Objective Our aim was to find the factors which predict a vertex presentation vaginal delivery (VD) in women who are admitted for a trial of external cephalic version (ECV). Study Design This is a retrospective cohort study of women who underwent a trial of ECV and delivered between November 2011 and December 2018 in a single tertiary center. The main outcome measure was successful VD of a fetus in the vertex presentation. Women who achieved VD in the vertex presentation or underwent cesarean delivery were compared on the basis of variety of predictive factors. Adverse neonatal and maternal outcomes were reported. Logistic regression was used for the multivariate analysis. Results A total of 946 women were included; 717 (75.8%) women had a successful ECV and 663 (70.1%) women had a VD in the vertex presentation. Parous women had 79.3% VD rate (570/719) and nulliparous women had 41.0% VD rate (93/227). Women with an amniotic fluid index (AFI) of 50 to 79, 80 to 200, and >200 mm had 34.8, 71.0, and 83.1% VD rate, respectively. Parous versus nulliparous women had an adjusted odds ratio (aOR) of 5.42 (95% confidence interval [CI]: 3.90–7.52, p < 0.001), women with AFI 50 to 79 mm compared with AFI 80 to 200 mm had an aOR of 0.21 (95% CI 0.12–0.37, p < 0.001), and women with an AFI >200 mm compared with AFI 80 to 200 mm had an aOR of 1.74 (95% CI: 1.03–2.92, p = 0.037) to achieve VD. The final prediction model for the chances of a VD based on data on admission for ECV was reported. The Hosmer-Lemeshow test was used to evaluate the goodness of fit of the model (p = 0.836). Conclusion Being parous and having an AFI >200 mm are positive independent predictive factors for achieving VD of a vertex presenting fetus after ECV. Whereas AFI 50 to 79 mm is a negative independent predictive factor. Key Points

We studied the association between parity and maternal and neonatal outcomes among twin deliveries. We conducted a retrospective analysis of twin deliveries outcomes by parity. Inclusion criteria included pregnancies >24 weeks and cephalic position of the presenting twin. Exclusion criteria included previous cesarean delivery. Women were divided into three groups based on parity: primiparas, multiparas (parity of 1-4), and grandmultiparas (parity ≥5). Primary outcome was mode of delivery. Secondary outcomes included maternal blood transfusion, ICU admission, 5 minute Apgar score and NICU admission of term neonates ( >37 weeks). We analyzed the outcomes of 575 women. There were 108 primiparas, 265 multiparas and 202 grandmultiparas. Delivery was significantly earlier in the primipara group vs. multiparas and grandmultiparas (36+1 vs. 36+5 and 36+5 weeks, respectively, p=0.01). Sixty-nine (63.9%) of primiparas delivered vaginally as did 240 (90.6%) multiparas and 189 (93.6%) grandmultiparas (p value< 0.001). Blood products transfusion rate was lower in the grandmultipara group compared with multiparas and primiparas (3.4%, 3.7% and 12.03%, p=0.002). The rate of second twin's 5 minute Apgar score < 7 was higher in the primipara group (7.4% vs. 0.3% and 0%, p< 0.001). There were no differences in rates of maternal ICU admissions and NICU admissions of term neonates. Our study suggests that among twin pregnancies, higher parity is associated with favorable maternal and neonatal outcomes compared to the outcome of women with low-order parity.

Aim The aim of this study was to determine the safety of vaginal delivery with a non-vertex second twin when the first twin is in the vertex presentation. Materials and methods A retrospective analysis was undertaken, utilizing a cohort of twin gestations in which the presenting twin was vertex and the second twin was either vertex (group A) or non-vertex (group B). We assessed maternal and neonatal outcomes including emergency cesarean delivery, 5-minute Apgar scores, cord arterial pH, NICU admissions, and adverse maternal postpartum outcomes including ICU admissions and the requirement of blood products. Results Six hundred and eighty-five women with a vertex presenting twin were admitted to labor and delivery. Three hundred and ninety-five women were included in group A (vertex/vertex) and 290 were included in group B (vertex/non-vertex). No statistically significant differences were found in the 5-minute Apgar scores, cord arterial pH, or in the rates of emergency cesarean deliveries, NICU admission, maternal blood transfusion or ICU admissions. Conclusion In conclusion, vaginal delivery of a breech second twin when the presenting twin is vertex was found as safe as vaginal delivery of twins in the vertex/vertex presentation.

