Publications by authors named "Raanan Meyer"

57 Publications

Relaparotomy post-cesarean delivery: characteristics and risk factors.

Arch Gynecol Obstet 2021 Apr 10. Epub 2021 Apr 10.

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

Purpose: Relaparotomy following cesarean delivery (CD) is performed at a rate of 0.2-1% of CD. The objective of the present study was to identify risk factors for relaparotomy following CD, and to examine whether there is a difference in the risk of relaparotomy between CD performed during different hours of the day.

Methods: A retrospective study on all CD over 10 years compared pregnancies that underwent laparotomy within 1 week following CD to those that did not.

Results: Sixty-four patients underwent relaparotomy out of 24,239 CDs (0.26%). In univariate analysis, relaparotomy was significantly associated with pregnancies following assisted-reproductive-technologies odds ratio (OR) 95% confidence interval (CI) 3.15 (1.90-5.22), hypertensive disorders of pregnancy OR 3.05 (1.62-5.72), twin pregnancies OR 95% CI 3.78 (2.21-6.48), preterm deliveries OR 95% CI 2.44 (1.46-4.10), placenta previa OR 95% CI 6.41(2.55-16.09) and urgent CD 1.74 (1.06-2.86), especially during the second-stage of labor OR 95% CI 2.73 (1.34-5.54). The time of day of CD did not influence the rate of relaparotomy. In a multivariable-regression analysis, the adjusted odds ratio for relaparotomy was 10.24 in CD due to placenta previa, and 5.28 in CD performed at the second-stage of delivery. At relaparotomy, active bleeding was found in 50 patients (78.1%), nearly half received packed cells, 12.5% developed consumptive coagulopathy, and 17.2% needed hospitalization in the intensive care unit. 6.3% underwent a second relaparotomy, mainly due to bleeding.

Conclusion: Placenta previa, and urgent CDs mainly those performed at the second stage of labor are risk factors for relaparotomy after CD.
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http://dx.doi.org/10.1007/s00404-021-06060-4DOI Listing
April 2021

Second stage expedite delivery of low birth weight neonates: Emergent cesarean delivery versus vacuum assisted delivery.

J Gynecol Obstet Hum Reprod 2021 Apr 2;50(8):102136. Epub 2021 Apr 2.

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

Objective: To determine maternal and neonatal outcomes among women undergoing second stage emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) of low birthweight neonates.

Materials And Methods: A retrospective cohort study from two tertiary medical centers. We included women who underwent either ECD or VAD during the second stage of labor, and delivered neonates with a birthweight of <2500 g during 2011-2019. Characteristics and outcomes were compared between the groups. The primary outcome was the rate of a composite adverse neonatal outcome, defined as the presence of ≥1 of the following: Apgar 5 min < 7, respiratory distress syndrome, neonatal intensive care unit admission, mechanical ventilation and intrapartum fetal death.

Results: The study cohort included 611 patients, of whom 46 had ECD and 565 had VAD. Baseline characteristics did not differ between the groups. The rate of Apgar score < 7 at 1 min was higher among the ECD group]10 (22%) vs. 29 (5%), OR (95% CI) 5.1 (2.3-11.3), p < 0.001[. Other neonatal and maternal outcomes were similar in both groups.

Conclusions: Neonatal and maternal outcomes do not differ substantially between ECD and VAD of neonates weighing <2500 g. This information may be useful when contemplating the preferred mode of delivery in this setting.
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http://dx.doi.org/10.1016/j.jogoh.2021.102136DOI Listing
April 2021

Risk factors for obstetric anal sphincter injury among women undergoing a trial of labor after cesarean.

Eur J Obstet Gynecol Reprod Biol 2021 Mar 10;260:37-41. Epub 2021 Mar 10.

The Department of Obstetrics and Gynecology, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel.

Objective: Data regarding the risks of obstetrical anal sphincter injury (OASI) among women who never delivered vaginally undergoing a trial of labor after cesarean (TOLAC) are scarce. We aimed to evaluate the risk factors and the rate of OASI among women undergoing TOLAC who never delivered vaginally.

Study Design: A retrospective cohort study of all women undergoing a TOLAC and never delivered vaginally between 3/2011 and 6/2020. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. We matched groups to earliest gestational age in which OASI has occurred. A further comparison was made between the study cohort and a cohort of primiparous women undergoing a vaginal delivery, including gestational ages at which OASI has occurred in that cohort.

Results: During the study period there were 2061 TOLACs among women without prior vaginal delivery. Of these, 76 % (1566/2061) had a successful vaginal delivery. Overall, 22/2061 (1.1 %) cases of OASI occurred. There was no difference in maternal demographic, obstetrical and medical history characteristics between the study groups. The mean gestational age at TOLAC was lower in the OASI group (39 ± 1 vs. 39 ± 1, p = 0.012). In multivariable regression analysis, gestational age was negatively associated with OASI [adjusted odds ratio, 95 % (confidence interval) 0.95 (0.91-0.99), for each day increase in gestational age)]. The rate of OASI in the study cohort did not differ from the rate of OASI among primiparous women during the same study period (347/27975, 1.2 %, p = 0.686).

Conclusion: Gestational age at delivery is the only predictor of OASI among women with no prior vaginal deliveries undergoing a TOLAC. The incidence of OASI in this population is 1.1 % and does not differ from that of primiparous women.
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http://dx.doi.org/10.1016/j.ejogrb.2021.03.006DOI Listing
March 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

Maternal Colonization With Group B Streptococcus and the Risk for Infection After Cervical Ripening With a Transcervical Foley Catheter.

