OBJECTIVES:Bacterial vaginosis (BV) and abnormal vaginal flora (AVF) are associated with maternal discomfort and preterm labour. Oral metronidazole and clindamycin are acceptable treatments during pregnancy for their eradication; however, direct comparative data between them during pregnancy are lacking. We compared the efficacy of metronidazole and clindamycin in eradicating BV/AVF among women at high risk for preterm labour. METHODS:In this multicentre randomized controlled trial, pregnant women at high risk for preterm labour were screened for BV/AVF using the Nugent criteria on vaginal smears. BV/AVF were defined as Nugent scores ≥4. Women diagnosed with BV/AVF were randomly allocated to receive either oral metronidazole 500 mg twice daily or oral clindamycin 300 mg twice daily for 1 week. After treatment, a repeat vaginal smear was obtained. If BV/AVF persisted, the alternative treatment was administered for an additional week, after which eradication was reassessed by vaginal smear. The primary outcome was the rate of BV/AVF eradication after first-line treatment. RESULTS:Of the 914 women screened, 170 (19%) tested positive for BV/AVF, and 82 and 84 women were analysed in the metronidazole and clindamycin groups, respectively. There were no significant differences between the metronidazole and clindamycin groups in the rate of BV/AVF eradication after first-line treatment (48 [60%] vs. 47 [56%]), total eradication rate after second-line treatment (63 [77%] vs. 63 [79%]), or the rate of preterm delivery/late miscarriage (30% vs. 24%), respectively. Among women who received metronidazole or clindamycin (as first- or second-line treatment), adverse effects were reported in 36 of 115 (31%) and 31 of 117 (26%), respectively, and treatment discontinuation because of adverse effects occurred in only 3% and 5%, respectively (p >0.05 for all comparisons). CONCLUSIONS:In pregnant women at high risk for preterm labour, oral metronidazole and clindamycin for the treatment of BV/AVF demonstrated similar efficacy, adverse effect profiles, and preterm delivery rates.

BACKGROUND:Coronavirus disease 2019 (COVID-19) causes severe complications in 15% of patients, many of whom are pregnant. Most infected women continue their pregnancies until term even though severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replicates in the decidua. OBJECTIVES:To assess the impact of SARS-CoV-2 infection remote from delivery on obstetric outcomes. METHODS:Women diagnosed with SARS-CoV-2 infection confirmed by polymerase chain reaction at least 14 days prior to delivery were enrolled prospectively and followed monthly until delivery. Their obstetric outcomes were compared to those of women who gave birth at our center during the year preceding the pandemic. The primary endpoint was a composite of hypertensive disorders of pregnancy, oligohydramnios, and fetal distress or meconium-stained amniotic fluid during labor. Other demographic and obstetric variables were also recorded. RESULTS:The obstetric outcomes of 143 patients were compared to those of 3565 patients who gave birth during the year preceding the pandemic. The composite rate of placental complications was significantly higher in the study group (58 [41%] vs. 593 [17%], respectively), with an odds ratio of 3.4 (95% confidence interval 2.4-4.7). There was also an increased rate of labor induction or advancing the elective cesarean date in the study group (37 [26%] vs. 601 [17%]). No significant differences were found in the Apgar score, cord pH or gestational age at infection. CONCLUSIONS:The risk of placental complications remains greater in pregnant women infected with SARS-CoV-2 after acute illness resolution. Those patients should be monitored closely until delivery.

INTRODUCTION:Obesity is a feature affecting nearly all life aspects. As the burden of obesity is increasing steadily, it leads to the increasing prevalence of diabetes, and most other common non-communicable diseases. A comprehensive approach for the prevention of obesity appears to constitute the most effective intervention to reduce their prevalence worldwide. In this review, we highlight pregnancy as a key period in a woman's life, which can improve compliance with different types of diet, physical activity, and behavioural programs, affecting the next generation's health, and breaking the vicious cycle of family obesity.

