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Cornthwaite K, van der Scheer JW, Kelly S, Schmidt-Hansen M, Burt J, Dixon-Woods M, Draycott T, Bahl R. Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1702-1713. [PMID: 38787368 PMCID: PMC11324922 DOI: 10.1111/aogs.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation. MATERIAL AND METHODS We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non-randomized comparative studies (n ≥ 30 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS-I, and certainty of evidence using GRADE. We synthesized data using meta-analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction. RESULTS We identified 24 eligible studies (11 randomized and 13 non-randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and/or the Fetal Pillow®. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (eg risk ratio of 3.41 [95% CI: 2.50-4.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction. CONCLUSIONS The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.
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Affiliation(s)
- Katie Cornthwaite
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
| | - Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Sarah Kelly
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | | | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Tim Draycott
- Royal College of Obstetricians & Gynaecologists, London, UK
- North Bristol NHS Trust, Bristol, UK
| | - Rachna Bahl
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
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Peled T, Muraca GM, Ratner M, Sela HY, Kirubarajan A, Weiss A, Grisaru-Granovsky S, Rottenstreich M. Impacted fetal head extraction methods at second stage cesarean and subsequent preterm delivery: A multicenter study. Int J Gynaecol Obstet 2024; 166:775-782. [PMID: 38235842 DOI: 10.1002/ijgo.15383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Second-stage cesarean delivery (CD) is associated with subsequent preterm birth (PTB). It has been suggested that an increased risk of PTB after second-stage cesarean delivery could be linked to a higher chance of cervical injury due to the extension of the uterine incision. Previous studies have shown that reverse breech extraction is associated with lower rates of uterine incision extensions compared to the "push" method. We aimed to investigate the association between the method of fetal extraction during second-stage CD and the rate of spontaneous PTB (sPTB), as well as other maternal and neonatal outcomes during the subsequent pregnancy. METHODS This was a multicenter retrospective cohort study. The study population included women in their first subsequent singleton delivery following a second-stage CD between 2004 and 2021. The main exposure of interest was the method of fetal extraction in the index CD ("push" method vs. reverse breech extraction). The primary outcome of this study was sPTB <37 weeks in the subsequent pregnancy. Secondary outcomes were overall PTB, trial of labor, and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling. RESULTS During the study period, 2969 index CD during second stage were performed, of those 583 met the inclusion criteria, of whom 234 (40.1%) had fetal extraction using the reverse breech extraction method, while 349 (59.9%) had the "push" method for extraction. In univariate analysis, women in those two groups had statistically similar rates of sPTB (3.7% vs. 3.0%; odds ratio [OR] 1.25, 95% CI: 0.49-3.19) and overall PTB (<37, <34 and <32 weeks), as well as other maternal, neonatal, and trial of labor outcomes. This was confirmed by multivariate analyses with an adjusted OR of 1.27 (95% CI: 0.43-3.71) for sPTB. CONCLUSION Among women with a previous second-stage CD, no significant difference was observed in PTB rates in the subsequent pregnancies following the "push" method compared to the reverse breech extraction method.
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Affiliation(s)
- Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Miri Ratner
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
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Cornthwaite KR, Bahl R, Lattey K, Draycott T. Management of impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024; 230:S980-S987. [PMID: 38462267 PMCID: PMC11000504 DOI: 10.1016/j.ajog.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/05/2022] [Accepted: 10/09/2022] [Indexed: 03/12/2024]
Abstract
Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.
