The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial

PURPOSE

The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms.

METHODS

A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range.

RESULTS

130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups.

CONCLUSION

Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.

Clinical features of isolated Fallopian tube torsion: evidence from a large series

We aimed at studying isolated Fallopian tube torsion (IFTT) in a relatively large cohort of women and to evaluate different features of IFTT in comparison to a large cohort of women with non-IFTT adnexal torsion (NIAT). This was a retrospective cohort study. We included women with surgically confirmed ovarian and/or Fallopian tube torsion between March 2011 and June 2020. Fifty-four cases of IFTT were surgically confirmed during the study period and were compared to 422 surgically confirmed NIAT. The rate of controlled ovarian hyperstimulation treatments, current pregnancy, and vomiting was lower in the IFTT group compared with the NIAT group. Cervical tenderness and vaginal discharge were more common in the IFTT group. Oedematous and enlarged ovaries were less common in the IFTT group. In multivariate regression analysis, the following factors were independently associated with IFTT: (i) vaginal discharge [adjusted odds ratio (aOR) 95% CI 8.16, 1.98-33.55]; (ii) cervical motion tenderness (aOR 95% CI 2.71, 1.01-7.29); (iii) fertility treatments (aOR 95% CI 0.26, 0.70-0.77); (iv) previous abdominal surgery (aOR 95% CI 0.46, 0.22-0.96); (v) vomiting (aOR 95% CI 0.38, 0.19-0.76); and (vi) enlarged ovary (aOR 95% CI 0.34, 0.18-0.65). In conclusion, we have identified factors positively and negatively associated with IFTT in a large cohort of women with adnexal torsion.

The association between uterine scar defect (niche) and the presence of symptoms

RESEARCH QUESTION

Is there association between the presence of a uterine niche and the presence of symptoms?

DESIGN

This cross-sectional study was conducted at a single tertiary medical centre. All women who underwent Caesarean section from January 2017 to June 2020 were invited to the gynaecological clinics, and requested to complete a questionnaire regarding symptoms related to the presence of a niche (heavy menstrual bleeding, intermenstrual spotting, pelvic pain, infertility). Transvaginal two-dimensional ultrasonography was performed to assess the uterus and uterine scar characteristics. The primary outcome was defined as the presence of a uterine niche, evaluated by length, depth, residual myometrial thickness (RMT) and ratio between the residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT).

RESULTS

Of 524 women who were eligible and scheduled for evaluation, 282 (54%) completed the follow-up; 173 (61.3%) were symptomatic and 109 (38.6%) asymptomatic. Niche measurements, including RMT/AMT ratio, were comparable between the groups. In a sub-analysis of each symptom, heavy menstrual bleeding and intermenstrual spotting were associated with reduced RMT (P = 0.02 and P = 0.04, respectively) compared with women with normal menstrual bleeding. An RMT less than 2.5 mm was significantly more prevalent in women reporting heavy menstrual bleeding (11 [25.6%] versus 27 [11.3%]; P = 0.01] and new infertility (7 [16.3%] versus 6 [2.5%]; P = 0.001]. In logistic regression analysis, infertility was the only symptom associated with an RMT less than 2.5 mm (B = 1.9; P = 0.002).

CONCLUSIONS

A reduced RMT was found to be associated with heavy menstrual bleeding and intermenstrual spotting, while values below 2.5 mm were also associated with infertility.

Prophylactic salpingectomy with delayed oophorectomy as a two-staged alternative for primary prevention of ovarian cancer in BRCA1/2 mutation carriers: women's point of view

OBJECTIVE

This study aimed to determine BRCA -mutation carrier women's interest and acceptability of participating in a study examining prophylactic salpingectomy with delayed oophorectomy (PSDO) as an alternative to the current recommendation for bilateral salpingo-oophorectomy for risk reduction.

METHODS

This is a cross-sectional questionnaire-based study. All women visiting the high-risk clinics for hereditary breast and ovarian cancer in a single tertiary medical center were asked to complete a questionnaire concerning the two-stage approach from October 2018 to December 2019. Before completing the questionnaire, detailed explanation was given by a senior physician regarding the procedure, related background, possible risks, and benefits.