Diabetes mellitus is a widely occurring disorder, and obesity is its main feature. As the burden of obesity is increasing steadily, it leads to the increasing prevalence of diabetes, as well as of the most common non-communicable diseases. A comprehensive approach for the prevention of obesity appears to constitute the most effective intervention to reduce their prevalence worldwide. Numerous measures were applied to treat obesity and prevent its complications, of them different types of diet, physical activity, behavioral programs, pharmacologic interventions, and surgical treatments – but all of them have a significant degree of dropping-off and weight-regain over time. In this review we highlight pregnancy as a key period in a woman’s life, which can improve compliance with these programs and affect the next generation’s health, breaking the vicious cycle of family obesity

Bacterial vaginosis (BV) and abnormal vaginal flora (AVF) are associated with preterm labor and woman's discomfort. Oral metronidazole and clindamycin are acceptable treatment during pregnancy to eradicate BV/AVF. In the present study we aimed to compare the efficacy of each treatment to eradicate BV/AVF in women at high risk for preterm labor (e.g. previous preterm delivery, short cervix, twins or preterm contractions). A multicenter randomized controlled trial was conducted. Pregnant women at high risk for preterm labor were screened for BV/AVF using the Nugent criteria in Vaginal smears. AVF and BV were defined as Nugent score 4-6 and 7-10, respectively. Women with BV/AVF were randomly allocated to receive either oral metronidazole 500 mgX2/d or oral clindamycin 300 mgX2/d for a week as recommended by the CDC. After treatment an additional vaginal smear was taken. If BV/AVF was still present, the other treatment was given for additional week, after which eradication was assessed by a vaginal smear. The primary outcome was the rate of BV/AVF eradication after the first treatment. Adverse effect rates and delivery week were also collected. Assuming that the rate of eradication after the first treatment was 70 versus 90%, the sample size required was 164 women (5% two-sided alpha, 90% power). Background characteristics and study outcomes are presented in table 1 and table 2. Comparing the metronidazole and clindamycin groups, there were no differences in the rate of BV/AVF eradication [48/81 (59%) and 47/84 (56%)], total eradication rate after the second treatment [64/81 (79%) and 62/84 (74%)], and the rate of preterm delivery [29% and 25% (P=0.59)], respectively. In women who received metronidazole and clindamycin (either first or second treatment), the rate of adverse effects was 33/113 (29%) and 31/117 (26%) and, only 3% and 5% discontinued treatment due to adverse effect, respectively. In pregnant women at high risk for preterm labor, oral metronidazole and clindamycin to treat BV/AFV, had similar efficacy and adverse effects and preterm delivery rates.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: To explore maternal humoral immune responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the rate of vertical transmission. Design: A prospective cohort study. Setting: Two university-affiliated medical centers in Israel. Population: Women positive for SARS-CoV-2 reverse-transcription-polymerase-chain-reaction (RT-PCR) test, during pregnancy were enrolled just prior to delivery. Methods: Levels of anti-SARS-CoV-2 spike-IgM, spike-IgG and nucleocapsid-IgG were tested in maternal and cord blood at delivery, and neonatal nasopharyngeal swabs were subjected to PCR testing. Main outcomes measures: The primary endpoint was the rate of vertical transmission, defined as either positive neonatal IgM, positive neonatal IgG with sero-negative mother or positive neonatal PCR. Results: Among 72 women, 36 (50%), 39 (54%) and 30 (42%) were positive for anti-spike-IgM, anti-spike-IgG and anti-nucleocapsid-IgG, respectively (p<0.0001 for IgG antibodies-comparison). At least 8/72 (11%) neonates were infected in utero; one had a positive PCR result and seven had positive IgG antibodies while their mothers were seronegative for the same IgG. IgM was not detected in cord blood. Anti-nucleocapsid-IgG and anti-spike-IgG were detected in 83% and 85% of neonates of seropositive mothers, respectively (Pearson coefficient correlation 0.8, p<0.001). The highest rate of positive maternal serology tests was 8-12 weeks post-infection (89% anti-spike IgG, 78% anti-spike-IgM and 67% anti-nucleocapsid-IgG). Thereafter, the rate of positive serology tests declined gradually; at 20 weeks post-infection, only anti-spike-IgG was detected in 33-50%. Conclusions: The rate of vertical transmission was at least 11%. Vaccination should be considered 3 months post-infection in pregnant women due to a decline in antibody levels.

