Previous assessments of maternal group B Streptococcus carrier rates in women delivering at Shaar... more Previous assessments of maternal group B Streptococcus carrier rates in women delivering at Shaare Zedek Medical Center ranged between 3.5 and 11% with neonatal sepsis rates of 0.2-0.9/1000 live births. Because of low colonization and disease rates, routine prenatal cultures of GBS were not recommended and intrapartum prophylaxis was mainly based on maternal risk factors. To determine whether this policy is still applicable. We performed prospective sampling and follow-up of women admitted for labor and delivery between February 2002 and July 2002. Vaginal and rectal cultures were obtained before the first pelvic examination. GBS isolation was performed using selective broth medium and identified by latex agglutination and serotyping. Demographic data were collected by means of a standardized questionnaire. Data on the newborns were collected throughout 2002. Of the 629 sampled women, 86 had a positive culture and a carrier rate of 13.7%. A borderline significantly higher carriage r...
The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by... more The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by placenta accreta in our population. Retrospective analysis of all deliveries between the years 1990-2000, and identification of all cases of placenta accreta, defined by clinical or histological criteria. For comparison purposes we defined two sub-groups: (i) all cases that ended with severe outcome and (ii) all patients who had a previous event of placenta accreta in one or more of their previous deliveries. We evaluated the potential risk factors leading to these conditions. The SPSS software package was used for statistical analysis. Univariate and multivariate analyses were performed by stepwise logistic regression. The study covered 34 450 deliveries from which 310 cases of placenta accreta were diagnosed (0.9 per cent). The risk factors associated with placenta accreta were previous cesarean delivery (12 per cent), advanced maternal age, high gravidity, multiparity, previous curet...
Acta Obstetricia Et Gynecologica Scandinavica, 2001
To compare the antepartum and intrapartum course of Jewish and Arab great-grandmultiparas from ce... more To compare the antepartum and intrapartum course of Jewish and Arab great-grandmultiparas from central and peripheral areas in Israel to age-matched control multiparous women. Medical records of four groups of parturients were compared: great-grandmultiparas (para > or = 9) and multiparae (para 2-5) delivering at Nazareth E.M.M.S. hospital (mostly Arabs) and Hadassah-Ein-Kerem hospital in Jerusalem (mostly Jews). The control groups consisted of demographically and geographically matched multiparas. Data was collected on prenatal care received, antepartum complications, as well as the intrapartum complications traditionally associated with high parity (e.g. malpresentation, placental abnormalities, peripartum hemorrhage, shoulder dystocia). Neonatal records were also examined to determine any neonatal morbidity or mortality. There were 139 and 141 great-grandmultiparas in the Nazareth and the Jerusalem study groups, respectively (mean parity was 10.1 and 10.9, respectively), and 142 and 139 multiparas in the Nazareth and the Jerusalem control groups, respectively (mean parity was 2.9 and 2.5, respectively). The rate of physician visits during the prenatal period in the Nazareth and the Jerusalem study groups was 2.3 +/- 2.4 and 3.2 +/- 2.7, respectively (p=0.0041). This rate was significantly higher in the controls of both areas (4.0 +/- 3.0 and 4.9 +/- 2.9, respectively). There was no difference in the rate of nurse visits in all groups in all areas. Maternal and neonatal outcomes were similar in both study groups, and were also similar in the control groups, but perinatal mortality was higher in both great-grandmultiparous groups compared to the controls (11/280 and 2/281, respectively; p<0.05). The differences in the intensity of prenatal care between these rural and urban areas did not affect the maternal outcomes of great-grandmultiparous pregnancies. In addition, there were no significant differences in maternal outcomes between great-grandmultiparas and multiparas in rural and urban areas although prenatal care was less intense in the former. However, increased incidence of perinatal mortality in the great-grandmultiparas may be due to factors unrelated to prenatal care intensity or quality.