RESULTS

The study population included 293 women, of whom 183 (62.4%) were BRCA1 mutation carriers, 97 (33.1%) were BRCA2 mutation carriers, and 13 (4.4%) had unknown familial mutation. Risk-reducing surgery was completed in 160 (55.17%) of the women. First-degree and second-degree family history was reported in 166 (57.24%) and 52 (17.9%) of the women, respectively. Among women surveyed, more than half of the women (n = 66 [51%]) who had yet to undergo risk-reducing surgery reported interest in having PSDO. Similarly, among those who had already received prophylactic surgery, 64 (40%) also considered PSDO to be an acceptable alternative. Multivariate logistic regression analysis found family history of related malignancies to be the only independent factor associated with reduced interest in a study of PSDO (odds ratio, 0.15 [95% confidence interval, 0.29-0.77]; P = 0.02).

CONCLUSIONS

Overall, BRCA -mutation carrier women indicated interest in PSDO risk-reducing surgery, taking into consideration the potential additional risk. These findings suggest that a clinical study exploring the equivalence of PSDO as alternative treatment is feasible.

One step total hysteroscopic removal of cervical ectopic pregnancy

Cervical ectopic pregnancy is a rare life-threatening obstetrical complication due to the potential of severe maternal hemorrhage. Hysterectomy was considered the gold standard treatment. However, advances in technology that allow early diagnosis have led to the development of alternative, more conservative treatments, including medical therapy and minimally invasive surgery. In this Surgeon's Corner article with accompanying video, we describe a one-step total hysteroscopic approach for the treatment of cervical ectopic pregnancy, performed in an asymptomatic patient with a non-viable cervical ectopic pregnancy at an early gestational age. The hysteroscopic resection was performed using a TruClear 5C mini-hysteroscope with dense tissue shaver. The patient was discharged 24 hours after the procedure with an uneventful postoperative course. We conclude that with proper patient selection, the one step total hysteroscopic approach for the treatment of cervical ectopic pregnancy may offer a surgical treatment that is effective and safe.

Perinatal Outcome Following the Suspension of Intrapartum Oxygen Treatment

Objective To evaluate whether the suspension of intrapartum maternal oxygen supplementation for non-reassuring fetal heart rate is associated with adverse perinatal outcomes. Study Design A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On 16/4/2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the seven months between 16/4/2020 and 14/11/2020. The control group included individuals that underwent labor during the seven months before 16/4/2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. Results The study group included 4932 individuals, compared to 4906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome [187 (3.8%) vs 120 (2.4%), p<0.001], including the rate of abnormal cord arterial pH <7.1 [119 (2.4%) vs. 56 (1.1%), p<0.01]. A higher rate of cesarean section due to non-reassuring fetal heart rate was noted in the study group [320 (6.5%) vs. 268 (5.5%), p=0.03]. A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome [aOR 1.60 (95% CI, 1.26-2.01)] while adjusting for labor induction, oxytocin administration, epidural analgesia, and presence of meconium-stained fluid. Conclusions Suspension of intrapartum oxygen treatment for non-reassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate.

Proteomic signature for detection of high-grade ovarian cancer in germline BRCA mutation carriers

No current screening methods for high-grade ovarian cancer (HGOC) guarantee effective early detection for high-risk women such as germline BRCA mutation carriers. Therefore, the standard-of-care remains risk-reducing salpingo-oophorectomy (RRSO) around age 40. Proximal liquid biopsy is a promising source of biomarkers, but sensitivity has not yet qualified for clinical implementation. We aimed to develop a proteomic assay based on proximal liquid biopsy, as a decision support tool for monitoring high-risk population. Ninety Israeli BRCA1 or BRCA2 mutation carriers were included in the training set (17 HGOC patients and 73 asymptomatic women), (BEDOCA trial; ClinicalTrials.gov Identifier: NCT03150121). The proteome of the microvesicle fraction of the samples was profiled by mass spectrometry and a classifier was developed using logistic regression. An independent cohort of 98 BRCA mutation carriers was used for validation. Safety information was collected for all women who opted for uterine lavage in a clinic setting. We present a 7-protein diagnostic signature, with AUC >0.97 and a negative predictive value (NPV) of 100% for detecting HGOC. The AUC of the biomarker in the independent validation set was >0.94 and the NPV >99%. The sampling procedure was clinically acceptable, with favorable pain scores and safety. We conclude that the acquisition of Müllerian tract proximal liquid biopsies in women at high-risk for HGOC and the application of the BRCA-specific diagnostic assay demonstrates high sensitivity, specificity, technical feasibility and safety. Similar classifier for an average-risk population is warranted.

