions for blood loss control.

Conclusions: Subsequent pregnancy following surgical myomectomy was not found to be associated with higher prevalence placental abnormality. Furthermore, other than manual lysis, the different modes of myomectomy did not necessitate any further intervention for complications associated with abnormal placentation requiring intervention.

Key Message: Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality.
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http://dx.doi.org/10.1080/14767058.2020.1849114DOI Listing
November 2020

Does a Large (>24 mm) Follicle Yield a Competent Oocyte/Embryo?

Gynecol Obstet Invest 2020 23;85(5):416-419. Epub 2020 Sep 23.

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

Aim: To evaluate the effect of large follicular size (≥24 mm) at day of oocyte retrieval on oocyte/embryo quality.

Patients And Methods: A cohort study was conducted in a single tertiary medical center between July 2018 and May 2019. Before ultrasound-guided follicular aspiration, follicles were measured and divided into 2 groups according to their maximal dimensional size: large: ≥24 mm and normal: <24 mm. Microscopic examination of the follicular aspirates was performed by an embryologist. Each follicle aspirated was evaluated for oocyte maturation, oocyte fertilization, and embryo quality.

Results: 428 follicles were measured, including 383 (62.81%) in the normal and 45 (14.06%) in the large follicle groups. Oocytes were achieved during aspiration from 297 (75.5%) and 29 (64.4%) of the normal and large follicle groups, respectively (p = 0.05). No in-between group differences were observed in mature oocyte (MII), fertilization, and top-quality embryo (TQE) rates. Nevertheless, once a zygote (2PN) was achieved, a trend toward a higher TQE rate/2PN was found in the large follicle group (16/19 [84.2%] vs. 115/171 [67.3%]; p = 0.062).

Conclusion: While a nonsignificant decrease in oocyte recovery rate was found in follicles ≥24 mm, the zygote and TQE per follicle were comparable.
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http://dx.doi.org/10.1159/000510876DOI Listing
April 2021

The effect of polyhydramnios on the success of trial of labor after cesarean delivery (TOLAC): A retrospective cohort.

Eur J Obstet Gynecol Reprod Biol 2020 Oct 27;253:187-190. Epub 2020 Aug 27.

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: Prediction of success of trial of labor after cesarean delivery (TOLAC) is of major importance. We investigated the impact of polyhydramnios on the success rate of TOLAC.

Study Design: A retrospective cohort study of all women with singleton pregnancies ≥ 34th weeks of gestation who underwent TOLAC after one previous cesarean delivery, between 2011 and 2016 in a single tertiary care center. Polyhydramnios was defined as amniotic fluid index ≥ 240 mm. Primary outcome was defined as the rate of successful TOLAC.

Results: 31,245 women gave birth during the study period, of them 1637 (5.3 %) women underwent TOLAC and met inclusion criteria. 39 (2.4 %) women with polyhydramnios were compared to a control group of 1598 (97.6 %) women with amniotic fluid index < 240 mm. Polyhydramnios significantly reduced the rate of successful TOLAC: 69.2 % (27/39) in the study group compared to 85.8 % (1371/1598) in the control group (P = 0.009). In a subgroup analysis based on amniotic fluid index, women with AFI > 270 mm had substantially lower TOLAC success rate [9/19 (47.4 %) vs 18/20 (90 %); P = 0.006]. There was no difference in the rate of uterine rupture between the groups (0/39 (o%) vs 9/1598 (0.56 %); P = 0.64). Logistic regression analysis revealed that polyhydramnios remained significantly associated with higher rates of cesarean delivery [OR 3.09 (95 % CI, 1.37-6.98)] after adjustment for confounding factors.

Conclusion: Polyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling.
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http://dx.doi.org/10.1016/j.ejogrb.2020.08.017DOI Listing
October 2020

Laboratory characteristics of pregnant compared to non-pregnant women infected with SARS-CoV-2.

Arch Gynecol Obstet 2020 09 22;302(3):629-634. Epub 2020 Jun 22.

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, 52621, Ramat Gan, Israel.

Key Message: Laboratory characteristics of SARS-CoV-2 infection did not differ between pregnant and non-pregnant women. A trend of lower lymphocyte count was observed in the pregnant women group PURPOSE: Laboratory abnormalities, which characterize SARS-CoV-2 infection have been identified, nevertheless, data concerning laboratory characteristics of pregnant women with SARS-CoV-2 are limited. The aim of this study is to evaluate the laboratory characteristics of pregnant compared to non-pregnant women with SARS-CoV-2 infection.