To determine whether induction of labor (IOL) after successful external cephalic version (ECV) is... more To determine whether induction of labor (IOL) after successful external cephalic version (ECV) is associated with an increased risk of cesarean delivery (CD) compared with IOL with spontaneous cephalic presentation. Retrospective case-control study. All women having IOL after successful ECV were eligible. Each woman in the study group was matched for parity, age and indication for induction with two consecutive controls having IOL and spontaneous cephalic presentation. The primary outcome measure was CD. Secondary outcomes measures were operative vaginal delivery, perineal tear/episiotomy and post-partum hemorrhage. 79 women enrolled in the study group were matched with 158 controls. The overall incidence of CD was significantly higher in the study group compared with the control group (20.3 vs. 10.1Ā %; OR 2.25, 95Ā % CI 1.06-4.79, PĀ =Ā 0.03). After dividing the groups according to parity, the difference in the CD rate remained statistically significant for nulliparous women (36.7 vs. 15Ā %; OR 3.28, 95Ā % CI 1.17-9.16, PĀ =Ā 0.02), but not for multiparous women (10.2 vs. 7.1Ā %; OR 1.48, 95Ā % CI 0.44-4.92, PĀ =Ā 0.53). There was no significant difference in adjusted odds ratios for secondary outcomes. Induction of labor after successful ECV in nulliparous women increased the risk of CD compared with IOL with spontaneous cephalic presentation.
in Vitro Cellular & Developmental Biology-plant, 1988
SummaryĀ Ā The culturing of human endometrium in conventional plastic dishes and media is only part... more SummaryĀ Ā The culturing of human endometrium in conventional plastic dishes and media is only partially successful, mainly because a growth of a heterogeneous population of cells is achieved. Naturally produced extracellular matrix closely resembles the subepithelial basement membrane and seems to affect both growth and differentiation of cells. These qualities of the extracellular matrix (ECM) were applied for obtaining endometrial epithelial
Journal of Maternal-Fetal and Neonatal Medicine, 2004
Monoamniotic twins are very uncommon and are characterized by a high perinatal mortality rate. Co... more Monoamniotic twins are very uncommon and are characterized by a high perinatal mortality rate. Cord entanglement, prematurity, congenital anomalies and twin to twin transfusion are reportedly the main causes of death, which usually occurs before 24 weeks' gestation. The aim of this study was to review the newly developed methods for diagnosis and treatment and suggest a reasonable approach to the management of these rare cases. We reviewed the English-language literature in the past 15 years through Medline search and subsequent examination of individual publications. In the past two decades, newer technologies such as advanced ultrasonography and color flow Doppler studies have enabled early diagnosis of this condition and its complications. Furthermore, new treatment modalities such as fetoscopy with laser coagulation of vascular anastomoses and treatment with non-steroidal anti-inflammatory drugs such as sulindac, to reduce amniotic fluid volume, may have contributed to a better outcome. Also, occlusion of one umbilical cord (fetal reduction) at an early stage has been suggested to prevent late complications. Cumulative experience suggests that the majority of cases can be diagnosed reliably at an early gestational age. Treatment with medical amnioreduction, surgical amnioreduction or fetal reduction in selected cases may be offered before 24 weeks' gestation. Later, intensive antepartum fetal surveillance should probably be offered until 32 weeks, at which point elective preterm delivery may be considered to prevent possible fetal death.
Journal of Maternal-Fetal and Neonatal Medicine, 2008
To improve patient consultation before external cephalic version (ECV) attempt at term by definin... more To improve patient consultation before external cephalic version (ECV) attempt at term by defining prognostic parameters for the success of the procedure. This was a prospective observational study set in a university teaching hospital. We prospectively collected demographic and obstetric data from 603 ECV attempts at our center for the period between January 1997 and June 2005. Analysis was performed by stepwise logistic regression of the demographic and obstetric parameters. The main outcome measure was success of ECV attempt. Success rates were 72.3% and 46.1% for multiparas and nulliparas, respectively. Prognostic parameters associated with successful ECV were amniotic fluid index > 7 cm, multiparity, non-frank breech, non-anterior placental location, and body mass index < 25. Prognostic parameters, particularly amniotic fluid index and multiparity, can help physicians in counseling parturients before deciding on ECV.