Should expectant management of heterotopic pregnancy be considered?

KEY MESSAGE

Both expectant and interventional managements are acceptable in selected cases, when heterotopic pregnancy is diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

PURPOSE

Heterotopic pregnancy, though relatively rare, is potentially a life-threatening condition. The aim of the study is to compare expectant versus interventional management of heterotopic pregnancies.

METHODS

This is a retrospective cohort study including all women diagnosed with heterotopic pregnancy on ultrasound from March 2011 to December 2020 in a single medical center. Expectant and interventional management outcomes were compared. Primary outcome was defined as live birth.

RESULTS

Forty-one women were diagnosed with heterotopic pregnancy during the study period. Management was expectant in 10 (24.4%) and interventional in 31 (75.6%) of the women. Expectant management was considered when the patient was stable, and the attending physician decided that the ectopic pregnancy did not continue to develop. Interventions included laparoscopic salpingectomy (n = 26), laparoscopic cornual resection (n = 2), laparotomic cornual resection (n = 1) and gestational sac aspiration (n = 2). The intra-uterine pregnancy continued to develop in 6 (60.0%) and 22 (81.5%) of the women in the expectant and interventional groups, respectively (p = 0.52). All women managed expectantly reached term delivery, as opposed to 17/22 (77.3%) in the intervention management group (p = 0.60). Multivariate analysis found serum β-hCG level as the only independent parameter associated with ongoing pregnancy rate (B = 0.001, p = 0.04).

CONCLUSIONS

Both expectant and interventional management were found to be acceptable when heterotopic pregnancy was diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

The effect of Covid-19 mRNA vaccine on serum anti-Müllerian hormone levels

STUDY QUESTION

Does the administration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine have an association with ovarian reserve as expressed by circulating anti-Müllerian hormone (AMH) levels?

SUMMARY ANSWER

Ovarian reserve as assessed by serum AMH levels is not altered at 3 months following mRNA SARS-CoV-2 vaccination.

WHAT IS KNOWN ALREADY

A possible impact of SARS-CoV-2 infection or vaccination through an interaction between the oocyte and the somatic cells could not be ruled out, however, data are limited.

STUDY DESIGN, SIZE, DURATION

This is a prospective study conducted at a university affiliated tertiary medical center between February and March 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Study population included reproductive aged women (18-42 years) that were vaccinated by two Pfizer-BioNTech Covid-19 vaccines (21 days apart). Women with ovarian failure, under fertility treatments, during pregnancy, previous Covid-19 infection or vaccinated were excluded from the study. Blood samples were collected for AMH levels before the first mRNA vaccine administration. Additional blood samples after 3 months were collected for AMH and anti-Covid-19 antibody levels. Primary outcome was defined as the absolute and percentage change in AMH levels.

MAIN RESULTS AND THE ROLE OF CHANCE

The study group consisted of 129 women who received two mRNA vaccinations. Mean AMH levels were 5.3 (±SD 4.29) µg/l and 5.3 (±SD 4.50) µg/l at baseline and after 3 months, respectively (P = 0.11). To account for possible age-specific changes of AMH, sub-analyses were performed for three age groups: <30, 30-35 and >35 years. AMH levels were significantly lower for women older than 35 years at all times (P = 0.001 for pre and post vaccination AMH levels versus younger women). However, no significant differences for the changes in AMH levels before and after vaccinations (Delta AMH) were observed for the three age groups (P = 0.46). Additionally, after controlling for age, no association was found between the degree of immunity response and AMH levels.

LIMITATIONS, REASONS FOR CAUTION

Although it was prospectively designed, for ethical reasons we could not assign a priori a randomized unvaccinated control group. This study examined plasma AMH levels at 3 months after the first vaccination. It could be argued that possible deleterious ovarian and AMH changes caused by the SARS-CoV-2 mRNA vaccinations might take effect only at a later time. Only longer-term studies will be able to examine this issue.

WIDER IMPLICATIONS OF THE FINDINGS

The results of the study provide reassurance for women hesitant to complete vaccination against Covid 19 due to concerns regarding its effect on future fertility. This information could be of significant value to physicians and patients alike.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by Sheba Medical Center institutional sources. All authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

The study protocol was approved by the 'Sheba Medical Center' Ethical Committee Review Board (ID 8121-21-SMC) on 8 February 2021 and was registered at the National Institutes of Health (NCT04748172).