Methods: A retrospective cohort study of all pregnant women with SARS-CoV-2 who were examined at the obstetric emergency room in a tertiary medical center between March and April 2020. Patients were compared with non-pregnant women with SARS-CoV-2 matched by age, who were examined at the general emergency room during the study period. All patients were confirmed for SARS-CoV-2 on admission. Clinical characteristics and laboratory results were compared between the groups.

Results: Study group included 11 pregnant women with SARS-CoV-2, who were compared to 25 non-pregnant controls. Respiratory complaints were the most frequent reason for emergency room visit, and were reported in 54.5% and 80.0% of the pregnant and control groups, respectively (p = 0.12). White blood cells, hemoglobin, platelets, and liver enzymes counts were within the normal range in both groups. Lyphocytopenia was observed in 45.5% and 32% of the pregnant and control groups, respectively (p = 0.44). The relative lymphocyte count to WBC was significantly reduced in the pregnant group compared to the controls [13.6% (4.5-19.3) vs. 26.5% (15.7-29.9); p = 0.003]. C-reactive protein [20(5-41) vs. 14 (2-52) mg/dL; p = 0.81] levels were elevated in both groups but without significant difference between them.

Conclusion: Laboratory characteristics of SARS-CoV-2 infection did not differ between pregnant and non-pregnant women, although a trend of lower lymphocyte count was observed in the pregnant women group.
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http://dx.doi.org/10.1007/s00404-020-05655-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307945PMC
September 2020

Do fertility treatments affect labor induction success rate? A retrospective cohort study.

J Matern Fetal Neonatal Med 2020 Jun 17:1-5. Epub 2020 Jun 17.

Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.

To evaluate labor induction success rate by Foley catheter (FC) on patients who conceived spontaneously, as compared to those who underwent fertility treatments. This retrospective cohort study included all pregnant women hospitalized at a single tertiary care center between January 2011 and May 2018 for induction of labor with FC. The study groups included patients with a singleton pregnancy who conceived after fertility treatments: controlled ovarian hyperstimulation (COH) or fertilization (IVF), while control group included patients who conceived spontaneously. Our primary outcome was the rate of cesarean deliveries. Regression analysis was conducted on the following parameters: age, gravidity, parity, the gestational week, and IVF. The study groups included 59, 321, and 3159 patients who conceived following COH, IVF, or spontaneously, respectively. While 72.1% of patients who conceived spontaneously had a vaginal delivery, only 62.7% and 58% of patients who conceived by COH and IVF had successful labor induction (respectively,  < .01). Similarly, significantly higher cesarean section (CS) rates were demonstrated by patients who conceived by COH and IVF (28.8% and 30%, respectively), compared to the control group (18.7%,  < .01). Regression analysis demonstrated that although age, parity, and the gestational week were significantly related to cesarean sections, no statistically significant association was found regarding fertility treatments ( = .050). The possible association between fertility treatments and cesarean delivery remains an important dilemma for obstetricians and fertility experts. While unadjusted analysis demonstrated such association among patients who undergo labor induction by FC, adjusted analysis has not supported that finding. Further studies focusing on the causes of failed vaginal delivery are needed to further expand our knowledge and to improve patient consultation.
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http://dx.doi.org/10.1080/14767058.2020.1779693DOI Listing
June 2020

Tampon loss - management among adolescents and adult women.

J Obstet Gynaecol 2021 Feb 5;41(2):275-278. Epub 2020 Jun 5.

Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

The widespread use of tampons carries a risk of tampon loss due to imperfect use. We performed a retrospective study including all women attending the emergency room (ER) with the complaint of tampon loss during 2011-2018. Overall, 72 women presented to the ER with a complaint of tampon loss. In 25% (18/72), a lost tampon was found on physical examination. The lost tampon was found in a higher rate among adolescents as compared to older women (4 (80%) vs. 14 (21%), 15.1,  = .01). Time from tampon loss to referral for evaluation was shorter among adolescents as compared to older women (7 ± 3 vs. 21 ± 21 h,  = .007). In most adolescents with a complaint of a lost tampon - it was eventually found on pelvic examination, as opposed to older women, in whom a finding was present in only one-fifth of cases. This highlights the importance of thorough examination of adolescents presenting due to tampon loss. The study protocol was approved by the Sheba Medical Center review board (March 15, 2018), 6345-19-SMC.IMPACT STATEMENT Very little is known regarding the distinguished phenomena of tampon loss among adult females. In most adolescents referred due to tampon loss - a tampon was found on pelvic examination, as opposed to older women. In most adolescents referred due to tampon loss - a tampon will be found on pelvic examination, as opposed to older women, in whom a finding is present in only one-fifth of cases. This highlights the importance of thorough examination of adolescents presenting with a loss of tampon.
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http://dx.doi.org/10.1080/01443615.2020.1755631DOI Listing
February 2021

Do Follicles of Obese Patients Yield Competent Oocytes/Embryos?

