Publications by authors named "Yoav Yinon"

92 Publications

Selective Reduction in Complicated Monochorionic Pregnancies: A Systematic Review and Meta-analysis of Different Techniques.

Am J Obstet Gynecol 2021 Oct 19. Epub 2021 Oct 19.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA. Electronic address:

Objective: This systematic review and meta-analysis aims to compare the perinatal outcomes of complicated monochorionic (MC) pregnancies after selective reduction by radiofrequency ablation (RFA), bipolar cord coagulation (BCC) and interstitial laser (IL).

Data Sources: We searched PubMed, Scopus, and Web of Science, from inception of the database until 26 April 2021.

Study Eligibility Criteria: Studies comparing at least two of selective reduction techniques among complicated MC pregnancies and presenting data on perinatal outcomes including gestational age (GA) at procedure, GA at delivery, procedure to delivery interval, preterm premature rupture of the membranes (PPROM), preterm birth (PTB), survival rate and birth weight were eligible.

Study Appraisal And Synthesis Methods: The random-effect model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I value.

Results: Ten studies with 734 cases of fetal reduction met the inclusion criteria, of which 9 studies with 674 fetuses were eligible for quantitative synthesis. Comparing RFA vs BCC (n=8 studies): RFA was associated with increased procedure to delivery interval (days) (mean difference 13.42, 95% CI 1.90, 24.94, P 0.02; I2 0.0%), decreased PTB (OR 0.50, 95% CI 0.29, 0.85, P 0.01; I2 3.0%) and decreased PPROM (OR 0.45, 95% CI 0.27, 0.73, P 0.001; I2 0.0%). RFA and BCC had comparable survival rates (OR 0.85, 95% CI 0.54, 1.35, P 0.49; I 0.0%). RFA vs IL (n=3 studies): There was no significant difference in GA at delivery (P 0.07) or survival (P 0.15). BCC vs IL (n=3 studies): BCC was associated with a higher survival rate (OR 3.21, 95% CI 1.13, 9.10, P 0.03; I2 0.0%), but GA at delivery was comparable between groups (P 0.16).

Conclusion: This study demonstrates that RFA has a greater procedure to delivery interval and decreased PPROM and PTB compared to BCC. Although there was no difference in GA at delivery for either BCC, RFA or IL, survival was higher with BCC compared to IL.
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http://dx.doi.org/10.1016/j.ajog.2021.10.018DOI Listing
October 2021

Fetal and Neonatal Brain Lesions Following Laser Ablation for Twin-to-Twin-Transfusion-Syndrome as Detected by Pre- and Post-Natal Brain Imaging.

Prenat Diagn 2021 Oct 20. Epub 2021 Oct 20.

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

Objective: To determine the rate of and risk factors for fetal and neonatal brain lesions following laser ablation for twin-to-twin transfusion syndrome (TTTS).

Methods: A retrospective cohort study of 83 women with monochorionic twin pregnancies who underwent ablation for TTTS at a single tertiary hospital. Post-laser survivors were followed-up with fetal neurosonogram every 2 weeks and fetal brain MRI at 28-32 weeks of gestation; post-natal brain imaging included neurosonogram. Cases with pre- and post-natal brain lesions were compared to those without.

Results: 153 fetuses survived the immediate post-laser period and underwent brain imaging. Of these, 17 (11.11%) exhibited brain lesions on prenatal imaging studies, and 36 (32.4%) on post-natal ultrasound. Later gestational age (GA) at the time of ablation (23.0 weeks vs. 21.4 weeks, p=0.0244), post-laser TAPS (29.41% vs. 9.56%, p=0.035) and birthweight discordancy (30% vs 9%, p=0.0025) were associated with prenatal brain lesions. Earlier GA at delivery (31.0 weeks vs. 32.2, p=0.0002) and post-laser TAPS (25% vs. 9.33%, p=0.038) were associated with post-natal brain lesions.

Conclusions: Survivors of ablation for TTTS are at risk for brain lesions, which can be detected prenatally. Incorporation of neurosonogram and fetal brain MRI into the routine surveillance of such pregnancies should be considered. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1002/pd.6061DOI Listing
October 2021

Labor induction in twin pregnancies: Does the perinatal outcome differ according to chorionicity?

Arch Gynecol Obstet 2021 Oct 2. Epub 2021 Oct 2.

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

Objective: To compare perinatal outcomes following induction of labor in dichorionic versus monochorionic twin pregnancies.

Study Design: A retrospective cohort study analyzing all women with twin pregnancies who underwent induction of labor in a single university-affiliated tertiary medical center. The cohort included 290 women who were divided into 2 groups according to chorionicity: (1) dichorionic twin pregnancies (n = 203); (2) monochorionic twin pregnancies (n = 87). Induction of labor methods included oxytocin infusion, extra-amniotic balloon catheter and artificial amniotomy. Primary outcome was defined as mode of delivery. Secondary outcomes included maternal and neonatal adverse events.

Results: Primary outcome did not differ between groups, with vaginal delivery rate of 92.1% in the dichorionic group and 94.2% in the monochorionic group. Women with dichorionic twins delivered later compared to monochorionic twins (38.00 weeks vs. 36.43 weeks, respectively, p < 0.001). While no differences were observed in Apgar scores or umbilical cord pH measurements, dichorionic twins were less frequently admitted to the neonatal intensive care unit compared to monochorionic twins (2.4% vs. 3.4%, p = 0.01 for 1st twin; and 6.9% vs. 10.3%, p = 0.089 for 2nd twin). Multivariate logistic regression adjusting outcomes to potential confounders, found gestational age at delivery to be the only variable significantly associated with neonatal intensive care unit admission rates (odds ratio 0.236, 95% confidence interval 0.152-0.366, p < 0.001).

