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Objective  Excessive gestational weight gain (GWG) has been associated with adverse pregnancy outcomes, including increased risk of cesarean delivery (CD). Data are limited on associations between GWG and outcomes in women undergoing trial of labor after cesarean (TOLAC). We aimed to investigate whether appropriate GWG impacts TOLAC outcomes. Study Design  We performed a retrospective cohort study of women undergoing TOLAC at a single institution from May 2007 to April 2016. Women were divided into three groups based on GWG as compared with the Institute of Medicine recommendations. The primary outcome was successful vaginal birth after cesarean (VBAC). Secondary outcomes included various perinatal morbidity markers. Results  A total of 614 women underwent TOLAC, of whom 444 (72.3%) had successful VBACs. When grouped by GWG in accordance with the Institute of Medicine guidelines, 149 (24.3%) women had GWG below guidelines, 224 (36.5%) met guidelines, and 241(39.3%) exceeded guidelines. There was no difference in the rate of VBAC success among the three groups. We also found no differences in secondary perinatal morbidity markers. Conclusion  We found no difference in TOLAC success rates with excess GWG. Providers should not consider excess GWG a risk factor for failed TOLAC, even in obese patients. [ABSTRACT FROM AUTHOR]

Objective  To identify factors associated with previable delivery in second trimester preterm rupture of membranes (PROM). Study Design  We conducted a single-center retrospective cohort study of women with pregnancies complicated by second trimester PROM (14.0–21.9 weeks' gestation) from 2000 to 2015 who elected expectant pregnancy management and achieved at least 24 hours latency. Maternal characteristics and clinical factors were compared among pregnancies that reached viability (≥ 23.0 weeks) and pregnancies delivered before viability (< 23.0 weeks) using appropriate statistical methods. Results  Of 73 pregnancies complicated by second trimester PROM, 49 (67%) delivered before viability. Maternal race, history of preterm birth, and tobacco use were similar between women who delivered < 23 weeks versus ≥ 23 weeks. Gestational age at PROM, cervical dilation > 1cm, Group B streptococcus carrier status, bacterial vaginosis, and chlamydial infection during pregnancy were similar between groups. Median time to delivery was significantly shorter in women who delivered < 23 weeks compared with those who reached ≥ 23 weeks (6 vs. 46 days, p  < 0.01). Conclusion  Previable delivery occurred in the majority of women with second trimester PROM. No maternal or clinical factors were associated with delivery prior to viability. Counseling women with second trimester PROM should include the inability to determine which pregnancies will reach viability. [ABSTRACT FROM AUTHOR]

Objective  To determine if patients with a history of low pregnancy-associated plasma protein A (PAPP-A) in an initial pregnancy are at higher risk for adverse obstetric outcomes in a subsequent pregnancy. Study Design  This was a retrospective cohort study in patients who underwent first trimester screening for PAPP-A in two consecutive pregnancies. Two groups were examined: patients who had low PAPP-A in the first pregnancy followed by normal PAPP-A in the second pregnancy and patients who had recurrent low PAPP-A. Maternal and neonatal outcomes were compared between the groups, with the primary outcome being intrauterine growth restriction (IUGR) or preeclampsia. Results  A total of 124 patients were included, representing 248 pregnancies. Ninety-two (74.2%) patients had normal PAPP-A in the second pregnancy, and 32 (12.9%) patients had recurrent low PAPP-A. Patients with recurrent low PAPP-A had a higher rate of IUGR or preeclampsia compared with patients with normal PAPP-A in the second pregnancy but this was not significantly different (12.5 vs. 10.9%, p  = 0.51). There were no significant differences for all other outcomes. Conclusion  Among patients with a history of low PAPP-A, patients with normal PAPP-A in the subsequent pregnancy have a similar risk of adverse neonatal outcomes compared with patients with recurrent low PAPP-A. [ABSTRACT FROM AUTHOR]

Objectives  To estimate the prevalence of gestational weight gain (GWG) adequacy according to the 2009 guidelines, and to examine the association between GWG adequacy and the adverse outcomes, stratified by prepregnancy body mass index (BMI). Study Design  A retrospective cohort study, using the 2011 to 2013 U.S. linked birth/infant death datasets, restricted to nonanomalous singleton live births at 37 to 41 weeks. The adverse outcomes included composite maternal morbidity (CMM), composite neonatal morbidity (CNM), and neonatal and infant mortalities. We used multivariable Poisson's regression models with robust error variance to examine the association between GWG adequacy and adverse outcomes. Results  Of 8,656,791 singleton live births, 20, 32, and 48% had inadequate, adequate, and excessive GWG, respectively. After multivariable regression adjustment, compared with adequate GWG, excessive GWG had 1.10 (1.08–1.13) and 1.12 (1.10–1.14) times higher risk of CMM and CNM, respectively; similar findings were observed in BMI subgroups. Compared with adequate GWG, inadequate GWG had 1.14 (1.03–1.26) and 1.12 (1.07–1.18) times higher risk of neonatal and infant mortalities, respectively. Similar results were noted among women with normal weight. Conclusion  Excessive GWG was associated with an increased risk of CMM and CNM, while inadequate GWG was associated with a higher risk of neonatal and infant mortalities. [ABSTRACT FROM AUTHOR]