BACKGROUND: Gestational diabetes mellitus should be treated adequately to avoid maternal hyperglycemia-related complications. Previously, probiotic supplements were suggested to improve fasting blood glucose in women with gestational diabetes mellitus. However, a major limitation of previous studies was that preprandial and especially postprandial glucose values, which are important predictors of pregnancy outcomes, were not studied.OBJECTIVE: This study aimed to examine the effect of a mixture of probiotic strains on maternal glycemic parameters, particularly preprandial and postprandial glucose values and pregnancy outcomes among women with gestational diabetes mellitus.STUDY DESIGN: A multicenter prospective randomized, double-blind, placebo-controlled trial was conducted. Women newly diagnosed with gestational diabetes mellitus were randomly allocated into a research group, receiving 2 capsules of oral probiotic formula containing Bifidobacterium bifidum, B lactis, Lactobacillus acidophilus, L paracasei, L rhamnosus, and Streptococcus thermophilus (>6 x 10(9)/capsule), and a control group, receiving a placebo (2 capsules/day) until delivery. Glycemic control was evaluated by daily glucose charts. After 2 weeks, pharmacotherapy was started in case of poor glycemic control. The primary outcomes were the rate of women requiring medications for glycemic control and mean daily glucose charts after 2 weeks of treatment with the study products.RESULTS: Forty-one and 44 women were analyzed in the treatment and placebo cohorts, respectively. Mean daily glucose during the first 2 weeks in the probiotics and placebo groups was 99.7 +/- 7.9 and 98.0 +/- 9.3 mg/dL, respectively (P=.35). The rate of women needing pharmacotherapy because of poor glycemic control after 2 weeks of treatment in the probiotics and placebo groups was 24 (59%) and 18 (41%), respectively (P=.10). Mean preprandial and postprandial glucose levels throughout the study period were similar between the groups (P>.05). There were no differences in maternal and neonatal outcomes, including birthweight and adverse effect profile between the groups.CONCLUSION: The oral probiotic product tested in this study did not affect glycemic control of women with gestational diabetes mellitus.

PURPOSE:Protein C global assay tests the global function of the protein C pathway, the most clinically significant anticoagulant pathway in humans. The objective of this study is to assess the difference in protein C global assay levels, throughout twin gestation, in naturally conceiving and ART-treated women.METHODS:This is a prospective cohort longitudinal study of pregnant women with twin gestation. Protein C Global evaluation was performed on frozen blood samples. Ninety-eight women with twin pregnancy, thirty-eight naturally conceived and sixty following ART, were evaluated on four occasions: during the first, second, and third trimesters, and 6 weeks or later after delivery (baseline).RESULTS:Protein C global assay levels were lower throughout pregnancy as compared to basal levels in both the naturally conceived and ART-conceived groups. However, protein C global assay levels were similar between the ART-conceived and naturally conceived twin pregnancies in all three trimesters. Perinatal complications were associated with decreased protein C global assay levels during the third trimester, although no difference was encountered between naturally conceived and ART-complicated twin pregnancies.CONCLUSION:While protein C global assay levels drop during twin pregnancy, there is no difference between ART-conceived and naturally conceived gestations. Decreased levels of protein C global assay during the third trimester were similarly associated with perinatal complications in both groups. Our results imply that twin pregnancy of itself is a more dominant factor for perinatal complications as compared to other factors, such as subfertility or the exposure to ART per se.

Pathogenic variants in the TTN gene have been reported to cause various cardiomyopathies and a range of skeletal muscle diseases, collectively known as titinopathies. We evaluated a consanguineous family multiple members affected with a lethal congenital contracture syndrome. Using exome sequencing, we identified a homozygous c.36122delC (p. P12041Lfs*20) variant in exon 167 in the fetal IC isoform of TTN. The finding expands the phenotypes that can be caused by pathogenic variants TTN, which should be considered in lethal congenital contracture syndromes, arthrogryposis multiplex congenita, congenital myopathies, and hydrops fetalis.