Conclusion: Labor induction might be considered for both di- and monochorionic uncomplicated twin pregnancies with excellent vaginal delivery rates. The higher rates of neonatal adverse outcomes among monochorionic twins are presumably related to earlier gestation age at delivery.
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http://dx.doi.org/10.1007/s00404-021-06272-8DOI Listing
October 2021

In-utero treatment of prenatal thoracic abnormalities by thoraco-amniotic shunts, short and long term neuro developmental outcome: A single center experience.

J Pediatr Surg 2021 Sep 4. Epub 2021 Sep 4.

The institute of obstetrical and gynaecological imaging, Department Obstetrics and Gynecology, The Chaim Sheba Medical Center at Tel Hashomer, Tel-Aviv University, Ramat Gan, 5262000, Israel; Sackler School of Medicine, Tel Aviv University, Israel. Electronic address:

Background: Severe primary fetal hydrothorax (PFH) and fetal lung lesions (FLL) such as congenital pulmonary airway malformation (CPAM) and Bronchopulmonary sequestration (BPS) are often treated by thoraco-amniotic shunt (TAS).

Objectives: To compare short and long-term outcome of fetuses treated by TAS due to FLL to those treated due to PFH.

Method: A retrospective analysis was performed for all fetuses treated by TAS, between the years 2004-2015, evaluating the short and long term neurodevelopmental outcome. Long term neurodevelopment was additionally analyzed prospectively by Vineland adaptive behavioral scale (VABS) standardized questionnaires.

Results: 38 fetuses were treated by 52 TAS insertions; of which 13 (35%) due to FLL and 25 due to PFH. Perinatal survival was high (87.9%) with 3 neonatal death and one termination of pregnancy (TOP). High survival rate persisted even in cases requiring recurrent shunt insertion (80% survival). There was no significant difference in short or long term outcome including perinatal survival (84% Vs 90%, P = 0.64) and hydrops resolution (91% Vs 63%, p = 0.19). Long term outcome, including rate of neurodevelopmental abnormalities (23.5% Vs 20%) and VABS score (91.3 ± 13.3 Vs 96.4 ± 14.7), were similar for both groups.

Conclusion: TAS insertion is effective and resulting in high perinatal survival even in cases when sequential insertion is needed. Short and long- term outcome of neonates with FLL treated by TAS are comparable to neonates treated due to PFH.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.08.019DOI Listing
September 2021

Maternal-neonatal transfer of SARS-CoV-2 immunoglobulin G antibodies among parturient women treated with BNT162b2 messenger RNA vaccine during pregnancy.

Am J Obstet Gynecol MFM 2021 Sep 20;4(1):100492. Epub 2021 Sep 20.

Department of Obstetrics and Gynecology, Sheba Medical Center, Tel HaShomer, Israel (Drs Nir, Schwartz, Toussia-Cohen, and Yinon); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon). Electronic address:

Background: The exclusion of pregnant women from initial COVID-19 messenger RNA vaccine trials raised hesitancy regarding the benefits of vaccination for pregnant women, hence little is known about vaccines' efficacy in this population.

Objective: To determine the maternal-neonatal transplacental transfer of SARS-CoV-2 antibodies among vaccinated parturient women. A control group of COVID-19-recovered patients was included to compare the immunoglobulin G levels between vaccinated and recovered patients.

Study Design: This is a prospective cohort study conducted in a single tertiary medical center in Israel between February and March 2021; parturient women vaccinated with the BNT162b2 messenger RNA vaccine during pregnancy were included and compared with COVID-19-recovered parturient women. SARS-CoV-2 immunoglobulin G antibodies were measured in maternal and cord sera, dried blood spot samples taken from newborns, and breast milk samples. The primary aim was to determine whether neonatal cord and dried blood spot samples were positive for SARS-CoV-2 antibodies and to evaluate the transfer ratio, defined as cord blood immunoglobulin G divided by maternal immunoglobulin G levels.

Results: The study included 64 vaccinated parturient women and 11 parturient women who had COVID-19 during pregnancy. All maternal blood sera samples and 98.3% of the cord blood sera samples were positive for SARS-Cov-2 immunoglobulin G with median concentrations of 26.1 (interquartile range, 22.0-39.7) and 20.2 (interquartile range, 12.7-29.0), respectively. Similarly, 96.4% of neonatal blood spot samples and all breast milk samples were positive for SARS-CoV-2 immunoglobulin G with median concentrations of 11.0 (interquartile range, 7.2-12.8) and 4.9 (interquartile range, 3.8-6.0), respectively. There was a significant positive correlation between maternal serum levels of SARS-CoV-2 immunoglobulin G and cord blood (r=0.483; P=.0001), neonatal blood spot (r=0.515; P=.004), and breast milk levels (r=0.396; P=.005) of SARS-CoV-2 immunoglobulin G. The median placental transfer ratio of SARS-COV-2 immunoglobulin G was 0.77. Comparison of vaccinated and recovered COVID-19 patients revealed significantly higher SARS-CoV-2 immunoglobulin G levels in maternal serum and cord blood among vaccinated women (P<.0001).