Objective  To test the hypothesis that maternal height is associated with adverse perinatal outcomes, controlling for and stratified by maternal body mass index (BMI). Study Design  This was a retrospective cohort study of all births in California between 2007 and 2010 (n  = 1,775,984). Maternal height was categorized into quintiles, with lowest quintile (≤20%) representing shorter stature and the uppermost quintile (≥80%) representing taller stature. Outcomes included gestational diabetes mellitus (GDM), preeclampsia, cesarean, preterm birth (PTB), macrosomia, and low birth weight (LBW). We calculated height/outcome associations among BMI categories, and BMI/outcome associations among height categories, using various multivariable logistic regression models. Results  Taller women were less likely to have GDM, nulliparous cesarean, PTB, and LBW; these associations were similar across maternal BMI categories and persisted after multivariable adjustment. In contrast, when stratified by maternal height, the associations between maternal BMI and birth outcomes varied by specific outcomes, for example, the association between morbid obesity (compared with normal or overweight) and the risk of GDM was weaker among shorter women (adjusted odds ratio [aOR], 95% confidence interval [CI]: 3.48, 3.28–3.69) than taller women (aOR, 95% CI: 4.42, 4.19–4.66). Conclusion  Maternal height is strongly associated with altered perinatal risk even after accounting for variations in complications by BMI. [ABSTRACT FROM AUTHOR]

Objective  To examine the change in body mass index (BMI) categories between pregnancies and its effect on adverse pregnancy outcomes. Study Design  We performed a retrospective cohort study of women with two consecutive deliveries from 2005 to 2010. Analysis was limited to women with BMI recorded at <24 weeks for both pregnancies. Standard BMI categories were used. Adverse pregnancy outcomes included preterm birth at <37 weeks, intrauterine growth restriction (IUGR), pregnancy-related hypertension, and gestational diabetes mellitus (GDM). Women with increased BMI category between pregnancies were compared with those who remained in the same BMI category. Results  In total, 537 women were included, of whom 125 (23%) increased BMI category. There was no association between increase in BMI category and risk of preterm birth, IUGR, or pregnancy-related hypertension. Women who increased BMI category had an increased odds of GDM compared with women who remained in the same BMI category (6.4 vs. 2.2%; p  = 0.018). The increased risk remained after controlling for age, history of GDM, and starting BMI (adjusted odds ratio: 8.2; 95% confidence interval: 2.1–32.7; p  = 0.003). Conclusion  Almost one-quarter of women increased BMI categories between pregnancies. This modifiable risk factor has a significant impact on the risk of GDM. [ABSTRACT FROM AUTHOR]

Objective  The aim of this study was to evaluate obstetric outcomes in relation to the extent of donor sperm exposure with and without egg donation. Materials and Methods  This is a retrospective cohort study in a single tertiary care center. All women with a singleton pregnancy who conceived following sperm donation (SD) were included. Obstetrics and neonatal outcomes for pregnancies following single SD were compared with pregnancies following repeat SD from the same donor. In a secondary analysis, we compared pregnancy outcomes among three modes of assisted reproductive technology (intrauterine insemination [IUI-SD], in vitro fertilization [IVF-SD], and IVF sperm + egg donation [IVF-SD + ED]). Results  A total of 706 pregnant women met the inclusion criteria, 243 (34.4%) following the first SD and 463 (65.6%) following repeat donations. Compared with repeat SDs, single donation was not associated with higher rates of preterm delivery (12.8 vs. 12.7%, respectively, p  = 0.99), preeclampsia (7.0 vs. 6.9%, p  = 0.999), and intrauterine growth restriction (4.1 vs. 3.9%, p  = 0.88). Pregnancies following IVF-SD + ED had increased risk for preeclampsia (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.5–6.6), preterm labor (AOR, 2.4; 95% CI, 1.1–5.4), and cesarean section (AOR, 2.1; 95% CI, 1.0–4.3) compared with IUI-SD and IVF-SD. Conclusion  The extent of donor sperm exposure did not correlate with obstetrics complications, but double gamete donation was associated with increased risk for preeclampsia, preterm labor, and cesarean section. [ABSTRACT FROM AUTHOR]

