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Objective: This study sought to test the hypothesis that among multiparous women requiring cervical ripening, mechanical ripening with a Foley catheter is more effective than prostaglandin preparations., Methods: This was a retrospective analysis of multiparous women with a singleton gestation who required cervical ripening in a single tertiary center from 2014 to 2019. Women who underwent cervical ripening with a Foley catheter (Foley group) were compared with women who underwent cervical ripening using a controlled-release dinoprostone vaginal insert (PGE 2 -CR group) or dinoprostone vaginal gel (PGE 2 -gel group). The primary outcome was the ripening-to-delivery interval., Results: A total of 229 women met the study criteria (Foley group: 95; PGE 2 -CR group: 83; PGE 2 -gel group: 51). Women in the Foley group had a significantly shorter ripening-to-delivery interval compared with women in the PGE 2 -CR group (16.2 ± 9.2 hours vs. 27.0 ± 14.8 hours; P < 0.001) and were more likely to deliver within 12 hours (47.4% vs. 12.0%; P < 0.001; adjusted relative risk [aRR] 3.87; 95% confidence interval [CI] 2.07-7.26) and within 24 hours (78.9% vs. 49.4%; P < 0.001; aRR 1.61; 95% CI 1.26-2.06). Women in the Foley group were also less likely to require a second ripening method compared with women in the PGE 2 -CR group (1.1% vs. 8.4%; P = 0.018; aRR 7.26; 95% CI 2.99-17.62). These differences were not observed when comparing the Foley and the PGE 2 -gel groups. The cesarean section rate was similar among the Foley group (9.5%), PGE 2 -CR group (9.6%; P = 0.970), and PGE 2 -gel group (11.8%; P = 0.664)., Conclusion: In multiparous women requiring cervical ripening, all methods of cervical ripening have a similar success rate. However, the use of a PGE 2 -CR insert is associated with a considerably longer interval to delivery compared with a Foley catheter or PGE 2 gel., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: This study sought to compare the latency from membrane rupture to delivery and subsequent neonatal outcomes in twin gestations complicated by preterm premature rupture of membranes (PPROM) of the presenting versus non-presenting sac., Methods: This was a retrospective study of twin pregnancies over a 7-year period diagnosed with PPROM between 12 and 37 weeks gestation with a latency period to delivery of >24 hours. The ruptured sac was identified by ultrasound scan. The study compared the latency period from PPROM to delivery and subsequent neonatal morbidity and mortality resulting from rupture of the presenting versus non-presenting sac. Obstetric and neonatal outcomes were evaluated using a matched-cohort subset analysis (Canadian Task Force Classification II-2)., Results: During the study period, 77 twin pregnancies diagnosed with PPROM satisfied the inclusion criteria. The mean latency periods from PPROM to delivery were 10.1 days (n = 7) when the presenting sac ruptured and 41.3 days (n = 10) when the non-presenting sac ruptured (P < 0.05). Neonatal death was higher with PPROM of the presenting than the non-presenting sac (21.4% vs. 0%, respectively; P = 0.05). Neonates were more likely to be affected by retinopathy of prematurity (57% vs. 19%; P < 0.05) but less likely to have persistent pulmonary hypertension of the newborn (0% vs. 25%; P < 0.05) when the rupture occurred in the presenting sac. The rates of other neonatal adverse outcomes were similar between the two groups., Conclusions: In twin gestations there is a longer latency from PPROM to delivery and fewer neonatal complications when rupture occurs in the non-presenting rather than the presenting sac., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study., Study Design: The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries., Results: Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P = 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score <7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation., Conclusion: Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Antenatal corticosteroids have been shown to decrease neonatal respiratory morbidity in singleton pregnancies when given during the late-preterm period (34 0/7 -36 6/7 weeks). Whether these findings also apply to late-preterm twins, who account for approximately one-third of infants born at 34 0/7 -35 6/7 weeks, is currently unclear. The answer to this question depends, in part, on whether the risk of respiratory morbidity among late-preterm twin infants is similar to that observed in late-preterm singletons. We aimed to assess the rate of respiratory morbidity among late-preterm twin infants using a secondary analysis of prospectively collected data from a large international multicenter trial, and to compare that rate with previous studies that used the same definition of respiratory morbidity., Study Design: This was a secondary analysis of the twin birth study. In the current study, we limited the analysis to women who gave birth during the late preterm period. The primary outcomes were the same primary composite respiratory morbidity variables that were used in the randomized controlled trial of Gyamfi-Bannerman et al., on the administration of betamethasone during the late preterm period in singletons (ALPS trial). The risk of respiratory morbidity among late preterm twins was stratified by gestational week at birth., Results: A total of 1163 women who gave birth to 2324 late preterm twin infants met the inclusion criteria. The rates of respiratory morbidity and severe respiratory morbidity were 16.5% and 8.9%, respectively. The risk of respiratory morbidity was highly dependent on gestational week at birth, being more than fourfold for infants born at 34 0/7 -34 6/7 weeks (aOR 4.30, 95%-CI 3.01-6.14) and more than twofold for infants born at 35 0/7 -35 6/7 weeks (aOR 2.12, 95%-CI 1.51-2.98) compared with infants born at 36 0/7 -36 6/7 weeks. The rate of respiratory morbidity and the theoretical number of women needed to be treated with betamethasone to prevent a single case of respiratory morbidity in the current study were similar to those reported in the APLS trial (16.5% vs. 14.4%, p = 0.103, and NNT 31 vs. 34, respectively)., Conclusions: The risk-benefit ratio of betamethasone with regard to neonatal respiratory morbidity in women with twins at risk of late-preterm birth is expected to be similar to that observed in singletons.