Conclusion: Our study demonstrated the efficient transfer of SARS-CoV-2 immunoglobulin G across the placenta in women, vaccinated with the BNT162b2 messenger RNA vaccine during pregnancy, to their neonates, with a positive correlation between maternal serum and cord blood antibody concentrations. In addition to maternal protection against COVID-19, the vaccine may also provide neonatal humoral immunity.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451978PMC
September 2021

Vaginal birth after cesarean in women with no prior vaginal delivery carrying a large for gestational age baby.

Birth 2021 Sep 17. Epub 2021 Sep 17.

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

Background: To study the factors associated with successful labor after cesarean (LAC) among women with no prior vaginal delivery, delivering a large for gestational age (LGA) baby.

Methods: A retrospective case-control study at two tertiary medical centers in Israel, including all women undergoing LAC with no prior vaginal delivery during 2010-2020, delivering a singleton LGA newborn. Factors associated with successful vaginal delivery were examined by a multivariable analysis.

Results: Overall, 323/505 (64.0%) had a successful LAC. Arrest of labor as the indication for previous CD was less common in the LAC success group [39 (12.1%) vs. 58 (31.9%), P < .001]. The rate of epidural analgesia was higher in the LAC success group [249 (77.1%) vs. 122 (67.0%), P = .014]. The rate of weight centile ≥97th was lower in the LAC success group [64 (19.8%) vs. 51 (28.0%), P = .035], as well as the rate of higher LAC birthweight than previous cesarean birthweight [264 (81.7%) vs. 162 (89.0%), P = .030]. In a multivariable logistic regression analysis, maternal height (aOR [95% CI]:1.09 (1.01, 1.17), P = .014) and epidural anesthesia (aOR [95% CI]:3.68 (1.31, 10.32), P = .013) were the only independent factors associated with LAC success.

Conclusions: Among primiparous women undergoing LAC carrying LGA newborns, the vaginal delivery rate is acceptable; however, uterine rupture risk is increased. Epidural administration is a modifiable factor and should be taken into consideration during LAC management.
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http://dx.doi.org/10.1111/birt.12590DOI Listing
September 2021

Presence of SARS-CoV-2 antibodies in lactating women and their infants following BNT162b2 messenger RNA vaccine.

Am J Obstet Gynecol 2021 Aug 2. Epub 2021 Aug 2.

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

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http://dx.doi.org/10.1016/j.ajog.2021.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327579PMC
August 2021

Trial of Labor After Cesarean of Small for Gestational Age Neonates Among Women with No Prior Vaginal Delivery - a Retrospective Study.

Reprod Sci 2021 Jul 21. Epub 2021 Jul 21.

Department of Gynecologic Oncology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.

To evaluate the characteristics and outcomes of women who had never delivered vaginally and underwent a trial of labor after cesarean (TOLAC) of small for gestational age (SGA) neonates, and to identify risk factors for unplanned repeat cesarean delivery. A retrospective cohort study from two tertiary medical centers. All women undergoing a TOLAC with no prior vaginal delivery, delivering a singleton SGA neonate at term between 2005 and 2020 were included. Factors associated with successful vaginal delivery were examined by a multivariable analysis. Of the 255 women who met the inclusion criteria and underwent TOLAC, 72.2% delivered vaginally. In a multivariable analysis, maternal height [adjusted odds ratio (aOR) (95% CI): 1.10 (1.02-1.19), p = 0.012] and epidural administration [aOR (95% CI): 2.78 (1.0-7.73), p = 0.050] were positively independently associated with TOLAC success, and hypertensive disorders were negatively independently associated with TOLAC success [aOR (95% CI): 0.52 (0.004-0.74), p = 0.029]. The success rate of TOLAC among women with no prior vaginal delivery, delivering a SGA neonate is relatively high. Maternal height, hypertensive disorders, and epidural administration are independent factors associated with TOLAC success. Epidural administration is a modifiable factor and should be taken in consideration during TOLAC management.
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http://dx.doi.org/10.1007/s43032-021-00697-xDOI Listing
July 2021

Do Serial Sonographic Assessments of Fetuses with Isolated Congenital Diaphragmatic Hernia Help Us Predict Survival?

Fetal Diagn Ther 2021 9;48(6):421-429. Epub 2021 Jul 9.

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

Objective: The aim of this study was to assess the ability of serial prenatal sonographic measurements, and specifically changes in the observed-to-expected lung-to-head ratio (O/E LHR) throughout gestation and to predict survival in congenital diaphragmatic hernia (CDH).

Methods: Retrospective study of CDH fetuses evaluated prenatally and treated postnatally in a single tertiary center, 2008-2020. Sonographic evaluations included side of herniation, liver involvement, and O/E LHR. All data were calculated to assess ability to predict survival.

Results: Overall, 94 fetuses were evaluated prenatally and delivered in our medical center. Among them, 75 had isolated CDH and 19 nonisolated. CDH was categorized as left (n = 76; 80.8%), right (n = 16; 17.0%), or bilateral (n = 2; 2.2%). Overall perinatal survival rate was 57% for all live-born infants, 68% in isolated CDH, and 40% in nonisolated (excluding 2 cases that underwent fetoscopic endoluminal tracheal occlusion and did not survive). The O/E LHR was lower in cases with perinatal death compared to survivors. In cases with multiple evaluations, the minimal O/E LHR was the most accurate predictor of survival and need for perinatal extracorporeal membrane oxygenation (ECMO) support. This remained significant when excluding twin pregnancies or when evaluating only isolated left CDH. In addition to disease severity, the side of herniation and liver position was associated with preoperative mortality.

