Archives of Gynecology and Obstetrics最新文献

Primary objective: To assess the association between Epidural Analgesia (EA) during Vaginal Birth After Cesarean (VBAC) and delivery mode (spontaneous or instrumental vaginal delivery). Secondary objectives include maternal and neonatal outcomes.

Methods: In this retrospective population-based cohort study, all women who underwent a VBAC with and without EA, between the years 1996-2016 at the Soroka University Medical Center (SUMC) were included. Women who delivered by cesarean section (elective and non-elective) and those who gave birth to a newborn with chromosomal abnormalities or major malformations, and multifetal gestations were excluded. Demographical, clinical, and obstetrical characteristics were recorded, and pregnancy complications and adverse perinatal outcomes were compared between the groups. The primary outcome was the type of delivery. Univariate analysis was followed by a multivariate analysis to control for confounders. A p value of < 0.05 was considered statistically significant.

Results: During the study period, 17,516 women who have had a previous CS met the inclusion criteria, of which 15% (n = 2652) used EA during labor, while the rest of the cohort 85% (n = 14,864) were non-EA users. Women in the EA group had higher rates of instrumental delivery and postpartum hemorrhage (PPH) as well as higher rates of oxytocin augmentation and a longer second stage of labor. The use of EA was found to be an independent risk factor for instrumental delivery after controlling for maternal age, ethnicity, parity, DM (diabetes mellitus), hypertensive disorders of pregnancy, oxytocin augmentation, prolonged second stage of labor, induction of labor, fertility treatments and oligohydramnios. However, no significant differences were observed regarding neonatal outcomes including perinatal mortality, birth weight, Apgar scores and shoulder dystocia rates.

Conclusion: EA for women undergoing a VBAC was associated with higher rates of instrumental delivery and PPH, oxytocin augmentation and a longer second stage of labor compared with women without EA. However, neonatal outcomes did not differ between the groups.

Objective: To assess and compare the diagnostic accuracy of radiologist, MR findings, and radiomics-clinical models in the diagnosis of placental implantation disorders.

Methods: Retrospective collection of MR images from patients suspected of having placenta accreta spectrum (PAS) was conducted across three institutions: Institution I (n = 505), Institution II (n = 67), and Institution III (n = 58). Data from Institution I were utilized to form a training set, while data from Institutions II and III served as an external test set. Radiologist diagnosis was performed by radiologists of varying levels of experience. The interpretation of MR findings was conducted by two radiologists with 10-15 years of experience in pelvic MR diagnosis, following the guidelines for diagnosis. Radiomics analysis extracted features from sagittal T2-weighted images and combined them with prenatal clinical features to construct predictive models. These models were then evaluated for discrimination and calibration to assess their performance.

Results: As measured by the area under the receiver operating characteristic curve (AUC), the diagnostic efficacy was 0.587 (0.542-0.630) for junior radiologists from Institution I, 0.568 (0.441-0.689) from Institution II, and 0.507 (0.373-0.641) from Institution III. The AUC was 0.623 (0.580-0.666) for senior radiologists from Institution I, 0.635 (0.508-0.749) from Institution II, and 0.632 (0.495-0.755) from Institution III. The diagnostic efficacy of MR findings was 0.648 (0.601-0.695) for Institution I, 0.569 (0.429-0.709) for Institution II, and 0.588 (0.442-0.735) for Institution III. The diagnostic efficacy of the radiomics-clinical model was significantly higher, with an AUC of 0.794 (0.754-0.833) for Institution I, 0.783 (0.664-0.903) for Institution II, and 0.816 (0.704-0.927) for Institution III. The diagnostic efficacy of the Fusion model was significantly higher, with an AUC of 0.867 (0.836-0.899) for Institution I, 0.849 (0.753-0.944) for Institution II, and 0.823 (0.708-0.939) for Institution III.

Conclusion: The fusion models demonstrated superior diagnostic efficacy compared to radiologists, MR findings, and the radiomics-clinical models. Furthermore, the diagnostic accuracy of PAS was notably higher when utilizing the radiomics-clinical models than when relying solely on radiologist diagnosis or MR findings.

Advances in knowledge: Radiomics analysis substantially augments the diagnostic precision in PAS, providing a significant enhancement over conventional radiologist and MRI findings. The diagnostic efficacy of the fusion model is notably superior to that of individual diagnostic modalities.

