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This study aimed at determining the proportion of women who receive antenatal corticosteroids (ACS) within the optimal time window before birth based on the indication for ACS, and to explore in more detail indications that are associated with suboptimal timing.A retrospective cohort study of all women who received ACS in a single tertiary center between 2014 and 2017. The primary outcome was an ACS-to-birth interval ≤ 7 days. Secondary outcomes were ACS-to-birth interval of ≤ 14 days, and the proportion women who received ACS but ultimately gave birth at term (≥ 37A total of 1261 women met the study criteria, of whom 401 (31.8%) and 569 (45.1%) received ACS within ≤ 7 days and ≤ 14 days before birth, respectively, and 203 (16.1%) ultimately gave birth at term. The proportion of women who received ACS within 7 days before birth was highest for women with preeclampsia (50.4%), and was lowest for women with an incidental finding of a short cervix (8.4%). In the subgroup of women with an incidental finding of a short cervix, the likelihood of optimal timing was not related to the magnitude of cervical shortening, history of preterm birth, multifetal gestation, presence of cervical funneling, or the presence of cervical cerclage.Over two-thirds of infants who are exposed to ACS do not get the maximal benefit from this intervention. The current study identified clinical indications for ACS that are associated with suboptimal timing of ACS where more research is needed to develop quantitative, indication-specific prediction models to guide the timing of ACS.

To evaluate the association between a single abnormal value on a 3-h 100 g oral glucose tolerance test (OGTT) results and future type-2 diabetes mellitus (Type-2 DM). Retrospective cohort study of women between 18 and 45 years of age who underwent a 3-h OGTT during pregnancy and delivered in a tertiary medical center between 2007 and 2014. The women were followed for a median period of 64 months postpartum. According to OGTT values, women were divided into three groups: normoglycemic (normal OGTT), single abnormal OGTT value (SAV) and gestational diabetes mellitus (two or more abnormal OGTT values, GDM). General pre-pregnancy characteristics, cardiovascular risk factors and future diagnosis of Type-2 DM, as the primary outcome, were recorded. During the study period, 5295 women underwent an OGTT and were followed for a median period of 64 months (interquartile range of 32). The cohort was divided as following: 3639 (68.73%) were normoglycemic, 854 (16.13%) had a SAV in the OGTT and 802 (15.15%) were diagnosed with GDM. Compared with normoglycemic controls, women with SAV and GDM tended to be older (32.20, 33.10 and 31.35 years for SAV, GDM and controls, respectively, p

To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD. This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries. Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73–8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39–0.97, and aOR 0.49; 95% CI 0.25–0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC. Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.

To evaluate whether induction of labor (IOL), as compared with expectant management, in gestational diabetes mellitus (GDM) mothers at term (between 370/7 and 406/7), decreases caesarean section (CS) rate and the rate of adverse composite neonatal outcomes. A retrospective cohort study, of all women with GDM and a singleton gestation who delivered at term in a single, tertiary, university-affiliated medical center (2007–2014). We compared outcomes of women who underwent IOL at each week of gestation between 370/7 and 406/7 weeks with women who were managed expectantly. The primary outcome was CS rate. Overall, 2472 GDM patients included in the study, of which 880 women had IOL. CS rate was not found to be significantly different between the groups at any gestational age. IOL at 37 weeks was associated with adverse composite neonatal outcome (aOR 2.2, 95% CI 1.4–3.6) and NICU admission (aOR 2.5, 95% CI 1.4–4.4). At 38 weeks, with NICU admission (aOR 2.0, 95% CI 1.4–2.9), and at 39 weeks with fracture of the clavicle. In a sub-analysis of nulliparous women, IOL at 37 weeks had higher odds of NICU admission and adverse composite neonatal outcomes, at 38 weeks with CS and at 39 weeks with fracture of the clavicle. IOL in GDM mothers at term does not reduce CS rate and may be associated with increased CS rate among nulliparous women at 38 weeks. It is also associated with increased risk for adverse composite neonatal outcome or NICU admission when done prior to 390/7 weeks.