Conclusion: O/E LHR is associated with perinatal survival. In cases with multiple evaluations, the minimal O/E LHR is the most accurate and significant predictor of perinatal mortality and need for ECMO support.
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http://dx.doi.org/10.1159/000515693DOI Listing
July 2021

Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium.

Am J Obstet Gynecol 2021 Jun 3. Epub 2021 Jun 3.

Fetal Medicine Foundation, London, United Kingdom.

Background: The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child.

Objective: This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair.

Study Design: All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at <30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry.

Results: There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P<.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P<.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P<.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study.

Conclusion: Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.
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http://dx.doi.org/10.1016/j.ajog.2021.05.044DOI Listing
June 2021

Fetal and Perinatal Outcome Following First and Second Trimester COVID-19 Infection: Evidence from a Prospective Cohort Study.

J Clin Med 2021 May 16;10(10). Epub 2021 May 16.

Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer 5262000, Israel.

A novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new strain of coronavirus causing coronavirus disease 2019 (COVID-19) disease, which emerged as a global pandemic. Data regarding the implications of COVID-19 disease at early gestation on fetal and obstetric outcomes is scarce. Thus, our aim was to investigate the effect of first and second trimester maternal COVID-19 disease on fetal and perinatal outcomes. This was a prospective cohort study of pregnant women with a laboratory-proven SARS-COV-2 infection contracted prior to 26 weeks gestation. Women were followed at a single tertiary medical center by serial sonographic examinations every 4-6 weeks to assess fetal well-being, growth, placental function, anatomic evaluation and signs of fetal infection. Amniocentesis was offered to assess amniotic fluid SARS-COV-2-PCR (polymerase chain reaction) and fetal brain magnetic resonance imaging (MRI) was offered at 30-32 weeks gestation. Demographic, obstetric and neonatal data were collected from history intake, medical charts or by telephone survey. Perinatal outcomes were compared between women infected at first vs. second trimester. 55 women with documented COVID-19 disease at early gestation were included and followed at our center. The mean maternal age was 29.6 ± 6.2 years and the mean gestational age at viral infection was 14.2 ± 6.7 weeks with 28 (51%) women infected at the first trimester and 27 (49%) at the second trimester. All patients but one experienced asymptomatic to mild symptoms. Of 22 patients who underwent amniocentesis, none had evidence of vertical transmission. None of the fetuses exhibited signs of central nervous system (CNS) disease, growth restriction and placental dysfunction on serial ultrasound examinations and fetal MRI. Pregnancies resulted in perinatal survival of 100% to date with mean gestational age at delivery of 38.6 ± 3.0 weeks and preterm birth <37 weeks rate of 3.4%. The mean birthweight was 3260 ± 411 g with no cases of small for gestational age infants. The obstetric and neonatal outcomes were similar among first vs. second trimester infection groups. We conclude SARS-CoV-2 infection at early gestation was not associated with vertical transmission and resulted in favorable obstetric and neonatal outcomes.
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http://dx.doi.org/10.3390/jcm10102152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156528PMC
May 2021

Is endothelial function impaired among women with placenta-mediated fetal growth restriction? Evidence from a prospective cohort study using peripheral artery tonometry.

Placenta 2021 06 27;109:32-36. Epub 2021 Apr 27.

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

Introduction: Women with pregnancies complicated by IUGR are at increased risk for future cardiovascular disease. Nevertheless, it is unknown whether endothelial function of women with pregnancies complicated by IUGR is already impaired during pregnancy. Hence, we evaluated maternal endothelial function in pregnancies complicated by IUGR due to placental dysfunction.

Methods: Prospective cohort study assessing systemic endothelial function of women with singleton pregnancies and estimated fetal weight (EFW) below 10th percentile and abnormal umbilical artery flow (n = 15). Control group included women with singleton pregnancies and normal EFW (n = 22). Endothelial function was assessed using EndoPAT™ device which evaluates the change in peripheral vascular tone in reaction to temporal ischemia, a process called reactive hyperemia. The ratio of the readings before and after ischemia is used to assess endothelial function and called reactive hyperemia index (RHI). Low RHI values indicate endothelial dysfunction.

Results: The median gestational age at endoPAT examination was comparable between the IUGR and control groups (32; IQR 31,33; p = 0.18). The median RHI was significantly lower in the IUGR group compared to the control group (1.3 vs 1.5, p = 0.02). Median gestational age at delivery and mean neonatal birth weight were lower in the IUGR group compared to the control group (36.7 (35.6,37.2) vs 37.7 (35.3, 39.3), p = 0.04 and 1647 ± 414 g vs 2785 ± 587 g, p < 0.001).

Discussion-: Pregnant women with IUGR due to placental dysfunction are characterized by impaired systemic endothelial function.
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http://dx.doi.org/10.1016/j.placenta.2021.04.013DOI Listing
June 2021

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis.

Lancet Gastroenterol Hepatol 2021 07 27;6(7):547-558. Epub 2021 Apr 27.

Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.

Background: Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes.

Methods: In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 μmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495.

Findings: The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016).

Interpretation: Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment.

Funding: Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.
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http://dx.doi.org/10.1016/S2468-1253(21)00074-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192305PMC
July 2021

Hematologic adaptation to mask-wearing among pregnant women and obstetrical outcome during the coronavirus disease 2019 pandemic.

