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Objectives: To investigate the rate, success and pregnancy outcome following a trial of labor after cesarean (TOLAC) in twin gestations. Study design: A retrospective study including all twin pregnancies with a single prior cesarean delivery between the years 2006 to 2011 was performed. Women with medical indications for cesarean delivery (CD) were excluded. Maternal and neonatal outcomes were compared between women who delivered by CD to those who underwent TOLAC. Stratified analysis using a multiple logistic regression model was performed to control for confounders., Results: During the years 2006-2011, 110 women met the inclusion criteria. Of these, 20% (n=22) underwent a TOLAC. The success rate of vaginal birth after cesarean was 77.2% (n=17). No cases of uterine rupture or dehiscence were noted. No significant difference was documented in neonatal outcome (including pH and Apgar scores) between the TOLAC and the CD group. Fertility treatment was noted as a risk factor for repeated CD (35.2 vs. 4.5%, OR=8.6, 95% CI 1.21-61.3, P=0.005). Using a multivariable analysis, with repeated CD as the outcome variable, controlling for confounders such as maternal age, and gestational age, fertility treatment was an independent risk factor for repeated CD (adjusted OR=5.2, 95% CI 0.01-0.70; P=0.02)., Conclusions: A TOLAC in twin gestation seems to be a safe option for the mother and newborn. Fertility treatment is an independent risk factor for repeated CD in twins.

In recent years there is a significant increase in the rate of the metabolic syndrome. Correspondingly, and possibly due to this increase, there is a significant increase in cardiovascular events in women. Contradictory to the concept that obstetric complication is limited to pregnancy, some obstetric complications may cause or seemingly provide a preliminary sign for future maternal morbidity. In recent years there have been an increasing number of studies that examined the theory that vascular-related complications of pregnancy may be associated with increased risk for future maternal cardiovascular morbidity. We present a review of the literature, in addition to a series of studies conducted in Soroka University Medical Center that examined the association between pregnancy complications such as preeclampsia, gestational diabetes mellitus, preterm delivery, placental abruption and recurrent pregnancy loss and future long term maternal cardiovascular morbidity.

Introduction: A velamentous cord insertion (VCI) describes a peripheral umbilical cord insertion to the placenta with blood vessels from the cord traversing fetal membranes before reaching the placental margin. These vessels remain unprotected and exposed to pressure and injury during pregnancy and labor., Objectives: To determine the risk factors for VCI, and assess the risk for complications and adverse outcomes of pregnancies with VCI., Methods: A retrospective cohort study of women who gave birth at Soroka Medical Center between the years 1988 to 2011. We examined the risk factors, complications and adverse outcomes of pregnancies with VCI compared to those without VCI., Results: During the study period there were 246,488 births, of which 200 had VCI. Multifetal gestation (OR = 9.2), infertility treatments (OR = 4.3) and chronic hypertension (OR = 2.2 were found as independent risk factors for VCI. In addition, intrauterine growth retardation (OR = 4.3), polyhydramnion (OR = 2.3), fetal malformations (OR = 2.2), placental abruption (OR = 8.2), preterm birth (OR = 4.6), cesarean delivery (OR = 3.3) and low Apgar score (OR = 2.3) had significant correlation to VCI. Finally, the presence of VCI was found as an independent risk factor (OR = 4.07) for perinatal mortality., Conclusion: Multifetal gestation and infertility treatments were the most important risk factors for VCI. These pregnancies had more complications and perinatal mortality. Given the results, we should consider close monitoring of pregnancies with the mentioned risk factors for the presence of VCI.

Soroka University Medical Center is a tertiary hospital, and the sole medical center in the Negev, the southern part of Israel. Soroka has invested in quality, service and research. The region has developed joint programs in order to advance the quality of medical care whilst optimizing the utilization of available resources. In this editorial we describe the path to leadership in quality of medical care, service and research.