Gynecol Obstet Invest 2020 2;85(3):290-294. Epub 2020 Jun 2.

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

Aim: This study evaluated the competency of oocytes/embryos derived from follicles >15 mm in diameter from obese patients, compared with nonobese patients.

Patients And Methods: A cohort study was conducted in a single tertiary medical center between July 2018 and May 2019. Before ultrasound-guided follicular aspiration, follicles were measured and those with maximal dimensional size >15 mm were tracked. Microscopic examination of the follicular aspirates was performed by an embryologist. Each follicle aspirated was evaluated for oocyte maturation, oocyte fertilization, and embryo quality.

Results: 457 follicles were measured: 380 (83.2%) in nonobese and 77 (16.8%) in obese patients. No in-between group differences were observed in the causes of infertility, patients' demographics, or ovarian stimulation characteristics. Oocytes were achieved during aspiration from 277 (72.8%) and 54 (70.0%) of the nonobese and obese groups, respectively (p = 0.67). No in-between group differences were observed in fertilization (2PN/oocyte), top quality embryo (TQE) per zygote (2PN), and TQE per follicle.

Conclusion: Oocyte recovery rate from follicles >15 mm is unrelated to patients' BMI. Moreover, the oocytes recovered from obese patients are competent yielding comparable zygote and TQE per follicle/oocyte, compared with nonobese patients. Further investigation is required to strengthen this finding.
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http://dx.doi.org/10.1159/000508226DOI Listing
November 2020

The association between follicle size and oocyte development as a function of final follicular maturation triggering.

Reprod Biomed Online 2020 Jun 20;40(6):887-893. Epub 2020 Feb 20.

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Research Question: To study the association between follicle size and oocyte/embryo quality, as a function of different triggering modes for final follicular maturation.

Study Design: Cohort study conducted in a single tertiary medical centre between July 2018 and May 2019. All women undergoing ovarian stimulation with triggering using human chorionic gonadotrophin (HCG), gonadotrophin-releasing hormone (GnRH) agonist or dual trigger (GnRHa + HCG) were included. Before ultrasound-guided follicular aspiration, follicles were measured and divided into three groups according to maximum dimensions: large ≥16 mm, medium 13-15 mm and small <13 mm. Microscopic examination of the follicular aspirates was performed by an embryologist. Each follicle aspirated was evaluated for oocyte maturation, oocyte fertilization and embryo quality.

Results: A total of 640 follicles were measured, including 402 (62.8%) in the large, 148 (23.1%) in the medium and 90 (14.1%) in the small groups. Oocytes were obtained during aspiration from 76.3%, 70.3% and 55.6% of the large, medium and small follicle groups, respectively (P = 0.001). The mature oocyte (metaphase II) rate was significantly higher in the large (P = 0.001) and medium (P = 0.01) compared with the small follicle group. Nevertheless, no between-group differences were observed in fertilization or top quality embryo rates among mature oocytes regardless of the size of the follicle from which they originated. Triggering mode did not influence oocyte recovery rate in the different follicle size groups.

Conclusion: A higher oocyte recovery rate was observed from follicles >13 mm, however, mature oocytes achieved similar fertilization and top quality embryo rates regardless of follicle size. Triggering mode did not influence oocyte recovery rate.
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http://dx.doi.org/10.1016/j.rbmo.2020.02.005DOI Listing
June 2020

Cesarean delivery with and without uterine artery embolization for the management of placenta accreta spectrum disorder-A comparative study.

Acta Obstet Gynecol Scand 2020 10 20;99(10):1374-1380. Epub 2020 May 20.

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

Introduction: The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder.

Material And Methods: A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used.

Results: During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups.

Conclusions: Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.
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http://dx.doi.org/10.1111/aogs.13868DOI Listing
October 2020

Uterine exteriorization versus intraperitoneal repair in primary and repeat cesarean delivery: a randomized controlled trial.