The aim of this study was to determine placental thickness by ultrasound examination throughout p... more The aim of this study was to determine placental thickness by ultrasound examination throughout pregnancy and establish the correlation of sonographically thick placenta with perinatal mortality and morbidity. Placental thickness was determined by routine sonographic examination throughout pregnancy in 561 normal singleton pregnancies. Thick placenta was determined as placenta that was above the 90th percentile. Gravidae between 20-22 weeks' gestation (n=193) and 32-34 weeks (n=73) were then divided into two groups according to placental thickness. The study group consisted of 44 gravidae with thick placenta. The control group included 151 gravidae with placental thickness between the 10th and 90th percentile. A comparison of perinatal mortality and morbidity rates as well as the incidence of small and large for gestational age neonates was conducted.A linear increase of placental thickness was found to correlate with gestational age throughout pregnancy. No statistical differences were observed between the two groups with regard to obstetrical variables such as maternal age, parity and gestational age at delivery. No correlation was found between placental thickness and maternal age or parity. The incidence of perinatal mortality was significantly higher among gravidae with thick placentae (6.82% versus 0.66 per cent, P=0.037, 95 per cent confidence interval 1.71-70.29). Birthweight at term was found to be above 4000 g in 20.45 per cent of the thick-placenta group as compared to 5.3 per cent in the control group (P=0.001, 95 per cent CI 2.08-13.85), and birthweight of less than 2500 g was found in 15. 9 per cent of the thick-placenta group as compared to 7.3 per cent in the control group (P=0.03, 95 per cent CI 1.11-8.14). The incidence of fetal anomalies was 9.1 per cent in the thick-placenta group and 3.97 per cent in the control group (not significant). Sonographically thick placenta is associated with increased perinatal risk with increased mortality related to fetal anomalies and higher rates of both small for gestational age and large for gestational age infants at term.
To compare the success of external cephalic version using spinal analgesia with no analgesia amon... more To compare the success of external cephalic version using spinal analgesia with no analgesia among nulliparas. A prospective randomized controlled trial was performed in a tertiary referral center delivery suite. Nulliparous women at term requesting external cephalic version for breech presentation were randomized to receive spinal analgesia (7.5 mg bupivacaine) or no analgesia before the external cephalic version. An experienced obstetrician performed the external cephalic version. Primary outcome was successful conversion to vertex presentation. Seventy-four women were enrolled, and 70 analyzed (36 spinal, 34 no analgesia). Successful external cephalic version occurred among 24 of 36 (66.7%) women randomized to receive spinal analgesia compared with 11 of 34 (32.4%) without, P=.004 (95% confidence interval [CI] of the difference: 0.0954-0.5513). External cephalic version with spinal analgesia resulted in a lower visual analog pain score, 1.76+/-2.74 compared with 6.84+/-3.08 without, P<.001. A secondary analysis logistic regression model demonstrated that the odds of external cephalic version success was 4.0-fold higher when performed with spinal analgesia P=.02 (95% CI, odds ratio [OR] 1.2-12.9). Complete breech presentation before attempting external cephalic version increased the odds of success 8.2-fold, P=.001 (95% CI, OR 2.2-30.3). Placental position, estimated fetal weight, and maternal weight did not contribute to the success rate when spinal analgesia was used. There were no cases of placental abruption or fetal distress. Administration of spinal analgesia significantly increases the success rate of external cephalic version among nulliparous women at term, which allows possible normal vaginal delivery. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00119184 I.
The request for cesarean section without medical indication has become one of the dilemmas faced ... more The request for cesarean section without medical indication has become one of the dilemmas faced by the obstetrician. Most recent studies that compare vaginal delivery with elective cesarean section find them equally safe. This comparison is lacking in the option of trial of labor, which may result in an assisted vaginal delivery or intrapartum cesarean section, both with increased morbidity and mortality for the mother and newborn. When considering elective cesarean section, the obstetrician has to take into account improved anesthetic techniques and the decrease in morbidity and mortality after cesarean section with the trend toward patient autonomy to decide on her own treatment. On the other hand, the obstetrician has to advise his patient of the best treatment with respect to possible complications in future pregnancies, such as placental complications and increased morbidity and mortality resulting from repeated cesarean sections. The advantage of cesarean section for pelvic floor protection does not exist after three consecutive cesarean sections and equals the rate of urinary incontinence after consecutive three vaginal deliveries. In countries such as ours, where most women wish for several children, the risk-benefit balance is toward repeated spontaneous vaginal deliveries.