Introduction: Illegal drug abuse causes significant health problems with consequences to the mother and the neonate, and an economic burden to the health system., Objectives: The present study aimed to investigate pregnancy and perinatal outcome in women using illegal drugs prior to and during pregnancy., Methods: A retrospective cohort study comparing pregnancy and neonatal outcomes of drug addicted women to the outcomes of other Jewish women. The study population includes all women who gave birth between the years 1989-2008 at the Soroka University Medical Center., Results: From a total of 106,000 deliveries, 119 women were known to be drug addicted. No significant differences were found between the groups regarding maternal age and origin, but more women in the addicted group smoked, and tacked prenatal care. More women in the addicted group had obstetrics complications such as: recurrent abortions, placenta previa, pLacental abruption and preterm labor. Illegal drug abuse was significantly associated with adverse perinatal outcomes such as low birth weight, congenital anomalies, peripartum death and prolonged hospitalizations., Conclusions: Illegal drug abuse is an independent risk factor for adverse obstetric and perinatal outcomes., Discussion: This study investigated a significant problem that may be underestimated in our population. The higher incidence of pLacental abruption, placenta previa, preterm tabor and low birth weight could be a sign for placentaL insult., Summary: Illegal drug abuse is an independent risk factor for adverse perinatal outcomes and causes an economic burden. Further national studies are needed to characterize the problem, and to develop appropriate intervention programs.

Objective: The goal was to examine the knowledge of ultrasound end users regarding safety of ultrasound in pregnancy, and to compare it to ultrasound end users in the United States., Methods: A questionnaire was distributed to ultrasound users at obstetrics and gynecology conventions and wards throughout the country, between the years 2008-2010, and compared to an identical questionnaire distributed in the United States., Results: A total of 143 end users completed the questionnaire; 92% of them are physicians, 71% gynecologists; 3.5% routinely perform Doppler ultrasound in the first trimester. Overall, 36% of the ultrasound end users thought that the number of ultrasounds performed in low-risk pregnancy should be limited. Although 44.1% were familiar with the term thermal index, only 22.4% answered the related question correctly; 26.6% were familiar with the term mechanical index, but only 4.9% described it correctly. More than 80% of the end users did not know where to find the acoustic indices while performing the examination. No significant difference in knowledge was found between the ultrasound end users in Israel and the United States., Conclusions: The poor level of knowledge regarding safety issues, found both in Israel and United States, raises the necessity to reexamine the methods of informing the relevant audience on the courses and training programs available on these matters.

As a form of energy, diagnostic ultrasound (DUS) has the potential to have effects on Living tissues, e.g. bioeffects. The two most likely mechanisms for bioeffects are heating and cavitation. Hyperthermia is considered teratogenic in human fetuses during the first trimester Actual temperature changes cannot be studied in the human fetus. The thermal index [TI) expresses the potential for rise in temperature at the ultrasound's focal point. The mechanical index (MI) indicates the potential for the ultrasound to induce inertial cavitation in tissues. Nevertheless, cavitation has not been documented in mammalian fetuses, since there is not an air-water interface, which is needed for the cavitation mechanism. Since an output of TI over 1.5 is a known hazard, the question is: What are the settings in which such hazardous exposure occurs? Our conclusions regarding safety of DUS, based on the data that has been available till now, are the following: (1) Ultrasound end-users are poorly informed regarding safety issues during pregnancy. Further efforts in the realm of education and training are needed in order to improve knowledge of end-users about the acoustic output of the machines and safety issues. (2) First trimester ultrasound is associated with negligible rise in the thermal index. (3) Increased acoustic output Levels, as expressed by TI levels, are reached while performing obstetrical Doppler studies. In particular, TI Levels may reach 1.5 and above. Doppler procedures should be performed with caution and should be as brief as possible during obstetrical ultrasound. (4) Acoustic exposure levels during 3D/4D ultrasound examination, as expressed by TI are comparable to the two-dimensional B-mode ultrasound.