Int J Gynaecol Obstet 2021 Aug 12;154(2):297-303. Epub 2021 May 12.

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

Objective: To evaluate the effect of the coronavirus disease 2019 (COVID-19) mask-wearing on hematological laboratory components and obstetrical outcomes among women delivering during the COVID-19 pandemic.

Methods: Laboratory results and obstetrical outcomes of women with singleton gestations, admitted for delivery during the COVID-19 mask-wearing period (April-June 2020) were compared with those of women delivering during the parallel period in 2019 and with a larger cohort derived from nine pre-pandemic years (March 2011-April 2020).

Results: Overall, 1838 women delivered during the COVID-19 pandemic. Compared with the pre-pandemic period, mean hemoglobin and fibrinogen levels were significantly higher during the mask-wearing period (12.15 ± 1.1 vs 11.96 ± 1.2, P < 0.001 and 472 ± 103.6 vs 448 ± 85.1 mg/dl, P < 0.001, respectively). Platelet levels were lower (200 ± 56.0 vs 206 ± 57.5 K/µl, P < 0.001). The rate of delivery at <34 weeks of gestation was lower during the mask-wearing period (1.1% vs 2%, odds ratio [OR] 0.57, 95% confidence intervals [CI] 0.37-0.88, P = 0.01), whereas cesarean delivery and postpartum hemorrhage rates were higher (26.7% vs 24.4%, OR 1.13, 95% CI 1.02-1.25, P = 0.022 and 4.1% vs 2.8%, OR 1.5, 95% CI 1.2-1.8, P = 0.001, respectively).

Conclusion: A hard-to-ventilate space created by wearing a mask during the COVID-19 era may be the underlying cause of the observed higher hemoglobin level among pregnant women, possibly affecting obstetrical outcomes.
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http://dx.doi.org/10.1002/ijgo.13715DOI Listing
August 2021

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

J Gynecol Obstet Hum Reprod 2021 Oct 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
October 2021

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.

Int J Gynaecol Obstet 2021 03;152 Suppl 1:3-57

Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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http://dx.doi.org/10.1002/ijgo.13522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252743PMC
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

Abnormal nuchal translucency followed by normal microarray analysis is associated with placental pathology-related complications.

Prenat Diagn 2021 Jun 25;41(7):855-860. Epub 2021 Jan 25.

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

Objective: Identify placental pathology-related complications, labor and neonatal outcomes in pregnancies complicated by pathological nuchal translucency (NT) with normal microarray analysis.

Methods: A retrospective study in which all women with singleton pregnancy who demonstrated NT above 3 mm and a normal microarray analysis were matched to women with normal NT and a normal microarray analysis (2013-2019) in a single tertiary academic center. The following placental pathology-related parameters were measured: preeclampsia, oligohydramnios, suspected intrauterine growth restriction, abnormal Doppler studies or small for gestational age (SGA) neonates. The primary outcome was defined as a composite of complications related to placental pathology including preeclampsia and SGA neonate. Secondary outcomes were labor complications and neonatal morbidity.

Results: A total of 185 women were included in the study: of them, 47 presented an abnormal NT (study group) and 138 presented normal NT (controls). Groups did not significantly differ in baseline characteristics. Regarding primary outcome, all placental-related complications frequencies were higher in the study group, with a composite rate of 17.02% versus 6.52% in controls (p = 0.042%). Secondary outcomes did not differ between groups.

Conclusions: Abnormal NT measurement presented in pregnancies with normal fetal microarray analysis is associated with higher rates of placental-related complications.
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http://dx.doi.org/10.1002/pd.5896DOI Listing
June 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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http://dx.doi.org/10.1097/AOG.0000000000004202DOI Listing
January 2021

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

Arch Gynecol Obstet 2021 06 29;303(6):1401-1405. 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
June 2021

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 Effect of Ovarian Stimulation on Endothelial Function-A Prospective Cohort Study using Peripheral Artery Tonometry.

J Clin Endocrinol Metab 2020 12;105(12)

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

Context: Gonadotropin-releasing hormone agonist (GnRH-a) serves as an alternative to human chorionic gonadotropin (hCG) to trigger final oocyte maturation, while it significantly reduces the risk of ovarian hyperstimulation syndrome (OHSS), probably by attenuating vascular/endothelial activation.

Objectives: The objectives of this work are to compare the effect of different modes of final follicular maturation (hCG vs GnRH-a) following ovarian stimulation (OS) for in vitro fertilization (IVF) on endothelial function.

Design And Setting: A prospective cohort study was conducted at a tertiary medical center.

Participants: Patients age 37 years or younger, undergoing OS for IVF, were allocated into 2 groups according to the type of final follicle maturation: the hCG group (n = 7) or the GnRH-a group (n = 8).

Intervention: Endothelial function was assessed by measurement of the peripheral arterial tonometry in reaction to temporary ischemia at 3 study points: day 3 of menstrual cycle (day 0), day of hCG/GnRH-a administration (day trigger) and day of oocyte pick-up (day OPU). The ratio of arterial tonometry readings before and after ischemia is called the reactive hyperemia index (RHI). Decreased RHI (< 1.67) indicates endothelial dysfunction.

Main Outcome Measures: The main outcomes measures of this study included endothelial function at 3 study points during OS with different modes of triggering final follicular maturation.