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Affiliation(s)
- Katie R Cornthwaite
- University of Bristol and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom.
| | - Rachna Bahl
- University Hospitals Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
| | | | - Tim Draycott
- North Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
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Blum M, Hochler H, Sela HY, Peled T, Ben-Zion O, Weiss A, Lipschuetz M, Rosenbloom JI, Grisaru-Granovsky S, Rottenstreich M. Failed vacuum and preterm delivery risk in the subsequent pregnancy: a multicenter retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:101121. [PMID: 37558127 DOI: 10.1016/j.ajogmf.2023.101121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/30/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Second-stage cesarean delivery is associated with subsequent preterm delivery. Failed vacuum-assisted delivery is a subgroup of second-stage cesarean delivery in which the fetal head is engaged deeper in the pelvis and, thus, is associated with an increased risk of short-term maternal complications. OBJECTIVE This study aimed to investigate the maternal and neonatal outcomes of women at their subsequent delivery after a second-stage cesarean delivery with failed vacuum-assisted extraction vs after a second-stage cesarean delivery without a trial of vacuum-assisted extraction. STUDY DESIGN This was a multicenter retrospective cohort study. The study population included all women in their subsequent pregnancy after a second-stage cesarean delivery who delivered in all university-affiliated obstetrical centers (n=4) in a single geographic area between 2003 and 2021. Maternal and neonatal outcomes of women who had second-stage cesarean delivery after a failed vacuum-assisted delivery were compared with women who had second-stage cesarean delivery without a trial of vacuum-assisted delivery. The primary outcome of this study was preterm delivery at <37 weeks of gestation. The secondary outcomes were vaginal birth rate and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling. RESULTS During the study period, 1313 women met the inclusion criteria, of whom 215 (16.4%) had a history of failed vacuum-assisted delivery at the previous delivery and 1098 (83.6%) did not. In univariate analysis, women with previously failed vacuum-assisted delivery had similar preterm delivery rates (<37, <34, <32, and <28 weeks of gestation), a successful trial of labor after cesarean delivery rates, uterine rupture, and hysterectomy. However, multivariable analyses controlling for confounders showed that a history of failed vacuum-assisted delivery is associated with a higher risk of preterm delivery at <37 weeks of gestation (adjusted odds ratio, 2.05; 95% confidence interval, 1.11-3.79; P=.02), but not with preterm delivery at <34 or <32 weeks of gestation. CONCLUSION Among women with a previous second-stage cesarean delivery, previously failed vacuum-assisted delivery was associated with an increased risk of preterm delivery at <37 weeks of gestation in the subsequent birth.
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Affiliation(s)
- Maayan Blum
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich)
| | - Hila Hochler
- Faculty of Medicine, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Hochler, Lipschuetz, and Rosenbloom).
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich)
| | - Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich)
| | - Ori Ben-Zion
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich)
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich)
| | - Michal Lipschuetz
- Faculty of Medicine, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Hochler, Lipschuetz, and Rosenbloom); Faculty of Medicine, Henrietta Szold Hadassah - Hebrew University School of Nursing, Jerusalem, Israel (Dr Lipschuetz)
| | - Joshua Isaac Rosenbloom
- Faculty of Medicine, Department of Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Hochler, Lipschuetz, and Rosenbloom)
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich)
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel (Drs Blum, Sela, Peled, Ben-Zion, Weiss, Grisaru-Granovsky, and Rottenstreich); Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel (Dr Rottenstreich)
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5
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Zhang VRY, Tan EL, Edison PE, Kanagalingam D. Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital. Singapore Med J 2023; 64:313-318. [PMID: 35706407 PMCID: PMC10219121 DOI: 10.11622/smedj.2022069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 11/26/2020] [Indexed: 11/18/2022]
Abstract
Introduction There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore. Methods A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed. Results A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation. Conclusion The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.