Background: The Twin Birth Study, a multicenter randomized controlled trial, found no differences in neonatal outcomes in women with twins randomized to planned cesarean or vaginal delivery. Nevertheless, women who present in spontaneous labor might expect a better outcome following a trial of vaginal delivery than undergoing cesarean delivery. In this secondary analysis, we aimed to compare neonatal outcomes of women who presented in spontaneous labor in the two arms of the Twin Birth Study., Methods: Women in whom the first twin was in the cephalic presentation were randomized between 32 + 0 and 38 + 6 weeks to planned vaginal delivery or cesarean. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity., Results: Of the 2804 women included in the Twin Birth Study, 823 women in the planned vaginal delivery arm and 612 in the planned cesarean arm presented in spontaneous labor. Although the odds ratio favored planned vaginal delivery, there was no statistically significant difference in the rate of primary outcome between the vaginal delivery and cesarean arms (1.8% vs 2.7%, respectively; P = 0.16; OR 1.49; 95% CI, 0.87-2.55). Similarly, the rates of the individual components of the primary outcome and of maternal adverse outcome were similar between the two arms., Conclusion: In women with twins who present in spontaneous labor between 32 + 0 and 38 + 6 weeks' gestation, where the first twin is cephalic, a policy of planned vaginal delivery or cesarean is not associated with significant differences in neonatal or maternal outcomes., (© 2018 Wiley Periodicals, Inc.)

Background:: Infrapatellar strapping is a treatment technique used in various knee pathologies; however, its effect on pain and functional performance among young athletes has not been studied., Objectives:: To evaluate the effect of infrapatellar strap on pain and jumping performance among young athletes diagnosed with patellar tendinopathy., Study Design:: Pre-/post-test (within-subject research design)., Methods:: A total of 16 young male basketball and volleyball athletes (age range, 12-18 years) diagnosed with patellar tendinopathy were included in the study. Infrapatellar strap was applied beneath the patella, over the patellar tendon. The athletes performed four jumping tests: squat jump, drop jump, single-leg jump, and jumps 30 s test, with and without the strap. Pain severity in the symptomatic knee during jumping was assessed using a visual analog scale and jumping performance parameters were assessed using an Optojump Next optical measurement system., Results:: Pain severity reported by the participants decreased in drop test, single-leg jump test, and jumps 30 s test while using the infrapatellar strap compared with no strap condition ( p < 0.05). No significant difference in jumping performance was found between jumping with and without the strap., Conclusion:: The infrapatellar strap was effective in reducing local pain among young male athletes without altered jumping performance., Clinical Relevance: The infrapatellar strap can be recommended to use during physical activity as part of the physical therapy treatments for patellar tendinopathy. Given the low cost, ease to use, and being a non-invasive method without adverse effects, it is an appropriate intervention for young athletes.