J Matern Fetal Neonatal Med 2020 Feb 2:1-6. Epub 2020 Feb 2.

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

The aim of this study is to evaluate the effect of uterine exteriorization versus intraperitoneal repair, in first compared to repeat cesarean delivery. A prospective randomized control single-blinded trial conducted in a single tertiary center between March 2014 and March 2015, including 32 and 63 women in first and recurrent cesarean sections, respectively. Inclusion criteria were elective operation and gestational age ≥37 weeks. Operative outcomes were compared between the groups including mean operative time, blood loss, hypotension, perioperative nausea and pain. Post-operative outcomes were further compared, including post-operative analgesia demand, first recognized bowel movement, nausea, length of hospital stay, fever, endometritis surgical site infection rate, and total satisfaction. During the study period, 45 and 50 women were designated for uterine exteriorization and intraperitoneal uterine repair, respectively. Mean blood loss was 452 cc (±10.44) for the extraperitoneal compared to 540 cc (±29.83) for the intraperitoneal uterine repair group ( = .004). No other significant differences in either intraoperative or postoperative complications were demonstrated in and between the groups. Intraperitoneal repair of uterine incision is associated with higher operative blood loss compared to uterine exteriorization. No other differences in operative and postoperative complication rates were found between the groups.
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http://dx.doi.org/10.1080/14767058.2020.1720638DOI Listing
February 2020

Long-term follow-up on fetuses with isolated sonographic finding of short long bones: a cohort study.

Arch Gynecol Obstet 2020 02 24;301(2):459-463. Epub 2019 Dec 24.

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, 52621, Ramat Gan, Israel.

Purpose: To evaluate the long-term outcome of fetuses with a diagnosis of isolated short long bones.

Methods: A retrospective review was conducted of all cases diagnosed with short long bones above 20 weeks of gestation during 2010-2017 in a single tertiary center. Exclusion criteria included abnormal sonographic findings other than short long bones, suspected genetic syndromes, chromosomal abnormalities, and abnormal Doppler flow indices. Follow-up was carried out by telephone questionnaire.

Results: During the study period, 54 (24.32%) women met inclusion criteria. Mean gestational age at delivery was 38.05 years (± 2.42 SD). Mean birth weight was 12-19th percentile according to the local fetal growth charts [2645 g (± 684 SD) 95% CI 2173-2980]. Median time for post-natal follow-up was 9.3 years (IQR 6.6-10.75). Growth below the 10th percentile was demonstrated in 27 (50%) children. 11 (20.37%) children were followed up by endocrinological clinics, of them 7 (12.96%) were treated with growth hormone. Three (5.6%) of the children were diagnosed with attention deficit hyperactivity disorder, an incidence that is considered lower than that of the general population (± 9%).

Conclusions: Prenatal fetal isolated short long bones diagnosed during the late second and third trimester is associated with short stature. No neurodevelopmental impact was observed in our study group.
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http://dx.doi.org/10.1007/s00404-019-05421-4DOI Listing
February 2020

Oral glucose tolerance test for suspected late onset gestational diabetes.

J Matern Fetal Neonatal Med 2019 Dec 18:1-5. Epub 2019 Dec 18.

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

Oral glucose tolerance test is used for the diagnosis of gestational diabetes at the second trimester, however, its use at term has been questioned. To compare obstetric outcomes in women with and without abnormal oral glucose tolerance test (OGTT) conducted at term due to large for gestational age (LGA) fetuses or polyhydramnios. A retrospective cohort study including all women ≥37 weeks of gestation, with normal glucose challenge test (GCT), who performed 100 g OGTT at term, due to LGA fetus or polyhydramnios between January 2012 and January 2017. Abnormal OGTT was considered according to Carpenter and Coustan criteria. Data are presented as median and inter-quadrantile range (IQR). Database included 34,897 women, of them, 1131 (3.2%) met inclusion criteria. A total of 150 (13.2%) and 981 (86.7%) women were included in the abnormal and the normal OGTT groups, respectively. Women in the abnormal OGTT group had higher glucose levels on GCT [126 (IQR 107-137) versus 110 (IQR 91-132) mg/dL;  = .001]. The rate of cesarean deliveries was twice as high in the abnormal OGTT group [37 (24.7%) versus 103 (10.5%);  = .001]. No difference in the rate of shoulder dystocia, postpartum hemorrhage (PPH) or third and fourth-degree perineal tear was observed among women who delivered vaginally. Abnormal OGTT at term was related to a higher rate of cesarean deliveries, with no difference in obstetrical complications among women who delivered vaginally.
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http://dx.doi.org/10.1080/14767058.2019.1702945DOI Listing
December 2019

Nonsurgical Management of Interstitial Pregnancies: Feasibility and Predictors of Treatment Failure.