Purpose To determine factors associated with a successful twin trial of labor after Cesarean delivery (TOLAC). Methods A retrospective cohort study was conducted at a single medical center in a population highly motivated for TOLAC (> 80%). The effect of maternal demographic and obstetric characteristics on the likelihood of twin TOLAC success was analyzed. Maternal complications and combined adverse outcome (uterine rupture, Apgar < 7 at 5 min, and umbilical cord pH < 7.1) were compared between singleton and twin TOLAC groups. Results Ninety-five women with a twin gestation and one previous Cesarean delivery comprised the study group. Five thousand seven hundred and three women with a singleton gestation and one previous Cesarean delivery comprised the control group. 30.5% and 83% of women with twin and singleton gestation, respectively, underwent a trial of labor. Women in the twin TOLAC group were significantly less likely to succeed and less likely to have a spontaneous unassisted vaginal delivery compared to women in the singleton TOLAC group. Maternal age less than 35 years, parity greater than two, and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, maternal complications, and for combined adverse outcome. Conclusions Twin TOLAC is not common, even in parturients highly motivated for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture, maternal complications, and combined adverse perinatal outcome than women undergoing TOLAC with a singleton gestation. Demographic and obstetric risk factors were identified which can aid the attending obstetrician in the counseling of these challenging cases.

Background: There is limited data regarding the safety of vaginal delivery in women infected with COVID-19. Our goal was to assess the safety of vaginal delivery in women infected with COVID-19 and the risk of neonatal infection. Methods: This was a single medical center cohort study. Data were collected about the outcome of twenty-one women with laboratory-confirmed COVID-19 infection who delivered between March 23, 2020, and May 8, 2020. Results: Twenty-one gravidas were diagnosed with COVID-19 infection. None required admission to the intensive care unit (ICU) and there were no fatalities. Seventeen delivered vaginally and four by caesareans. Apgar scores of all neonates were 9 at 1 min and 10 at 5 min. One neonate was diagnosed with COVID-19 infection 24 h after birth. Conclusions: Vaginal delivery in women infected with COVID-19 is not associated with a significant risk of neonatal infection. Copyright (C) 2020, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC.

Objective We compared neonatal immunity after vaccination against SARS-CoV-2 during pregnancy to that achieved after maternal infection. Study design We tested cord blood from women infected with SARS-CoV-2 during pregnancy (group 1, n = 29), women who were vaccinated during pregnancy (group 2, n = 29) and from women not infected and not vaccinated (Group 3, n = 21) for titers of antibodies to both SARS-CoV-2 spike and ‘N’ proteins. Results Seventy-nine women were included: Antibodies against SARS-CoV-2 spike protein were detected in all samples from Group 1 and 2. Antibodies to the ‘N’ protein were detected in 25/29 samples in Group 1. None of the samples from Group 3 had antibodies to either protein. Mean titers of SARS-CoV-2 antibodies were significantly higher in Group 2 than in Group 1 ( p < 0.05). Conclusions Neonates born to mothers vaccinated during pregnancy have higher antibody titers and may therefore have more prolonged protection than those born to women infected during pregnancy.

We examined the dynamics of coronavirus 2019 (COVID-19) transmission within families. Our investigation demonstrated significantly lower rates of COVID-19 positivity in children compared with adults residing in the same household. Children of 5–17 years of age were 61% and children of 0–4 years of age were 47% less likely to have positive polymerase chain reaction results compared with adults residing in the same household.