Obstet Gynecol 2021 04;137(4):662-663

Department of Obstetrics & Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, and the Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel.

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http://dx.doi.org/10.1097/AOG.0000000000004306DOI Listing
April 2021

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

The role of sonographic head circumference in the occurrence of subgaleal hemorrhage following vacuum delivery.

J Matern Fetal Neonatal Med 2021 Feb 3:1-6. Epub 2021 Feb 3.

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

Objective: Subgaleal hemorrhage (SGH) is a severe neonatal morbidity that is associated with vacuum-assisted delivery (VAD). Large sonographic head circumference (sHC) was previously associated with complicated VAD. Nevertheless, the association of large sHC with SGH formation following VAD is underreported. We aim to evaluate the role of sonographic head circumference (sHC) with SGH formation following attempted VAD.

Methods: A retrospective case-control study. Cases comprised singleton pregnancies for whom attempted VAD resulted in SGH with an sHC measured within 2 weeks from delivery. Controls were VAD deliveries which not resulted in SGH, with an sHC measured within 2 weeks from delivery. We matched controls in a 1:1 ratio by gestational age, parity and year of delivery.

Results: Overall, 118 women were included in the SGH study group and were matched to 118 controls. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birth weight in the SGH group (median 3422 vs. 3195 grams,  = .001). sHC did not vary between groups (median 336 mm in SGH groups vs. 333,  = .08). Rate of sHC >90th and >95th percentile did not significantly differ between the groups (13.6% vs. 8.5%, 6.8% vs. 3.4%,  = .21,  = .37, for SGH vs. controls, respectively). In multivariate regression analysis, sHC was not found to be independently associated with SGH - aOR (95% CI) 1.004 (0.97-1.03). Receiver operating characteristic curves of sHC for SGH formation underlined an area under the curve of 0.58 (95% CI) (0.51-0.65).

Conclusions: sHC is not associated with SGH formation following VAD.
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http://dx.doi.org/10.1080/14767058.2021.1882983DOI Listing
February 2021

Re: Obstetric anal sphincter injuries (OASIS) in multiparous women with the use of epidural anaesthesia: A retrospective cohort study.

Aust N Z J Obstet Gynaecol 2021 Apr 1;61(2):E20-E21. Epub 2021 Feb 1.

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

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http://dx.doi.org/10.1111/ajo.13315DOI Listing
April 2021

The association of vacuum-assisted delivery and shoulder dystocia among macrosomic newborns: a retrospective study.

Arch Gynecol Obstet 2021 Jan 20. Epub 2021 Jan 20.

Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Purpose: Although shoulder dystocia (ShD) is associated with fetal macrosomia and vacuum-assisted delivery (VAD), the independent role of the latter in the occurrence of ShD is yet to be completely elucidated, as it is difficult to study its true independent contribution to ShD formation in the presence of many confounding factors. Therefore, we aimed to study whether VAD is independently associated with an increased risk for ShD among macrosomic newborns.

Methods: A retrospective cohort study from a single tertiary medical center including all women who delivered vaginally a macrosomic infant during 2011-2020. We allocated the study cohort into two groups: (1) VAD (2) spontaneous vaginal deliverys, and analyzed risk factors for ShD. A multivariate regression analysis was performed to identify determinants independently associated with ShD occurrence.

Results: Of 2,664 deliveries who met the study inclusion criteria, 118 (4.4%) were VAD. The rate of ShD in the entire cohort was 108/2664 (4.1%). The following factors were more frequent among the VAD group: no previous vaginal delivery [odds ratio (OR) 2.4 (95% confidence interval (CI) 1.4-4.0, p < 0.001)], prolonged second stage (OR 11.9; 95% CI 8.1-17.6, p < 0.01), induction of labor (OR 2.4; 95% CI 1.5-3.8, p < 0.01) and ShD (OR 2.0; 95% CI 1.0-4.1, p = 0.04). ShD was associated with higher rates of maternal height < 160 cm (OR 2.0; 95% CI 1.3-3.1, p < 0.01), pregestational diabetes (OR 7.2; 95% CI 2.0-26.8, p = 0.01), hypertensive disorder (OR 2.6; 95% CI 1.1-6.2, p = 0.02) and higher birthweight (mean 4,124 vs. 4,167 g, p < 0.01). On multivariate regression analysis, the following factors remained independently associated with ShD occurrence: increased birthweight (aOR 1.0; 95% CI 1.0-1.0, p < 0.01), pregestational diabetes (aOR 5.3; 95% CI 1.1-25.0, p = 0.03), while maternal height was negatively associated with ShD (aOR 0.9; 95% CI 0.9-0.9, p < 0.01).

Conclusion: In deliveries of neonates above 4000 g, VAD did not independently increase the risk of ShD occurrence. Therefore, when expeditious delivery of a macrosomic infant is required, VAD is a viable option.
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http://dx.doi.org/10.1007/s00404-020-05941-4DOI Listing
January 2021

Neonatal and maternal outcome of small-for-gestational-age neonates delivered by vacuum-assisted delivery.

Int J Gynaecol Obstet 2021 Jan 18. Epub 2021 Jan 18.

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

Objective: To evaluate the association between neonatal weight centile and neonatal and maternal morbidity following vacuum-assisted delivery (VAD) among term nulliparous women.

Methods: A retrospective cohort study of all nulliparous women who delivered at term by VAD between 2011 and 2019. Deliveries were allocated into two groups and compared: (1) delivery of an small-for-gestational-age (SGA) neonate, and (2) delivery of an appropriate-for-gestational-age (AGA) neonate.