J Minim Invasive Gynecol 2020 Mar - Apr;27(3):625-632. Epub 2019 Jun 15.

Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (all authors).

Study Objectives: To describe the management of interstitial pregnancies in a tertiary medical center, identify factors associated with treatment failure, and report subsequent pregnancy outcome.

Design: Retrospective cohort study.

Setting: Department of Gynecology in a tertiary medical center.

Patients: All women who were admitted to and treated for interstitial pregnancy at our center between 2011 and 2019.

Interventions: The women were originally assigned to undergo expectant, medical, or surgical treatment. The women's background and clinical data were compared according to initial treatment modality. Nonsurgical (expectant and medical) management outcomes were analyzed to identify risk factors for treatment failure. Subsequent pregnancy outcomes were described separately.

Measurement And Main Results: Thirty-seven cases of interstitial pregnancy were identified. There were high rates of pregnancy achieved by in vitro fertilization (45.9%) and a history of ipsilateral salpingectomy (43.2%) among these patients. At presentation, the mean age of the study cohort was 34.76 years, and the median β-human chorionic gonadotropin level was 3853.0, and median gestational age was 7.0, respectively. The nonsurgical management success rate was 70.0%. Uterine rupture occurred during treatment in 5 cases (16.6%). Gestational sac diameter significantly affected treatment failure (p = .03), and a diameter >20 mm was observed in all cases of failed non-surgical treatment. Data on future fertility was available for 21 (58.3%) women: 13 (61.9%) had a subsequent pregnancy, 1 of which was a recurrent interstitial pregnancy. The median interpregnancy interval was 8.1 months, and all but 3 pregnancies reached third trimester and resulted in a live birth, with an overall cesarean delivery rate of 61.5%. None of the subsequent pregnancies were complicated by uterine rupture, and no serious adverse outcomes were noted in any of the subsequent intrauterine pregnancies that reached third trimester.

Conclusion: Successful nonsurgical management of an interstitial pregnancy is feasible, although appropriate selection of cases is advised. A large gestational sac is a risk factor for treatment failure and should prompt surgical intervention. Subsequent pregnancies can generally be considered safe and with a favorable outcome.
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http://dx.doi.org/10.1016/j.jmig.2019.06.008DOI Listing
October 2020

Ovarian reserve after uterine artery embolization in women with morbidly adherent placenta: A cohort study.

PLoS One 2018 29;13(11):e0208139. Epub 2018 Nov 29.

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

Objective: To evaluate ovarian reserve in women after preservative cesarean delivery using uterine artery embolization due to morbidly adherent placenta.

Study Design: A historical cohort study including all women admitted to a single tertiary care center, with morbidly adherent placenta that had preservative cesarean delivery with bilateral uterine artery embolization. Inclusion criteria included gestational age >24 weeks, singleton pregnancy and placenta increta / percreta. Exclusion criteria included maternal age > 43 years old and cesarean hysterectomy. Control group included women attending the infertility clinic due to male factor or single women conceiving via sperm donation, matched by age. Blood samples were collected on day 2-5 of menstruations for hormonal profile and Anti Mullarian Hormone (AMH) levels. Primary outcome was ovarian reserve evaluated by the levels of AMH.

Results: 59 women underwent preservative cesarean delivery using uterine artery embolization during the study period. 21 women met inclusion criteria (33.9%) and were matched controls (n = 40). Circulating levels of E2 and FSH did not differ significantly between the two groups (p = 0.665, p = 0.396, respectively). AMH was lower in the study group (median 0.8 IQR 0.44-1.80) compared to the controls (median 2.08 IQR 1.68-3.71) (p = 0.001). This finding was consistent in linear multivariate regression analysis where the group of cesarean delivery using bilateral artery embolization due to placenta accrete was significantly predictive for the levels of AMH (B = -1.308, p = 0.012).

Conclusion: Women post preservative cesarean delivery using uterine artery embolization due to placenta accrete have lower ovarian reserve compare to controls matched by age.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208139PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6264507PMC
May 2019

Outcomes of singleton versus twin pregnancies in the fifth and sixth decades.

