The GOAL study: a prospective examination of the impact of factor V Leiden and ABO(H) blood groups on haemorrhagic and thrombotic pregnancy outcomes

Factor V Leiden (FVL) and ABO(H) blood groups are the common influences on haemostasis and retrospective studies have linked FVL with pregnancy complications. However, only one sizeable prospective examination has taken place. As a result, neither the impact of FVL in unselected subjects, any interaction with ABO(H) in pregnancy, nor the utility of screening for FVL is defined. A prospective study of 4250 unselected pregnancies was carried out. A venous thromboembolism (VTE) rate of 1·23/1000 was observed, but no significant association between FVL and pre-eclampsia, intra-uterine growth restriction or pregnancy loss was seen. No influence of FVL and/or ABO(H) on ante-natal bleeding or intra-partum or postpartum haemorrhage was observed. However, FVL was associated with birth-weights >90th centile [odds ratio (OR) 1·81; 95% confidence interval (CI<sub>95</sub>) 1·04–3·31] and neonatal death (OR 14·79; CI<sub>95</sub> 2·71–80·74). No association with ABO(H) alone, or any interaction between ABO(H) and FVL was observed. We neither confirmed the protective effect of FVL on pregnancy-related blood loss reported in previous smaller studies, nor did we find the increased risk of some vascular complications reported in retrospective studies

Amniotic fluid embolism: A rare complication of second-trimester amniocentesis

Amniotic fluid embolism occurring following diagnostic amniocentesis is extremely rare. Only 2 cases have been reported in the English literature over the past 55 years, the most recent one approximately 3 decades ago. We present a case of amniocentesis at 24 weeks' gestation that was performed as part of an evaluation of abnormal fetal ultrasound findings. Immediately following amniotic fluid aspiration, maternal hemodynamic collapse occurred, initially diagnosed and treated as anaphylactic shock. Shortly after initial therapy, coagulopathy was noted and amniotic fluid syndrome suspected. Rapid response restored maternal hemodynamic stability; however, the fetus had suffered fatal damage

Amniotic fluid embolism: A rare complication of second-trimester amniocentesis

Amniotic fluid embolism occurring following diagnostic amniocentesis is extremely rare. Only 2 cases have been reported in the English literature over the past 55 years, the most recent one approximately 3 decades ago. We present a case of amniocentesis at 24 weeks' gestation that was performed as part of an evaluation of abnormal fetal ultrasound findings. Immediately following amniotic fluid aspiration, maternal hemodynamic collapse occurred, initially diagnosed and treated as anaphylactic shock. Shortly after initial therapy, coagulopathy was noted and amniotic fluid syndrome suspected. Rapid response restored maternal hemodynamic stability; however, the fetus had suffered fatal damage

Pulmonary edema occurring after isoxsuprine and dexamethasone treatment for preterm labor: Case report

Peer Reviewe

New Israeli sonographic estimated fetal weight growth curves as compared to current birth weight growth curves: On what should diagnosis of intrauterine growth disorders be based?

Background Two types of growth curves are commonly used to diagnose fetal growth disorders: neonatal birth weight (BW) and sonographic estimated fetal weight (EFW). The debate as to which growth curve to use is universal. Objectives To establish sonographic EFW growth curves for the Israeli population and to assess whether the use of the BW growth curves currently adapted in Israel leads to underdiagnosis of intrauterine growth disorders. Methods Biometric data collected during a 6 year period was analyzed to establish sonographic EFW growth curves between 15–42 weeks of gestation for the Israeli population. Growth curves were compared to previously published sonographic EFW growth curves. A comparison with the Israeli BW growth curves was performed to assess the possibility of underdiagnosis of intrauterine growth disorders. Results Out of 42,778 sonographic EFW studies, 31,559 met the inclusion criteria. The sonographic EFW growth curves from the current study resembled the EFW curves previously published. The comparison of the current sonographic EFW and BW growth curves revealed under-diagnosis of intrauterine growth disorders during the preterm period. Four percent of the fetuses assessed between 26–34 weeks would have been suspected of being growth restricted; 2.8 percent of the fetuses assessed between 30–36 weeks would have been suspected of having macrosomia, based on the BW growth curves. Conclusions New Israeli sonographic EFW growth curves resemble previously published sonographic EFW curves. Using BW growth curves may lead to the under-diagnosis of growth disorders. We recommend adopting sonographic EFW growth to diagnose intrauterine growth disorders.</p

New Israeli sonographic estimated fetal weight growth curves as compared to current birth weight growth curves: On what should diagnosis of intrauterine growth disorders be based?

Background Two types of growth curves are commonly used to diagnose fetal growth disorders: neonatal birth weight (BW) and sonographic estimated fetal weight (EFW). The debate as to which growth curve to use is universal. Objectives To establish sonographic EFW growth curves for the Israeli population and to assess whether the use of the BW growth curves currently adapted in Israel leads to underdiagnosis of intrauterine growth disorders. Methods Biometric data collected during a 6 year period was analyzed to establish sonographic EFW growth curves between 15–42 weeks of gestation for the Israeli population. Growth curves were compared to previously published sonographic EFW growth curves. A comparison with the Israeli BW growth curves was performed to assess the possibility of underdiagnosis of intrauterine growth disorders. Results Out of 42,778 sonographic EFW studies, 31,559 met the inclusion criteria. The sonographic EFW growth curves from the current study resembled the EFW curves previously published. The comparison of the current sonographic EFW and BW growth curves revealed under-diagnosis of intrauterine growth disorders during the preterm period. Four percent of the fetuses assessed between 26–34 weeks would have been suspected of being growth restricted; 2.8 percent of the fetuses assessed between 30–36 weeks would have been suspected of having macrosomia, based on the BW growth curves. Conclusions New Israeli sonographic EFW growth curves resemble previously published sonographic EFW curves. Using BW growth curves may lead to the under-diagnosis of growth disorders. We recommend adopting sonographic EFW growth to diagnose intrauterine growth disorders.</p