OBJECTIVE:The cornerstone of concerns over trial of labor after cesarean (TOLAC) is the risk of uterine rupture. The purpose of this study was to document the rate of uterine rupture during TOLAC and to delineate its severity and consequences. MATERIALS AND METHODS:We retrospectively collected the data on vaginal and cesarean deliveries after a previous cesarean section with specific emphasis on uterine rupture and dehiscence in our center from 2006 through 2013. RESULTS:22,670 deliveries were registered, with 18.2% rate of cesarean section. 2890 women had a single cesarean scar; of them 1206 delivered vaginally and 194 were re-operated during unsuccessful TOLAC. Seven cases of uterine rupture and 16 cases of dehiscence were recorded. There were no maternal, intrapartum or neonatal deaths, and no cesarean hysterectomy. There was one re-laparotomy, one ICU admission, and one blood transfusion; one neonate was admitted to NICU. TOLAC was successful in 86.1% of cases. CONCLUSIONS:Cautious selection and close monitoring of candidates are the cornerstones of successful management of TOLAC. Readily available facilities for emergency cesarean delivery and concerted obstetrical team can save the mother and child from catastrophic complications.

OBJECTIVE:To investigate whether early and short follicular administration of GnRH antagonist using the flexible protocol has the potential to improve IVF-ET clinical results. DESIGN:Prospective, controlled, randomized study. SETTING:University-affiliated assisted reproductive technology unit. PATIENT(S):Fifty-three consecutive infertile women were enrolled to the study and control groups. INTERVENTION(S):Both groups were treated with recombinant FSH and the flexible GnRH antagonist protocol. Women in the study group were additionally supplemented with three injections of GnRH antagonist (0.25 mg/d on days 1, 2, and 3 of the menstrual cycle). MAIN OUTCOME MEASURE(S):Hormonal milieu, oocyte meiotic status, competence for normal fertilization, cleavage, and clinical pregnancy rate. RESULT(S):Both groups had comparable baseline characteristics. The duration of recombinant FSH treatment was significantly longer in the study group as compared with the control group (10.9+/-3.1 and 9.7+/-1.3 days, respectively). The number of follicles>or=14 mm and E2 level on the day of hCG administration, number of retrieved oocytes, and endometrial thickness were similar between the two groups. However, the fertilization rate was significantly higher in the study as compared with the control group (85%+/-16% and 69%+/-24%, respectively). Moreover, the cumulative rate of mature first polar body oocytes was significantly higher in the study group as compared with the control group (93% and 85%, respectively). Concomitantly, day-3 FSH and LH levels after initiation of treatment were significantly lower in the study as compared with the control group (6.1+/-2.4 mIU/mL vs. 7.2+/-1.9 mIU/mL and 2.4+/-1.6 mIU/mL vs. 5.6+/-2.7 mIU/mL, respectively). CONCLUSION(S):Early and short follicular GnRH antagonist supplementation using flexible GnRH antagonist treatment improves the meiotic status and competence of retrieved oocytes. It seems that early and short pituitary shutdown has the potential to improve clinical results in IVF-ET GnRH antagonist cycles.

Abdominal compartment syndrome is a consequence of increased intraabdominal pressure. It can be triggered by inflammation, hemorrhage, chemical peritonitis, or prolonged insufflations during laparoscopy. It is a well-known phenomenon for intensive care specialists, but gynecologists are relatively unfamiliar with its occurrence. A woman with heterotopic pregnancy underwent urgent laparoscopy because of abdominal hemorrhage. The postoperative course was complicated by abdominal pain, ascites, bowel dysfunction, and renal failure, which resolved rapidly after catheterization and paracentesis. In this case, abdominal compartment syndrome developed after unremarkable laparoscopy, and appeared to be triggered by change of progesterone formulation. Decompression by paracentesis was lifesaving, and led to rapid resolution of the symptoms.