To evaluate the association between a single abnormal value on a 3-h 100 g oral glucose tolerance test (OGTT) results and future type-2 diabetes mellitus (Type-2 DM).Retrospective cohort study of women between 18 and 45 years of age who underwent a 3-h OGTT during pregnancy and delivered in a tertiary medical center between 2007 and 2014. The women were followed for a median period of 64 months postpartum. According to OGTT values, women were divided into three groups: normoglycemic (normal OGTT), single abnormal OGTT value (SAV) and gestational diabetes mellitus (two or more abnormal OGTT values, GDM). General pre-pregnancy characteristics, cardiovascular risk factors and future diagnosis of Type-2 DM, as the primary outcome, were recorded.During the study period, 5295 women underwent an OGTT and were followed for a median period of 64 months (interquartile range of 32). The cohort was divided as following: 3639 (68.73%) were normoglycemic, 854 (16.13%) had a SAV in the OGTT and 802 (15.15%) were diagnosed with GDM. Compared with normoglycemic controls, women with SAV and GDM tended to be older (32.20, 33.10 and 31.35 years for SAV, GDM and controls, respectively, p 0.001); with higher rates of pre-pregnancy obesity (18.62%, 20.77% and 13.22% for SAV, GDM and controls, respectively, p 0.001), pre-pregnancy hyperlipidemia (13.35%, 15.30% and 10.52% for SAV, GDM and controls, respectively, p = 0.021) and pre-pregnancy chronic hypertension (5.50%, 4.43% and 3.18% for SAV, GDM and controls, respectively, p = 0.01). Post-pregnancy Type-2 DM was diagnosed at a higher rate among women with SAV or GDM (2.69% for SAV, 7.39% for GDM and 0.66% for normoglycemic controls, p 0.001). Using a cox proportional hazard regression, SAV and GDM were significantly and independently associated with a higher rate of future overt type-2 diabetes (adjusted aOR 3.59 for SAV and 11.38 for GDM, p 0.001). In a sub-analysis of the OGTT values, overall, abnormal fasting glucose had the highest correlation with developing future Type-2 DM (8.95% compared with 6.02% for OGTT_60, 6.03% for OGTT_120 and 7.35% for OGTT_180, p 0.001). A predictive model, combining multiple risk factors, as pre-pregnancy obesity and hypertension with SAV complicating the index pregnancy showed a risk as high as 3.40% for developing future Type-2 DM.SAV is independently associated with a significant higher rate of future Type-2 DM, as early as 5 years following the index pregnancy.

To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD.This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries.Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73-8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39-0.97, and aOR 0.49; 95% CI 0.25-0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC.Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.

Uterine activity plays a crucial role in labor, especially when utero-tonic materials are administered. We aimed to determine the electrical responsiveness of the uterine musculature to labor augmentation with oxytocin using electrical uterine myography (EUM) technology, and to assess whether the kinetics of the EUM device may serve as a predictor for successful vaginal delivery. EUM prospectively measured electrical uterine activity in women with singleton gestations at term (≥ 37 + 0 weeks) undergoing labor augmentation by oxytocin administration. The results were reported as the EUM index, which represented the mean electrical activity in 10-min intervals and measured in units of microwatt per second (mW/s). Measurements were performed at least 30 min before oxytocin initiation and until at least four contractions per 10 min were recorded by standard tocodynamometry. The delta EUM index was defined as the difference between the mean EUM index before and after the initiation of oxytocin. The mean EUM index increased significantly during oxytocin augmentation in all the parturients (P