A clinical prediction model for adnexal torsion in pediatric and adolescent population

PURPOSE

To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women.

METHODS

A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model.

RESULTS

Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23-8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19-8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02-7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively.

CONCLUSIONS

We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III.

Blood fatty acid analysis reveals similar n-3 fatty acid composition in non-pregnant and pregnant women and their neonates in an Israeli pilot study

Maternal docosahexaenoic acid (DHA) is required during pregnancy to supply for normal fetal growth and development. This pilot study aimed to assess the unknown fatty acid (FA) composition in a cohort of non-pregnant and pregnant Israeli women at term and their offspring on a normal diet without n-3 FA supplementation. The fatty acid profile, analyzed using gas chromatography, showed significantly higher plasma monounsaturated (MUFA) and lower n-6 FA percent distribution with similar n-3 index, in pregnant compared to non-pregnant women. RBC exhibited significantly higher MUFA with similar n-3 index, in pregnant compared to non-pregnant women. N-3 FA significantly correlated between neonates' plasma, with higher n-3 index, and pregnant women's DHA. Conclusion: DHA levels in non-pregnant and pregnant Israeli women at term were comparable and the DHA in pregnant women's plasma positively correlated with their neonate's level, suggesting an efficient mother-fetus FA transfer and/or fetal fatty acid metabolism to longer FA products.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

Women at advanced maternal age with dichorionic twin pregnancies had significantly higher rates of gestational diabetes mellitus, cesarean deliveries and fetal weight discordancy as compared with younger women. In contrast, the incidence of preeclampsia was not affected by maternal age.

The influence of lifestyle of OB/GYN female residents on gynecological and obstetrical outcomes: A cross-sectional study

OBJECTIVE

To learn the influence of obstetrics and gynecology (OB/GYN) female residents' lifestyle on obstetric and gynecological characteristics compared to women matched by age from the general population.

STUDY DESIGN

A cross-sectional multicenter study including OB/GYN female residents from ten different hospitals in Israel, who completed an internet questionnaire published during 2017-2018, that were compared to women matched by age from the general population. Questions dealt with lifestyle habits, obstetrical and gynecological outcomes. Data are presented as median and inter-quartile range.

RESULTS

During the study period 97 women completed the questionnaire, of them 56 (57.7%) OB/GYN female residents and 41(42.3%) controls. No statistically significant differences were found between the groups regarding age, marital status, gravidity and parity. However, lifestyle characteristics reported by OB/GYN female residents differed compared to controls: OB/GYN female residents found their work more stressogenic [53 (94.6%) vs. 20 (48.8%); p = 0.001], suffered from deprived sleep [42(75.6%) vs. 13(31.8%); p = 0.001], were less punctilious on dental hygiene [13(23.2%) vs. 27(65.8%); p = 0.001] and reported maintaining a less healthy diet [35(62.5%) vs. 15(36.6%); p = 0.003]. Despite these differences, general happiness reported by both groups was comparable (35(62.5%) vs. 27(65.9%) for OB/GYN and control women respectively; p = 0.73). Pregnancy rate was found to be more than double in the resident's group [30 (53.6%) vs. 9 (22%); p = 0.002], with no differences in the rates of: complications during pregnancy [51(91.1%) vs. 38(92.7%); p = 0.78]; abortions [10 (17.9%) vs. 8 (19.5%); p = 0.84]; augmentation of labor [5 (9%) vs. 7 (17.1%); p = 0.18]; or cesarean deliveries [7(12.5%) vs. 7(17%); p = 0.48]. Logistic regression analysis found both parity and residency as independent variables significantly associated with pregnancy rate [(B = 0.69, p = 0.047), (B = 1.95, p = 0.016), respectively].

CONCLUSION

Although resident women in OB/GYN reported on more adverse lifestyle parameters, comparable obstetric and gynecological outcomes were seen, with residency and parity being independently associated with higher pregnancy rate.

Adnexal torsion recurrence-is the adnexal twist degree a risk factor? A retrospective cohort study

OBJECTIVE

To evaluate whether the adnexal twist degree is related to torsion recurrence and whether there is a dose-dependent correlation.

DESIGN

A retrospective cohort study.

SETTING

Single tertiary medical centre.

POPULATION

The study includes non-pregnant patients operated, for the first time, for adnexal torsion, between 2011 and 2018.