Purpose: To examine the association between blastocyst morphology and chromosomal status utilizing pre-implantation genetic testing for aneuploidy (PGT-A).

Methods: A single-center retrospective cohort study including 169 in-vitro fertilization cycles that underwent PGT-A using Next Generation Sequencing (2017-2022). Blastocysts were morphologically scored based on Gardner and Schoolcraft's criteria. Chromosomal analysis results included: euploid; aneuploid (single or double); segmental; mosaic; and complex (≥ 3 chromosome abnormalities). We examined associations between morphological parameters and chromosomal statuses of biopsied embryos utilizing multivariate logistic regression.

Results: Overall, 855 blastocysts underwent PGT-A (PGT-A alone: N = 804; unaffected PGT for monogenic disease (PGT-M) embryos along with PGT-A: N = 51). Of these, 826 were successfully analyzed, with 321 euploid embryos (38.86%). Various morphological parameters (embryo quality, inner cell mass (ICM), trophectoderm (TE), and expansion stage) were more frequent within the double (n = 72, 8.72%), complex (n = 97, 11.74%), mosaic (n = 139, 16.83%), and segmental aneuploidy (n = 28, 3.39%) groups, with similar associations between different morphological parameters and single aneuploidy (n = 169, 20.46%). Utilizing multivariate logistic regression, higher expansion, embryo quality, and TE and ICM grades, were associated with increased odds of euploidy (versus non-euploidy). Higher expansion was a positive predictor of single versus double aneuploidy (aOR 2.94, 95% CI 1.52-5.56, p = 0.001); and higher ICM grade was a positive predictor of single versus complex aneuploidy (aOR 2.86, 95% CI 1.15-7.12, p = 0.024). No morphological parameter was found to be associated with single versus mosaic aneuploidy.

Conclusion: Various morphological parameters are associated with euploidy and different aneuploidy statuses of pre-implantation blastocysts. These findings may aid in the selection of the assumed best chromosomally structured blastocyst for transfer when PGT-A is not performed.

Introduction: Pregnancy induces a hypercoagulable state, characterized by increased coagulation factors and decreased anticoagulants, alongside ongoing fibrinolysis marked by elevated D-dimer (DD) levels. Reference values for DD in pregnancy often exceed the non-pregnant cutoff due to these changes. Elevated DD levels are common in late pregnancy and may correlate with complications such as gestational diabetes, hypertension, and preterm delivery, particularly in cases of preterm premature rupture of membranes (PPROM). This study investigates the association between DD levels, the duration from PPROM diagnosis to delivery, and neonatal outcomes.

Methods: This retrospective study was conducted at the Department of Perinatology, Etlik City Hospital, Ankara, Turkey, from October 2022 to May 2023. Eighty patients with PPROM between 24 and 36 weeks of gestation were included. Routine blood tests and coagulation parameters, including DD, were monitored every other day for 2 weeks. Patients were classified into two subgroups based on whether labor occurred within 7 days of PPROM diagnosis. Statistical analyses included the Mann-Whitney U test, Student's t test, Chi-square test, Friedman test, Durbin-Conover test, generalized estimating equations (GEE), and ROC analysis.

Results: Gestational age at admission was significantly lower in patients who delivered later than 7 days post-PPROM. Significant differences were observed in ultrasonographic measurements, with larger fetal parameters in the early delivery group. Higher DD levels at the third follow-up correlated with shorter durations to delivery (p = 0.021). Longitudinal analysis showed significant fluctuations in DD levels over time, particularly near delivery. The GEE analysis demonstrated a strong inverse relationship between DD levels and time to delivery (p = 0.004), supported by ROC analysis (AUROC = 0.811).

Conclusions: Elevated DD levels are associated with shorter durations from PPROM diagnosis to delivery, indicating their potential utility in predicting labor onset. Monitoring DD levels may help in clinical decision-making for managing PPROM, including planning neonatal care and timing of interventions.