Parity is a reassuring prognostic variable when considering TOLAC. High parity is also considered a risk factor for uterine rupture. The aim of this study was to determine whether patients with high parity are at increased risk of poor TOLAC outcomes. A retrospective cohort was conducted at a single medical centre with approximately 10,000 deliveries per year between 2012-2018. The study group included women post one caesarean section carrying a singleton fetus in vertex presentation who attempted TOLAC. The cohort was divided into three groups: Group 1 – women who had a parity of 1; Group 2 - parity of 2- 4 and Group 3 - parity of 5 and above. The primary outcome was successful TOLAC. Secondary outcomes included mode of delivery, uterine rupture and combined adverse outcome (uterine rupture, Apgar < 7, pH < 7.1, PPH and OASIS). Data was analysed using Fishers exact test and chi squared tests 5447 women comprised the study group: Group 1 – 879 patients, Group 2 - 2,374 patients and Group 3 - 2,194 patients. No significant between group differences were found in gestational age and neonatal birth weight. Rates of a successful TOLAC were 80.6%, 95.4% and 95.5% respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 and group 3 (OR 5.02, 95% CI 3.9-6.5, p < 0.001) and (OR 5.17, 95% CI 4.0-6.7, p< 0.001) respectively. There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8-1.4, p=0.89). Operative delivery rate differed significantly between all 3 groups, 25%, 6.2% and 3.6%, for groups 1, 2 and 3 respectively (p< 0.001). Combined adverse outcome and specifically, uterine rupture were significantly higher in group 1 compared to group 2 (6.7% vs. 2.7%, p< 0.001 and 1.02% vs. 0.29%, p= 0.019 respectively) and group 3 (6.7% vs. 2.2%, p < 0.001, and 1.02% vs. 0.2%, p=0.005 respectively) There were no differences between group 2 and group 3 (2.7% Vs 2.2%, p=0.39 and 0.29% Vs 0.2% p=0.78) Multiparity has a protective effect on TOLAC outcomes. This protective effect is maintained even in grand-multiparous patients.

The purpose of the study was to compare the efficacy and safety of induction of labor with misoprostol amongst primiparas, multiparas and grandmultiparas. We conducted a retrospective cohort study of all women who underwent induction of labor with prostaglandin E1. Inclusion criteria included term singleton pregnancies. Exclusion criteria included multiple gestation, history of Cesarean delivery, and fetuses with intrauterine growth restrictions or known anomalies. All women received 50 micrograms misoprostol orally and this dose was repeated every four hours if active labor did not develop, up to a maximal dose of 300 micrograms. We divided the women into three groups: primiparas, multiparas (defined as parity of 1-4), and grandmultiparas (defined as para 5 and above). Primary outcome was mode of delivery and secondary outcome was neonatal 5 minute Apgar and umbilical cord (UA) pH. We defined efficiency as the duration from administration of the first cytotec dose until delivery. We also collected data on maternal and neonatal complications. Between January-December 2017, 1713 women underwent induction of labor: 523 were primiparas, 656 were multiparas and 534 were grandmultiparas. Four hundred and seventy-nine (91.6%) primiparas delivered vaginally as did 640 (97.6%) multiparas and 521(97.6%) grandmultiparas. Induction to delivery interval was significantly longer in primiparas (mean: 29.7 hours; 95% CI: 27.8-31.7 hours), and there was no significant difference between multiparas (mean: 18.6 hours; 95% CI: 17.3-20.0 hours) and grandmultiparas (mean: 18.6 hours; 95% CI: 17.0 -20.1 hours). There were no cases of uterine rupture, and the rates of postpartum hemorrhage and endometritis were similar among the three groups The rate of 5 minute Apgar score below 7 and UA pH<7.1 were not significantly different between the groups. Using misoprostol for labor induction is efficient and safe in primiparas, multiparas, and grandmultiparas.