Sliding sign for intra-abdominal adhesion prediction before repeat cesarean delivery

Background The sliding sign (the relative motion between the abdominal and uterine wall as assessed by ultrasonography) may help identify severe intraabdominal adhesions before repeat cesarean delivery. Methods We conducted a prospective observational study of scheduled repeat cesarean deliveries. Using transabdominal ultrasonography, while the parturient breathed deeply, the ultrasonographer recorded a video clip in a sagittal plane lateral to the umbilicus. These clips were assessed for the presence (sliding-positive) or absence (sliding-negative) of relative movement between the maternal abdominal and uterine wall. Surgeons blinded to ultrasonography results graded the severity of intraperitoneal adhesions intraoperatively. Study outcomes were the accuracy of the preoperative sliding sign for prediction of severe adhesions and its association with surgical times and bleeding. Experience We recruited 370 women. A negative sliding sign was associated with severe adhesions (sensitivity 56%, 95% CI 35–76; specificity 95%, 95% CI 93– 97). A similar accuracy (sensitivity 64%, 95% CI 43–82; specificity 94%, 95% CI 92–97) was achieved by combining the sliding sign with a history of adhesions in the previous surgery. In multivariable models, a negative sliding sign was significantly correlated with a longer interval from skin incision to delivery and increased risk for bleeding. Conclusion A negative sliding sign predicts severe intra-abdominal adhesions encountered during repeat cesarean delivery, longer time to delivery, and a higher chance of bleeding.</p

To drain or not to drain: intraperitoneal closed-suction drainage placement during cesarean delivery

Introduction: Intraperitoneal closed suction drains are occasionally placed during cesarean delivery. This study aims to ascertain the prevalence, associated factors, outcome, and risks of intraperitoneal closed-suction drain placed during cesarean delivery. Material and methods: A retrospective cohort study of all women undergoing cesarean delivery in a single center from 2005 to 2015. We excluded cases of cesarean hysterectomy and women who had hollow viscus injury. Cesarean deliveries were categorized into two groups based on intraperitoneal drain use: drain + and drain−.The study aims were to describe: (1) drain use prevalence; (2) factors associated with drain use; (3) interval to relaparotomy due to intraperitoneal bleeding and outcome of drain use; and (4) unique drain-related adverse outcome. Statistics: univariate, multivariable, and inverse probability treatment weighting (IPTW) analysis. Results: After applying the inclusion and exclusion criteria, 16 581 (99.3%) cesareans were included. An intraperitoneal drain was used in 1264 (7.6%) cesareans, ranging from 4.4 to 18.8% in women with no and four or more cesareans, respectively. Comparing the drain + and drain- groups, multivariable analysis revealed that the factors associated with the use of a drain included (OR, 95%CI) uterine rupture (5.14, 3.15–8.38), intrapartum fever (2.65, 1.87–3.75), previous cesareans (2.29, 2.00–2.68), second-stage cesarean (2.21, 1.64–2.74), preterm delivery (1.89, 1.63–2.19), spontaneous onset of labor (1.42, 1.24–1.63), and maternal age greater than 35 years (1.35, 1.19–1.54); p  Conclusions: Drain use in our study resulted in a shorter time to relaparotomy for intraperitoneal hemorrhage. However, it was associated with a higher risk for puerperal fever and a 0.5% risk for relaparotomy for removal of the drain.</p

Sliding sign for intra-abdominal adhesion prediction before repeat cesarean delivery

Background The sliding sign (the relative motion between the abdominal and uterine wall as assessed by ultrasonography) may help identify severe intraabdominal adhesions before repeat cesarean delivery. Methods We conducted a prospective observational study of scheduled repeat cesarean deliveries. Using transabdominal ultrasonography, while the parturient breathed deeply, the ultrasonographer recorded a video clip in a sagittal plane lateral to the umbilicus. These clips were assessed for the presence (sliding-positive) or absence (sliding-negative) of relative movement between the maternal abdominal and uterine wall. Surgeons blinded to ultrasonography results graded the severity of intraperitoneal adhesions intraoperatively. Study outcomes were the accuracy of the preoperative sliding sign for prediction of severe adhesions and its association with surgical times and bleeding. Experience We recruited 370 women. A negative sliding sign was associated with severe adhesions (sensitivity 56%, 95% CI 35–76; specificity 95%, 95% CI 93– 97). A similar accuracy (sensitivity 64%, 95% CI 43–82; specificity 94%, 95% CI 92–97) was achieved by combining the sliding sign with a history of adhesions in the previous surgery. In multivariable models, a negative sliding sign was significantly correlated with a longer interval from skin incision to delivery and increased risk for bleeding. Conclusion A negative sliding sign predicts severe intra-abdominal adhesions encountered during repeat cesarean delivery, longer time to delivery, and a higher chance of bleeding.</p