Objective  This retrospective cohort study examined the effect of birth order on neonatal morbidity and mortality in very preterm twins. Study Design  Using 2005 to 2012 data from the Canadian Neonatal Network, very preterm twins born between 24 0/7 and 32 6/7 weeks of gestation were included. Odds of morbidity and mortality of second-born cotwins compared with first-born cotwins were examined by matched-pair analysis. Outcomes were neonatal death, severe brain injury (intraventricular hemorrhage grade 3 or 4 or persistent periventricular echogenicity), bronchopulmonary dysplasia, severe retinopathy of prematurity (ROP) (> stage 2), necrotizing enterocolitis (≥ stage 2), and respiratory distress syndrome (RDS). Multivariable analysis was performed adjusting for confounders. Result  There were 6,636 twins (3,318 pairs) included with a mean gestational age (GA) of 28.9 weeks. A higher rate of small for GA occurred in second-born twins (10 vs. 6%). Mortality was significantly lower for second-born twins (4.3 vs. 5.3%; adjusted odds ratio: 0.75; 95% confidence interval [CI]: 0.59-0.95). RDS (66 vs. 60%; adjusted odds ratio: 1.40; 95% CI: 1.29-1.52) and severe retinopathy (9 vs. 7%; adjusted odds ratio: 1.46; 95% CI: 1.07-2.01) were significantly higher in second-born twins. Conclusion  Thus, while second-born twins had reduced odds of mortality, they also had increased odds of RDS and ROP., Competing Interests: Funding: No funding was received specifically for this study. The Canadian Neonatal Network Coordinating Centre is based at the Maternal-Infant Care Research Centre (Mount Sinai Hospital, Toronto, Ontario, Canada), which is supported by grant funding from the Canadian Institutes of Health Research and Mount Sinai Hospital. The funding source had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. Conflict of Interest None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: This secondary analysis for the Twin Birth Study, an international, multicenter trial, aimed to compare the cesarean section rates and safety between methods of induction of labor in twin pregnancies., Methods: Women with twin pregnancies where the first twin was in a cephalic presentation and who presented for labor induction, were non-randomly assigned to receive prostaglandin or amniotomy and/or oxytocin. Main outcome measures were the rates of unplanned cesarean section and neonatal and maternal mortality or serious morbidity., Results: 153 (41.5%) were induced by prostaglandin (prostaglandin group) and 215 (58.5%) were induced by amniotomy and/or oxytocin alone (no prostaglandin group). Induction using prostaglandin was more common in countries with a low perinatal mortality rate <10/1000 (45.7 versus 32.5%, p = 0.02). Cesarean section rates were similar in the two groups: 62/153 (40.5%) in the prostaglandin group and 87/215 (40.5%) in the no prostaglandin group (odds ratio 1, 95% CI 0.65-1.5). Nulliparity, late maternal age, non-cephalic presentation of twin B and high country's perinatal mortality rate were found to be independently associated with the induction to end with an unplanned cesarean section. There were no significant differences between groups with respect to maternal or neonatal adverse outcomes., Conclusions: The need for cervical ripening by prostaglandin had no effect on the incidence of cesarean delivery or an abnormal outcome. There is a significant risk of unplanned cesarean section independent of chosen induction method., Trial Registration: This trial was registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN74420086 ; December 9, 2003) and retrospectively registered at the www.clinicaltrials.gov (identifier NCT 00187369 ; September 12, 2005).