The incidence of abnormal umbilical waveforms in triplet and quadruplet pregnancies and its corre... more The incidence of abnormal umbilical waveforms in triplet and quadruplet pregnancies and its correlation with adverse pregnancy outcome was studied by a retrospective review of all our triplet and quadruplet pregnancies (1986-1993) with documented Doppler flow assessment. Obstetrical outcomes were analyzed in relation to abnormal umbilical artery waveforms. Nineteen triplet and 4 quadruplet pregnancies were studied. Of 73 fetuses, 6 had abnormal umbilical artery waveforms (8.2%). All abnormal waveforms were characterized by persistent absence of the end-diastolic velocities (AEDV). In comparing the abnormal and normal groups, significant differences were found in birth weights (910+/-433 vs. 1,724+/-434 g; p = 0.0004), small for gestational age rate [5/6 (83%) vs. 5/67 (7.5%); p = 0.0003], and perinatal mortality rate [3/6 (50%) vs. 2/67(3%); p = 0.001]. There were no differences in congenital anomalies, gestational age at birth, and neonatal intensive care admission. In conclusion, it seems that Doppler umbilical artery waveforms in multiple pregnancies were either normal or extremely abnormal (e.g. AEDV). AEDV was associated with adverse perinatal outcomes such as low birth weight, growth restriction and perinatal mortality.
To study the association of umbilical cord presentation found on antenatal ultrasound and the inc... more To study the association of umbilical cord presentation found on antenatal ultrasound and the incidence of cord prolapse in labor. We reviewed the antenatal records of all deliveries in the Mount Sinai Hospital in a 5-year period and conducted two separate retrospective studies. In the first study we reviewed the antenatal sonograms of all women with proven cord prolapse for cord presentation (study A). In the second study we reviewed the obstetrical outcome of pregnancies where sonographic cord presentation was identified in the third trimester of pregnancy (study B). In study A, 16,551 delivery records were reviewed and 42 patients were found to have had clinical cord prolapse (0.25%). Sonograms were available for 16 of these 42 patients. Only 2 of them (12.5%) had cord presentation on ultrasound scan. In study B, cord presentation was reported in 13 of 8,122 consecutive sonograms (0.16%). Six of these patients (6/13, 46%) had been scanned once. Three required cesarean delivery for malpresentation and cord presentation on ultrasound (3/13, 23%), while the other 3 had uncomplicated vaginal deliveries (23%). The remaining 7 patients had repeat scans which revealed persistent cord presentation in 3 (23%). All 3 underwent cesarean delivery, 1 following cord prolapse. The other 4 spontaneously converted to vertex with resolution of cord presentation as proven at delivery (31%). Cord presentation and cord prolapse are not synonymous. Documented cord presentation during the third trimester necessitates repeat scans and intrapartum sonographic assessment to determine the mode of delivery.
It is generally assumed that the intrauterine device (IUD) exerts its action by altering endometr... more It is generally assumed that the intrauterine device (IUD) exerts its action by altering endometrial receptivity for the implanting embryo. The most frequently encountered endometrial reaction reported in the presence of an IUD is a chronic inflammatory reaction which may be responsible for the alterations in the normal physiology of the human endometrium. In order to evaluate the endometrial response to the IUD when pregnancy occurs with the device in situ, we have examined the morphology of decidual tissue obtained during interruptions of pregnancy of 32 patients who had conceived in the presence of IUDs. Twenty-three decidual specimens, obtained during interruption of pregnancies without an IUD, served as controls. The incidence of chronic inflammatory reaction was 6.25% in the presence of an IUD and 4.34% in the control group. The incidence of chronic endometritis reported in nonpregnant IUD users is higher (14-100%) than the incidence of chronic endometritis observed in both groups. This observation may be the result of the generally observed alterations in the immune system during a normal pregnancy, but may also be interpreted as a primary reduced endometrial reaction to the IUD, consequently leading to the contraceptive failure in this group.
