Maya Frank Wolf

Aim: To compare maternal and neonatal outcomes of induction strategies initiated with slow‐release vaginal dinoprostone (10 mg) or balloon catheter in multiparous women undergoing term induction of labor with an unfavorable cervix. Methods: This retrospective cohort study included 802 multiparous women with singleton pregnancies at ≥ 37 weeks' gestation, Bishop score < 8, and a medical indication for induction of labor at a tertiary university‐affiliated center (2020–2025). Women underwent cervical ripening with either a balloon catheter ( n = 522) or a slow‐release vaginal dinoprostone insert ( n = 280). The co‐primary outcomes were the cervical ripening‐to‐delivery interval and delivery within 24 h. Multivariable analyses identified independent predictors of delivery interval and cesarean birth. Results: Compared with balloon catheter, dinoprostone was associated with a shorter cervical ripening‐to‐delivery interval (11.6 vs. 19.4 h; p < 0.001). Delivery within 12 h was more frequent with dinoprostone (51.4% vs. 26.1%; p < 0.001), whereas delivery within 24 h did not differ significantly between groups (75.7% vs. 71.1%; p = 0.183). Dinoprostone was also associated with a higher spontaneous vaginal delivery rate (95.0% vs. 90.0%; p = 0.015) and a lower cesarean delivery rate (3.2% vs. 8.2%; p = 0.006). Intrapartum fever occurred less frequently with dinoprostone (1.4% vs. 4.2%; p = 0.036), while no statistically significant differences were observed in measured neonatal outcomes, including NICU admission. Conclusions: Among multiparous women undergoing term induction of labor, dinoprostone was associated with a shorter cervical ripening‐to‐delivery interval, higher spontaneous vaginal delivery rates, and lower cesarean rates than balloon catheter. Delivery within 24 h was similar between groups, with no significant differences in measured neonatal outcomes.

Objective: The objective of this study was to describe and compare maternal infectious morbidity, microbiological findings, and neonatal outcomes among pregnancies with early (n = 136) and late ( n = 548) PPROM. Expectant management was applied using a 7‐day antibiotic regimen (ampicillin‐based until March 2023, followed by cefuroxime‐based prophylaxis). Patients with active labor or clinical infection at admission were excluded. Primary outcomes were clinical chorioamnionitis and early‐onset neonatal sepsis. Results: Late PPROM was associated with lower rates of postpartum maternal infectious morbidity than early PPROM, including lower rates of intrapartum fever (2.6% vs. 6.6%), postpartum fever (0.2% vs. 2.9%), and surgical site infection (0.8% vs. 12.3%). In exploratory adjusted analysis, cefuroxime‐based prophylaxis was associated with lower observed odds of clinical chorioamnionitis compared with ampicillin‐based prophylaxis, whereas late versus early PPROM was not independently associated with clinical chorioamnionitis. Conclusion: Among pregnancies with PPROM managed expectantly, late PPROM was associated with lower observed rates of maternal infectious morbidity compared with early PPROM.