Objective: The objective of this study was to estimate the influence of maternal body mass index (BMI) on progress and outcomes of labor induction using mechanical devices., Methods: This study was a secondary analysis of data collected during the Cook Catheter vs. Foley Catheter study, a series of prospective randomized trials of women requiring cervical ripening for labor induction. The duration, characteristics, and outcomes of labor were analyzed after stratification by BMI categories. Outcomes assessed included time from device insertion to delivery, successful ripening, cesarean delivery rates, and any maternal and neonatal adverse events., Results: One hundred and eighty-one patients were stratified according to BMI categories, with 102 study participants classified as normal weight (BMI ≤30) and 79 as obese (BMI >30). Maternal satisfaction from the induction process was significantly lower in the obese group compared to the normal weight group (5.95 ± 3.14 vs. 7.58 ± 2.7, respectively, in a 1-10 scale, p = 0.009). The cesarean delivery rate was similar in the normal weight and the obese groups (17.6 vs. 25.3 %, respectively, p = 0.27). No statistical differences were found in all other outcomes evaluated, including a sub-analysis of the different mechanical devices., Conclusions: During the process of mechanical cervical ripening, maternal satisfaction, but not objective obstetrical parameters, was influenced by increased maternal BMI. The trial is registered at ClinicalTrials.gov, no: NCT00604487. Trial registry name is "Induction of Labor in Patients with Unfavorable Cervical Conditions."

Objective: To evaluate a possible dose-response relationship between active maternal smoking during pregnancy and adverse perinatal outcome., Design: Retrospective cohort study., Setting: Population-based in Montreal, Quebec, Canada., Population: Women who gave birth to a liveborn or stillborn infant during the period of January 2001 to December 2007., Methods: Active smokers of different daily cigarette consumption (n=1646) were identified through maternal self-reporting. The reference group comprised 19,292 non-smoking women who delivered during the same period., Main Outcome Measures: Birth weight, preterm delivery rate, fetal and neonatal mortality and morbidity, and congenital malformations., Results: Preterm delivery rate was significantly higher in the smoking group compared with controls (22.2% vs. 12.4%, P<0.05), as was intrauterine fetal demise (1.4% vs. 0.3%, P<0.05). Newborns of active smokers were more likely to weigh less (3150±759 g vs. 3377±604 g, P<0.05), suffer from respiratory distress syndrome (2.5% vs. 1.3%, P<0.05), suffer from a cardiac malformation (1.5% vs. 0.8%, P<0.05), and die (neonatal death 1.2% vs. 0.6%, P<0.05). A dose-response relationship was demonstrated between levels of daily cigarette smoking and several adverse outcomes. Using multiple regression models, smoking was found to be an independent predictor of preterm delivery (odds ratios (OR) 1.9, 95% confidence intervals (95%CI) 1.6-2), and intrauterine fetal demise (OR 2.4, 95%CI 1.4-4.2)., Conclusion: Any amount of daily smoking appears to harm the fetus and newborn. As pregnancy may be a "window of opportunity" for behavioural changes, efforts to promote smoking cessation should be encouraged.

Objective: To compare the efficacy and safety of the trans-cervical double balloon catheter with and without extra-amniotic saline infusion (EASI) for cervical ripening., Methods: This is a secondary analysis of a prospective randomized study conducted between November 2007 and January 2011 evaluating different ripening methods. Women presenting for labor induction were assigned to receive the double balloon catheter with (study group) or without EASI (control group). Outcomes included time from device insertion to delivery, cesarean section rates, and adverse events., Results: One hundred and sixty women completed the study. Cesarean section rate (8.3% in study group, versus 20% in controls p = 0.07) and ripening success were comparable between the groups. Catheter insertion to delivery interval was significantly shorter and spontaneous catheter expulsion rate was significantly higher in the study group (14:19 hours versus 20:45 hours, p < 0.001, and 68.5% versus 51%, p = 0.04, respectively). Hospitalization length was significantly shorter in the study arm. There were no differences in other outcomes evaluated. A multivariable analysis found the EASI to be an independent predictor of a shorter insertion to delivery interval., Conclusions: The addition of EASI to the double balloon catheter for cervical ripening results in a shorter labor induction process without compromising its safety.