Results: Overall, 3116 women were included in the study; 2878 (92.4%) were AGA and 163 (5.2%) were SGA and comprised the study groups. Neonatal and maternal adverse outcomes did not vary between groups. Rates of composite neonatal adverse outcome for SGA and AGA neonates were 26 (16.0%) versus 462 (16.1%), respectively (P = 0.972). Duration of the second stage of labor and rate of prolonged second stage were significantly lower among the SGA group compared with the AGA group (P < 0.001 for both comparisons). Maternal rates of anal sphincter injury and postpartum hemorrhage did not differ between groups.

Conclusion: Neonatal outcomes among SGA neonates delivered by VAD at term did not differ from those of AGA neonates. Maternal outcome did not differ. These data provide reassurance for practitioners to perform VAD in SGA neonates at term.
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http://dx.doi.org/10.1002/ijgo.13603DOI Listing
January 2021

Prediction of adverse neonatal outcome among newborns born through meconium-stained amniotic fluid.

Int J Gynaecol Obstet 2021 Jan 14. Epub 2021 Jan 14.

The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Objective: To study maternal and intrapartum factors associated with adverse neonatal outcome in deliveries complicated by meconium-stained amniotic fluid (MSAF).

Methods: A retrospective cohort study of all women with singleton gestations undergoing trial of labor with MSAF during 2011-2020. Deliveries with adverse neonatal outcome were compared with deliveries without.

Results: Overall, 11 329 were included; 376 (3.3%) neonates were diagnosed with adverse neonatal outcomes. Multivariable regression analysis underlined the following factors as independently associated with composite adverse neonatal outcome: pregestational diabetes (odds ratio [OR] 3.21, 95% confidence interval [CI] 1.09-9.43, P = 0.031), polyhydramnios (OR 2.14, 95% CI 1.33-3.44, P = 0.002), fever (OR 2.52, 95% CI 1.67-3.80, P < 0.001), and amnioinfusion (OR 1.73, 95% CI 1.24-2.2438, P = 0.003). When 0, 1, 2, and 3 of the independent risk factors identified were present, the rates of adverse neonatal outcome were 2.9%, 5.5%, 10.0%, and 100%, respectively.

Conclusion: The current study's results suggest that special attention should be payed to deliveries complicated by MSAF and with any of the following factors-polyhydramnios, intrapartum fever, amnioinfusion, and pregestational diabetes.
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http://dx.doi.org/10.1002/ijgo.13592DOI Listing
January 2021

Factors Associated with More Than 500 Grams Inaccuracy in Sonographic Fetal Weight Estimation.

Isr Med Assoc J 2021 Jan;23(1):43-47

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

Background: The sonographic assessment of estimated fetal weight (EFW) is essential for identification of fetuses in weight extremes and aids in peripartum management. However, there are inconsistent reports regarding EFW accuracy.

Objectives: To examine maternal and fetal determinants associated with unreliable EFW.

Methods: A retrospective case-control study was conducted at a single, tertiary medical center between 2011 and 2019. All term, singleton deliveries with a sonographic EFW within 2 weeks of delivery were included. Unreliable EFW was defined as > 500 grams discordance between it and the actual birth weight. We allocated the study cohort into two groups: unreliable EFW (cases) and accurate EFW (controls).

Results: Overall, 41,261 deliveries met inclusion criteria. Of these, 1721 (4.17%) had unreliable EFW. The factors positively associated with unreliable EFW included body mass index > 30 kg/m2, weight gain > 20 kg, higher amniotic fluid index, pregestational diabetes, gestational age > 410/7, and birth weight ≥ 4000 grams. On multiple regression analysis, pregestational diabetes (odds ratio [OR] 2.22, 95% confidence interval [95%CI] 1.56-3.17, P < 0.001) and a higher birth weight (OR 1.91, 95%CI 1.79-2.04, P < 0.001) were independently associated with unreliable EFW. On analysis of different weight categories, pregestational diabetes was associated with unreliable EFW only among birth weights ≥ 3500 grams (OR 3.28, 95%CI 1.98-5.44, P< 0.001) and ≥ 4000 grams (OR 4.27, 95%CI 2.31-7.90, P < 0.001).

Conclusions: Pregestational diabetes and increased birth weight are independent risk factors for unreliable EFW and should be considered when planning delivery management.
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January 2021

The Significance of Fetal Brain Ventricular Asymmetry Without Dilation.

J Ultrasound Med 2021 Jan 11. Epub 2021 Jan 11.

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

Objectives: Fetal brain non-dilated ventricular asymmetry (NDVA) is a common finding on prenatal ultrasound exams. However, the optimal prenatal management in these cases remains unknown. We aimed to evaluate the benefit of prenatal genetic and magnetic resonance imaging (MRI) exams performed in cases of fetal NDVA detected on ultrasound.

Methods: A historical cohort study from a tertiary medical center. Singleton pregnancies with fetal brain NDVA diagnosed on ultrasound were included. We defined ventricular asymmetry as a difference of ≥2.0 mm between the lateral ventricles and ventricular dilation as ventricular width of >10.0 mm. Outcomes were evaluated with genetic exams (karyotype and chromosomal microarray analysis [CMA]) and fetal brain MRI.