Previous assessments of maternal group B Streptococcus carrier rates in women delivering at Shaar... more Previous assessments of maternal group B Streptococcus carrier rates in women delivering at Shaare Zedek Medical Center ranged between 3.5 and 11% with neonatal sepsis rates of 0.2-0.9/1000 live births. Because of low colonization and disease rates, routine prenatal cultures of GBS were not recommended and intrapartum prophylaxis was mainly based on maternal risk factors. To determine whether this policy is still applicable. We performed prospective sampling and follow-up of women admitted for labor and delivery between February 2002 and July 2002. Vaginal and rectal cultures were obtained before the first pelvic examination. GBS isolation was performed using selective broth medium and identified by latex agglutination and serotyping. Demographic data were collected by means of a standardized questionnaire. Data on the newborns were collected throughout 2002. Of the 629 sampled women, 86 had a positive culture and a carrier rate of 13.7%. A borderline significantly higher carriage r...
The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by... more The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by placenta accreta in our population. Retrospective analysis of all deliveries between the years 1990-2000, and identification of all cases of placenta accreta, defined by clinical or histological criteria. For comparison purposes we defined two sub-groups: (i) all cases that ended with severe outcome and (ii) all patients who had a previous event of placenta accreta in one or more of their previous deliveries. We evaluated the potential risk factors leading to these conditions. The SPSS software package was used for statistical analysis. Univariate and multivariate analyses were performed by stepwise logistic regression. The study covered 34 450 deliveries from which 310 cases of placenta accreta were diagnosed (0.9 per cent). The risk factors associated with placenta accreta were previous cesarean delivery (12 per cent), advanced maternal age, high gravidity, multiparity, previous curet...
Acta Obstetricia Et Gynecologica Scandinavica, 2001
To compare the antepartum and intrapartum course of Jewish and Arab great-grandmultiparas from ce... more To compare the antepartum and intrapartum course of Jewish and Arab great-grandmultiparas from central and peripheral areas in Israel to age-matched control multiparous women. Medical records of four groups of parturients were compared: great-grandmultiparas (para > or = 9) and multiparae (para 2-5) delivering at Nazareth E.M.M.S. hospital (mostly Arabs) and Hadassah-Ein-Kerem hospital in Jerusalem (mostly Jews). The control groups consisted of demographically and geographically matched multiparas. Data was collected on prenatal care received, antepartum complications, as well as the intrapartum complications traditionally associated with high parity (e.g. malpresentation, placental abnormalities, peripartum hemorrhage, shoulder dystocia). Neonatal records were also examined to determine any neonatal morbidity or mortality. There were 139 and 141 great-grandmultiparas in the Nazareth and the Jerusalem study groups, respectively (mean parity was 10.1 and 10.9, respectively), and 142 and 139 multiparas in the Nazareth and the Jerusalem control groups, respectively (mean parity was 2.9 and 2.5, respectively). The rate of physician visits during the prenatal period in the Nazareth and the Jerusalem study groups was 2.3 +/- 2.4 and 3.2 +/- 2.7, respectively (p=0.0041). This rate was significantly higher in the controls of both areas (4.0 +/- 3.0 and 4.9 +/- 2.9, respectively). There was no difference in the rate of nurse visits in all groups in all areas. Maternal and neonatal outcomes were similar in both study groups, and were also similar in the control groups, but perinatal mortality was higher in both great-grandmultiparous groups compared to the controls (11/280 and 2/281, respectively; p<0.05). The differences in the intensity of prenatal care between these rural and urban areas did not affect the maternal outcomes of great-grandmultiparous pregnancies. In addition, there were no significant differences in maternal outcomes between great-grandmultiparas and multiparas in rural and urban areas although prenatal care was less intense in the former. However, increased incidence of perinatal mortality in the great-grandmultiparas may be due to factors unrelated to prenatal care intensity or quality.