Background: Recent research has put the spotlight on two different aspects of pregnancy after bariatric surgery: safety of the mother and fetus, and the procedure's effectiveness in preventing the complications surrounding reproduction and pregnancy often seen in the obese woman., Objective: To evaluate the pregnancy outcome foLlowing bariatric surgery., Results: Although there are severaL reports documenting poor perinatal outcomes and late surgical complications during pregnancies subsequent to bariatric surgery, systematic studies have generaLLy not proven such an association., Conclusions: Pregnancy after bariatric surgery appears to be safe, and in general perinatal outcome is better when compared to pregnancies of obese women. Providers should be familiar with potential complications related to postoperative pregnancies and be prepared to provide appropriate interventions such as nutritional supplementation and band adjustment when necessary.

Neonatal hemochromatosis (NH) is a rare disease which has been characterized as severe neonatal liver disease in association with extrahepatic siderosis in a distribution similar to that seen in HFE-associated hereditary hemochromatosis. The clinical presentation is severe liver dysfunction that could lead to intrauterine fetal death or the neonate death. The treatment is antioxidants, chelation or cocktail liver transplant. The prognosis is very bad with less than 40% survival. The etiology and pathogenesis are yet unknown. It has been considered to be a syndrome in which a number of primary etiologies, such as infection, genetic-metabolic disease and toxic insult, lead to a common phenotype. The common hypothesis now is that NH is a consequence of gestational alloimmune disease. The basis for this theory rests on the pattern of recurrence. Little direct evidence for an immune mechanism exists. The fact that high-dose intravenous immunoglobulin appears to lessen the severity, improve infant survival, but not prevent its recurrences, strengthens this idea. The authors present a twenty nine years old Bedouin woman, married with no children. Her bad obstetrical history included one first trimester spontaneous abortion, five intrauterine fetal death and one post partum death. The present review discusses the clinical and epidemiological characteristics of this disease, and focuses on the etiology and treatment.

Objective: To determine obstetric and perinatal outcome of planned home deliveries in Israel., Methods: A retrospective study was performed including planned home deliveries in Israel between the years 2003 and 2007., Results: Data regarding 1749 planned home deliveries was retrieved. Of these, 1594 (91.1%) were managed successfully. The rate of cesarean deliveries was 3.3% and the rate of instrumental deliveries was 1.0%. No cases of maternal mortality were noted. However, one patient was hospitalized for more than 5 days due to cesarean complications. One case of sudden infant death syndrome occurred 30 hours after home delivery., Conclusion: With proper selection of low risk parturients, planned home deliveries are basically associated with favorable outcomes. Further prospective studies should substantiate our results in order to provide clear indications for home deliveries.

In the industrialized world, approximately 12% of couples suffer from infertility. As a result of its collective political and historical experience, Israel boasts one of the world's most progressive fertility policies ranging from hormonal treatment to In Vitro Fertilization (IVF). Approximately 40% of the causes of infertility are attributed to the woman. Among the factors contributing to reduced fertility are endocrine factors, immune factors and mechanical factors. Studies have accumulated information regarding the contribution of psychological factors to infertility in women. Among the identified risk factors are depression, anxiety and stress-dependent changes like altered heart rate and increased blood cortisol levels. The hypothalamic-pituitary-adrenal axis (HPA) has been shown to be an important mediator of infertility, involved in the excretion of CRH, ACTH and cortisol, respectively. Data gathered in the literature suggests the involvement of the HPA axis on the hypothalamic-pituitary-gonadotropic axis (HPG). Specifically, changes in diurnal excretion patterns of cortisol have been shown to accompany mental stress and to mediate the down-regulation of the HPG axis. This impact could possibly involve inhibitory mechanisms at the pituitary level, by reducing the release of FSH and LH by GnRH. Furthermore, research has shown that the effect of cortisol on the HPG axis is dependent on the endocrine status of the ovary in its different stages within the menstrual cycle. From the studies presented in this review it can be hypothesized that stress can induce altered cortisol-excretion patterns along the menstrual cycle, which ultimately affect the hormonal profile in critical stages of the fertilization process.