Results: The mean RHI values at day 0 were within the normal range for all patients and comparable between both groups (hCG: 1.7 ± 0.3 vs GnRH-a: 1.79 ± 0.4, P = .6). All patients presented a decrease in RHI values on day trigger, which did not differ between the 2 groups (1.62 ± 0.3 vs 1.4 ± 0.2, respectively, P = .2). However, the hCG group demonstrated a further decrease in RHI on day OPU, whereas patients who received GnRH-a had restored normal endothelial function reflected by increased RHI values (1.4 ± 0.2 vs 1.75 ± 0.2, respectively, P = .03).

Conclusions: Triggering final follicular maturation with GnRH-a restored normal endothelial function, whereas hCG trigger resulted in a decrease in endothelial function.
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http://dx.doi.org/10.1210/clinem/dgaa681DOI Listing
December 2020

Does antenatal steroids treatment in twin pregnancies prior to late preterm birth reduce neonatal morbidity? Evidence from a retrospective cohort study.

Arch Gynecol Obstet 2020 11 29;302(5):1121-1126. Epub 2020 Jul 29.

Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, affiliated with the Sackler School of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel.

Purpose: To evaluate whether antenatal corticosteroids (ACS) administration during the late-preterm (LPT) period in twin pregnancies is associated with decreased rate of neonatal morbidity.

Methods: A retrospective cohort study including a total of 290 women with twin pregnancies resulting in live births of 580 neonates who delivered during LPT period between 2016 and 2018 at a tertiary medical center. Patients were allocated into two groups according to ACS exposure. Obstetric and neonatal outcomes were compared between the groups. Primary outcome was neonatal composite respiratory morbidity, defined as the occurrence of at least one of the followings: RDS, TTN, O2 requirement, CPAP use or mechanical ventilation.

Results: Patients exposed to ACS were older and more commonly complicated by gestational diabetes compared to the non-exposed group. Moreover, women exposed to ACS delivered earlier (35.6 vs. 36.3 weeks, P < 0.001) and more frequently by cesarean section (76.4% vs. 54.1%, P = 0.002) compared to the non-exposed group. The rate of composite respiratory morbidity did not differ between the groups. Nevertheless, neonates exposed to ACS had higher rates of neonatal intensive care unit (NICU) admission and hypoglycemia compared to neonates without prior ACS exposure (27.8% vs. 11.7%, P = 0.001; 49.3% vs. 27.1%, P < 0.001, respectively). Multivariable logistic regression revealed that gestational age at delivery was the sole independent risk factor for NICU admission, whereas late-preterm ACS exposure was the only risk factor for hypoglycemia.

Conclusion: LPT-ACS administration in twin pregnancies complicated by LPT birth in our study did not reduce neonatal respiratory morbidity but was associated with higher rates of hypoglycaemia.
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http://dx.doi.org/10.1007/s00404-020-05709-wDOI Listing
November 2020

Outcome of two sequential singleton pregnancies and twin pregnancies among primiparous women at advanced age undergoing IVF.

Arch Gynecol Obstet 2020 11 18;302(5):1113-1119. Epub 2020 Jul 18.

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

Purpose: To compare the obstetrical and detailed neonatal outcomes of primipara of advanced maternal age conceiving two sequential singleton pregnancies by IVF with those of primipara conceiving twins by IVF.

Methods: A retrospective study of all primiparous women aged ≤ 38 years and conceived by IVF who delivered sequential singletons or delivered twins at a single tertiary university affiliated medical center between 2011 and 2019. We performed two main comparisons: 1. First vs. second singleton pregnancies. 2. Two singleton pregnancies vs. twin pregnancies.

Results: Overall, there were 63 women with consecutive singleton IVF pregnancies. The median age was 40.0 at first pregnancy and 42.0 in the second pregnancy. Pregnancy and delivery complications rates did not differ significantly between the first and the second singleton pregnancies, including gestational hypertensive disorders (7 (11.1%) vs. 4 (6.3%), p = 0.530), gestational diabetes mellitus (13 (20.6%) vs 18 (28.5%), p = 0.410), intrauterine growth restriction (6 (9.5%) vs. 4 (6.3%), p = 0.744), or cesarean delivery (25 (39.7%) vs. 29 (46%), p = 0.589). Rates of delivery before 32 weeks gestation were similar for both first and second singleton pregnancies (1.6%, p > 0.999). The proportion of neonatal adverse outcome in both first and second singleton pregnancies groups was low and did not differ between the groups. Compared with women who delivered sequential singletons, women with twin pregnancies had significantly higher cesarean delivery rates (113 (83.7%) vs. 29 (46%), p < 0.001) and lower gestational ages at delivery (36.2 vs. 38.4, p < 0.001) than women with two singleton deliveries. Adverse neonatal outcomes were significantly higher for twin pregnancies, including birthweight < 1500 g (17 (12.6%) vs. 2 (3.2%), p = 0.036), neonatal intensive care unit admission (57 (42.2%) vs. 4 (6.3%), p < 0.001), neonatal hypoglycemia (23 (17%) vs. 3 (4.8%), p = 0.017), and respiratory distress syndrome (14 (10.4%) vs. 1 (1.6%), p = 0.040). Length of neonatal hospitalization was significantly longer for twins (9 vs. 5 days, p < 0.001). The rate of gestational hypertensive disorders (preeclampsia and gestational hypertension) was similar between the groups, but the rates of severe preeclampsia trended higher among women who carried twins (8 (5.9%) vs. 0, p = 0.057).