Results: During the study period, there were 145 cases diagnosed with NDVA on ultrasound that comprised the cohort study. The rate of abnormal karyotype was 1.8% (1/56) and of abnormal CMA was 10% (3/30). The rate of minor additional CNS findings did not differ between ultrasound and MRI (3.4 versus 2.8%, respectively, p = .74). No major additional fetal brain findings were detected on MRI performed after ultrasound.

Conclusions: In cases diagnosed with NDVA on ultrasound, no significant additional anomalies were detected on fetal brain MRI. The rate of abnormal genetic tests was relatively high and warrants further studies.
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http://dx.doi.org/10.1002/jum.15626DOI Listing
January 2021

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes.

Arch Gynecol Obstet 2021 May 2;303(5):1255-1261. Epub 2021 Jan 2.

Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Purpose: We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols.

Methods: A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center.

Results: The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions.

Conclusion: Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.
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http://dx.doi.org/10.1007/s00404-020-05914-7DOI Listing
May 2021

Predictors of adverse neonatal outcome in pregnancies complicated by placenta previa.

Placenta 2021 Jan 9;104:119-123. Epub 2020 Dec 9.

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

Introduction: We aimed to underline the determinants of adverse neonatal outcome in gestations complicated by placenta previa (PP).

Methods: A retrospective study including all women diagnosed with placenta previa carrying a singleton gestation who delivered between 2011 and June 2019. Gestations with adverse neonatal outcomes were compared to those without. In a secondary analysis, we further studied the rate of Placenta accreta spectrum (PAS) in relation to number of previous cesarean deliveries.

Results: Overall, 548/84,558 (0.6%) singleton deliveries were complicated by PP (0.6%). PAS was noted in 105 (19.2%) cases. After exclusion of PAS cases, adverse neonatal outcome occurred in 149/443 (33.6%), median gestational age of delivery was 37 with a median birthweight of 2780 g. In a univariate analysis, adverse neonatal outcome was associated with emergent delivery and general anesthesia [56.8% vs. 20.8%, OR 5.00 (95% CI) 3.24-7.72, p < 0.001 and 54.4% vs. 24.8%, OR 3.60 (95% CI) 2.37-5.47, p < 0.001, respectively]. Gestational age at delivery was lower in the adverse outcome group (mean 35 vs. 37 , p < 0.001). In a multivariate regression analysis, general anesthesia and gestational age at delivery were independently associated with adverse neonatal outcome [adjusted odds ratio (aOR) 2.26 (95% CI) 1.18-4.31, p = 0.01, aOR 1.10 (95% CI) 1.05-1.16, p < 0.001. Analysis of the rate of PAS among women with previous cesarean delivery and PP revealed that no cases of PAS were noted when no prior cesarean delivery was present. The rate of PAS for previous 1, 2, 3, 4 and 5 cesarean deliveries was 26.7%, 43.5%, 65.5%, 55.6% and 66.7% respectively.

Discussion: Efforts should be made to avoid general anesthesia in deliveries of PP.
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http://dx.doi.org/10.1016/j.placenta.2020.12.005DOI Listing
January 2021

Fetal Head Station at Second-Stage Dystocia and Subsequent Trial of Labor After Cesarean Delivery Success Rate.

Obstet Gynecol 2021 Jan;137(1):147-155

Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, and the Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel.

Objective: To investigate whether fetal head station at the index cesarean delivery is associated with a subsequent trial of labor success rate among primiparous women.

Methods: A retrospective cohort study conducted at two tertiary medical centers included all primiparous women with subsequent delivery after cesarean delivery for second-stage dystocia during 2009-2019, identified from the electronic medical record databases. Univariate and multivariate analyses were performed to assess the factors associated with successful trial of labor after cesarean (TOLAC) (primary outcome). Additionally, all women with failed TOLAC were matched one-to-one to women with successful TOLAC, according to factors identified in the univariate analysis.

Results: Of 481 primiparous women with prior cesarean delivery for second-stage dystocia, 64.4% (n=310) attempted TOLAC, and 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index cesarean delivery, as compared with those with higher head station (79.0% vs 60.5%, odds ratio [OR] 2.46, 95% CI 1.49-4.08). The proportion of neonates weighing more than 3,500 g in the subsequent delivery was lower in those with successful TOLAC compared with failed TOLAC (29.7% vs 43.2%, OR 0.56, 95% CI 0.33-0.93). In a multivariable analysis, lower fetal head station at the index cesarean delivery was the only independent factor associated with TOLAC success (adjusted OR 2.38, 95% CI 1.43-3.96). Matching all women with failed TOLAC one-to-one to women with successful TOLAC, according to birth weight and second-stage duration at the subsequent delivery, lower fetal head station at the index cesarean delivery remained the only factor associated with successful TOLAC.

Conclusion: Lower fetal head station at the index cesarean delivery for second-stage dystocia was independently associated with a higher vaginal birth after cesarean rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to deliver vaginally after prior second-stage arrest.
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January 2021

Extremely early pregnancy (<6 mo) after sleeve gastrectomy: maternal and perinatal outcomes.

Surg Obes Relat Dis 2021 Feb 24;17(2):356-362. Epub 2020 Sep 24.

Department of Surgery, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel.

Background: Data are scarce regarding outcomes of pregnancies occurring very early after bariatric surgery.

Objectives: We compared outcomes of pregnancies occurring extremely early (surgery-to-conception interval <6 mos) after laparoscopic sleeve gastrectomy (LSG) with those occurring later (≥6 mos postsurgery).

Setting: A university hospital.

Methods: We reviewed the records of all women who underwent LSG and delivered during 2006-2019.