Objective: To evaluate the risk of adverse perinatal outcomes among pregnant women previously hospitalized for bipolar disorder., Study Design: We completed a population-based cohort study of women with a singleton delivery in Ontario, Canada (2003 to 2011). Women previously hospitalized for bipolar disorder (n = 1859) or major depressive disorder (n = 3724) were each compared to women without a documented mental illness (n = 432,358). Main study outcomes were preterm birth, severe small for gestational age <3rd percentile birthweight, and severe large for gestational age >97th percentile birthweight. Secondary outcomes included stillbirth, congenital malformations, neonatal morbidity and readmission to hospital <28 days. Odds ratios (ORs) were adjusted for maternal age, parity, prepregnancy obesity, substance use, and diabetes mellitus or hypertension before or during pregnancy., Results: Bipolar disorder (adjusted OR [AOR], 1.95; 95% confidence interval [CI], 1.68-2.26) and major depressive disorder (AOR, 1.91; 95% CI, 1.72-2.13) were each associated with preterm birth. Bipolar disorder was associated with severe large for gestational age (AOR, 1.31; 95% CI, 1.03-1.67). Major depressive disorder was associated with severe small for gestational age (AOR, 1.22; 95% CI, 1.05-1.42). Both mood disorder groups had significantly higher risk of congenital malformations, neonatal morbidity, and neonatal hospital readmission. Although study covariates explained some of the increased risk, we could not address all potential explanatory factors., Conclusion: Women previously hospitalized for bipolar disorder are at increased risk of adverse perinatal outcomes compared with the general population. Their level of risk is comparable to women previously hospitalized for major depressive disorder. These risks must be considered in the management of pregnant women with a history of major mood disorders. Attention to potentially modifiable risk factors such as obesity, diabetes, and hypertension before and during pregnancy could reduce the risk for adverse perinatal outcomes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy of two mechanical devices for cervical ripening: double versus single balloon catheters, both with extra-amniotic saline infusion (EASI)., Methods: Women at term with a singleton pregnancy presenting for labor induction were assigned to receive the double balloon catheter (with EASI) or the single balloon catheter (with EASI). Outcomes included time from device insertion to delivery, rates of successful vaginal delivery and occurrence of adverse events., Results: One hundred and eighty-six women completed the study. Ripening success was comparable between the double and single balloon arms (96.4% versus 92.7%, p = 0.55, respectively). Balloon insertion to delivery interval was significantly shorter, and cesarean section rate was significantly lower in the double balloon arm compared with the single balloon arm (14.3 versus 15.8 h, p = 0.04 and 8.3% versus 20%, p = 0.05, respectively). There were no significant differences in maternal characteristics, satisfaction or adverse outcomes., Conclusions: This study is the first documented assessment of the double balloon catheter combined with EASI. Our findings suggest that the double balloon catheter results in reduced time to delivery and higher vaginal delivery rates, compared with the single balloon catheter with EASI, without compromising maternal or fetal safety.

Objective: To examine whether plasma levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) during the first 20 weeks of pregnancy can predict preeclampsia in the second half of pregnancy., Methods: The study population included 150,10 registered births. Receiver operating characteristic (ROC) curve analysis was used to describe the relationship between different values of AST and ALT during the first 20 weeks of pregnancy in the prediction of preeclampsia., Results: Using ROC curve analyses, elevated ALT levels were significantly associated with both mild preeclampsia (p < 0.001) and severe preeclampsia (p = 0.032). However, an ALT level of 50 IU/L had a sensitivity of only 3.3% (despite a specificity of 97%) in the prediction of severe preeclampsia. While no significant association was noted between AST levels and mild preeclampsia (p = 0.669), elevated levels of AST during this period were significantly associated with severe preeclampsia (p = 0.027). However, AST of 50I U/L had a sensitivity of only 2.0% (despite a specificity of 98%) in the prediction of severe preeclampsia., Conclusions: Higher levels of the liver enzymes AST and ALT during the first 20 weeks of pregnancy are associated with higher risk for the development of severe preeclampsia in the second half of the pregnancy. Nevertheless, there is no clinical cutoff value that can be practically used for the prediction of preeclampsia.