To evaluate the best performing formula for macrosomia prediction in pregnancies complicated by diabetes.A retrospective analysis was performed of 1060 sonographic fetal biometrical measurements performed within 7 days of delivery in term pregnancies (37-42 gestational weeks) complicated by diabetes. Sonographic prediction of macrosomia (≥ 4000, ≥ 4250, and ≥ 4500 g) was evaluated utilizing ten previously published formulas by: (1) calculating for each macrosomia threshold the sensitivity, specificity, positive and negative predictive value, and ± likelihood ratio for macrosomia prediction; (2) comparing the systematic and random error and the proportion of estimates 10% of birth weights between macrosomic and non-macrosomic neonates. Best performing formula was determined based on Euclidean distance.97 (9.2%) macrosomic neonates ( 4000 g) were included. Median birth weight was 3380 (1866-3998) g for non-macrosomic and 4198 (4000-5180) g for macrosomic neonates. Higher macrosomia cutoff was associated with higher specificity and lower sensitivity. We found a considerable variation between formulas in different accuracy parameters. Hadlock's formula (1985), based on abdominal circumference, femur length, head circumference and biparietal diameter, had the shortest Euclidean distance, reflecting the highest accuracy.Prediction of macrosomia among women with diabetes differs significantly between formulas. In our cohort, the best performing formula for macrosomia prediction was Hadlock's formula (1985).

To determine neonatal birthweight (BW) thresholds for adverse maternal and neonatal outcome following vaginal delivery. A retrospective cohort study of all women with singleton pregnancies who underwent vaginal delivery in a university-affiliated tertiary hospital (1996–2015). The association between BW and adverse outcome in neonates with BW ≥ 3500 g (> 90th centile BW at 37 weeks’ gestation) with 100 g-increment groups was explored. Pregnancies complicated by diabetes mellitus, fetal anomalies or cesarean deliveries were excluded. The composite neonatal outcome was defined as shoulder dystocia or brachial plexus injury. The composite maternal outcome was defined as postpartum hemorrhage or third- or fourth-degree perineal tears. Of the 121,728 deliveries during the study period, 26,920 (22.1%) met inclusion criteria. Of these, 1024 (3.8%) had a composite adverse maternal outcome and 947 (3.5%) had a composite adverse neonatal outcome. The rates of composite maternal outcomes increased significantly only at a BW of 4800 g and above. The composite neonatal outcomes increased significantly only at a BW of 4400 g and above. In multivariate analysis, after subcategorizing our cohort into 3 BW groups [3500–3999 g (control, n = 23,030); 4000–4399 g (n = 3494); ≥ 4400 g (n = 396)], BW was associated with adverse neonatal outcomes in a dose-dependent manner. In the BW ≥ 4400 g group, to prevent one case of shoulder dystocia or Erb’s palsy, 12 cesarean deliveries needed to be performed. For non-diabetic mothers who deliver vaginally, neonatal BW ≥ 4400 g was associated with a significant increase in adverse neonatal outcomes, whereas neonatal BW ≥ 4800 g was associated with a significant increase in adverse maternal outcomes.

Increased birthweight is a risk factor for early neonatal complications, as well as cardiovascular and metabolic disease later in adulthood. We aimed to assess birthweight trends and the rate of large for gestational age newborns in women in their third delivery according to birthweight in the first and second deliveries. A retrospective cohort study of all women who delivered their first three consecutive deliveries in a single medical center (1994–2013). Only non-diabetic women with term (≥ 37 weeks) singleton deliveries in all three deliveries were included. BW centile (according to local gender- and gestational age-specific birth curves) trends between deliveries was assessed. In addition, the risk for large for gestational age (≥ 90th centile) infants in the third delivery was assessed according to the presence or absence of large for gestational age in previous deliveries. Pregnancies complicated by multiple gestations, preeclampsia, chronic or gestational hypertension or fetal anomalies were excluded. Of the 121,728 deliveries during the study period, 3521 women (10,563 deliveries [8.6%]) met inclusion criteria. Mean birthweight centile in the first, second and third deliveries were 47.2 ± 26.3, 58.3 ± 25.8 and 61.5 ± 24.7, respectively (p

