Dehiscence of cesarean section scar during pregnancy and delivery — risk factors

Objective: We wanted to identify risk factors for dehiscence of cesarean section (CS) scars in patients undergoing repeatedcesarean section.Material and methods: This was a retrospective case-control study over a 3-year period in our medical center (2011–2014),comparing women who had repeated CS without complications and women diagnosed with dehiscence. Data were collectedfrom medical records and the groups were compared for demographic and obstetrical data.Results: Dehiscence was identified in 27 women, while 54 women without dehiscence were the control group. Statisticallysignificant differences were found in the need for augmentation, the number of previous cesarean sections, cesarean sectionin the active phase of labor and length of hospitalization.Discussion: The need for augmentation of labor, CS in the nonactive stage and more than one cesarean section, all increasedthe risk of dehiscence. There was no association between dehiscence and scar pain, time elapsed since the previouscesarean section, the method of wound closure or fever

COVID-19 Pandemic Development in Jordan-Short-Term and Long-Term Forecasting

In this study, we proposed three simple approaches to forecast COVID-19 reported cases in a Middle Eastern society (Jordan). The first approach was a short-term forecast (STF) model based on a linear forecast model using the previous days as a learning data-base for forecasting. The second approach was a long-term forecast (LTF) model based on a mathematical formula that best described the current pandemic situation in Jordan. Both approaches can be seen as complementary: the STF can cope with sudden daily changes in the pandemic whereas the LTF can be utilized to predict the upcoming waves’ occurrence and strength. As such, the third approach was a hybrid forecast (HF) model merging both the STF and the LTF models. The HF was shown to be an efficient forecast model with excellent accuracy. It is evident that the decision to enforce the curfew at an early stage followed by the planned lockdown has been effective in eliminating a serious wave in April 2020. Vaccination has been effective in combating COVID-19 by reducing infection rates. Based on the forecasting results, there is some possibility that Jordan may face a third wave of the pandemic during the Summer of 2021.In this study, we proposed three simple approaches to forecast COVID-19 reported cases in a Middle Eastern society (Jordan). The first approach was a short-term forecast (STF) model based on a linear forecast model using the previous days as a learning data-base for forecasting. The second approach was a long-term forecast (LTF) model based on a mathematical formula that best described the current pandemic situation in Jordan. Both approaches can be seen as complementary: the STF can cope with sudden daily changes in the pandemic whereas the LTF can be utilized to predict the upcoming waves' occurrence and strength. As such, the third approach was a hybrid forecast (HF) model merging both the STF and the LTF models. The HF was shown to be an efficient forecast model with excellent accuracy. It is evident that the decision to enforce the curfew at an early stage followed by the planned lockdown has been effective in eliminating a serious wave in April 2020. Vaccination has been effective in combating COVID-19 by reducing infection rates. Based on the forecasting results, there is some possibility that Jordan may face a third wave of the pandemic during the Summer of 2021.Peer reviewe

Early planned labor induction vs expectant management in late preterm pre-labor rupture of membranes: maternal and neonatal outcomes

Objectives: To compare expectant management with early planned labor induction in pregnancies complicated by late preterm pre-labor rupture of membranes (PPROM). Material and methods: A retrospective file review was conducted in a single tertiary center from January 2015 to Sep-tember 2019. Singleton pregnancies complicated by late PPROM at 34–36 completed weeks of gestation were enrolled. We compared maternal and neonatal complications between expectant management and early planned labor induction. Results: We retrospectively assigned 41 women to the expectant management group and 39 to the early planned labor induction group. No difference was found in the mode of delivery between the groups. Women in the expectant manage-ment group had a longer antepartum hospital stay compared with the induction group (median of three versus one day, p < 0.01). Neonates were delivered at a more advanced gestational age in the expectant management group compared with that in the induction group (35 5/7 versus 35 2/7 weeks, p < 0.01). In the induction group, 74.4% of the neonates were admitted to the intensive care unit (ICU), and 66.7% received antibiotics compared with 51.2% of neonates admitted to ICU and 29.3% receiving antibiotics in the expectant management group (p = 0.04 and p < 0.01, respectively). Conclusions: In pregnancies complicated by late PPROM, early labor induction was associated with a shorter antepartum maternal hospital stay but a higher neonatal ICU admission rate and more frequent antibiotic administration than expect-ant management. We consider expectant management to be an acceptable alternative to early labor induction in PPROM