Preeclampsia, one of the main complications in pregnancy, affects 5-7% of all pregnancies, and is a leading cause of maternal and perinatal mortality. The placenta plays a pivotal role in the etiology of preeclampsia, and particularly, the trophoblast cells of the placenta. It is now believed that preeclampsia is a two stage disease. In the first stage, a defective implantation and placentation, causes a reduction in uteroplacental perfusion and placental ischemia/hypoxia. Placental ischemia may promote the release of a variety of factors to the maternal circulation. In the second stage, these factors initiate a cascade of cellular and molecular events leading to endothelial and vascular dysfunction. The endothelial dysfunction leads to the clinically recognized symptoms of the syndrome, which include hypertension, proteinuria, thrombocytopenia and impaired liver function. Hypertension is mediated by various endothelial and non-endothelial regulatory factors that are altered in preeclampsia. This review aims to summarize the recent knowledge on the implication of the placenta and various angiogenic factors in the pathogenesis of preeclampsia.

The Chernobyl accident, the recent terrorists' attacks and constant threats, have all once again evoked the fear of a nuclear disaster, in Israel and worldwide. Iodine-131 is a major fission product of nuclear reactors and is highly likely to be released into the atmosphere in severe nuclear disasters. The radioiodine is released as a gas, easily spreads over large areas and is easily absorbed via the respiratory system. Iodine-131 emits gamma and beta radiation in high energies, and is readily absorbed by the thyroid which is a target organ for iodine. The resulting exposure to the thyroid might be very high. A sharp increase in thyroid cancer incidence in children was observed following the Chernobyl accident. This article reviews the medical knowledge about strategies and medications aimed at minimizing the absorption of radioiodine into the thyroid. In addition to regular safety means such as sheltering, restriction of locally produced food products and relocation of the population, the best prophylaxis against thyroid exposure is overloading the gland with stable iodine (as potassium iodide), as soon as possible. Recently, the Israeli government decided to distribute Potassium Iodide tablets to the population in the vicinity of the two nuclear research centers in the country. When this treatment is contraindicated, iodine free thionamides or potassium perchlorate are suggested.

Obesity is a worldwide growing epidemic. The negative influence of obesity is huge and considered to be one of the major contributors to health problems in the western world. There is a significant association between obesity and diabetes mellitus, ischemic heart disease, some cancers and syndromes of sleep apnea. Furthermore, obesity was described to have a negative influence on fertility, pregnancy, labor and pregnancy outcomes. It was also discovered that obesity was significantly associated with gestational hypertension, preeclampsia, gestational diabetes mellitus and complications in cesarean delivery and anesthesia. This review aims to present updates on the relationship between obesity and pregnancy and labor outcomes, emphasizing the significance of obesity as a risk factor for adverse pregnancy outcome.

Objective: To determine breastfeeding patterns according to the ethnic origin of mothers of 2-year old babies in two Well Child-Care Clinics in Beer Sheva and Ofakim, Israel., Methods: A cross-sectional study was performed including all mothers of 2-year old babies in two Well Child-Care Clinics in Beer Sheva and Ofakim. A structured interview was given to 132 mothers, which included demographic data and breast-feeding characteristics., Results: A total of 106 mothers (80%) initiated and maintained breast-feeding. Mean duration of breast-feeding was 10.7 weeks (SD = 13). Women of North-African ethnicity were less likely to maintain breast-feeding (8.8 +/- 21.1) as compared to mothers of Iranian/Iraqi/Turkish descent (29.7 +/- 39.8) (p < 0.05). Mean duration of breast-feeding among mothers who worked out of their house was significantly longer as compared to housewives (7.7 +/- 14.5 vs. 16.9 +/- 29.3; p = 0.05). These women had a higher level of education as compared to the housewives (14.0 +/- 2.7 years vs. 11.6+/- 1.4 years; p < 0.01). Mothers of three children were less likely to maintain breast-feeding as compared to mothers of two children (8.8 +/- 10.6 weeks vs. 16.1 +/- 19.7 weeks; p < 0.05)., Conclusions: Special efforts in the realm of education regarding the importance of breast-feeding should be focused on mothers of North-African descent, secular women, housewives and those having three or more children. Further prospective studies should investigate the efficacy of educational programs as well as support groups regarding breast-feeding.