Chronic hypertension in pregnancy is traditionally classified according to degree of blood pressure (BP) elevation. Alternatively, stratifying women as high or low risk based on the etiology of hypertension, baseline work-up, and comorbid medical conditions will better inform clinicians about thresholds to initiate antihypertensive therapy, target BPs, frequency of antepartum visits, and timing of delivery. Women classified as high-risk chronic hypertension as described here require stricter BP management and more frequent follow-up visits as their associated rates of adverse maternal and/or fetal/neonatal outcomes appear higher than women classified as low-risk chronic hypertension. The latter group can in most cases be managed similarly to the general obstetric population. [ABSTRACT FROM AUTHOR]

Background While anti-β2 glycoprotein 1 (anti-β2GP1) antibody positivity is included in the diagnostic criteria for antiphospholipid syndrome (APS), the association between anti-β2GP1 and the obstetrical complications of APS has been inconsistently reported and remains unclear. Objective We completed a case-control study nested within the Canadian Ottawa and Kingston (OaK) Birth Cohort to evaluate the association between anti-β2GP1 antibody positivity and placenta-mediated pregnancy complications. Study Design Five hundred cases were randomly selected among pregnant women who experienced any of the following independently adjudicated placenta-mediated pregnancy complications: preeclampsia, placental abruption, late pregnancy loss (≥ 12 weeks' gestation), and birth of a small-for-gestational age (SGA) infant < 10th percentile. Five hundred pregnant women without any placenta-mediated pregnancy complications were selected as controls. Stored blood samples were analyzed for the presence of anti-β2GP1 antibodies by enzyme-linked immunosorbent assay. Results Anti-β2GP1 immunoglobulin G (IgG) and/or immunoglobulin M (IgM) antibodies in titers ≥ 20 G/M units (> 99th percentile) were present in 24 of 497 (4.8%) of controls and 33 of 503 (6.6%) of cases. There was no significant difference between cases and controls for the composite outcome of any placenta-mediated pregnancy complications (odds ratio, 1.38, 95% confidence interval [CI], 0.8-2.37, p = 0.25). Conclusion Our results call into question the association between anti-β2GP1 antibodies and placenta-mediated pregnancy complications, with further research needed. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to assess whether the location of the trocar insertion site for laser treatment of twin-twin transfusion syndrome was associated with preterm-premature rupture of membranes (PPROM) and preterm birth (PTB). Study Design In this study trocar location was documented in the operating room. Lower uterine segment (LUS) location was defined as any insertion <10 cm vertically from the pubic symphysis. Lateral location was defined as ≥5 cm horizontally from the midline. Patient characteristics were tested against three outcomes: PPROM ≤ 21 days postoperative, PTB < 28 weeks, and PTB < 32 weeks. For each outcome, multiple logistic models were fitted to examine the effect of trocar location, controlling for potential risk factors. Results A total of 743 patients were studied. Patients with LUS location were twice as likely as those with a more superior location to have PPROM ≤ 21 days (OR = 2.33, 1.12-4.83, p = 0.0236). Patients with both a LUS and Lateral location were over six times more likely to have PPROM ≤ 21 days (OR = 6.66, 2.36-18.78, p = 0.0003). Trocar insertion site was not associated with PTB. Conclusion We found that trocar insertion in the LUS, particularly the lateral LUS, was associated with an increased risk of PPROM. [ABSTRACT FROM AUTHOR]

Objective This study aims to investigate the perinatal outcome of fetuses with polyhydramnios and/or accelerated growth among women with a normal oral glucose challenge test (oGCT). Methods Singleton, nonanomalous pregnancies with an oGCT(< 130 mg/dL) at 24 to 28 weeks, who subsequently demonstrate polyhydramnios (amniotic fluid index > 24 cm or maximum vertical pocket > 8 cm) and/or accelerated growth (abdominal circumference > 95th percentile) on two-third trimester examinations were studied. Maternal demographics, delivery, and neonatal information were recorded. Cases were compared with a reference group (normal oGCT with neither abnormal third-trimester growth nor polyhydramnios). Results A total of 282 pregnancies were in the study group, and 663 were in the reference group. Deliveries in the study group were at a higher risk for birth weight (BW)% > 90%, standard deviation, and postpartum hemorrhage when compared with the reference group (adjusted odds ratio: 2.3-5.6). Pregnancies complicated by both polyhydramnios and accelerated fetal growth were significantly more likely to result in a BW% > 90% (odds ratio [OR]: 18.5; 95% confidence interval [CI]: 8.9-38.6) and PPH (OR: 4.2; 95% CI: 2.4-7.6). Conclusion Pregnancies with normal oGCT that develop polyhydramnios and accelerated growth are at higher risk for maternal and neonatal complications. Isolated polyhydramnios without accelerated growth increases the risk for delivery complications but not neonatal morbidity. [ABSTRACT FROM AUTHOR]