Introduction: Gestational diabetes mellitus (GDM) is associated with increased neonatal morbidity in singleton pregnancies, but evidence in multifetal pregnancies is limited. Current diagnostic thresholds are largely extrapolated from singleton data; It remains unclear whether plurality modifies GDM‐associated neonatal and long‐term offspring outcomes. We wanted to evaluate neonatal complications and long‐term offspring healthcare utilization associated with GDM in multifetal versus singleton pregnancies, and to assess effect modification by plurality and the impact of gestational age at delivery. Material and Methods: This multicenter retrospective cohort study utilized electronic medical records across six university‐affiliated medical centers in Israel (1/1/2010–6/30/2024). All live births at 22 weeks' gestation or later or with birthweight of >500 g were included. Four exposure groups were defined by plurality and GDM status (ICD‐9 code 648.8x): singleton without GDM, singleton with GDM, multifetal without GDM, and multifetal with GDM. Short‐term neonatal complications (neonatal hypoglycemia, neonatal ICU admission, respiratory distress, intraventricular hemorrhage, and growth abnormalities) and long‐term offspring outcomes were assessed by hospital‐based health‐care utilization (e.g., neurology, ophthalmology, cardiology). Multivariable Firth logistic and ordinary least squares regression models were adjusted for maternal age, body mass index, parity, and fertility treatment. Additional models adjusted for gestational age were performed. False discovery rate correction and GDM‐by‐plurality interaction terms were applied. Results: Of 134 517 pregnancies (136 579 live‐born offspring) to 104 023 mothers, 10 605 singleton (7.9%) and 256 multifetal (0.2%) pregnancies were complicated by GDM. In multifetal pregnancies, GDM was not associated with increased short‐term neonatal complications nor with lower adjusted odds of neonatal hypoglycemia (adjusted odds ratio [aOR], 0.30; 95% CI: 0.18–0.49), neurologic (aOR, 0.37; 95% CI: 0.24–0.59), or ophthalmologic (aOR, 0.49; 95% CI: 0.31–0.77) health‐care utilization. Adjustment for gestational age attenuated associations for neonatal intensive care unit admission but did not fully explain interactions for hypoglycemia or selected long‐term outcomes. Conversely, GDM in singleton pregnancies was associated with increased neonatal morbidity. Conclusions: Associations between GDM and neonatal and offspring outcomes differ by plurality. Risk stratification strategies derived from singleton pregnancies may not fully capture risk profiles in multifetal pregnancies.

Objectives: To evaluate the clinical significance of late-onset cervical shortening diagnosed between 24.0 and 34.0 weeks of gestation following normal midtrimester screening, and to assess its association with spontaneous preterm birth (sPTB) and adverse neonatal outcomes. We also examined whether obstetric history modifies this risk. Design: Retrospective cohort study. Participants/Materials: A total of 500 singleton pregnancies with normal midtrimester cervical length (CL) who were subsequently diagnosed with cervical shortening (<25 mm) between 24.0 and 34.0 weeks of gestation. Setting: Tertiary, university-affiliated medical center (Galilee Medical Center, Israel), March 2020 to May 2025. Methods: Patients with asymptomatic late cervical shortening were categorized into three groups: <10 mm, 11–15 mm, and 16–25 mm. CL measurements were further stratified by gestational age at diagnosis (24.0–27.6, 28.0–31.6, and 32.0–34.0 weeks). The primary outcome was sPTB <37 weeks. Secondary outcomes included sPTB <34 and <32 weeks and neonatal morbidity. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs). Receiver operating characteristic (ROC) curve analysis was performed to determine gestational age–specific CL thresholds for predicting sPTB. Results: Results: A total of 500 patients were included: 24/500 (4.8%) with CL <10 mm, 80/500 (16.0%) with CL 11–15 mm, and 396/500 (79.2%) with CL 16–25 mm. Baseline characteristics were comparable across groups. Rates of sPTB <37 weeks were 18/24 (75.0%) in patients with CL <10 mm, 42/80 (52.5%) in those with CL 11–15 mm, and 99/396 (25.0%) in those with CL 16–25 mm (p<0.001). Similarly, sPTB <34 weeks occurred in 14/24 (58.3%), 20/80 (25.0%), and 33/396 (8.3%), and sPTB <32 weeks in 11/24 (45.8%), 12/80 (15.0%), and 20/396 (5.1%) (all p<0.001). When stratified by cervical length groups, sPTB rates did not differ according to obstetric history among patients with CL <10 mm and 11–15 mm. In contrast, among patients with CL 21–25 mm, sPTB occurred in 7/26 (26.9%) of those with a prior sPTB, 17/78 (21.8%) of nulliparas, and 10/78 (12.8%) of those with a prior term birth (p=0.041). ROC analysis identified gestational age–specific thresholds for predicting sPTB <37 weeks: 22 mm at 24.0–27.6 weeks (AUC 0.69, p<0.001), 20 mm at 28.0–31.6 weeks (AUC 0.62, p=0.002), and 18 mm at 32.0–34.0 weeks (AUC 0.72, p<0.001). Correspondingly, sPTB rates were higher below these cutoffs: 49.1% vs. 18.2% (p<0.001), 49.1% vs. 23.2% (p<0.001), and 43.9% vs. 18.8% (p<0.001), respectively. Limitations: The retrospective design may introduce selection and information bias. Measurements were performed by multiple clinicians, potentially leading to inter-observer variability. Residual confounding cannot be excluded. Conclusions: Late-onset cervical shortening after normal midtrimester screening is strongly associated with spontaneous preterm birth and adverse neonatal outcomes. The degree of shortening and obstetric history significantly influence risk, particularly in patients with moderate late shortening. Gestational age–specific cervical length thresholds may enhance late pregnancy risk stratification and support individualized surveillance and management strategies.