Women with a history of gestational diabetes mellitus (GDM) significantly increase the risk of developing type 2 diabetes later in life. Although the increased glucose levels typically return to normal range after delivery for most GDM women, a significant proportion of GDM women develop impaired glucose tolerance or overt diabetes after delivery. Several factors associated with postpartum glucose abnormalities have been identified, yet the link between fasting glucose levels at diagnosis of GDM and postpartum glucose abnormalities remains unclear. In this retrospective study with 866 GDM women, we found that 12.5% presented with abnormal postpartum fasting glucose levels (prediabetes). Among those with postpartum fasting glucose abnormalities (n = 109), 63 (57%) women had abnormal fasting glucose levels at diagnosis, indicating an odds ratio of 1.662 (95% CI: 1.12, 2.479, p < 0.001) for these GDM women developing postpartum fasting glucose abnormalities, compared to those GDM women with normal postpartum fasting glucose levels. Additionally, of GDM women with abnormal postpartum glucose levels (n = 109),70 (64%) presented with abnormal fasting glucose levels one day before delivery. The odds ratio for these GDM women presenting with abnormal postpartum fasting glucose levels was 3.751 (95% CI: 2.462, 5.664, p < 0.001) compared to those GDM women with normal postpartum fasting glucose levels. Furthermore, GDM women with additional insulin treatment or delivered an LGA infant significantly increased the risk of developing postpartum fasting glucose abnormalities. Our findings suggest that abnormal fasting glucose levels at diagnosis or shortly before delivery could be a predictive indicator for postpartum glucose abnormalities in GDM women.

Purpose: To comprehensively compare the diagnostic ability and inter-reader agreement of magnetic resonance imaging (MRI) findings for predicting massive hemorrhage after cesarean section in patients with placental malposition, aiming to identify the most reliable and objective indicators.

Methods: Totally, 148 consecutive patients with placental malposition underwent MRI and cesarean section at our hospital between January 2014 and July 2021. The patients were divided into massive and non-massive hemorrhage groups. MRI findings of placenta accreta, placental position, and placental volume were evaluated by two radiologists, and inter-reader agreement was calculated. Diagnostic ability for predicting massive hemorrhage was evaluated using receiver operating characteristic analysis.

Results: Intraplacental T2 dark bands (100% vs. 58.2%, p = 0.001), placental bulge (50% vs. 3.7%, p < 0.001), loss of retroplacental T2 hypointense line (100% vs. 67.2%, p = 0.01), myometrial thinning (92.9% vs. 57.5%, p = 0.009), total placenta previa (64.3% vs. 23.9%, p = 0.033), and anterior placenta (35.7% vs. 10.5%, p = 0.02) were significantly observed in massive hemorrhage group. Partial placental volume of lower uterine segment (PV_partial) was larger in massive hemorrhage group (166 [108-214] cm³ vs. 70 [43-112] cm³ p < 0.001), had the second highest intraclass correlation coefficient (0.84), and had the highest area under the curve (0.81) for diagnosing massive hemorrhage.

Conclusion: This study revealed PV_partial is an accurate and objective indicator for massive hemorrhage, independent of radiologists' experience. This indicator potentially enables prediction of massive hemorrhage, improving pre-operative planning in high-risk pregnancies.

Purpose: To quantify the separation between maternal blood cell-free (cf)DNA markers in preeclampsia and unaffected pregnancies and compare with existing markers. This approach has not been used in previous studies.

Methods: Comprehensive systematic literature search of PubMed to identify studies measuring total cfDNA, fetal cf(f)DNA or the fetal fraction (FF) in pregnant women. Included-studies of asymptomatic pregnancies with subsequent preeclampsia (cases) and unaffected pregnancies (controls) tested in the first or second trimester and before the clinical onset of preeclampsia. Excluded-studies not reporting the median or mean, standard deviation, inter-quartile range or range in cases and controls. Information from 26 eligible studies was entered into a meta-analysis to estimate, for each marker, the Mahalanobis distance, a measure of separation between the overlapping distributions in preeclampsia and unaffected pregnancies. This was compared with estimates for mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI), pregnancy associated plasma protein (PAPP)-A and placental growth factor (PlGF).

Results: The mean Mahalanobis distance for total cfDNA was 0.44 (95% CI 0.12-0.76), which fell between UtA-PI (0.53) and the absolute value of PAPP-A (- 0.36). For cffDNA the distance was 1.03 (0.37-1.69), which is superior to MAP (0.74), UtA-PI, PlGF (- 0.57) and PAPP-A. The distance for FF was - 0.34 (- 0.56 to - 0.12), similar to PAPP-A.