Objective Obesity and cervical insufficiency are leading causes of morbidity in pregnancy. We assess the relationship between maternal body mass index (BMI) and second-trimester cervical length. Methods A secondary analysis of a nested case-control study of women with singleton gestations enrolled from 2006 to 2008. The primary exposure was first-trimester BMI, categorized per World Health Organization criteria: normal (18.5 to ≤ 25 kg/m²), overweight (25 to ≤ 30 kg/m²), and obese (> 30 kg/m²). The primary outcome was cervical length > 75th percentile. Results Among 391 pregnant women observed, the median cervical length was 3.6 cm, and the median BMI was 24.8 kg/m². In multivariable analyses, after adjusting for BMI, age, race, parity, smoking, and gestational age at delivery, women who were overweight (adjusted odds ratio [AOR]: 2.18; 95% CI: 1.20-3.96) and obese (AOR: 2.83; 95% CI: 1.47-5.43) were more than two times more likely to have a cervical length > 75th percentile. When cervical length and BMI were assessed linearly, for each 1.0 kg/m² increase in BMI, cervical length increased by 0.25 mm. These results were robust to utilizing different cutoffs of cervical length and pre-pregnancy BMI. Conclusion This study demonstrates a relationship between BMI and cervical length suggesting that obesity may be associated with longer cervical length. These results will need to be replicated in larger cohorts undergoing universal cervical length assessment. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate the predictive value of vaginal fluid biomarkers for chorioamnionitis and adverse perinatal outcomes in women with preterm premature rupture of membranes (PPROM). Methods We recruited women with PPROM, without clinical chorioamnionitis, between 22 and 36 weeks' gestation. Vaginal fluid was collected on admission for the measurement of metalloproteinase-8 (MMP-8), interleukin-6 (IL-6), lactate, and glucose concentration. Placental pathology and neonatal charts were reviewed. Primary outcomes were histological chorioamnionitis and adverse neonatal neurological outcomes (intraventricular hemorrhage grade 2 or 3, periventricular leukomalacia, or hypoxic/ ischemic encephalopathy). Linear regression analyses were used to adjust for gesta-tional age at PPROM. Results Twenty-seven women were recruited at a mean gestational age of 31.6 ± 3.1 weeks, including 25 (93%) with successful collection of vaginal fluid sample. Histological chorioamnionitis and adverse neonatal neurological outcomes were observed in nine (33%) and four (15%) cases, respectively. In univariate analysis, MMP-8, IL-6, glucose, and lactate concentrations in vaginal fluid were associated with the risk of chorioamnionitis but not anymore after adjustment for gestational age at PPROM. MMP-8 concentration was the only biomarker associated with adverse neurological outcome, and it remained significant after adjustment for gestational age at PPROM (p = 0.02). Conclusion Vaginal fluid inflammatory biomarkers at admission for PPROM could predict adverse perinatal outcomes. [ABSTRACT FROM AUTHOR]