Objectives: To compare maternal infectious morbidity following artificial versus spontaneous rupture of membranes (ROM) after cervical ripening with a balloon catheter and oxytocin augmentation. Although amniotomy is commonly performed to shorten labor, evidence regarding its infectious consequences after mechanical cervical ripening remains limited and inconsistent. Design: Retrospective cohort study including 1,115 term singleton pregnancies induced with a transcervical balloon catheter followed by oxytocin between January 2020 and May 2024. Participants were categorized according to mode of ROM: artificial (amniotomy) or spontaneous. Participants/Materials: Eligible participants were patients with term (≥37 weeks) singleton pregnancies undergoing induction with a balloon catheter and oxytocin. Exclusion criteria included multiple gestations, prelabor ROM, non-cephalic presentation, and major fetal anomalies. A total of 1,115 patients met the inclusion criteria. Setting: The study was conducted at Galilee Medical Center, a tertiary referral hospital affiliated with the Azrieli Faculty of Medicine, Bar-Ilan University, Israel. Data were obtained from institutional medical records for deliveries between January 2020 and May 2024. Institutional review board approval was obtained, and informed consent was waived due to the retrospective design. Methods: Clinical, obstetric, microbiological, and neonatal data were extracted from electronic records. The primary outcome was clinical chorioamnionitis. Secondary outcomes included intrapartum fever, microbiological findings, mode of delivery, and neonatal complications. Continuous variables were analyzed using Student’s t-test and categorical variables using χ² or Fisher’s exact test. Firth penalized logistic regression was performed to assess independent associations between ROM mode and outcomes, adjusting for potential confounders. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Results: Among 1,115 patients, 725 (65%) underwent amniotomy and 390 (35%) experienced spontaneous ROM. Amniotomy was associated with higher rates of clinical chorioamnionitis (3.0% vs. 0.3%, p<0.001), intrapartum fever (7.4% vs. 1.5%, p<0.001), and positive chorioamniotic cultures (11.3% vs. 6.2%, p=0.005), particularly Enterobacteriaceae. Despite a shorter ROM-to-delivery interval (6.4 vs. 12.2 hours, p<0.001), amniotomy was associated with higher cesarean delivery rates (13.5% vs. 3.3%, p<0.001), including for non-reassuring fetal heart rate (9.2% vs. 1.5%, p<0.001). Neonatal outcomes did not differ between groups. In adjusted analyses, amniotomy remained independently associated with clinical chorioamnionitis (adjusted OR 8.51; 95% CI 2.17–78.46; p=0.001), intrapartum fever (adjusted OR 4.04; 95% CI 1.84–10.46; p<0.001), and cesarean delivery (adjusted OR 5.27; 95% CI 2.61–10.32; p<0.001). Limitations: The retrospective single-center design limits causal inference and generalizability. Residual confounding, provider-dependent decision-making, and lack of data on vaginal examinations may have influenced the findings. The study was underpowered to detect rare neonatal infectious outcomes. Conclusions: Artificial ROM following balloon catheter ripening was associated with increased maternal infectious morbidity and higher cesarean delivery rates, despite shortening labor duration. However, it is possible that, in some cases, amniotomy was performed in response to suspected fetal compromise in an attempt to expedite delivery. Therefore, causal relationships between amniotomy and the observed outcomes, including cesarean delivery, cannot be definitively established. These findings support a selective, individualized approach to ROM management and warrant further investigation in prospective studies.