Objective: To determine whether proangiogenic immature myeloid cells are present in human placentas., Study Design: Biopsies were obtained from 61 placentas of term pregnancies. Percentage of CD45(+)CD33(+)LIN2(-)HLADR(-) immature myeloid cells of total CD45(+) hematopoietic cells was determined by flow cytometry. Location of immature myeloid cells in the placenta was identified using confocal microscopy. The proangiogenic potential of immature myeloid cells was analyzed by endothelial tube formation., Results: Immature myeloid cells comprise ∼25% of human placental CD45(+) hematopoietic cells and infiltrate placentas in proximity of blood vessels. The percentage of immature myeloid cells correlated positively with placental weight (r(2) = 0.108, P = .01) and birthweight (r(2) = 0.087, P = .02). Endothelial tube formation was increased in the presence of immature myeloid cells as compared with the presence of CD45(+)LIN2(+) control cells., Conclusion: Human placentas are populated by immature myeloid cells in the proximity of blood vessels. Consistent with their involvement in angiogenesis, immature myeloid cells accelerated endothelial tube formation. The presence of immature myeloid cells in pathologic pregnancies warrants further studies., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: To compare the efficacy of two mechanical devices for cervical ripening: Foley catheter with extra-amniotic saline infusion and the Cook cervical ripening balloon., Methods: Women at term with a singleton pregnancy who presented for labor induction were randomly assigned to the Foley catheter or the Cook cervical ripening balloon (costs $3 and $41, respectively). The main outcome measures included time from device insertion to delivery, rates of successful vaginal delivery and occurrence of adverse events., Results: The study was completed by 188 women. Time from balloon insertion to expulsion and from insertion to delivery was significantly shorter in the Foley catheter group when compared with the Cook cervical ripening balloon group (6.9 ± 4.2 vs. 10.1 ± 4.7 hours, p = .001 and 19.6 ± 11.4 vs. 23.4 ± 15.5 hours, p = .03, respectively). There were no significant differences in other outcomes., Conclusions: Considering its shorter induction process and lower cost, Foley catheter with extra-amniotic saline infusion is superior to the Cook cervical ripening balloon for initiating cervical ripening.

Background: Postpartum hemorrhage may be a life-threatening event and may result from coagulation defects., Case: We report a case of a multigravida woman who developed rapidly progressive postpartum bleeding as a result of acquired factor VIII inhibitors. Repeated laparotomies and massive transfusions failed to achieve adequate control of bleeding. Laboratory studies revealed a prolonged activated partial thromboplastin time, and the presence of specific inhibitors was soon established. The patient responded only partially to steroids and immunotherapy. Upon administration of rituximab, an anti-CD-20 monoclonal antibody, control of bleeding was achieved., Conclusion: Early diagnosis of acquired hemophilia as a rare cause of postpartum hemorrhage is crucial, because specific therapy may be life saving.

Background: Women frequently suffer perineal trauma while giving birth. Interventions to increase the possibility for an intact perineum are needed., Objectives: To evaluate the effectiveness of antenatal perineal massage in increasing the likelihood of delivering with an intact perineum., Methods: This single blinded prospective controlled trial included 234 nulliparous women with a singleton fetus. Women allocated to the study group were instructed to practice a 10 minute perineal massage daily from the 34th week of gestation until delivery. Primary outcome measures included the episiotomy rate; first, second, third and fourth-degree perineal tear rates; and intact perineum. Secondary outcomes were related to specific tear locations and the amount of suture material required for repair., Results: Episiotomy rates, overall spontaneous tears and intact perineum rates were similar in the study and control groups. Women in the massage group had slightly lower rates of first-degree tears (73.3% vs. 78.9%, P = 0.39) and slightly higher rates of second-degree tears (26.7% vs. 19.3%, P= 0.39), although both of these outcomes did not reach statistical significance. The rates of anterior perineal tears were significantly higher in the massage group (9.5% vs. 3%, P = 0.05), whereas internal lateral tears rates were slightly lower but without statistical significance (11.5% vs.13.1%, P=0.44)., Conclusions: The practice of antenatal perineal massage showed neither a protective nor a detrimental significant effect on the occurrence of perineal trauma.