Results: Of 196 women, 23 (11.7%) became pregnant within 6 months of surgery. For these women, the median surgery-to-conception interval was 116 [interquartile range 76-161] days, compared with 903 [465-1377] days for the remaining cohort. Three (13.0%) women turned out postoperatively to be pregnant at the time of LSG. Compared with women who conceived later, the extremely early pregnancy group had lower gestational weight gain (median 4 versus 10 kg, P < .001), including negative gestational weight gain in 9 (39.1%) women. The proportion of small for gestational age (SGA) infants was higher among women who conceived within 6 months after surgery rather than later (26.1% versus 10.4%, P = .04). Other maternal and perinatal outcomes were similar between the groups. In multivariate analysis, conceiving within 6 months after LSG was the only independent factor associated with delivering a SGA infant (odds ratio [95% confidence interval]: 3.35 (1.12, 10.01), P = .03).

Conclusions: Pregnancy occurring in the first 6 months after LSG was independently associated with a higher rate of SGA infants. Delaying conception during the very early postoperative period is recommended. Providing adequate contraception and excluding the presence of early pregnancy at the time of surgery are of utmost importance.
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http://dx.doi.org/10.1016/j.soard.2020.09.025DOI Listing
February 2021

Isolated oligohydramnios - should induction be offered after 36 weeks?

J Matern Fetal Neonatal Med 2020 Nov 29:1-6. Epub 2020 Nov 29.

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

Objective: Isolated oligohydramnios (IO) - oligohydramnios in the absence of maternal or gestational comorbidity is debated as an indication for induction of labor. Previous meta-analyses regarding perinatal outcomes of IO at term have yielded conflicting results. We aimed to investigate the neonatal outcomes among gestations with IO delivered at 36°-39.

Methods: The study cohort included all women undergoing a trial of labor between during 2011 and 2019 of a singleton gestation with cephalic presentation between 36° and 40°. We allocated the study groups into women with IO and those with normal amniotic fluid volume. Neonatal outcomes were compared between the groups and in relation to gestational age and induction of labor.

Results: Overall, there were 529/17,709 (3.0%) IO cases. IO was associated with maternal age <25 years (OR [95% CI] 1.62 (1.20-2.20),  = .001). Induction of labor was more common with IO (OR [95% CI] 1.33 (1.05-1.69)  = .01. IO was associated with preterm delivery (OR [95% CI] 1.81 (1.36-2.40),  < .001). The rate of neonatal adverse outcome did not differ between study groups. Overall composite adverse neonatal outcome occurred among 1,399/17,709 (7.9%) deliveries. Adverse neonatal outcome was associated with induction of labor (OR [95% CI] 1.61 (1.40-1.86),  < .001) and low birth weight (OR [95% CI] 7.41 (6.27-8.75),  < .001). When Stratified by gestational age, neonatal adverse outcome did not differ between IO and no IO groups. When examining cases of induction of labor per gestational age, induction of labor at 36 weeks among IO gestations, was associated with adverse neonatal outcome as compared to no IO group (OR [95% CI] 5.7 (1.23-26.3),  = .04).

Conclusions: Induction of labor in gestations complicated by IO at 36 weeks gestational age is associated with an increased risk for adverse neonatal outcome. Our study results adds to the current literature regarding outcomes of IO and time of delivery.

Synopsis: Induction of labor in gestations complicated by IO at 36 weeks gestational age is associated with an increased risk for adverse neonatal outcome.
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http://dx.doi.org/10.1080/14767058.2020.1852546DOI Listing
November 2020

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

Impact of the COVID-19 Outbreak on Routine Obstetrical Management.

Isr Med Assoc J 2020 Aug;22(8):483-488

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

Background: Channeling medical resources for coronavirus disease-2019 (COVID-19) management can potentially endanger routine healthcare practices. As a preventive measure, a department of obstetrics and gynecology in Israel constructed a separate, designated complex for its COVID-19-exposed patients.

Objectives: To evaluate the effect of the COVID-19 pandemic infection control measures on obstetric care in the obstetrical emergency department and delivery unit.

Methods: The authors collected data retrospectively from February 2020 to March 2020 and compared it to data of a parallel period in 2019.

Results: From 1 February 2020 to 28 March 2020, 3897 women were referred to the emergency department (ED), compared to 4067 the previous year. Mean duration of treatment until decision and referral indications did not differ between 2020 and 2019 (207 vs. 220 minutes, P = 0.26; urgent referrals 58.8% vs. 59.2%, P = 0.83). A per-week comparison showed a significant reduction in ED referrals only in the last week of the period (337 [2020] vs. 515 [2019], P < 0.001). The proportion of women admitted to the delivery unit in active labor was significantly higher in the last three weeks (39.1% vs. 28.2%, P = 0.005). During February and March 2020, 1666 women delivered, compared to 1654 during February and March 2019. The proportion of types and modes of delivery did not differ. In a per-week comparison, the number of deliveries did not differ (mean 208 vs. 206, P = 0.88).

Conclusions: With timely preparation and proper management, negative impact of COVID-19 can be reduced in obstetrical emergency departments.
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August 2020

Vaginal delivery in SARS-CoV-2-infected pregnant women in Israel: a multicenter prospective analysis.

Arch Gynecol Obstet 2020 Oct 29. Epub 2020 Oct 29.

Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.

Key Message: Among SARS-CoV-2-infected mothers, vaginal delivery rates were high and associated with favorable outcomes with no cases of neonatal COVID-19.

Purpose: To investigate the mode of delivery and its impact on immediate neonatal outcome in SARS-CoV-2-infected women.