Objective The aim of the article is to determine whether prior spontaneous abortion (SAB) or induced abortion (IAB), or the interpregnancy interval are associated with subsequent adverse pregnancy outcomes in nulliparous women. Methods We performed a secondary analysis of data collected from nulliparous women enrolled in a completed trial of vitamins C and E or placebo for preeclampsia prevention. Adjusted odds ratios (ORs) for maternal and fetal outcomes were determined for nulliparous women with prior SABs and IABs as compared with primigravid participants. Results Compared with primigravidas, women with one prior SAB were at increased risk for perinatal death (adj. OR, 1.5; 95% CI, 1.1-2.3) in subsequent pregnancies. Two or more SABs were associated with an increased risk for spontaneous preterm birth (PTB) (adj. OR, 2.6, 95% CI, 1.7-4.0), preterm premature rupture of membranes (PROM) (adj. OR, 2.9; 95% CI, 1.6-5.3), and perinatal death (adj. OR, 2.8; 95% CI, 1.5-5.3). Women with one previous IAB had higher rates of spontaneous PTB (adj. OR, 1.4; 95% CI, 1.0-1.9) and preterm PROM (OR, 2.0; 95% CI, 1.4-3.0). An interpregnancy interval less than 6 months after SAB was not associated with adverse outcomes. Conclusion Nulliparous women with a history of SAB or IAB, especially multiple SABs, are at increased risk for adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Objective The objectives of this study are to evaluate the frequency and type of preterm birth (PTB) in women with prior preeclampsia and to compare neonatal outcomes between spontaneous PTB (SPTB) and medically indicated PTB (IPTB) groups. Study Design A secondary analysis of data in women with prior preeclampsia enrolled in a multicenter randomized trial for preeclampsia prevention. Delivery indications were categorized as SPTB and IPTB. Primary outcomes were rates of SPTB and IPTB by gestational age (GA). The rates of composite respiratory morbidity and neonatal intensive care unit (NICU) admission were compared between the PTB groups. Results Of the 606 pregnancies studied, 142 (23%) pregnancies were delivered at < 37 weeks: 67 (47%) pregnancies were caused by SPTB and 75 (53%) pregnancies were caused by IPTB. Of those who delivered preterm, 89 (63%) were in the late preterm period. The overall rate of the composite neonatal morbidity was 23%. The rates of composite neonatal morbidity, NICU admission, and perinatal death were not different between the groups. The frequency of small for gestational age (SGA) infants was higher in the IPTB group as compared with the SPTB group (21.3 vs. 1.4%, p = 0.01). Conclusion Women with prior preeclampsia are at high risk for PTB (SPTB and IPTB), particularly late PTB, as well as increased risk for SGA. [ABSTRACT FROM AUTHOR]

Objective: We sought to compare neonatal outcomes in twin pregnancies following moderately preterm birth (MPTB), late preterm birth (LPTB), and term birth and determine the indications of LPTB. Study Design: We performed a retrospective cohort study. MPTB was defined as delivery between 320/7 and 336/7 weeks and LPTB between 340/7 and 366/7 weeks. The composite neonatal adverse respiratory outcome was defined as respiratory distress syndrome and/or bronchopulmonary dysplasia. The composite neonatal adverse nonrespiratory outcome included early onset culture-proven sepsis, necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, or periventricular leukomalacia. LPTB cases were categorized as spontaneous (noniatrogenic), evidence-based iatrogenic, and non-evidence-based (NEB) iatrogenic. Results: Of the 747 twin deliveries during the study period, 453 sets met the inclusion criteria with 22.7% (n = 145) MPTB, 32.1% (n = 206) LPTB, and 15.9% (n = 102) term births. Compared with term neonates, the composite neonatal adverse respiratory outcome was increased following MPTB (relative risk [RR] 24; 95% confidence interval [CI] 3.0 to 193.6) and LPTB (RR 13.7; 95% CI 1.8 to 101.8). Compared with term neonates, the composite neonatal adverse nonrespiratory outcome was increased following MPTB (RR 22.3; 95% CI 3.9 to 127.8) and LPTB (RR 5.5; 95% CI 1.1 to 27.6). Spontaneous delivery of LPTB was 63.6% (n = 131/206) and the rate of iatrogenic delivery was 36.4% (n = 75/206). The majority, 66.6% (n = 50/75), of these iatrogenic deliveries were deemed NEB, giving a total of 24.2% (50/206) NEB deliveries in LPTB group. Conclusion: Our data demonstrate a high rate of late preterm birth among twin pregnancies, with over half of nonspontaneous early deliveries due to NEB indications. Although our morbidity data will be helpful to providers in counseling patients, our finding of high NEB indications underscores the need for systematic evaluation of indications for delivery in LPTB twin deliveries. Furthermore, this may lead to more effective LPTB rate reduction efforts. [ABSTRACT FROM AUTHOR]

Objective: Reduced maternal plasma levels of the peptide vasodilator adrenomedullin have been associated with adverse pregnancy outcomes. We measured the extent to which genetic polymorphisms in the adrenomedullin signaling pathway are associated with birth weight, glycemic regulation, and preeclampsia risk. Study Design: We genotyped 1,353 women in the Pregnancy, Infection, and Nutrition Postpartum Study for 37 ancestry-informative markers and for single-nucleotide polymorphisms in adrenomedullin (ADM), complement factor H variant (CFH), and calcitonin receptor-like receptor (CALCRL). We used linear and logistic regression to model the association between genotype and birth weight, glucose loading test (GLT) results, preeclampsia, and gestational diabetes (GDM). All models were adjusted for pregravid body mass index, maternal age, and probability of Yoruban ancestry. p values of < 0.05 were considered statistically significant. Results: Among Caucasian women, ADM rs57153895, a proxy for rs11042725, was associated with reduced birth weight z-score. Among African-American women, ADM rs57153895 was associated with increased birth weight z-score. Two CALCRL variants were associated with GDM risk. CFH rs1061170 was associated with higher GLT results and increased preeclampsia risk. Conclusion: Consistent with studies of plasma adrenomedullin and adverse pregnancy outcomes, we found associations between variants in the adrenomedullin signaling pathway and birth weight, glycemic regulation, and preeclampsia. [ABSTRACT FROM AUTHOR]