To determine whether induction of labor (IOL) after successful external cephalic version (ECV) is... more To determine whether induction of labor (IOL) after successful external cephalic version (ECV) is associated with an increased risk of cesarean delivery (CD) compared with IOL with spontaneous cephalic presentation. Retrospective case-control study. All women having IOL after successful ECV were eligible. Each woman in the study group was matched for parity, age and indication for induction with two consecutive controls having IOL and spontaneous cephalic presentation. The primary outcome measure was CD. Secondary outcomes measures were operative vaginal delivery, perineal tear/episiotomy and post-partum hemorrhage. 79 women enrolled in the study group were matched with 158 controls. The overall incidence of CD was significantly higher in the study group compared with the control group (20.3 vs. 10.1Ā %; OR 2.25, 95Ā % CI 1.06-4.79, PĀ =Ā 0.03). After dividing the groups according to parity, the difference in the CD rate remained statistically significant for nulliparous women (36.7 vs. 15Ā %; OR 3.28, 95Ā % CI 1.17-9.16, PĀ =Ā 0.02), but not for multiparous women (10.2 vs. 7.1Ā %; OR 1.48, 95Ā % CI 0.44-4.92, PĀ =Ā 0.53). There was no significant difference in adjusted odds ratios for secondary outcomes. Induction of labor after successful ECV in nulliparous women increased the risk of CD compared with IOL with spontaneous cephalic presentation.
in Vitro Cellular & Developmental Biology-plant, 1988
SummaryĀ Ā The culturing of human endometrium in conventional plastic dishes and media is only part... more SummaryĀ Ā The culturing of human endometrium in conventional plastic dishes and media is only partially successful, mainly because a growth of a heterogeneous population of cells is achieved. Naturally produced extracellular matrix closely resembles the subepithelial basement membrane and seems to affect both growth and differentiation of cells. These qualities of the extracellular matrix (ECM) were applied for obtaining endometrial epithelial
Journal of Maternal-Fetal and Neonatal Medicine, 2004
Monoamniotic twins are very uncommon and are characterized by a high perinatal mortality rate. Co... more Monoamniotic twins are very uncommon and are characterized by a high perinatal mortality rate. Cord entanglement, prematurity, congenital anomalies and twin to twin transfusion are reportedly the main causes of death, which usually occurs before 24 weeks' gestation. The aim of this study was to review the newly developed methods for diagnosis and treatment and suggest a reasonable approach to the management of these rare cases. We reviewed the English-language literature in the past 15 years through Medline search and subsequent examination of individual publications. In the past two decades, newer technologies such as advanced ultrasonography and color flow Doppler studies have enabled early diagnosis of this condition and its complications. Furthermore, new treatment modalities such as fetoscopy with laser coagulation of vascular anastomoses and treatment with non-steroidal anti-inflammatory drugs such as sulindac, to reduce amniotic fluid volume, may have contributed to a better outcome. Also, occlusion of one umbilical cord (fetal reduction) at an early stage has been suggested to prevent late complications. Cumulative experience suggests that the majority of cases can be diagnosed reliably at an early gestational age. Treatment with medical amnioreduction, surgical amnioreduction or fetal reduction in selected cases may be offered before 24 weeks' gestation. Later, intensive antepartum fetal surveillance should probably be offered until 32 weeks, at which point elective preterm delivery may be considered to prevent possible fetal death.
Journal of Maternal-Fetal and Neonatal Medicine, 2008
To improve patient consultation before external cephalic version (ECV) attempt at term by definin... more To improve patient consultation before external cephalic version (ECV) attempt at term by defining prognostic parameters for the success of the procedure. This was a prospective observational study set in a university teaching hospital. We prospectively collected demographic and obstetric data from 603 ECV attempts at our center for the period between January 1997 and June 2005. Analysis was performed by stepwise logistic regression of the demographic and obstetric parameters. The main outcome measure was success of ECV attempt. Success rates were 72.3% and 46.1% for multiparas and nulliparas, respectively. Prognostic parameters associated with successful ECV were amniotic fluid index > 7 cm, multiparity, non-frank breech, non-anterior placental location, and body mass index < 25. Prognostic parameters, particularly amniotic fluid index and multiparity, can help physicians in counseling parturients before deciding on ECV.