Methods: A prospective study following pregnant women diagnosed with COVID-19 who delivered between March 15th and July 4th in seven university affiliated hospitals in Israel.

Results: A total of 52 women with a confirmed diagnosis of COVID-19 delivered in the participating centers during the study period. The median gestational age at the time of delivery was 38 weeks, with 16 (30.8%) cases complicated by spontaneous preterm birth. Forty-three women (82.7%) underwent a trial of labor. The remaining 9 women underwent pre-labor cesarean delivery mostly due to obstetric indications, whereas one woman with a critical COVID-19 course underwent urgent cesarean delivery due to maternal deterioration. Among those who underwent a trial of labor (n = 43), 39 (90.7%) delivered vaginally, whereas 4 (9.3%) cases resulted in cesarean delivery. Neonatal RT-PCR nasopharyngeal swabs tested negative in all cases, and none of the infants developed pneumonia. No maternal and neonatal deaths were encountered.

Conclusions: In this prospective study among SARS-CoV-2-infected mothers, vaginal delivery rates were high and associated with favorable outcomes with no cases of neonatal COVID-19. Our findings underscore that delivery management among SARS-CoV-2-infected mothers should be based on obstetric indications and may potentially reduce the high rates of cesarean delivery previously reported in this setting.
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http://dx.doi.org/10.1007/s00404-020-05854-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594971PMC
October 2020

Implementation of machine learning models for the prediction of vaginal birth after cesarean delivery.

J Matern Fetal Neonatal Med 2020 Oct 25:1-7. Epub 2020 Oct 25.

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

Objective: Accurate prediction of vaginal birth after cesarean is crucial for selecting women suitable for a trial of labor after cesarean (TOLAC). We sought to develop a machine learning (ML) model for prediction of TOLAC success and to compare its accuracy with that of the MFMU model.

Methods: All consecutive singleton TOLAC deliveries from a tertiary academic medical center between February 2017 and December 2018 were included. We developed models using the following ML algorithms: random forest (RF), regularized regression (GLM), and eXtreme gradient-boosted decision trees (XGBoost). For developing the ML models, we disaggregated BMI into height and weight. Similarly, we disaggregated prior arrest of progression into prior arrest of dilatation and prior arrest of descent. We applied a nested cross-validation approach, using 100 random splits of the data to training (80%, 792 samples) and testing sets (20%, 197 samples). We used the area under the precision-recall curve (AUC-PR) as a measure of accuracy.

Results: Nine hundred and eighty-nine TOLAC deliveries were included in the analysis with an observed TOLAC success rate of 85.6%. The AUC-PR in the RF, XGBoost and GLM models were 0.351 0.028, 0.350 0.028 and 0.336 0.024, respectively, compared to 0.325 0.067 for the MFMU-C. The algorithms performed significantly better than the MFMU-C (-values = .0002, .0004, .0393 for RF, XGBoost, GLM respectively). In the XGBoost model, eight variables were sufficient for accurate prediction. In all ML models, previous vaginal delivery and height were among the three most important predictors of TOLAC success. Prior arrest of descent contributed to prediction more than prior arrest of dilatation, maternal height contributed more than weight.

Conclusion: All ML models performed significantly better than the MFMU-C. In the XGBoost model, eight variables were sufficient for accurate prediction. Prior arrest of descent and maternal height contribute to prediction more than prior arrest of dilation and maternal weight.
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http://dx.doi.org/10.1080/14767058.2020.1837769DOI Listing
October 2020

A marked decrease in preterm deliveries during the coronavirus disease 2019 pandemic.

Am J Obstet Gynecol 2021 02 15;224(2):234-237. Epub 2020 Oct 15.

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

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http://dx.doi.org/10.1016/j.ajog.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7560113PMC
February 2021

The association between vacuum-assisted vaginal delivery and anal sphincter injury.

Int Urogynecol J 2020 Sep 30. Epub 2020 Sep 30.

The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Introduction: Vacuum-assisted vaginal delivery (VAVD) is considered a major risk factor for obstetric anal sphincter injuries (OASIS). However, it is difficult to estimate its true contribution to the occurrence of OASIS, as its performance may be confounded by other determinants. Therefore, we aimed to evaluate the association of VAVD with OASIS among primiparous women compared to SVD.

Methods: A retrospective cohort study including all primiparous women who vaginally delivered a cephalic singleton gestation during the years 2011 to 2020. As VAVDs were not performed before 34 gestational weeks, we capped the cohort at this gestational age. Women were allocated into two groups: VAVDs and spontaneous vaginal deliveries (SVD). We compared women with OASIS to those without and performed a multivariate analysis including factors that were found significant in the univariate analysis. We further divided the whole cohort into different subcategories. The primary outcome was the rate of OASIS in VAVD compared to SVD.

Results: Overall, 23,272 primiparous vaginal deliveries were available for evaluation. Of these, 3595 delivered by VAVD and 19,677 delivered spontaneously. OASIS occurred in 421 (1.8%) of the deliveries. OASIS were more common in VAVDs than in SVDs [83 (2.3%) vs. 338 (1.7%), respectively, OR (95% CI) 1.35 (1.06-1.72), p = 0.01]. After multivariate regression analysis, OASIS were not found to be independently associated with the mode of delivery [aOR 1.21 (95% CI) 0.88-1.68, P = 0.23]. In a categorical analysis of OASIS rates by risk factors and mode of delivery, VAVD was not associated with an increase in OASIS among women giving birth to neonates weighing > 3500 g compared to SVD [OR (95% CI) 1.02 (0.65-1.62), P = 0.90].