Objective Quantify neonatal morbidity by week of gestation for twins compared with singletons. Study Design We performed a population-based retrospective cohort study of all Ohio births from 2006 to 2007. Composite neonatal morbidity consisting of Apgar score < 7 at 5 minutes, assisted ventilation > 6 hours, neonatal transport, or seizures was compared between singletons and twins from 34 to 41 weeks. Results Neonatal morbidity was the lowest in twins delivered at 37 completed weeks and 2 weeks later for singletons at 39 weeks. Twin morbidity rapidly increased after 37 weeks and reached 15.8% at 41 weeks versus the singleton morbidity rate of 3.4% at 41 weeks. Twins delivered at 39 weeks and beyond were more than twice as likely to incur neonatal morbidity compared with singletons. Conclusion The lowest rate of neonatal morbidity occurs at 37 weeks for twins versus 39 weeks for singleton births. The increased risk after 37 weeks for twins accelerates at a faster rate compared with that for singletons born past 39 weeks. [ABSTRACT FROM AUTHOR]

Objective The enforcement of a one-step gestational diabetes mellitus (GDM) diagnosis would capture more patients with milder forms of glucose intolerance thereby increasing the incidence. We propose to identify characteristics predicting the need for medical therapy in such patients. Study Design Retrospective chart review of patients with mild GDM, defined as a fasting plasma glucose (FPG) < 95 mg/dL on the 3-hour 100-g oral glucose tolerance test (OGTT). Patients requiring medical therapy for glucose control were compared with diet-controlled patients. A predictive model was constructed with variables of significance. Results Included were 143 patients requiring medical therapy and 224 diet-treated patients. Mean FPG on 3-hour OGTT, prepregnancy body mass index (BMI), and BMI at 26 to 30 weeks were all significantly higher in patients requiring therapy. Combining several variables produced a predictive model with 76% sensitivity, 52% specificity, 48% positive predictive value, and 78% negative predictive value. Conclusions Antenatal factors (alone or in combination) do not allow for prediction of the possible need for therapy in mild GDM patients. [ABSTRACT FROM AUTHOR]

Objective: To assess the evidence available on the use of vitamin C supplementation greater than recommended dietary intake to reduce preterm birth rates. Study Design: Systematic review of randomized controlled trials using vitamin C alone or with one other supplement other than iron. Trials must report preterm birth rates but can have other primary outcomes. Preterm birth is defined as birth at less than 37 weeks' gestational age for this review. Review focused on studies with populations representative of Organization for Economic Co-operation and Development countries. Results: Inadequate level of evidence on the use of vitamin C alone to prevent preterm birth rates in low-risk populations based on one study. Three studies provided convincing evidence of no benefit in low-risk groups of use of vitamins C and E combined. Three studies provided adequate evidence of no benefit in high-risk groups of use of vitamins C and E combined. Conclusion: The available evidence supports no benefit gained from using vitamin C to prevent preterm birth. Evidence does not support limiting use of vitamin C supplementation for other indications. [ABSTRACT FROM AUTHOR]

Objective To develop a prediction model for cesarean delivery (CD) in the second stage of labor using classification and regression tree (CART) analysis. Study Design Retrospective cohort of term women who reached 10-cm dilation. The primary outcome was CD at 10-cm dilation. Logistic regression and CART analysis were performed to identify factors that best predict second-stage CD. Only factors known at the time a patient reaches 10-cm dilation were used. Results Of 5,388 subjects who reached 10 cm, 88 (1.6%) underwent CD. The logistic regression model identified 4 risk factors for CD and produced an area under the receiver operator characteristic curve of 0.75 (95% confidence interval 0.70 to 0.81). CART analysis identified the most important variable in predicting second-stage CD was a station at or higher than 0 at complete dilatation, but correctly classified only 19.3% of CD. Conclusion Second-stage cesarean cannot be reliably predicted based on antenatal and intrapartum characteristics by logistic regression or CART techniques. [ABSTRACT FROM AUTHOR]