The aim of this study was to determine placental thickness by ultrasound examination throughout p... more The aim of this study was to determine placental thickness by ultrasound examination throughout pregnancy and establish the correlation of sonographically thick placenta with perinatal mortality and morbidity. Placental thickness was determined by routine sonographic examination throughout pregnancy in 561 normal singleton pregnancies. Thick placenta was determined as placenta that was above the 90th percentile. Gravidae between 20-22 weeks' gestation (n=193) and 32-34 weeks (n=73) were then divided into two groups according to placental thickness. The study group consisted of 44 gravidae with thick placenta. The control group included 151 gravidae with placental thickness between the 10th and 90th percentile. A comparison of perinatal mortality and morbidity rates as well as the incidence of small and large for gestational age neonates was conducted.A linear increase of placental thickness was found to correlate with gestational age throughout pregnancy. No statistical differences were observed between the two groups with regard to obstetrical variables such as maternal age, parity and gestational age at delivery. No correlation was found between placental thickness and maternal age or parity. The incidence of perinatal mortality was significantly higher among gravidae with thick placentae (6.82% versus 0.66 per cent, P=0.037, 95 per cent confidence interval 1.71-70.29). Birthweight at term was found to be above 4000 g in 20.45 per cent of the thick-placenta group as compared to 5.3 per cent in the control group (P=0.001, 95 per cent CI 2.08-13.85), and birthweight of less than 2500 g was found in 15. 9 per cent of the thick-placenta group as compared to 7.3 per cent in the control group (P=0.03, 95 per cent CI 1.11-8.14). The incidence of fetal anomalies was 9.1 per cent in the thick-placenta group and 3.97 per cent in the control group (not significant). Sonographically thick placenta is associated with increased perinatal risk with increased mortality related to fetal anomalies and higher rates of both small for gestational age and large for gestational age infants at term.
To compare the success of external cephalic version using spinal analgesia with no analgesia amon... more To compare the success of external cephalic version using spinal analgesia with no analgesia among nulliparas. A prospective randomized controlled trial was performed in a tertiary referral center delivery suite. Nulliparous women at term requesting external cephalic version for breech presentation were randomized to receive spinal analgesia (7.5 mg bupivacaine) or no analgesia before the external cephalic version. An experienced obstetrician performed the external cephalic version. Primary outcome was successful conversion to vertex presentation. Seventy-four women were enrolled, and 70 analyzed (36 spinal, 34 no analgesia). Successful external cephalic version occurred among 24 of 36 (66.7%) women randomized to receive spinal analgesia compared with 11 of 34 (32.4%) without, P=.004 (95% confidence interval [CI] of the difference: 0.0954-0.5513). External cephalic version with spinal analgesia resulted in a lower visual analog pain score, 1.76+/-2.74 compared with 6.84+/-3.08 without, P<.001. A secondary analysis logistic regression model demonstrated that the odds of external cephalic version success was 4.0-fold higher when performed with spinal analgesia P=.02 (95% CI, odds ratio [OR] 1.2-12.9). Complete breech presentation before attempting external cephalic version increased the odds of success 8.2-fold, P=.001 (95% CI, OR 2.2-30.3). Placental position, estimated fetal weight, and maternal weight did not contribute to the success rate when spinal analgesia was used. There were no cases of placental abruption or fetal distress. Administration of spinal analgesia significantly increases the success rate of external cephalic version among nulliparous women at term, which allows possible normal vaginal delivery. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00119184 I.
The request for cesarean section without medical indication has become one of the dilemmas faced ... more The request for cesarean section without medical indication has become one of the dilemmas faced by the obstetrician. Most recent studies that compare vaginal delivery with elective cesarean section find them equally safe. This comparison is lacking in the option of trial of labor, which may result in an assisted vaginal delivery or intrapartum cesarean section, both with increased morbidity and mortality for the mother and newborn. When considering elective cesarean section, the obstetrician has to take into account improved anesthetic techniques and the decrease in morbidity and mortality after cesarean section with the trend toward patient autonomy to decide on her own treatment. On the other hand, the obstetrician has to advise his patient of the best treatment with respect to possible complications in future pregnancies, such as placental complications and increased morbidity and mortality resulting from repeated cesarean sections. The advantage of cesarean section for pelvic floor protection does not exist after three consecutive cesarean sections and equals the rate of urinary incontinence after consecutive three vaginal deliveries. In countries such as ours, where most women wish for several children, the risk-benefit balance is toward repeated spontaneous vaginal deliveries.