Intrahepatic cholestasis of pregnancy — prevalence and ethnic distribution in northern Israel

Objectives: Intrahepatic cholestasis of pregnancy (ICP) is charachterized by pruritis and elevated serum bile acids (BA) and is associated with adverse obstetrical outcomes. ICP etiology is poorly understood and its incidence varies with ethnicity and geographical distribution. Objectives: Explore the prevalence and characteristics of ICP in the different Northern Israeli ethnic groups and compare maternal and perinatal outcomes according to disease severity. Material and methods: Single-center retrospective study. Women who were diagnosed with ICP based on clinical presentation and elevated fasting BA (≥ 10 μmol/L) were included. Disease incidence, maternal and neonatal complications were explored according to ethnic subgroups analysis and obstetrical complications were examined according to disease severity. Results: The incidence of ICP in the study population was 0.58%. Higher ICP incidence was found in our cohort compared with other reports arising from Central Israel (p < 0.001). The Christian patients had a higher incidence of ICP (1.1%) and preeclampsia (23.1%). A higher rate of neonatal intensive care unit (NICU) admissions was found in the Arab Muslim and Christian groups compared with the Jewish and Druze groups (p = 0.007). A higher rate of preeclampsia was found in the severe (BA ≥ 40 μmol/L) ICP group (p < 0.001). Patients in the severe ICP group had earlier gestational age at delivery (37 versus 38.14 weeks, p < 0.001). Birth weight was significantly lower in the severe ICP group (p = 0.018). Conclusions: The incidence of ICP at our institution was 0.58%, which is higher compared with previous reported Israeli incidence. Higher ICP and preeclampsia incidence were found among Arab Christian patients

Mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov-2 infection: An international cohort study

Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (740%) had emergency surgery and 280 (248%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (261%) patients. 30-day mortality was 238% (268 of 1128). Pulmonary complications occurred in 577 (512%) of 1128 patients; 30-day mortality in these patients was 380% (219 of 577), accounting for 817% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 175 [95% CI 128-240], p<00001), age 70 years or older versus younger than 70 years (230 [165-322], p<00001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (235 [157-353], p<00001), malignant versus benign or obstetric diagnosis (155 [101-239], p=0046), emergency versus elective surgery (167 [106-263], p=0026), and major versus minor surgery (152 [101-231], p=0047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Antenatal ultrasound findings in choanal atresia: A case report and review of the literature

Choanal atresia occurs in about 1 in 5000 births and is associated with other structural and genetic abnormalities. Choanal atresia is usually diagnosed postnatally due to respiratory distress, and rarely diagnosed antenatally. Here, a woman with severe polyhydramnios is described, whose fetus was diagnosed antenatally with isolated bilateral choanal atresia, as evident by persistent absence of flow through the nostrils on ultrasound. A literature review is presented of the antenatal findings of choanal atresia, using ultrasound and other imaging modalities. An association of choanal atresia with polyhydramnios should be considered. Examining flow through the fetal nose, using color Doppler, might aid in diagnosing choanal atresia. If this condition is suspected, a detailed ultrasound scan should be done to rule out other anomalies. Fetal magnetic resonance imaging has been suggested as an additional imaging tool in selected patients. Genetic counselling and invasive prenatal testing should be offered

The association between acute lower abdominal pain over a previous caesarean scar and uterine rupture

Pregnant women with previous caesarean delivery might suffer from acute lower abdominal pain located at the site of previous caesarean scar (CS). The association between this complaint and uterine rupture (UR) is not fully understood. Therefore, we aimed to examine the risk of UR in women with acute persistent abdominal pain (APAP) over a previous CS and to investigate all the women with UR, with or without APAP and with or without previous CS, in order to determine risk factors, clinical presentation and management. We performed a retrospective analysis on two study groups: women who had APAP over previous CS and women who had UR. We found an incidence of UR in patients with APAP over the previous CS was 0.7%; which doubled the total UR rate among women with previous caesarean in our medical centre (0.35%). Forty percent of the women with APAP over a previous CS had preterm delivery. Twenty percent of the cases of UR occurred in preterm weeks. To conclude, APAP over a previous CS is associated with a doubled risk of UR. Considering this symptom as a preliminary sign of UR might lead to elevated rate of iatrogenic preterm deliveries.Impact statement What is already known on this subject? Women with UR may present with abdominal pain which may vary from non-specific mild discomfort to severe acute abdominal pain. Additionally, these women may suffer from acute persistent abdominal pain (APAP) located over the previous caesarean scar. The clinical significance of APAP in these women has not been fully investigated. What do the results of this study add? Lower abdominal pain located at the site of previous CS is associated with a doubled risk of UR. Considering this complaint as a major sign of UR might lead to an elevated rate of iatrogenic preterm deliveries. What are the implications of these findings for clinical practice and/or further research? Further studies are needed to explore whether women with a single complaint of APAP over CS could be managed expectantly and even offered a trial of labour after caesarean delivery (CD)