Conclusion: Among primiparous women VAVD did not increase the risk of OASIS compared to SVD.
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http://dx.doi.org/10.1007/s00192-020-04534-8DOI Listing
September 2020

Chorioamnionitis at latent phase more than doubles the risk for cesarean delivery compared to chorioamnionitis at active phase.

Arch Gynecol Obstet 2021 04 29;303(4):905-910. Epub 2020 Sep 29.

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

Purpose: Chorioamnionitis, or intraamniotic infection, is a common condition, carrying an increased risk of intrapartum cesarean delivery (CD). The morbidity related to chorioamnionitis is more common in those undergoing CD, as compared to those with successful vaginal delivery. We aimed to examine the risk factors associated with CD among women with chorioamnionitis.

Methods: A retrospective cohort study from a tertiary medical center. We included women at term carrying a singleton gestation with suspected chorioamnionitis undergoing a trial of labor between 2011 and 2019. The primary outcome was the mode of delivery.

Results: Data from 1436 women with chorioamnionitis were analyzed; 1288 (89.7%) were nulliparous. Overall, 1064 (74.1%) delivered vaginally, and 372 (25.9%) by CD. The rate of CD was significantly higher in nulliparous as compared to parous parturients (26.9% vs. 16.9%, P = 0.008), and in those with fever onset at latent phase as compared to those in whom fever appeared at active labor (≥ 6 cm) (47.0% vs. 18.1%, P < 0.001). In a multivariate analysis, CD was positively associated with: onset of fever at latent phase (aOR [95% CI] 4.75 (3.54, 6.32), P < 0.001), nulliparity (aOR [95% CI] 3.25 (1.98, 5.34), P < 0.001), maternal age (aOR [95% CI] 1.52 (1.10, 2.09), P = 0.01) and birth weight (aOR [95% CI] 1.23 (1.04, 1.44), P = 0.01).

Conclusion: Women with chorioamnionitis had a high rate of CD. Nulliparity and onset of fever prior to active labor were the strongest independent predictors of CD. It remains to be determined whether those deemed at high risk for failed trial of labor, should undergo CD earlier in the course of labor to improve chorioamnionitis-related outcomes.
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http://dx.doi.org/10.1007/s00404-020-05815-9DOI Listing
April 2021

Risk factors for obstetric anal sphincter injury among parous women.

Arch Gynecol Obstet 2021 03 25;303(3):709-714. Epub 2020 Sep 25.

The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: Nulliparity and operative vaginal delivery are established risk factor for obstetric anal sphincter injury (OASI). However, risk factors for OASIS occurrence among parous women delivering vaginally are not well-established. We aimed to study the risk factors for OASI occurrence among parous women.

Methods: A retrospective study including all parous women who delivered vaginally at term during 2011-2019 at a university hospital. Deliveries of parous women with OASI were compared to deliveries without OASI. The risk factors associated with OASI were investigated.

Results: Overall, 35,397 women were included in the study with an OASI rate of 0.4% (n = 144). A higher rate of only one previous vaginal delivery was noted in the OASI group (78.5% vs. 46.4%, OR [95% CI] 4.20, 2.82-6.25, p < 0.001). The rate of vacuum-assisted deliveries was comparable between the study groups. The median birth weight was higher among the OASI group (3566 vs. 3300 g, p < 0.001), as was the rate of macrosomic neonates (19.4% vs. 5.5%, OR [95% CI] 4.15, 2.74-6.29, p < 0.001). On multivariate logistic regression analysis, only two factors were independently positively associated with the occurrence of OASI: a history of only one previous vaginal delivery (adjusted OR [95% CI] 4.34, 2.90-6.49, p = 0.001), and neonatal birth-weight (for each 500 g increment) (adjusted OR [95% CI] 2.51, 1.84-3.44, p < 0.001).

Conclusions: Among parous women, the only factors found to be independently positively associated with OASI were the order of parity and neonatal birth-weight. Vacuum-assisted delivery was not associated with an increased risk of OASI among parous women.
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http://dx.doi.org/10.1007/s00404-020-05806-wDOI Listing
March 2021

Obstetric and Perinatal Outcomes in Pregnancies Conceived After Preimplantation Genetic Testing for Monogenetic Diseases.

Obstet Gynecol 2020 10;136(4):782-791

Department of Obstetrics and Gynecology and the Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer; The Sackler School of Medicine and the Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Tel Aviv University, Tel Aviv, Israel.

Objective: To investigate whether the addition of embryo biopsy performed during preimplantation genetic testing for monogenic diseases is associated with a higher risk of obstetric and neonatal complications compared with in vitro fertilization (IVF) without preimplantation genetic testing or spontaneously conceived pregnancies.

Methods: This is a cohort study of all pregnancies conceived after preimplantation genetic testing for monogenic diseases (PGT-M group) from 2006 to 2018 at Sheba Medical Center, Israel. The control groups included patients who had conceived spontaneously (spontaneous conception group) or by IVF without preimplantation genetic testing (IVF group) and delivered at Sheba Medical Center. The obstetrics outcomes were compared among the groups. Multivariable regression modeling was performed, focusing on the relationship between preimplantation genetic testing and adverse outcomes.