The incidence of abnormal umbilical waveforms in triplet and quadruplet pregnancies and its corre... more The incidence of abnormal umbilical waveforms in triplet and quadruplet pregnancies and its correlation with adverse pregnancy outcome was studied by a retrospective review of all our triplet and quadruplet pregnancies (1986-1993) with documented Doppler flow assessment. Obstetrical outcomes were analyzed in relation to abnormal umbilical artery waveforms. Nineteen triplet and 4 quadruplet pregnancies were studied. Of 73 fetuses, 6 had abnormal umbilical artery waveforms (8.2%). All abnormal waveforms were characterized by persistent absence of the end-diastolic velocities (AEDV). In comparing the abnormal and normal groups, significant differences were found in birth weights (910+/-433 vs. 1,724+/-434 g; p = 0.0004), small for gestational age rate [5/6 (83%) vs. 5/67 (7.5%); p = 0.0003], and perinatal mortality rate [3/6 (50%) vs. 2/67(3%); p = 0.001]. There were no differences in congenital anomalies, gestational age at birth, and neonatal intensive care admission. In conclusion, it seems that Doppler umbilical artery waveforms in multiple pregnancies were either normal or extremely abnormal (e.g. AEDV). AEDV was associated with adverse perinatal outcomes such as low birth weight, growth restriction and perinatal mortality.
To study the association of umbilical cord presentation found on antenatal ultrasound and the inc... more To study the association of umbilical cord presentation found on antenatal ultrasound and the incidence of cord prolapse in labor. We reviewed the antenatal records of all deliveries in the Mount Sinai Hospital in a 5-year period and conducted two separate retrospective studies. In the first study we reviewed the antenatal sonograms of all women with proven cord prolapse for cord presentation (study A). In the second study we reviewed the obstetrical outcome of pregnancies where sonographic cord presentation was identified in the third trimester of pregnancy (study B). In study A, 16,551 delivery records were reviewed and 42 patients were found to have had clinical cord prolapse (0.25%). Sonograms were available for 16 of these 42 patients. Only 2 of them (12.5%) had cord presentation on ultrasound scan. In study B, cord presentation was reported in 13 of 8,122 consecutive sonograms (0.16%). Six of these patients (6/13, 46%) had been scanned once. Three required cesarean delivery for malpresentation and cord presentation on ultrasound (3/13, 23%), while the other 3 had uncomplicated vaginal deliveries (23%). The remaining 7 patients had repeat scans which revealed persistent cord presentation in 3 (23%). All 3 underwent cesarean delivery, 1 following cord prolapse. The other 4 spontaneously converted to vertex with resolution of cord presentation as proven at delivery (31%). Cord presentation and cord prolapse are not synonymous. Documented cord presentation during the third trimester necessitates repeat scans and intrapartum sonographic assessment to determine the mode of delivery.
It is generally assumed that the intrauterine device (IUD) exerts its action by altering endometr... more It is generally assumed that the intrauterine device (IUD) exerts its action by altering endometrial receptivity for the implanting embryo. The most frequently encountered endometrial reaction reported in the presence of an IUD is a chronic inflammatory reaction which may be responsible for the alterations in the normal physiology of the human endometrium. In order to evaluate the endometrial response to the IUD when pregnancy occurs with the device in situ, we have examined the morphology of decidual tissue obtained during interruptions of pregnancy of 32 patients who had conceived in the presence of IUDs. Twenty-three decidual specimens, obtained during interruption of pregnancies without an IUD, served as controls. The incidence of chronic inflammatory reaction was 6.25% in the presence of an IUD and 4.34% in the control group. The incidence of chronic endometritis reported in nonpregnant IUD users is higher (14-100%) than the incidence of chronic endometritis observed in both groups. This observation may be the result of the generally observed alterations in the immune system during a normal pregnancy, but may also be interpreted as a primary reduced endometrial reaction to the IUD, consequently leading to the contraceptive failure in this group.
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Papers by Yossef Ezra