Eur J Obstet Gynecol Reprod Biol 2018 Dec 6;231:255-261. Epub 2018 Nov 6.

The Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Electronic address:

Background: Pregnancies in the fifth and sixth decades of life have been increasing, but current data are limited regarding the outcomes of twin compared with singleton pregnancies in this age group and to twin pregnancies at younger age.

Objective: To compare obstetrical and neonatal outcomes of IVF conceived pregnancies, in twin gestations of women who were ≥45 years old at delivery to singletons at similar age and twin gestations at the age of <35 years, and to assess if the complications are mainly influenced by the very advanced maternal age or by the multifetal pregnancy.

Study Design: A retrospective cohort study from a single tertiary medical center of women aged ≥45 at delivery between March 2011 and January 2018 and women aged <35 at delivery with twin pregnancies that conceived by IVF. Exclusion criteria were spontaneous pregnancies or pregnancies after ovulation induction, monochorionic twin pregnancies, higher order multiple gestations, or women that underwent fetal reduction. Pregnancy, delivery, postpartum and neonatal outcomes were compared between singleton and twin pregnancies. Multivariate logistic regression was used to evaluate the association between twin pregnancies and adverse outcomes.

Results: Out of 67,355 deliveries, 612 were of women ≥45 years old, of whom 492 women conceived via IVF (395 singleton and 97 twin pregnancies). Of those, 60 women were ≥50 years old, 49 of them carried singleton and 11 carried twin pregnancies. Baseline characteristics were similar between groups. Women at the fifth and sixth decades with twins had significantly higher rates of preeclampsia (32.0% vs. 10.9%, p < 0.001), gestational diabetes mellitus (35.4% vs. 23.8%, p = 0.020), preterm deliveries <32 weeks of gestation (8.2% vs. 1.3%, p = 0.001), and fetal growth restriction (18.6% vs. 7.6%, p = 0.001) compared with singleton pregnancies at similar maternal age. After multivariate analysis adjusting for confounders, the odds ratio for the composite of preeclampsia, gestational hypertension, intrauterine fetal growth restriction, and placental abruption was 3.19 for twin compared with singleton pregnancies and 1.73 for gestational diabetes mellitus. Pregnancy complications among older women with twins were also significantly higher when compared with younger women with twins (<35 years old). Women in the fifth and sixth decades with twins had higher rates of cesarean deliveries (91.8% vs. 56.4%, p<0.001), gestational hypertension, preeclampsia, and gestational diabetes mellitus (10.3% vs. 4.2%., p=0.016; 32.0% vs. 6.2%, p<0.001; 35.1% vs. 8.1%, p<0.001, respectively) than the younger group carrying twins.

Conclusions: Twin pregnancies in the fifth and sixth decades carry significantly higher complications rate compared with singleton pregnancies at the same age and twin pregnancies at younger age.
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http://dx.doi.org/10.1016/j.ejogrb.2018.11.007DOI Listing
December 2018

Long-term outcome of MR-guided focused ultrasound treatment and laparoscopic myomectomy for symptomatic uterine fibroid tumors.

Am J Obstet Gynecol 2018 10 11;219(4):375.e1-375.e7. Epub 2018 Sep 11.

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Fibroid tumors are the most common benign tumors in women of reproductive age. Treatment is usually indicated for those who are symptomatic, with different techniques being used.

Objective: The purpose of this study was to compare the long-term outcome of laparoscopic myomectomy with magnetic resonance-guided focused ultrasound for symptomatic uterine fibroid tumors.

Study Design: A cohort study was conducted on all patients with symptomatic uterine fibroid tumors who were admitted to a single tertiary care center and treated operatively with laparoscopic myomectomy or treated conservatively with magnetic resonance-guided focused ultrasound from January 2012 until January 2017. Assessment for further interventions and sustained fibroid-associated symptoms was performed, with the use of the Uterine Fibroid Symptom and Quality of Life symptom severity score.

Results: One hundred fifty-four women met the inclusion criteria. Complete follow-up evaluation was achieved for 64 women who underwent laparoscopic myomectomy and for 68 women who were treated by magnetic resonance-guided focused ultrasound. Follow-up time was similar for the 2 groups (median, 31 months [interquartile range, 17-51 months] vs 36 months [interquartile range, 24-41]; P=.95). The rate of additional interventions was 5 (7.8%) and 9 (13.2%), respectively (P=0.312). Similarly, the Uterine Fibroid Symptom and Quality of Life symptom severity score questionnaire score at follow-up interviews revealed comparable median scores of 17 (interquartile range, 12-21) vs 17 (interquartile range, 13-22) for laparoscopic myomectomy and magnetic resonance-guided focused ultrasound, respectively (P=.439). Analysis of each of the symptoms separately (bleeding, changes in menstruation, abdominal pain, bladder activity, nocturia, fatigue) did not change these findings, nor did a multivariate analysis.