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Affiliation(s)
| | - Eng Loy Tan
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore
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Ammitzbøll ILA, Andersen BR, Lange KHW, Clausen T, Løkkegaard ECL. Risk factors for and consequences of difficult fetal extraction in emergency caesarean section. A retrospective registry-based cohort study. Eur J Obstet Gynecol Reprod Biol 2023; 283:74-80. [PMID: 36801595 DOI: 10.1016/j.ejogrb.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION This study aimed to assess risk factors for difficult fetal extraction in emergency caesarean sections, focusing on top-up epidural anesthesia compared to spinal anesthesia. Additionally, this study addressed consequences of difficult fetal extraction on neonatal and maternal morbidity. MATERIAL AND METHODS This retrospective registry-based cohort study included 2,332 of 2,892 emergency caesarean sections performed with local anesthesia during 2010-2017. Main outcomes were analyzed by crude and multiple adjusted logistic regression providing odds ratios. RESULTS Difficult fetal extraction was found in 14.9% of emergency caesarean sections. Risk-factors for difficult fetal extraction included top-up epidural anesthesia (aOR:1.37[95 %CI 1.04-1.81]), high pre-pregnancy BMI (aOR:1.41[95 %CI 1.05-1.89]), deep fetal descent (ischial spine: aOR:2.53[95 %CI 1.89-3.39], pelvic floor: aOR:3.11[95 %CI 1.32-7.33]), and anterior placental position (aOR:1.37[95 %CI 1.06-1.77]). Difficult fetal extraction was associated with increased risk of low umbilical artery pH 7.00-7.09 (aOR:3.50[95 %CI 1.98-6.15]) pH ≤ 6.99 (aOR:4.20[95 %CI 1.61-10.91]), five-minute Apgar score ≤ 6 (aOR:3.41[95 %CI 1.49-7.83]) and maternal blood loss (501-1,000 ml: aOR:1.65[95 %CI 1.27-2.16], 1,001-1,500 ml: aOR:3.24[95 %CI 2.24-4.67], 1,501-2,000 ml: aOR:3.94[95 %CI 2.24-6.94] and ≥ 2001 ml: aOR:2.76[95 %CI 1.12-6.82]). CONCLUSION This study identified four risk factors for difficult fetal extraction in emergency caesarean section: top-up epidural anesthesia, high maternal BMI, deep fetal descent and anterior placental position. Additionally, difficult fetal extraction was associated with poor neonatal and maternal outcomes.
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Affiliation(s)
- I L A Ammitzbøll
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark.
| | - B R Andersen
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - K H W Lange
- Department of Clinical Medicine, University of Copenhagen, Denmark; Department of Anesthesiology, Nordsjællands Hospital, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - T Clausen
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - E C L Løkkegaard
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
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Feng S, Gu J. The utilization of transperineal ultrasound following fetal heart deceleration after epidural analgesia: a case report. BMC Pregnancy Childbirth 2022; 22:873. [PMID: 36424553 PMCID: PMC9685891 DOI: 10.1186/s12884-022-05197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/09/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We report a case of fetal heart rate decelerations and relaxation of pelvic muscles and fetal descent using transperineal ultrasound after initiation of epidural labor analgesia. CASE PRESENTATION A 32-year-old woman, G1P0 with gestational age of 40 weeks, required epidural analgesia when her cervical dilatation was 2 cm. Baseline transperineal ultrasound examination was performed before epidural puncture. The fetal heart rate tracing was normal before the initiation of analgesia. Approximately 10 min after the epidural administration of the loading dose, the patient reported onset of analgesia and the FHR tracing showed variable-decelerations. There was no hypotension or evidence of uterine tachysystole. Transperineal ultrasound was performed again after epidural analgesia took effect. The anteroposterior diameter of the levator hiatus increased from 5.3 to 6.6 cm and angle of progress increased from 116°to 133°. The relaxation of pelvic muscle and rapid descent of fetal head may have contributed to the FHR deceleration. The midwife elevated the fetal head through the vagina with her hand, and the FHR recovered soon thereafter. CONCLUSIONS Changes in fetal heart rate after initiation of neuraxial analgesia are unpredictable. In addition to FHR and tocodynametric monitoring, performing TPU may helpful in distinguishing the reasons for FHR change and initiating corresponding corrective measures.