Conclusions: Sequential singleton pregnancies at primipara women of advanced maternal age have an overall very good outcome, with no clinically significant difference between the pregnancies. In addition, their outcome is much better compared with twins.
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http://dx.doi.org/10.1007/s00404-020-05700-5DOI Listing
November 2020

Esophageal atresia in twins compared to singletons: In utero manifestation and characteristics.

Prenat Diagn 2020 10 5;40(11):1418-1425. Epub 2020 Aug 5.

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

Objective: Esophageal atresia with/without tracheo-esophageal fistula (EA/TEF) is more common among twins. The detection of polyhydramnios might be altered in twins, leading to EA/TEF underdiagnosis, prenatally. The aim of the study was to compare the prenatal manifestation of EA/TEF between twins and singletons.

Methods: A 12-year study of EA/TEF cases was performed at a tertiary center. Cases exhibiting (a) small/absent stomach or (b) polyhydramnios were considered "suspected"; cases with (c) esophageal pouch were considered "detected." We compared the rate and timing of appearance of these signs between the groups.

Results: There were 76 cases of EA/TEF, of which 17 were a co-twin. All twin pairs were EA/TEF discordant. The prevalence of EA/TEF at our center was 1:750 for twins (1:319 monochorionic and 1:1133 dichorionic) and 1:2399 for singletons. The rate of small/absent stomach, polyhydramnios and pouch in twins vs singletons was 23.5%, 47.1%, 29.4% and 39.7%, 72.4%,34.5%, respectively (P = .2, P = .09 and P = .7). Esophageal pouch was detected earlier in twins (P = .03). Twins were scanned more frequently (×1.8 times, P = .01).

Conclusion: EA/TEF is more prevalent in twins. Despite lower rate of polyhydramnios, twins were similarly detected prenatally as singletons, and this was accomplished earlier in pregnancy; perhaps reflecting more frequent scans.
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http://dx.doi.org/10.1002/pd.5785DOI 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

Perinatal Outcome of Twin Pregnancies Complicated by Rupture of Membranes at 13-20 Weeks: Is Selective Termination an Appropriate Management Option?

Ultraschall Med 2020 Aug 15;41(4):e17-e22. Epub 2020 Jun 15.

ObGyn, Chaim Sheba Medical Center, Tel Hashomer, Israel.

Objective:  To evaluate the outcome of twin pregnancies that were complicated by rupture of membranes at 13-20 weeks of gestation and were managed by expectant management or by selective termination.

Methods:  A retrospective cohort study of all bichorionic twin pregnancies that were referred to three fetal medicine units between 2001 and 2016, due to rupture of membranes of one sac at 13-20 weeks of gestation. Women without clinical signs of infection who opted for expectant management or selective termination were included.

Results:  20 patients met the inclusion criteria. 7 of them were managed expectantly and 13 underwent selective termination. In the expectant management group there was one case of fetal demise and two cases of neonatal death, resulting in a survival rate of 79 %. The median gestational age at delivery was 30 weeks. 3 neonates suffered from prematurity-related complications and 2 suffered from oligohydramnios-related orthopedic complications. Following selective termination the survival rate was 50 % (all fetuses that were not reduced), the median gestational age at delivery was 39 weeks, and the neonatal outcome was favorable. The maternal outcome was favorable in both groups.

Conclusion:  Selective termination in twin pregnancies complicated by rupture of membranes at 13-20 weeks has a favorable outcome and should be offered.
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http://dx.doi.org/10.1055/a-1176-0919DOI Listing
August 2020

The role of fetal head circumference in the formation of obstetric anal sphincter injuries following vacuum deliveries among primiparous women.

Arch Gynecol Obstet 2020 06 3;301(6):1423-1429. Epub 2020 May 3.

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

Purpose: To evaluate the association of sonographic fetal head circumference (HC) with obstetric anal sphincter injury (OASIS) occurrence among primiparous women who underwent vacuum-assisted delivery (VAD).

Methods: A retrospective study of all primiparous women who delivered at term by VAD between 2011 and 2019 and underwent ultrasound with fetal biometry within 1 week prior to delivery. Women who suffered OASIS were compared to women without OASIS.

Results: Overall, 74 of 3222 (2.3%) primiparous women suffered an OASIS. As compared with control, women with OASIS were younger (median 28 vs. 30 years, p = 0.001), had higher BMI (median 28.2 vs. 26.9 kg/m, p = 0.03), and had a longer second stage of labor (median 190 vs. 168 min, p = 0.01). Fetal head circumference was larger in the OASIS group (mean 334 vs. 330 mm, p = 0.03), occiput posterior fetal head position was more prevalent (12 (16%) vs. 232 (7.4%), OR [95% CI]: 2.43 (1.29-4.57), p = 0.004), and the rate of mediolateral episiotomy performed was lower (58 (78.0%) vs. 2777 (88.2%), OR [95% CI]: 0.48 (0.27-0.85), p = 0.01). Multivariate regression modeling identified higher fetal HC (aOR [95% CI] 1.03 (1.001-1.06), p = 0.04) and occiput posterior (aOR [95% CI] 2.5 (1.16-5.71), p = 0.01) as independently positively associated with OASIS. Mediolateral episiotomy and maternal age were independently negatively associated with an OASIS (aOR [95% CI] 0.39 (0.18-0.85), p = 0.01); aOR [95% CI] 0.4 (0.17-0.60), p = 0.001).