Conclusion: Satisfaction with long-term outcome and rate of reinterventions after magnetic resonance-guided focused ultrasound treatment or laparoscopic myomectomy for uterine fibroid tumors was comparable. Further larger randomized trials are needed to confirm these findings.
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http://dx.doi.org/10.1016/j.ajog.2018.09.002DOI Listing
October 2018

Outcome of magnetic resonance-Guided focused ultrasound surgery (MRgFUS) for FIGO class 1 fibroids.

Eur J Obstet Gynecol Reprod Biol 2018 Feb 14;221:119-122. Epub 2017 Dec 14.

Department of Gynecology, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: Intracavitary uterine fibroids and fibroids that distort the uterine cavity are associated with excessive vaginal bleeding and infertility. While intracavitary fibroids smaller than 4 cm are usually treated safely by operative hysteroscopy, larger fibroids may require multiple surgeries or more extensive surgery with possible damage to the integrity of the uterine wall. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive approach for treating uterine fibroids, mainly the intramural type. We present the outcome of MRgFUS treatment for intracavitary fibroids (FIGO class 1) in cases that could not be treated by hysteroscopy due to either fibroid size or patient refusal. (Canadian Task Force II-1).

Study Design: A retrospective cohort study from a single tertiary referral center. A total of 68 patients were treated by MRgFUS for symptomatic uterine fibroids from January 2013 to December 2016. Six of them had FIGO class 1 fibroids. Adverse effects and short- and long-term outcomes (quality of life issues and need for additional surgical intervention) were assessed during ambulatory clinic visits and by phone interviews.

Results: The mean ± SD fibroid volume on MRI screening was 86.3 ± 60.9 cm. Six of those patients underwent the procedure (mean age 40.5 ± 5.6 years, range 33-48). The follow-up duration was 24.1 ± 12.0 months. Four patients were not interested in future fertility and did not undergo additional treatment, while the two who planned to conceive underwent another surgical intervention (one underwent operative hysteroscopy after reduction of fibroid size and the other underwent laparoscopic myomectomy).

Conclusion: This preliminary study shows that MRgFUS can be a feasible treatment option for FIGO class 1 uterine fibroids. Shrinkage of fibroids by MRgFUS can obviate or facilitate subsequent surgical intervention in selected cases.
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http://dx.doi.org/10.1016/j.ejogrb.2017.12.025DOI Listing
February 2018

The Yield of Abdominal Ultrasound in the Evaluation of Elevated Liver Enzymes during the Second and the Third Trimester of Pregnancy.

Gynecol Obstet Invest 2017 19;82(5):517-520. Epub 2017 May 19.

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

Aims: To determine the clinical yield of abdominal ultrasound in the evaluation of elevated liver enzymes (ELEs) in the second and the third trimester of pregnancy.

Methods: A retrospective cohort study including all pregnant women admitted to a single tertiary care center was conducted between April 2011 and January 2015 with ELE. Inclusion criteria included gestational age above 24 weeks and ELEs, abdominal ultrasound report, and live fetus. Exclusion criteria included known maternal liver disease, structural or chromosomal fetal anomalies, and positive serology for viral hepatitis. All patients underwent abdominal ultrasound. A significant finding of this study led to a change in treatment.

Results: One hundred and twenty patients (41.8%) met inclusion criteria: 93 (77.5%) had a normal scan and 27 (22.5%) had abnormal findings. Significant ultrasound findings were found only in 2 (1.6%) patients: gallstones in the common bile duct and suspected autoimmune hepatitis. There were no significant differences between patients with and without ultrasound findings in the rate of cholestasis of pregnancy, preeclampsia, chronic hypertension, and gestation diabetes.

Conclusion: Abdominal ultrasound examination in this population has a low clinical yield. The decision to perform an abdominal ultrasound must be individualized based on the obstetric history, clinical findings, and the level of liver enzymes.
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http://dx.doi.org/10.1159/000453612DOI Listing
June 2018

Second dose of PGE vaginal insert versus Foley transcervical balloon for induction of labor after failure of cervical ripening with PGE vaginal insert.