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Affiliation(s)
- Shimiao Feng
- grid.461863.e0000 0004 1757 9397Department of Anesthesiology, West China Second University Hospital, Sichuan University, 20#, Section 3 Renmin Nan Road, Chengdu, Sichuan 610041 China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, 20#, Section 3 Renmin Nan Road, Chengdu, Sichuan 610041 China
| | - Juan Gu
- grid.461863.e0000 0004 1757 9397Department of Anesthesiology, West China Second University Hospital, Sichuan University, 20#, Section 3 Renmin Nan Road, Chengdu, Sichuan 610041 China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, 20#, Section 3 Renmin Nan Road, Chengdu, Sichuan 610041 China
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Rada MP, Ciortea R, Măluțan AM, Prundeanu I, Doumouchtsis SK, Bucuri CE, Blaga LD, Mihu D. Maternal and neonatal outcomes associated with delivery techniques for impacted fetal head at cesarean section: a systematic review and meta-analysis. J Perinat Med 2022; 50:446-456. [PMID: 35119802 DOI: 10.1515/jpm-2021-0572] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Late first-stage or second-stage cesarean section is commonly associated with fetal head impaction, leading to maternal and neonatal complications. This situation requires safe delivery techniques, but the optimal management remains controversial. The aim of this meta-analysis was to compare maternal and neonatal outcomes associated with delivery techniques via cesarean section. METHODS An electronic search of three databases, from inception to June 2021, was conducted. Cohort and randomised comparative studies on maternal and neonatal outcomes associated with techniques to deliver an impacted fetal head during cesarean section were included. The methodological quality of the primary studies was assessed. Review Manager 5.4 was used for statistical analyses. RESULTS Nineteen articles, including 2,345 women were analyzed. Three fetal extraction techniques were identified. Meta-analyses showed that the "pull" technique carries lower risks as compared to the "push" technique and the "Patwardhan" technique is safer compared to the "push" or the "push and pull" technique. CONCLUSIONS In the absence of robust evidence to support the use of a specific technique, the choice of the obstetrician should be based on best available evidence. Our study suggests that the "pull", as well as the "Patwardhan" technique represent safe options to deliver an impacted fetal head.
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Affiliation(s)
- Maria Patricia Rada
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Răzvan Ciortea
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Mihai Măluțan
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Prundeanu
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Stergios K Doumouchtsis
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, Epsom, UK.,Laboratory of Experimental Surgery and Surgical Research N. S. Christeas, Athens University Medical School, Athens, Greece.,St George's University of London, London, UK.,American University of the Caribbean, School of Medicine, Pembroke Pines, Florida, USA.,School of Medicine, Ross University, Miramar, FL, USA
| | - Carmen Elena Bucuri
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Dr. Constantin Papilian Military Emergency Clinical Hospital, Cluj-Napoca, Romania
| | - Ligia Daniela Blaga
- Department of Neonatology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan Mihu
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Wyn Jones N, Mitchell EJ, Wakefield N, Knight M, Dorling J, Thornton JG, Walker KF. Impacted fetal head during second stage Caesarean birth: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 2022; 272:77-81. [PMID: 35290876 DOI: 10.1016/j.ejogrb.2022.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence of, and complication rates from, impacted fetal head at full dilatation Caesarean birth in the UK, and record what techniques were used. DESIGN Prospective observational study using the UK Obstetric Surveillance System (UKOSS). SETTING 159 (82%) of the 194 UK hospitals with obstetric units. POPULATION All women who underwent second stage Caesarean birth in the UK between 1st March and 31st August 2019. Further information was collected on cases where a dis-impaction technique was used, or the operating surgeon experienced 'difficulty' in delivering the head. METHODS Prospective observational study. MAIN OUTCOME MEASURES Technique(s) used, maternal and neonatal outcomes. RESULTS 3,518 s stage Caesarean births reported. The surgeon used a dis-impaction technique or reported 'difficulty' in 564 (16%) of these. The most common dis-impaction techniques used were manual elevation of the head by an assistant through the vagina (n = 235) and a fetal "pillow" (n = 176). Thirteen babies (2%) died or sustained severe injury. Four babies died (two directly attributable to the impacted fetal head). CONCLUSIONS Difficulty with delivery of the fetal head and the use of dis-impaction techniques during second stage Caesarean sections are common but there is no consensus as to the best method to achieve delivery and in what order.