METHODS

Information regarding the degree of adnexal twist was collected from surgical reports. Recurrence was identified using a computerised database and ascertained via telephone with a response rate of 87.2% (253/290).

MAIN OUTCOME MEASURES

Adnexal torsion recurrence rate.

RESULTS

A total of 182 women who had undergone laparoscopic detorsion met the inclusion criteria. Twenty-two had torsion recurrence (12.1%). Adnexal twist degree in the primary event was associated with a higher recurrence risk: 4.3% of women with twist degree ≤360 (n = 3/70), 14.5% of women with twist degree of 361-720 (n = 9/62) and 20% of women with twist degree >720 (n = 10/50) (P = 0.03). The median twist degree was 540 (interquartile range [IQR] 360-855) and 720 (IQR 675-1080) degrees in the control and study groups, respectively (P = 0.005). Additional possibly associated factors for recurrence were evaluated. Age emerged as a possible risk factor, with a median age of 19 years in the recurrence group (IQR 14-27 years) versus 28.5 (IQR 19-36 years) in the non-recurrence group (P < 0.01). Logistic regression analysis revealed that together with age, adnexal twist degree remained significantly associated with torsion recurrence (odds ratio [OR] 1.98, 95% CI 1.09-3.61; P = 0.02).

CONCLUSION

Adnexal twist degree was found to be positively associated with the risk of torsion recurrence.

TWEETABLE ABSTRACT

Adnexal twist degree was found to be positively associated with the risk of torsion recurrence.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

Enlarged ovary is independently associated with preoperative rAT diagnosis. Coupled with information regarding the previous surgical approach in previous AT and current IVF use, these factors could be used to efficiently predict rAT among women with a previous AT.

Placenta accreta spectrum in subsequent pregnancy following myomectomy

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY MESSAGE

Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality.

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

AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

While a nonsignificant decrease in oocyte recovery rate was found in follicles ≥24 mm, the zygote and TQE per follicle were comparable.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

Polyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling.

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

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.

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

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

Tampon loss - management among adolescents and adult women

The widespread use of tampons carries a risk of tampon loss due to imperfect use. We performed a retrospective study including all women attending the emergency room (ER) with the complaint of tampon loss during 2011-2018. Overall, 72 women presented to the ER with a complaint of tampon loss. In 25% (18/72), a lost tampon was found on physical examination. The lost tampon was found in a higher rate among adolescents as compared to older women (4 (80%) vs. 14 (21%), 15.1, p = .01). Time from tampon loss to referral for evaluation was shorter among adolescents as compared to older women (7 ± 3 vs. 21 ± 21 h, p = .007). In most adolescents with a complaint of a lost tampon - it was eventually found on pelvic examination, as opposed to older women, in whom a finding was present in only one-fifth of cases. This highlights the importance of thorough examination of adolescents presenting due to tampon loss. The study protocol was approved by the Sheba Medical Center review board (March 15, 2018), 6345-19-SMC.IMPACT STATEMENTWhat is already known on this subject? Very little is known regarding the distinguished phenomena of tampon loss among adult females.What do the results of this study add? In most adolescents referred due to tampon loss - a tampon was found on pelvic examination, as opposed to older women.What are the implications of these findings for future clinical practice and/or further research? In most adolescents referred due to tampon loss - a tampon will be found on pelvic examination, as opposed to older women, in whom a finding is present in only one-fifth of cases. This highlights the importance of thorough examination of adolescents presenting with a loss of tampon.

Do Follicles of Obese Patients Yield Competent Oocytes/Embryos?

AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

Oocyte recovery rate from follicles >15 mm is unrelated to patients' BMI. Moreover, the oocytes recovered from obese patients are competent yielding comparable zygote and TQE per follicle/oocyte, compared with nonobese patients. Further investigation is required to strengthen this finding.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.

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

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

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

Objective

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

Study design

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

Results

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

Conclusion

Women post preservative cesarean delivery using uterine artery embolization due to placenta accrete have lower ovarian reserve compare to controls matched by age.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

Satisfaction with long-term outcome and rate of reinterventions after magnetic resonance-guided focused ultrasound treatment or laparoscopic myomectomy for uterine fibroid tumors was comparable. Further larger randomized trials are needed to confirm these findings.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

Abdominal ultrasound examination in this population has a low clinical yield. The decision to perform an abdominal ultrasound must be individualized based on the obstetric history, clinical findings, and the level of liver enzymes.