J Matern Fetal Neonatal Med 2017 Sep 6;30(17):2074-2077. Epub 2016 Oct 6.

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

Purpose: To determine the success rate of induction of labor (IOL) using Foley transcervical balloon (FTB) versus prostaglandin E (PGE) vaginal insert, following failure of cervical ripening with PGE vaginal insert.

Materials And Methods: A retrospective cohort study of all pregnant women admitted for IOL with either FTB or PGE vaginal insert. Either second dose of PGE vaginal insert or FTB was used as a second line treatment after failure (not giving birth in 24 h from insertion) of first PGE vaginal insert.

Results: During the study period, 1162 women were admitted for IOL. Failure was reported in 322/852 (37.8%) in the FTB versus 162/310 (52.2%) in the PGE group (p < 0.001). Among 162 patients treated with PGE as first line who did not deliver after 24 h, 14 had spontaneous rupture of membranes, 15 underwent stripping and 42 were in still in active labor. The remainder were allocated to either second trial of PGE treatment (n = 58) or FTB (n = 33) with failure rate higher in the PGE group, not statistically significant (p = 0.23).

Conclusion: IOL with FTB was not superior to PGE vaginal insert for IOL following failure of cervical ripening with PGE vaginal insert.
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http://dx.doi.org/10.1080/14767058.2016.1236252DOI Listing
September 2017

Reduced fetal movement: factors affecting maternal perception.

J Matern Fetal Neonatal Med 2016 15;29(8):1318-21. Epub 2015 Jul 15.

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

Objective: Evaluate physiologic factors associated with reduced maternal perception of fetal movements (RFM).

Methods: A historical cohort study of all women (years 2011-2013, n = 399) that visited the maternal emergency room (ER) (gestational age 24 + 0-42 + 0) due to RFM (group A), that was compared to a control group consisted from women with normal perception of fetal movements (group B). Groups were compared for maternal characteristics (age, gravity, parity, BMI), gestational age, placental location, gestational age at birth and fetal outcomes (birth-weight and Apgar scores).

Results: In a multivariate regression analysis, including maternal age, height, weight, BMI, gestational age on admission to ER, gravity, parity and placental location, only two variables remained significantly associated with RFM - nulliparity (OR = 2.28, p = 0.001) and anterior placenta (OR = 1.44, p = 0.034). Group A was not associated with lower Apgar scores (1 and 5-min, p = 0.40 and 0.57, respectively) or low birth-weight (p = 0.76), nor was it associated with prematurity (p = 0.41), low (<7) 5-min Apgar score, fetal death or neonatal death.

Conclusions: Reduced fetal movements are associated with anterior placenta and nulliparity.
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http://dx.doi.org/10.3109/14767058.2015.1047335DOI Listing
October 2016

Perinatal outcome after fetal reduction from twin to singleton: to reduce or not to reduce?

Fertil Steril 2015 Feb 20;103(2):428-32. Epub 2014 Nov 20.

Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel.

Objective: To determine whether reduction of twin gestation to singleton pregnancy is associated with improved perinatal outcome.

Design: A retrospective cohort study.

Setting: Single tertiary care medical center.

Patient(s): A cohort of 63 singleton pregnancies after reduction from dichorionic-diamniotic twins gestation and 62 dichorionic-diamniotic nonreduced twins.

Intervention(s): Fetal reduction between 11 and 14 weeks of gestation.

Main Outcome Measure(s): Obstetric outcome.

Result(s): The rates of preterm delivery at <34 weeks (1.6% in pregnancies after reduction vs. 11.7% in nonreduced twins) and at <37 weeks of gestation (9.5% vs. 56.7%) were significantly lower in patients whose pregnancies were reduced to singletons. The rates of miscarriage of one twin (0% vs. 4.8%) and early pregnancy loss before 24 weeks of gestation as well as the rates of gestational diabetes (11.1% vs. 10%), hypertensive diseases of pregnancy (6.3% vs. 15%), and intrauterine growth restriction (0% vs. 3.3%) were similar in both groups.

Conclusion(s): Fetal reduction of twins to singleton is associated with a lower risk of prematurity and superior perinatal outcome compared with nonreduced twins. Therefore, the option of fetal reduction should be considered in certain cases of twin pregnancies, where the risk for adverse outcome seems exceptionally high.
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http://dx.doi.org/10.1016/j.fertnstert.2014.10.027DOI Listing
February 2015