Objective: To compare sonographic, maternal, and clinical estimations of fetal weight in women with severe and morbid obesity (BMI ≥ 35 kg/m ² ) at term. Methods: We conducted a prospective study on multiparous women with singleton term pregnancies. We analyzed absolute error, absolute percentage error, and rates of error > 10%, > 15%, and > 20%; and error > 500 g for each method. Results: Our study included 103 women with a median pre‐delivery BMI of 37.9 (35.0–50.4) kg/m ² . Clinical estimation showed a higher mean error than maternal estimation (140.1 vs. −51.6 g, p < 0.001). The absolute error was comparable for the sonographic and maternal estimations (209 and 210 g, respectively); these values were lower ( p = 0.02) than that of clinical estimation (250 g). For sonographic estimation, the absolute percentage error was lower than for the clinical estimation (6.0% vs. 7.5%, p = 0.018). Similarly, for the maternal estimation, the absolute error was lower than for the clinical estimation (6.3% vs. 7.5%, p = 0.005). A greater proportion of women exhibited an absolute percentage rate error exceeding 15% with clinical estimation than with maternal estimation (15.1% vs. 2.9%, p = 0.002). A higher proportion of women displayed an absolute percentage rate error exceeding 20% with clinical estimation than with sonographic estimation (7.8% vs. 1.0%, p = 0.016) and with maternal estimation (7.8% vs. 0%, p = 0.008). Conclusion: In women with a BMI ≥ 35 kg/m ² , sonographic weight estimation and maternal estimation showed similar levels of accuracy, and both surpassed that of clinical estimation. Our findings demonstrate the potential utility of maternal estimation as an additional tool supporting the standard use of ultrasound. Trial Registration: ClinicalTrials.gov identifier: NCT05478798

Objectives: Early-onset Group B Streptococcus (GBS) infection is a major cause of neonatal morbidity and mortality, which can be prevented through intrapartum antibiotic prophylaxis (IAP). First-line β-lactams (penicillin or ampicillin) are preferred, whereas clindamycin is reserved for patients with a confirmed high-risk penicillin allergy and documented susceptibility. Increasing clindamycin resistance and concerns about intra-amniotic efficacy highlight the need to evaluate maternal outcomes. This study examined maternal infectious morbidity, neonatal outcomes, and microbiological findings in GBS-positive term patients receiving ampicillin versus clindamycin IAP. Design: This retrospective cohort study was conducted between March 2021 and March 2024 at a tertiary university-affiliated hospital. Participants/Materials: Singleton term pregnancies (≥37 weeks) with a documented positive GBS vaginal-rectal culture obtained within 5 weeks before delivery were included. Patients received either ampicillin (n = 1,833) according to the institutional protocol or clindamycin (n = 78) if they reported a severe β-lactam allergy. No intrapartum clindamycin susceptibility testing was performed. Setting: The study was conducted at a tertiary university-affiliated hospital between March 2021 and March 2024. Methods: The co-primary outcomes were clinical chorioamnionitis and admission to the neonatal intensive care unit (NICU). Secondary maternal outcomes included intrapartum fever, postpartum fever, postpartum antibiotic administration use, and cesarean delivery. Secondary neonatal outcomes included a 5-min Apgar score of 18 h (aOR 4.9, 95% CI 1.6–15.7, p = 0.006) and cervical ripening by catheter balloon (aOR 4.1, 95% CI 1.2–13.6, p = 0.023). Postpartum, GBS-positive chorioamniotic cultures were significantly more frequent among patients who received clindamycin compared with those who received ampicillin (28.2% vs. 10.5%; p < 0.001). Limitations: This retrospective, single-center study may be subject to bias and has limited generalizability. The small clindamycin group reduced the power for rare outcomes. Penicillin allergy was self-reported without confirmatory testing, and clindamycin susceptibility was not assessed intrapartum. Conclusions: Among GBS-positive term patients, intrapartum clindamycin prophylaxis was associated with markedly higher maternal infectious morbidity and increased GBS detection in chorioamniotic cultures compared with ampicillin, without significant differences in neonatal outcomes. These findings raise concerns about the intra-amniotic effectiveness of clindamycin and support minimizing its use whenever possible. Further prospective studies are warranted to confirm these findings and to evaluate alternative prophylactic regimens for patients with penicillin allergy.