To determine factors associated with a successful twin trial of labor after caesarean section (TOLAC) and compare maternal and neonatal outcomes for TOLAC in twin versus singleton gestations. A retrospective cohort was conducted at a single medical centre, in a population highly motivated for TOLAC (>80%) with about 10,000 deliveries per year between the years 2012-2017. The effect of maternal demographic and obstetrical characteristics on the likelihood of twin TOLAC success was analysed. For statistical purposes, combined adverse outcome (uterine rupture, Apgar <7 at 5 minutes and umbilical cord pH < 7.1) was compared between the singleton and twin groups. Data was analysed using Fishers exact test and chi squared tests. 95 women with a twin gestation and one previous caesarean section comprised the study group. 5703 women with a singleton gestation and one previous caesarean section comprised the control group. 29 (30.5%) and 4734 (83%) women with twin and singleton gestation respectively underwent a trial of labor (p=0.00, OR 0.087, 95% CI 0.056 - 0.135). Mean gestational age in the twin group was 36.7± 1.5 weeks. Women in the twin TOLAC group were less likely to succeed (75.9% Vs 92.7%, p=0.004, OR 4.02 95% CI 1.71-9.48) and less likely to have a spontaneous unassisted vaginal delivery (p=0.003, OR 3.4 95% CI 1.6-7.2) compared to women in the singleton TOLAC group. Maternal age less than 35, parity greater than two and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, [2 cases (6.9%) vs 20 cases (0.4%) respectively, (p=0.008, OR 17.5, 95% CI 3.89 – 78.4)] and for combined adverse outcome (p=0.004, OR 10.81, 95% CI 3.17-36.9). Twin TOLAC is not common, even in extremely highly motivated parturients for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture and combined adverse perinatal outcome. Demographic and obstetric risk factors were identified and may aid the attending obstetrician in the challenging counselling of such cases.

Background: Major liver resection during pregnancy is extremely rare. When required, the associated physiologic and anatomic changes pose specific challenges and greater risk for both mother and fetus Materials and methods: Three cases of major liver resection during pregnancy due to different etiologies are presented. The relevant literature is reviewed and discussed. Results: We present three cases of major liver resection due to giant liver hemangioma with Kasabach-Merrit syndrome, giant hydatid cyst, and intrahepatic cholangiocarcinoma, at gestational week (GW) 17, 19, and 30, respectively. All patients had an uneventful postoperative course, continued the pregnancy and gave birth at GW 38. Conclusion: Major liver resection can be performed safely during pregnancy. A multidisciplinary team of surgeons, anesthesiologists and gynecologists, in a highly experienced tertiary hepatobiliary center, should be involved.

Daily oral iron supplementation in pregnancy improves maternal iron stores and reduces the risk of low birth weights and neurodevelopmental delay. We sought to assess the efficacy of doubling daily iron supplements in iron deficient anemic (IDA) pregnant women with twin gestations. A prospective randomized controlled trial conducted at a women's health center from 1/ 2009 to 5/2013. 172 women with IDA and twin gestations were randomized to receive one or two capsules of ferrous sulfate daily from 16 weeks to 6 weeks postpartum. Women were excluded if they were non-compliant with their drug regimen or had conditions affecting iron levels (malabsorption, acute or chronic gastrointestinal diseases, IV iron administration etc). The primary outcome was maternal Hb concentration at 32 weeks. Secondary outcomes included ferritin and Hb concentrations during the 2nd and 3rd trimesters and postpartum, neonatal outcomes and maternal gastrointestinal side effects. 73 women were randomized to receive one capsule (group A) and 74 received two capsules (group B). Both groups had similar mean hemoglobin concentrations (96 gr/l vs 97 gr/dl) and ferritin levels at allocation (8.6 ng/ml vs 8.5 ng/ml). Hemoglobin concentrations at 32 weeks were higher in group B than in group A (106.3 gl/l vs 100.9 gl/l, respectively, p=0.045) as were ferritin levels (14.1 ng/ml vs 10.3 ng/ml, respectively, p=0.038), as remained so throughtout the third trimester and during peurperium. Neonatal outcomes and side effect profile were similar in both groups, with comparable birth weights (2505gr vs 2534 gr), preterm birth (10% in each group) and gastrointestinal effects (23.3% vs 24.3%). Doubling the iron supplementation dose improves hemoglobin concentrations among pregnant ID women with twin gestations, but has no effect on neonatal outcomes and side effect profile.