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Affiliation(s)
- Nia Wyn Jones
- Clinical Associate Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK
| | - Eleanor J Mitchell
- Assistant Professor of Clinical Trials, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Natalie Wakefield
- Trial Manager, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Marian Knight
- Professor of Maternal and Child Population Health, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jon Dorling
- Consultant Neonatologist and Professor of Paediatrics, Neonatal Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, UK
| | - Jim G Thornton
- Emeritus Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK
| | - Kate F Walker
- Clinical Associate Professor of Obstetrics, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK.
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10
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Tamauchi S, Moriyama Y, Suzuki S, Ikeda Y, Yoshikawa N, Kajiyama H. Achievement of live birth after overcoming two gynecological malignancies treated with radical trachelectomy and medroxyprogesterone acetate therapy. J Obstet Gynaecol Res 2021; 47:4101-4105. [PMID: 34463005 DOI: 10.1111/jog.15001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/30/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022]
Abstract
Cervical cancer is a human papilloma virus-related disease, whereas endometrial cancer and atypical endometrial hyperplasia (AEH) are hormone-related diseases, so co-occurrence of the two is possible. However, scientific studies about such cases are rare. We encountered a case of cervical adenocarcinoma and AEH in a 33-year-old nulliparous woman. Two fertility-sparing treatments were performed, a radical trachelectomy for the cervical cancer and high-dose medroxyprogesterone acetate treatment for the AEH. After remission of the diseases, the patient became pregnant by in vitro fertilization and delivered a baby at 36 weeks' gestation by cesarean section. Although the patient had two uterine malignancies, proper evaluation of the diseases, consultation with the patient and her husband, and appropriate management led to fertility preservation, and live birth was achieved.
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Affiliation(s)
- Satoshi Tamauchi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Moriyama
- Department of Obstetrics and Gynecology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shiro Suzuki
- Department of Gynecologic Oncology, Aichi Cancer Center, Nagoya, Japan
| | - Yoshiki Ikeda
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuhisa Yoshikawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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11
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Committee Opinion No. 415: Impacted Fetal Head, Second-Stage Cesarean Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:406-413. [PMID: 33640101 DOI: 10.1016/j.jogc.2021.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To review the most effective clinical approaches to disengage an impacted fetal head during cesarean delivery. TARGET POPULATION Women who undergo cesarean delivery of an infant with a deeply impacted head. OPTIONS The "push" technique (from below) or the "pull" technique (reverse breech extraction). OUTCOMES Proper management of this clinical scenario can reduce maternal and perinatal morbidity and mortality. BENEFITS, HARMS, AND COSTS Using an evidence-informed approach when an impacted fetal head is anticipated has the potential to reduce maternal and fetal complications and short- and long-term harm and their associated costs. Research into the value of simulation learning, regular labour assessments, and team preparedness for possible interventions will help inform quality care. EVIDENCE The following search terms were entered into PubMed/Medline, Google Scholar, and Cochrane for the publication period 2012-2019: • 'Guidelines' 'manual' • 'Caesarean Section' • 'full dilation' • 'operative delivery' • 'impacted head' • 'Caesarean' AND 'full dilation' AND 'impacted head' • 'Caesarean' AND 'second stage of labour' OR 'second stage' AND 'impacted head' • 'Caesarean' OR 'operative delivery' AND 'impacted head' A total of 32 articles were retrieved and 24 were deemed appropriate to include as references. Many of these articles represented expert opinion. Randomized controlled trials had small sample sizes and were conducted in settings that limit the generalizability of their findings to the Canadian population.20 INTENDED USERS: Intrapartum health care providers.