Objective To examine the effect of cigarette smoking during pregnancy on the development of preterm premature rupture of membranes (PPROM) categorized by gestational age. Methods We conducted a retrospective cohort study of 17,961 births using data from the McGill Obstetric and Neonatal Database between years 2001 and 2006. Our exposure was defined according to self-reported maternal cigarette smoking status categorized as nonsmoker, smoker of 1 to 10 cigarettes per day, and smoker of > 10 cigarettes per day. The outcome was measured as incidence of premature rupture of membranes (PROM) among gestational age categories of < 28, < 32, < 37, and > 37 weeks. Unconditional logistic regression analysis and Wald test for trend were used to estimate the adjusted risk of PPROM according to smoking status. Results Among the study population, 640 cases of PPROM (<37 weeks) and 40 cases of PROM (>37 weeks). After adjusting for confounding variables, smoking > 10 cigarettes per day was associated with an increased risk of PPROM at < 28 weeks (odds ratio [OR] 5.28; 95% confidence interval [CI] 2.20 to 12.7); < 32 weeks (OR 2.36; 95% CI 1.09 to 5.11; < 37 weeks (OR 1.97; 95% CI 1.32 to 2.94); and > 37 weeks (OR 3.19; 95% CI 0.92 to 11.0). Smoking 1 to 10 cigarettes per day was not associated with a significant risk of PPROM at any gestational age. Conclusion Heavy cigarette smoking increases the risk of PPROM more so at early gestational age than at term. [ABSTRACT FROM AUTHOR]

In nonpregnant populations, sleep-disordered breathing (SDB) has been associated with cardiovascular and metabolic disease. Few studies have examined the relationship between SDB and adverse pregnancy outcomes (APO). The objective of this study was to examine the association between SDB and APO. Women who had a delivery as well as an in-laboratory polysomnogram (PSG) were identified. Demographics, PSG results, and pregnancy outcomes were abstracted from the medical record. Absence of SDB was defined as an apnea hypopnea index (AHI) of <5, mild SDB as an AHI of 5 to 14.9, and moderate to severe SDB as an AHI of ≥15. The primary outcome was a composite measure of APO: pregnancy-related hypertension, gestational diabetes, or preterm birth ≤34 weeks. We identified 143 women who had undergone a PSG and a delivery. Increasing severity of SDB was associated with an increasing risk of the composite APO: AHI <5, 18.1%; AHI 5 to 14.9, 23.5%; AHI ≥15, 38.5% (p = 0.038). Obese women (body mass index ≥30) with moderate to severe SDB had the highest rate of APO, 41.7%. SDB, especially moderate to severe disease, may be associated with APO. However, it is unclear if SDB is a risk factor for APO independent of obesity. [ABSTRACT FROM AUTHOR]

We examined the association between midtrimester intra-amniotic sludge and spontaneous preterm birth (PTB) in asymptomatic women undergoing amniocentesis. We performed a prospective cohort study of women having an amniocentesis for fetal karyotyping between 14 and 24 weeks' gestation. Cervical length and the presence of amniotic sludge were assessed by transvaginal ultrasound. Amniotic fluid concentrations of matrix metalloproteinase-8, glucose and lactate were measured. Early (<32 weeks) and late (32 to 36 weeks) preterm premature rupture of membranes (PPROM) and spontaneous PTB constituted primary outcomes. Nonparametric analyses were conducted. Three hundred ten women, including 94 (30%) with free-floating echogenic particles and 16 (5%) with dense amniotic sludge, were recruited. Dense amniotic sludge was linked with early (13%) but not with late (0%) primary outcome (p<0.01). Two women with combined dense amniotic sludge and short cervix delivered 4 and 10 weeks later (at 20 and 25 weeks, respectively) and had a higher median amniotic lactate concentration than controls (p<0.05). A third woman with dense amniotic sludge at 15 weeks was diagnosed with a short cervix and an intra-amniotic infection at 22 weeks that was eradicated with intravenous antibiotics. Midtrimester dense amniotic sludge is associated with early PPROM and spontaneous PTB. [ABSTRACT FROM AUTHOR]