To stratify maternal and neonatal outcomes of trials of labor after previous cesarean delivery (TOLAC) by gestational age. Retrospective cohort study of all singleton pregnancies with one previous cesarean delivery in TOLAC at term between 2007 and 2014. We compared outcomes of delivery at an index gestational week, with outcomes of women who remained undelivered at this index gestational week (ongoing pregnancy). Odds ratios and 95% confidence intervals were adjusted for maternal age, previous vaginal delivery, induction of labor, epidural use, presence of meconium, and birth weight > 4000 g. Overall, 2849 women were eligible for analysis. Of those, 2584 (90.7%) had a successful TOLAC and 16 women (0.56%) had uterine rupture. Those rates did not differ significantly for any gestational age (GA) group. Following adjustment for possible confounders, GA was not found to be independently associated with adverse maternal or neonatal outcomes. Among women at term with a single previous cesarean delivery, GA at delivery was not found to be an independent risk factor for TOLAC success or uterine rupture. We suggest that GA by itself will not serve as an argument for or against TOLAC.

To estimate the association of fetal head position prior to vacuum extraction (VE) and pregnancy outcome. A retrospective cohort study of singleton pregnancies who underwent VE. Pregnancy outcome of occipito-anterior (OA) position of the fetal head was compared to those with occipito-posterior (OP) position. Amongst overall 12,063 women undergoing trial of labor, there were 1118 (9.2 %) VE deliveries. Of them, 871 (77.9 %) had OA and 247 (22.1 %) had OP position of the fetal head. Except for a higher rate of nulliparity in the OA group, no significant differences between the groups regarding pregnancy complications and birthweight were noted. In the OP group, there were higher rates of prolonged 2nd-stage of labor as an indication for VE (49.8 vs. 36.5 %, p

To evaluate the impact of vacuum extraction on birth injuries among low birth weight neonate (2000–2499 g). Retrospective cohort study of women with singleton pregnancies > 34 weeks, birth weight of 2000–3500 g, undergoing vacuum extraction, between 2007 and 2014. Outcomes were compared between neonates who weighed 2000–2499 g and 2500–3500 g. Out of 62,102 deliveries, 5064 (8.2%) met the inclusion criteria, of which 269 (5.3%) neonates were included in the 2000–2499 g group. In this group, gestational age at delivery was lower, the rate of preeclampsia without and with severe features was higher, the rate of induction of labor was higher as was the rate of intermediate/abnormal fetal heart rate tracings as an indication for vacuum extraction (46.2% vs. 28.0%, P

To determine the perinatal outcome associated with cup detachment during vacuum-assisted vaginal delivery (VAVD). A retrospective cohort study of all women attempting VAVD in a tertiary hospital (2012–2014). Singleton-term pregnancies were included. Antepartum fetal death and major fetal structural or chromosomal abnormalities were excluded. Primary outcome was neonatal birth trauma (subgaleal hematoma, subarachnoid hematoma, subdural hematoma, skull fracture, and/or erb’s palsy). Secondary outcomes were maternal complications or other neonatal morbidities. Outcomes were compared between women after ≥1 cup detachment (study group) and the rest (control group). Logistic regression analysis was utilized to adjust results to potential confounders. Overall, 1779 women attempted VAVD during study period. Of them, in 146 (8.2%), the cup detached prior to delivery; 130/146 (89%) had a single detachment. After detachment, 4 (2.7%) delivered by cesarean section, 77 (52.7%) delivered after cup reapplication, and 65 (44.6%) delivered spontaneously. Women in the study group were more likely to undergo VAVD due to prolonged second stage, and were characterized by lower rates of metal cup use. Neonates in the detachment group had higher rates of subarachnoid hematoma and composite neonatal birth trauma (2.7 vs. 0.1% and 4.8 vs. 1.8%, respectively, p