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12
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Bloch C, Dore S, Hobson S. Opinion de comité n° 415 : Césarienne au deuxième stade avec enclavement de la tête fœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:414-422. [PMID: 33640102 DOI: 10.1016/j.jogc.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIF Passer en revue les stratégies cliniques les plus efficaces pour désengager une tête fœtale enclavée pendant la césarienne. POPULATION CIBLE Les femmes qui subissent une césarienne lorsque la tête fœtale est fortement enclavée. OPTIONS La technique par poussée (par le bas) ou par traction (grande extraction du siège par voie abdominale). RéSULTATS: La prise en charge adéquate de cette situation clinique peut réduire les risques de morbidité et mortalité maternelle et périnatale. BéNéFICES, RISQUES ET COûTS: Lorsque l'on anticipe un enclavement de la tête fœtale, il est possible de réduire le risque de complications maternelles et fœtales, les atteintes à court et à long terme ainsi que les coûts associés en adoptant une stratégie fondée sur des données probantes. Les recherches sur la valeur de l'apprentissage par simulation, les évaluations régulières pendant le travail et la préparation de l'équipe aux interventions possibles aideront à orienter les soins de qualité. DONNéES PROBANTES: Les termes de recherche suivants ont été utilisés dans les bases de données PubMed-Medline, Google Scholar et Cochrane pour la période de publication de 2012 à 2019 : • "Guidelines" "manual" • "Caesarean Section" • "full dilation" • "operative delivery" • "impacted head" • "Caesarean" AND "full dilation" AND "impacted head" • "Caesarean" AND "second stage of labour" OR "second stage" AND "impacted head" • "Caesarean" OR "operative delivery" AND "impacted head" Au total, 32 articles ont été récupérés et 24 ont été jugés adéquats comme références. Plusieurs de ces articles étaient des opinions d'experts. Les essais cliniques randomisés avaient des échantillons de petite taille et ont été menés dans des contextes qui limitent la généralisabilité de leurs résultats à la population canadienne20. PROFESSIONNELS CIBLES Fournisseurs de soins de santé intrapartum.
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13
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Sommerstein R, Marschall J, Atkinson A, Surbek D, Dominguez-Bello MG, Troillet N, Widmer AF. Antimicrobial prophylaxis administration after umbilical cord clamping in cesarean section and the risk of surgical site infection: a cohort study with 55,901 patients. Antimicrob Resist Infect Control 2020; 9:201. [PMID: 33349269 PMCID: PMC7754587 DOI: 10.1186/s13756-020-00860-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization (WHO) recommends administration of surgical antimicrobial prophylaxis (SAP) in cesarean section prior to incision to prevent surgical site infections (SSI). This study aimed to determine whether SAP administration following cord clamping confers an increased SSI risk to the mother.
Methods Study design: Cohort. Setting: 75 participating Swiss hospitals, from 2009 to 2018. Participants: A total of 55,901 patients were analyzed. Main outcome measures: We assessed the association between SAP administration relative to incision and clamping and the SSI rate, using generalized linear multilevel models, adjusted for patient characteristics, procedural variables, and health-care system factors. Results SAP was administered before incision in 26′405 patients (47.2%) and after clamping in 29,496 patients (52.8%). Overall 846 SSIs were documented, of which 379 (1.6% [95% CI, 1.4–1.8%]) occurred before incision and 449 (1.7% [1.5–1.9%]) after clamping (p = 0.759). The adjusted odds ratio for SAP administration after clamping was not significantly associated with an increased SSI rate (1.14, 95% CI 0.96–1.36; p = 0.144) when compared to before incision. Supplementary and subgroup analyses supported these main results. Conclusions This study did not confirm an increased SSI risk for the mother in cesarean section if SAP is given after umbilical cord clamping compared to before incision.