We compared the rates of abnormal 1-hour glucose challenge tests (GCT) and gestational diabetes (GDM) between women receiving 17α-hydroxyprogesterone caproate (17-P) and women who did not receive 17-P to determine if the effect varies based on the number of doses received or in a group of high-risk obese women. We performed a secondary analysis of a prospective cohort study where women with a history of a previous preterm delivery in the antecedent pregnancy followed at a high-risk clinic were offered 17-P. GCT was performed after the initiation of 17-P, and doses given prior to testing were recorded. Rates of abnormal GCT and GDM were compared between those receiving 17-P (n=67) and controls (n=140). Mean glucose values (112.4 versus 111.3, p=0.8), rate of abnormal GCT (23.9% versus 20%, adjusted odds ratio 1.45, 95% confidence interval 0.7 to 3.0), and rate of GDM (6% versus 8.6%, adjusted odds ratio 1.21, 95% confidence interval 0.3 to 4.5) were similar between groups. In this prospective study, 17-P administration to women at risk of recurrent preterm delivery did not significantly affect glucose tolerance. [ABSTRACT FROM AUTHOR]

We employed accepted, validated symptom-based screening measures to discern attributable risk of obstructive sleep apnea (OSA) to adverse pregnancy outcomes, taking into account potential maternal confounders. Commonly employed OSA screening measures (Berlin and Epworth scales) were performed in the second and third trimesters; maternal and neonatal outcome data were thereafter obtained. The relationship between OSA and outcomes of interest were explored in stratified and multivariate models controlling for potential confounders. The overall prevalence of OSA was 25.4%. Given a nonlinear increase by body mass index (BMI) strata (8.9%, 46%; p<0.0001), stratified multivariate analysis was subsequently performed. Among nonobese (BMI <30) gravidae, frequency of preeclampsia was significantly higher among women with OSA (adjusted odds ratio=6.58, 95% confidence interval=1.04, 38.51; p=0.035). Among the obese (BMI ≤30) gravidae, infant birth weight ratio (or birth weight by gestational age) was higher with OSA + screening than OSA --(1.099 versus 1.035; p=0.04), and this association remained significant after adjustment for potential confounders (p=0.05). OSA prevalence increases significantly among obese gravidae, raising concerns for the overall validity of commonly employed screening measures in pregnancy. Nevertheless, OSA status continues to exert an independent influence, as obese and nonobese gravidae are at increased risk for a limited number of adverse perinatal outcomes in multivariate models. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe how obstetricians in the community define a short cervix prior to cerclage placement. A secondary analysis of cerclages placed for the diagnosis of short cervix, defined by either digital or ultrasound examination, were identified from a cohort of 1076 cerclages placed at a community hospital from January 1, 2000, through December 31, 2004. Two hundred twenty-six cerclages were placed for the diagnosis of short cervix. Fifty-eight women (25.7%) were nulliparous. The mean estimated gestational age at placement was 15.4 ? 3.8 weeks. More than half of the cerclages (n = 125; 55.3%) were placed prior to 15 weeks estimated gestational age. Of those cases with documented cervical length by ultrasound (n = 171), 36 of these patients (21.1%) had a cervical length of ? 25 mm. The most common indications for cerclage placement were short cervix only (40.3%), previous cone biopsy/loop electrocautery excision procedure (28.8%), and multiple gestation (9.7%). In a community hospital, cerclages for short cervix are often performed in nulliparous women without antecedent risk factors at a gestational age when cervical length is not a reliable tool for predicting adverse pregnancy outcome. [ABSTRACT FROM AUTHOR]

The purposes of this study were (1) to determine the prevalence of oligohydramnios (amniotic fluid index < 5.0 cm) among fetuses with intrauterine growth restriction (IUGR) and newborns identified as small for gestational age (SGA), and (2) among fetuses with IUGR, to determine the predictive accuracy of amniotic fluid index (AFI) ? versus > 5.0 cm for adverse peripartum outcomes. This was a retrospective review of high-risk pregnancy that had reliable gestational age (GA) and needed weekly biophysical profile (BPP). Along with 95% confidence intervals (CIs), we calculated the likelihood ratios (LRs) and used guidelines promulgated by Evidence-Based Medicine Working Group. Among the 1859 singletons undergoing BPP, IUGR (estimated fetal weight < 10% for GA) was suspected in 22% (n = 410) and the prevalence of oligohydramnios was 6% (95% CI, 4 to 8%). SGA (birthweight ? 10%) occurred among 28% (n = 517) of newborns and oligohydramnios was noted in 6% (95% CI, 4 to 8%). Among fetuses with IUGR, the LR of oligohydramnios to predict cesarean delivery for nonreassuring fetal heart tracing was 2.0 (range, 0.8 to 5.0); for newborns small for gestational age, 1.9 (range, 1.2 to 3.1), and for neonatal intensive care unit admission, 1.4 (range, 0.6 to 2.3) More than 90% of patients with IUGR or SGA have AFI > 5.0 cm, and oligohydramnios with IUGR is a poor predictor of peripartum complications. [ABSTRACT FROM AUTHOR]