To estimate the impact of indication for vacuum-assisted vaginal delivery on neonatal and maternal adverse outcome.Retrospective analysis of women carrying singleton-term pregnancies undergoing vacuum-assisted vaginal delivery in a tertiary hospital (2007-2014). Cohort was stratified by indication: non-reassuring fetal heart rate or prolonged second stage. Primary outcome was adverse neonatal outcome and secondary outcome was maternal morbidity. Logistic regression analysis was utilized to adjust for potential confounders.Overall, 4931 women met inclusion criteria. Delivery indication was prolonged second stage in 3143 (64%) cases and non-reassuring fetal heart rate in 1788 (36%). In the non-reassuring fetal heart rate group, there were higher rates of cephalohematoma, low 5-min Apgar-score, and asphyxia. In the prolonged second-stage group, there were higher rates of sepsis and post-partum hemorrhage. Composite neonatal birth trauma and maternal morbidity were higher for vacuum-assisted vaginal delivery following prolonged second stage. Following adjustment for confounders cephalohematoma (aOR 1.21, 95% CI 1.04-1.41), low 5-min Apgar-score (aOR 2.91, 95% CI 1.26-4.67) and asphyxia (aOR 1.81 95% CI 1.35-2.44) remained significant in the non-reassuring fetal heart rate group and neonatal sepsis remained significant for the prolonged second-stage group (aOR 1.77, 95% CI 1.38-2.27), p 0.05 for all. However, there was no longer difference in the composite birth trauma, other neonatal or maternal morbidity.The indication for vacuum-assisted vaginal delivery has an impact on neonatal outcome. While cephalohematoma, low 5' Apgar score, and asphyxia were more common in the non-reassuring fetal heart rate group, neonatal sepsis was more common in cases of prolonged second stage of labor.

Previous studies have suggested that a variety of maternal and obstetrical characteristics may predict successful prostaglandin E2 (PGE2) cervical ripening. However, in most studies women were administered vaginal tablets or gel so scarce is known regarding potential predictors in women administrated slow-release vaginal inserts. We aimed to characterize the response of cervical ripening for labor induction using slow-release PGE2 vaginal insert and to identify predictors for success. A retrospective cohort study in a single center (2013–2015). The association between maternal characteristics at admission and cervical ripening success/failure were explored. Cervical ripening failure was defined as a Bishop’s score

To identify risk factors for post-partum hemorrhage (PPH) following vacuum assisted vaginal delivery (VAVD). A retrospective study of all women with singleton pregnancies who underwent VAVD in a tertiary hospital (2012–2014). PPH was defined as any of the following: ≥500 ml estimated blood loss, hemoglobin drop ≥3 g/dl (difference between pre- and post-VAVD hemoglobin levels) or the need for blood products transfusion. Characteristics of women with PPH following VAVD were compared to those of women with no PPH following VAVD. Of 1,154 VAVDs, 295 (25.6 %) had PPH. Women in the PPH group were more often nulliparous (83.1 vs. 70.5 %, p = 0.001) and had higher rate of hypertensive disorders (4.4 vs. 1.4 %, p = 0.001). The rate of episiotomy (87.8 vs. 81.6 %, p = 0.01) was higher in the PPH group. In multivariate analysis, risk factors for PPH were (Odds Ratio, 95 % Confidence Interval) hypertensive disorders (2.40, 1.03–5.58, p = 0.04), induction of labor (1.42, 1.01–2.10, p = 0.04) and longer second (1.003, 1.001–1.006, p = 0.03) and 3rd (1.02, 1.01–1.04, p = 0.004) stages of labor. Risk factors for PPH following VAVD can be identified and should be taken into consideration at the immediate post-partum period.

As conflicting data exist concerning the implications of isolated oligohydramnios on pregnancy outcome at term, we aimed to assess this association in low-risk pregnancies. A retrospective cohort study of term pregnancies with sonographic finding of isolated oligohydramnios (amniotic fluid index (AFI)