Conclusions: Sonographic large fetal HC is associated with OASIS occurrence during VAD. The only modifiable predictor of OASIS detected was mediolateral episiotomy, found to be protective against OASIS.
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http://dx.doi.org/10.1007/s00404-020-05558-7DOI Listing
June 2020

Which way is better to deliver the very heavy baby: mode of delivery, maternal and neonatal outcome.

Arch Gynecol Obstet 2020 04 3;301(4):941-948. Epub 2020 Mar 3.

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

Purpose: Currently there are no existing data regarding the maternal and neonatal outcomes for nulliparous women delivering neonates with birthweight above 4500 g. We aim to evaluate birth outcome among these subset of parturients.

Methods: A retrospective study of nulliparous delivering a singleton fetus weighing  ≥ 4500 g in two tertiary medical centers between 2007 and 2018. Women who chose to undergo a trial of labor (TOL) were compared to those who underwent elective cesarean delivery (CD).

Results: Overall, 121 women were included. Seventy eight (65.4%) women elected a TOL while 43 (34.6%) had elective CD. Of women who chose TOL, 46 (59%) delivered with unassisted vaginal delivery, 28 (36%) by intrapartum CD, and 4 (5%) by assisted vaginal delivery, reaching TOL success rate of 64% (50/78). The rates of shoulder dystocia and anal sphincter injury in vaginal deliveries were 5/50 (10%) and 2/50 (4%) respectively. Successful TOL was negatively associated with the presence of gestational diabetes [5 (18%) vs. 0 (0%), OR 0.8 (95% CI 0.7-0.9), p = 0.005], and was positively associated with maternal height (median 170 cm vs. 165 cm, p = 0.002), epidural analgesia [42 (84%) vs. 16 (57%), OR 3.5 (95% CI 1.2-9.8), p = 0.009] and spontaneous onset of labor (38 (76%) vs. 10 (36%), OR 5.7 (95% CI 2.1-15.6), p = 0.001. Neonates born after TOL were more commonly complicated by meconium aspiration syndrome as compared to no TOL (9 (11%) vs. 0 (0%), OR 1.1 (95% CI 1.04-1.22, p = 0.02). Only maternal height was independently associated with successful TOL (aOR 6.9 (95% CI 1.03-46.3, p = 0.04). Maternal and neonatal adverse composite outcomes were associated with gestational hypertensive disorders (10 (50%) vs. 5 (5%). OR 19.2 (5.5-67.4), p < 0.001) and with delivery before 40 weeks (9 (57%) vs, 86 (82%), OR 3.5 (95% CI 1.2-10.6, p = 0.02), respectively.

Conclusions: Trial of vaginal delivery in nulliparous with fetuses ≥ 4500 g was associated with a high failure rate, with only two thirds of parturients achieving successful vaginal delivery. Nevertheless, neonatal outcomes mostly did not differ according to the mode of delivery. Maternal height was the only factor associated with successful vaginal delivery.
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http://dx.doi.org/10.1007/s00404-020-05474-wDOI Listing
April 2020

Trial of Labor After Cesarean in Adolescents - A Multicenter Study.

J Pediatr Adolesc Gynecol 2020 Aug 19;33(4):398-402. Epub 2020 Feb 19.

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

Study Objective: Data regarding trial of labor after cesarean delivery (TOLAC) among young women are limited. The aim of this study was to assess the TOLAC success rate and its related factors among adolescent women who had never delivered vaginally.

Design: A multicenter retrospective cohort study of all adolescent women aged ≤21 years with a history of 1 previous cesarean delivery, who delivered in 2 tertiary medical centers during 2007-2019. Women were allocated to 2 groups: 1) women who underwent TOLAC, and 2) women who had a repeat cesarean delivery with no trial of labor. Maternal and neonatal outcomes were compared between the two groups. In addition, perinatal outcomes were compared between women with successful and unsuccessful TOLAC.

Results: The study cohort included 167 women who had a previous caesarean delivery; 117 underwent TOLAC and 50 underwent a repeat cesarean delivery with no trial of labor. Neonatal birthweight (median 2937 vs 3170 g, P = .03) and gestational age at delivery (median 38 weeks vs 39, P = .009) were lower in the repeat cesarean group as compared to those undergoing TOLAC. Overall, 97 of 117 participants (83%) had a successful TOLAC. Failed TOLAC was associated low birthweight as compared to successful TOLAC (5 [25%] vs 7 [7%], odds ratio [OR] 4.3, 95% confidence interval [CI] 1.2-15.3, P = .02), and birthweight difference between current and previous deliveries was higher in the failed TOLAC group (median 315 vs 197 g, P = .04). Rates of neonatal Apgar score at 1 minute < 7 and of neonatal intensive care unit admission were higher in the TOLAC failure group (4 [20%] vs 5 [5%], OR 4.6, 95% CI 1.1-19.0, P = .03, and 4 [20%] vs 4 [4%], OR 5.8, 95% CI 1.3-25.6, P = .02), respectively). In a multivariable logistic regression analysis, only low birthweight was independently associated with TOLAC failure (adjusted OR 9.9, 95% CI 2.1-45.4, P = .003). Two cases of uterine rupture occurred in the no trial of labor group, whereas none were encountered in participants undergoing TOLAC.

Conclusions: TOLAC in adolescent women who had never delivered vaginally is associated with a relatively high success rate.
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http://dx.doi.org/10.1016/j.jpag.2020.02.006DOI Listing
August 2020
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