Traditionally, women used to deliver their babies at home. In 1927, in England and Wales, 85% of births took place at home. By 1970 the position was reversed. The move from home to institutional delivery has been accompanied by changes in the institutions themselves and in the type of care provider. There are two kinds of out-of-hospital deliveries: 1. Planned home deliveries--women who decide to deliver in their home with the assistance of midwives or other consultant obstetric facilities. Few cases from this group, however, end up in the hospital; 2. Unplanned home deliveries or delivery en-route to the hospital--when women enter the active phase of labor rapidly, resulting in accidental out-of-hospital deliveries. The study aims to review the available literature and to describe the incidence, obstetrical characteristics and perinatal outcome of out-of-hospital deliveries.

We examined the relationship between occupation and clinical characteristics during pregnancy and medical recommendations to stop working. Using a case-control design, we compared 58 working women who had preterm births, with 126 who had delivered at term. All women were interviewed postpartum while still in hospital. There were no differences between the groups with regard to physical activity outside the home, weekly work hours, nor duration of work. Only a small proportion had been exposed to unusually difficult working conditions, to hazardous agents or to a very uncomfortable working environment. Women who had had preterm births were advised more often to leave their jobs or modify their working patterns. Multivariate analysis revealed that the physician's decision to recommend cessation of work was influenced primarily by complications during the current pregnancy. It appears that our patients at risk for preterm birth are probably correctly identified, and receive appropriate guidelines as to working patterns. It is possible that a poor obstetric history or previous abortions may paradoxically have a protective effect, as they influence the physician to recommend cessation of work.

The relationship between physical activity at home and at work during pregnancy and preterm birth was studied. Using a case-control design, 99 women who delivered preterm were compared with 189 women who had term deliveries. The risk of preterm birth was tested in relation to characteristics of work in and outside the home. All women were interviewed post-partum before discharge. There were no statistically significant differences between the groups in relation to sociodemographic and obstetrical factors, but level of education was significantly lower in the study group versus the control group (p = 0.001). Women who delivered preterm had devoted less time 3 months prior to delivery to household chores (mean of 3.7 hours vs. 4.8 hours in the control group, p = 0.002). They also had spent less time walking around the home than the controls (1.2 vs. 1.5 hours, p = 0.02). There were no differences between the groups in relation to physical activity outside the home, not during working hours, nor in duration of work. Significantly fewer women who delivered preterm were active in sports (odds ratio 0.22; 95% confidence interval 0.50-0.65; p = 0.002). A low level of education was significantly related to the risk of preterm birth, which may have resulted from lesser compliance with their physician's recommendations. It appears that in women not used to significant physical activity but who had access to adequate prenatal care, physical effort during pregnancy was not related to a higher risk of preterm birth.

Cervical pregnancy is a rare but serious complication. The most frequent presenting symptom is vaginal bleeding, and is thus common in inevitable abortion. Examination reveals a dilated cervix containing products of conception derived from the emptied uterine cavity. The pathologic criteria are cervical glands opposite the placental site, attachment to and actual invasion of the cervix by the placenta, a portion of the placenta below the posterior reflection, and no fetal parts in the corpus uteri. Treatment ranges from hysterectomy to treatment with chemical agents, mostly methotrexate. We present a case of ectopic, cervical pregnancy with exaggerated placental site in the cervix.