Results: Final analysis included 345 singleton and 76 twin deliveries in the PGT-M group. The spontaneous conception group included 5,290 singleton and 92 twin deliveries. The IVF group included 422 singleton and 101 twin deliveries. Among singleton pregnancies, patients in the PGT-M group had a higher rate of hypertensive disorders (6.9%) compared with those in the spontaneous conception group (2.3%; odds ratio [OR] 3.3; 95% CI 1.9-4.8; adjusted odds ratio [aOR] 14.8; 95% CI 7.4-29.8) and the IVF group (4.7%; OR 1.5; 95% CI 0.8-2.7; aOR 5.9; 95% CI 1.9-18.2). Likewise, patients in the PGT-M group had a higher rate of small-for-gestational age neonates (12.4%) compared with those in the spontaneous conception group (3.9%; OR 3.4; 95% CI 2.4-4.9; aOR 2.3; 95% CI 1.5-3.4) and the IVF group (4.5%; OR 3; 95% CI 1.7-5.2; aOR 2.5; 95% CI 1.7-5.2). Among twin pregnancies, patients in the PGT-M group also had an increased rate of hypertensive disorders compared with those in the spontaneous conception group (4.3%; OR 4.1; 95% CI 1.2-13.3; aOR 10.9; 95% CI 2.3-50) and the IVF group (4%; OR 4.5; 95% CI 1.4-14.7; aOR 3.7; 95% CI 1.1-12.8).

Conclusion: Pregnancies conceived after preimplantation genetic testing for monogenic disorders were associated with an increased risk of obstetric complications compared with pregnancies conceived spontaneously or by IVF without preimplantation genetic testing.
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http://dx.doi.org/10.1097/AOG.0000000000004062DOI Listing
October 2020

Risk of anal sphincter injury in trial of labor post cesarean section.

Acta Obstet Gynecol Scand 2021 01 26;100(1):147-153. Epub 2020 Sep 26.

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

Introduction: We wanted to evaluate whether secundiparas who achieved vaginal birth after cesarean (VBAC) were at an increased risk for obstetric anal sphincter injury (OASI) compared to primiparas who delivered vaginally, with a stratification by the mode of delivery-spontaneous or operative vaginal delivery.

Material And Methods: We conducted a retrospective cohort study of primiparous women who delivered by vacuum-assisted delivery between March 2011 and June 2019. Primiparas delivering vaginally and secundiparas undergoing VBAC were compared. The cohort was further stratified into two categories: spontaneous vaginal delivery and operative vaginal delivery.

Results: Overall, 23 822 primiparas who delivered vaginally and 1596 secundiparas who underwent VBAC were analyzed. Operative vaginal delivery was performed in 4561 deliveries. OASI rate did not differ between the VBAC and primipara groups (1.3% vs 1.8%, P = .142). A total of 20 857 women delivered by spontaneous vaginal delivery, among them 1180 (5.7%) women were secundiparas and 19 677 (94.3%) were primiparas. OASI rate was comparable between the secundiparas undergoing VBAC and primiparas delivering vaginally (17 [1.4%] vs 338 [1.7%], P = .436). A total of 4561 women delivered by operative vaginal delivery, among them 416 (9.1%) were secundiparas and 4145 (90.9%) were primiparas. The rate of operative vaginal deliveries was higher among the VBAC group compared with the primipara group (6.1% vs 17.4%, P < .001). However, women undergoing successful VBAC had lower rates of OASI compared with primiparas (3 [0.7%] vs 96 [2.3%]; odds ratio [OR] 0.30, 95% CI 0.09-0.97, P = .032). After multivariate logistic regression including all statistically significant factors, OASI was not associated with VBAC in spontaneous or operative vaginal deliveries (adjusted OR 0.85, 95% CI 0.51-1.40 and 0.39, 95% CI 0.12-1.28, respectively).

Conclusions: Secundiparas undergoing VBAC were not at a higher risk of OASI when compared with primiparas delivering vaginally, either in spontaneous or operative vaginal deliveries. This information might aid when counseling women contemplating a trial of labor after cesarean--to address their concerns regarding the risks and benefits of VBAC.
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http://dx.doi.org/10.1111/aogs.13977DOI Listing
January 2021

Management of labor after external cephalic version.

J Perinat Med 2020 Aug 18;49(1):30-35. Epub 2020 Aug 18.

Department of Obstetrics and Gynecology, Meuhedet HMO, Jerusalem, Israel.

Objectives: Current literature evaluating the role of induction of labor (IOL) following successful external cephalic version (ECV) attempt as compared to expectant management is limited. We aim to assess the risk of cesarean delivery in those undergoing immediate IOL following successful ECV as compared to those who were expectantly managed.

Methods: A retrospective cohort study of successful external cephalic versions. The study group included 57 women that were induced after procedure in the lack of maternal or fetal indications for induction of labor. These women were compared to 341 expectantly managed women. Maternal and fetal characteristics and outcomes were compared.

Results: Gestation age at delivery was higher among the expectant management group (401/7 vs. 384/7, median, p=0.002) as compared to the induction group. Cesarean delivery rates were similar between both groups (28 [8.2%] vs. 3 [5.3%], p=0.44). In a multivariate logistic regression analysis, only nulliparity was significantly associated with cesarean delivery (adjusted odds ratio 3.42, confidence interval 1.61-7.24, p=0.001). No correlation was found between the version-to-delivery interval and the risk for cesarean delivery.

Conclusions: Induction of labor after successful ECV was not shown to influence cesarean delivery rates. As immediate IOL may result in higher rate of early-term deliveries, and in light of the lack of clinical benefit, we advocate against elective IOL following successful ECV.
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http://dx.doi.org/10.1515/jpm-2020-0290DOI Listing
August 2020