Knowledge of Human Papillomavirus (HPV), Attitudes and Practices Towards Anti-HPV Vaccination Among Israeli Pediatricians, Gynecologists, and Internal Medicine Doctors: Development and Validation of an Ad Hoc Questionnaire

Human papillomavirus (HPV) is a highly widespread virus which is responsible for one of the most common sexually transmitted infections. Two main preventative strategies exist: anti-HPV vaccination and cervical screening. Health-care workers play a key role in promoting public health campaigns; however, vaccine hesitancy is an often under-recognized challenge. To investigate the overall knowledge of HPV and HPV-related issues, as well as the attitudes and practices of health professionals towards recommending the anti-HPV vaccine, an ad hoc knowledge, attitudes, and practices (KAP) questionnaire was developed and validated in a sample of 139 Israeli pediatricians, gynecologists, and internal medicine doctors. The KAP questionnaire was found to be psychometrically valid and sound (with an rKR-20 coefficient of 0.74 for the second part and a Cronbach’s alpha of 0.85 for the third part). Furthermore, the present study confirmed the importance of health-care providers in recommending the immunization practice. Parents that had been strongly advised by health-care providers to vaccinate their children accepted immunization for their girls (odds ratio (OR) 1.09 (95% CI 1.04–1.14)) and boys (OR 1.06 (95% CI 1.02–1.10)), had a lower probability of deciding to postpone the immunization appointment (OR 0.81 (95% CI 0.66–0.98)), had fewer doubts and concerns about the vaccine (OR 0.69 (95% CI 0.54–0.89)), and had a lower probability of refusing the vaccination (OR 0.93 (95% CI 0.86–0.99)). Interestingly, the use of new, emerging tools such as ad hoc websites, applications, and other interactive devices reduced vaccine hesitancy (OR 0.90 (95% CI 0.82–0.99)) and concerns about the side-effects of the vaccine (OR 0.92 (95% CI 0.86–0.99)). However, among Israeli health-care workers, knowledge was generally moderate, with updated information lacking in about 30% of surveyed health-care providers and approximately 20% of them not recommending the anti-HPV vaccine among boys. This study has practical implications for policy- and decision-makers in that they should be aware of the overall level of knowledge among health-care workers and should implement ad hoc educational interventions to address gaps in knowledge and help medical providers routinely recommend the anti-HPV vaccine both to male and female children and adolescents

Monochorionic diamniotic in vitro fertilization twins have a decreased incidence of twin-to-twin transfusion syndrome.

To compare the incidence of twin-to-twin transfusion syndrome (TTTS) in spontaneous versus IVF-conceived twin pregnancies. Retrospective multicenter study. University-affiliated tertiary medical centers. Women admitted for 11-14 week's scan between January 1997 and July 2013 who were diagnosed with monochorionic (MC) diamniotic twin pregnancies. None. Mode of conception, TTTS. The study cohort included 327 pregnant women with live MC diamniotic twins. Of them, 284 (86.9%) and 43 (13.1%) were spontaneous and IVF conceived, respectively. The mean maternal age was significantly higher in IVF compared with in spontaneously conceived pregnancies (33.8 ± 5.5 vs. 31.6 ± 5.4, respectively). Thirty-seven twins (11.3%) had TTTS, of whom 36/284 (12.7%) versus 1/43 (2.3%) were spontaneously and IVF conceived, respectively. The mean week of delivery was significantly lower in MC twins diagnosed with TTTS compared with those without TTTS (32.7 ± 3.3 vs. 35.5 ± 2.5, respectively). Furthermore, there was a significantly higher birthweight discordancy in twins diagnosed with TTTS compared with those without (20.6% vs. 11%, respectively). The significantly lower proportion of TTTS found in IVF-conceived twins may suggest a different embryological process that lies at the core of IVF conception of monozygotic twinning