Conclusion: All three markers have a potential preeclampsia screening role, particularly cffDNA. However, to estimate the screening performance in combination with existing markers further large studies are needed. The current analysis will help in the power calculation for such studies.

Purpose: The objective of this study is to evaluate the impact of pelvic floor physical therapy (PFPT) on symptoms and quality of life in women who experienced third- and fourth-degree perineal tears (Obstetric Anal Sphincter Injuries, OASIS) during childbirth. OASIS can lead to anal incontinence and dyspareunia, having important implications regarding the quality of life and health of women but, unfortunately, there is no standard practice for postpartum care following OASIS.

Methods: In this retrospective observational study, patients diagnosed with OASIS between January 2016 and June 2023 were enrolled. Since 2016, all women with OASIS have been routinely referred for physiatric evaluation and pelvic floor rehabilitation. Validated questionnaires (Wexner score and Marinoff scale) were administered to enrolled women to assess anal incontinence and dyspareunia.

Results: The study included 148 women, of whom 88 responded to the questionnaires. Participants were divided into two groups: those who underwent PFPT (N = 68) and those who declined it (N = 20). The mean follow-up period was 1447.35 days. The Wexner score was lower in the PFPT group compared to the no-PFPT group (p = 0.050). The Marinoff score did not show a statistically significant difference between the two groups (p = 0.381).

Conclusion: PFPT was shown to be effective in reducing AI symptoms in women with OASIS, improving quality of life and maintaining its effects in the long term, but without providing benefits for dyspareunia. Strengths of this study include the use of validated questionnaires, the long follow-up period, and the involvement of a specialized team of physiatrists and physiotherapists.

Objective: To examine the impact of a new image enhancement technique on the distribution of NT measurements.

Methods: In this retrospective study, nuchal translucency (NT) images that were taken with the GE Voluson E22 ultrasound machine between May and September 2024 were collected. One operator took manual and automated NT measurements in an NT image without radiant enhancement mode followed by automated measurements in NT images with minimum, medium and maximum radiant mode. The automated measurement in the NT images without radiant mode were considered gold standard. The relative bias of the gold standard, the manual measurement and the automated measurements with the radiant enhancement technology were compared using median and 25-75th interquartile range as well as by the Wilcoxon test.

Results: The database search yielded 352 NT images from 101 pregnant women. Average maternal age of the study population was 34.0 years and average crown-rump length was 68.3. The median NT thickness was 1.7 mm for both the manual and automated measurements done without the use of radiant mode. The median automated measurement with minimum, medium and maximum radiant mode was 2.00, 2.05 and 2.10 mm, respectively. All automated measurements were significantly higher than the gold standard.

Discussion: The use of the radiant mode results in an increase in the NT thickness. This effect should be taken into account when calculating the risk for chromosomal abnormalities.

Purpose: This study aimed to assess the impact of absorbable subcutaneous staples for skin closure in cesarean delivery (CD) on maternal morbidity.

Methods: A retrospective cohort study was conducted at a single tertiary university-affiliated medical center between January 2011 and April 2022. In 2020, a new technique involving absorbable subcutaneous staples for skin closure in CD was introduced. We compared surgical outcomes among three groups: non-absorbable staples, absorbable subcutaneous staples, and absorbable subcutaneous sutures. Data were compared between the three groups and demographic, obstetric, and surgical characteristics were analyzed using univariate and multivariate analysis.

Results: During the study period, 31,660 CDs were performed in our center. The data of 31,419 CDs were available for analysis. Absorbable subcutaneous staples were associated with a significantly shorter surgery time in comparison to non-absorbable staples and sutures (52 min vs 53 min vs 60 min, p < 0.001). No differences were found in rates of wound infections or any surgical site surgery in the 45 days following CD. In a multivariate analysis: the use of absorbable subcutaneous staples was associated with a significantly lower risk for prolonged hospitalization > 5 days (OR 0.6, p < 0.001) and re-admission within 45 days (OR 0.8, p = 0.04).

Conclusion: The use of absorbable subcutaneous staples for skin closure during CD is associated with shorter surgery times and a lower risk of prolonged hospitalization and readmission within 45 days.