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Affiliation(s)
- Rami Sommerstein
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland. .,Swissnoso, National Center for Infection Control, Bern, Switzerland.
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.,Swissnoso, National Center for Infection Control, Bern, Switzerland
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, University of Bern, Bern, Switzerland.,Swiss Society of Obstetrics and Gynaecology, Bern, Switzerland
| | - Maria Gloria Dominguez-Bello
- Department of Biochemistry and Microbiology, Rutgers School of Environmental and Biological Science, New Brunswick, NJ, USA
| | - Nicolas Troillet
- Swissnoso, National Center for Infection Control, Bern, Switzerland.,Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Andreas F Widmer
- Swissnoso, National Center for Infection Control, Bern, Switzerland. .,Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland.
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14
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Hofmeyr GJ, Singata-Madliki M. The second stage of labor. Best Pract Res Clin Obstet Gynaecol 2020; 67:53-64. [PMID: 32360366 DOI: 10.1016/j.bpobgyn.2020.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/19/2020] [Accepted: 03/28/2020] [Indexed: 11/26/2022]
Abstract
The second stage of labor, from full cervical dilatation to complete birth of the baby or babies, constitutes the time of greatest risk for the baby. Birth attendants at all levels require training in the skills necessary to overcome difficulties that may arise unexpectedly during the second stage, particularly poor progress, shoulder dystocia, and breech birth. The mother should receive emotional support and encouragement to bear down instinctively when she feels the urge to do so, in the position she feels enables her to push most effectively, but not the supine position. The baby's heart rate should be monitored after every second contraction. Recent guidelines such as those of the World Health Organization(WHO) recommend allowing 2-3 h for the second stage of labor. Uterine fundal pressure has not been shown to be effective, and may be dangerous. Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience.
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Affiliation(s)
- G J Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health, East London, South Africa; Obstetrics and Gynaecology Department, University of Botswana, Gaborone, Botswana.
| | - M Singata-Madliki
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health, East London, South Africa
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15
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Gil M, Chill HH, Kogan L, Porat S, Levitt L, Eliasi E, Dior U. Preferred way of delivery of the impacted fetal head in cesarean sections during second stage of labor. J Obstet Gynaecol Res 2019; 45:2386-2393. [PMID: 31502321 DOI: 10.1111/jog.14115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/25/2019] [Indexed: 11/30/2022]
Abstract
AIM To compare maternal and neonatal outcomes between the 'head first' and 'legs first' delivery methods during a second stage cesarean section. METHODS We conducted a retrospective study between January 2009 and May 2015 at a large public university tertiary referral center. Included were all women who underwent cesarean delivery with a fully dilated cervix and a fetal head at the level of the ischial spines or below. The study population was divided into two groups according to way of fetal delivery: The 'legs first' (reverse breech) method and the 'head first' method. Demographics and maternal and fetal outcomes were retrieved for both groups. RESULTS During the study period 447 women underwent a cesarean section while their cervix was fully dilated. Of them, 321 met the inclusion criteria: One hundred and twenty-one (38%) were delivered using the 'legs first' method and 200 (62%) were delivered using the 'head first' method. Indication for surgery and fetal head station was similar for both groups. While no difference in overall intraoperative uterine incision extension rate was observed, a higher rate of uterine incision extension was demonstrated in the 'head first' group in cases in which the second stage was longer than 180 min (33 vs 8 cases, P = 0.02). No differences in maternal postoperative complication rates and neonatal outcomes were observed. CONCLUSION Fetal extraction via the 'legs first' method during prolonged second stage of labor may lower maternal morbidity. Method of delivery does not seem to have an effect on neonatal outcomes.
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Affiliation(s)
- Moran Gil
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Henry H Chill
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Liron Kogan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shay Porat
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lorinne Levitt
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Elior Eliasi
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Uri Dior
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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