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Objective: To estimate the incidence of women with vasa previa in Australia and to describe risk factors, timing of diagnosis, clinical practice, and perinatal outcomes.Methods: A prospective population-based cohort study was undertaken using the Australasian Maternity Outcomes Surveillance System between May 1, 2013, and April 30, 2014, in hospitals in Australia with greater than 50 births per year. Women were included if they were diagnosed with vasa previa during pregnancy or childbirth, confirmed by clinical examination or placental pathology. The main outcome measures included stillbirth, neonatal death, cesarean delivery, and preterm birth.Results: Sixty-three women had a confirmed diagnosis of vasa previa. The estimated incidence was 2.1 per 10,000 women giving birth (95% CI 1.7-2.7). Fifty-eight women were diagnosed prenatally and all had a cesarean delivery. Fifty-five (95%) of the 58 women had at least one risk factor for vasa previa with velamentous cord insertion (62%) and low-lying placenta (60%) the most prevalent. There were no perinatal deaths in women diagnosed prenatally. For the five women with vasa previa not diagnosed prenatally, there were two perinatal deaths with a case fatality rate of 40%. One woman had an antepartum stillbirth and delivered vaginally and the other four women had cesarean deliveries categorized as urgent threat to the life of a fetus with one neonatal death. The overall perinatal case fatality rate was 3.1% (95% CI 0.8-10.5). Two thirds (68%) of the 65 neonates were preterm and 29% were low birth weight.Conclusion: The outcomes for neonates in which vasa previa was not diagnosed prenatally were inferior with higher rates of perinatal morbidity and mortality. Our study shows a high rate of prenatal diagnosis of vasa previa in Australia and associated good outcomes. [ABSTRACT FROM AUTHOR]

Prenatal aneuploidy screening has changed dramatically in recent years with increases in the types of chromosomal abnormalities reliably identified and in the proportion of aneuploid fetuses detected. Initially, screening was available only for trisomies 21 and 18 and was offered only to low-risk pregnancies. Improved detection with the quadruple- and first-trimester multiple marker screens led to the option of aneuploidy screening for women 35 years of age and older. Cell-free DNA tests now screen for common autosomal trisomies and sex chromosome aneuploidies. Cell-free DNA screening is particularly effective in older women because of higher positive predictive values and lower false-positive rates. Integrated first- and second-trimester multiple marker tests provide specific risks for trisomies 21, 18, and possibly 13, and may detect an even wider range of aneuploidies. Given current precision in risk assessment, based on maternal age and preferences for screening or diagnostic tests, counseling has become more complex. This review addresses the benefits and limitations of available aneuploidy screening methods along with counseling considerations when offering them. [ABSTRACT FROM AUTHOR]

The principle of avoiding the worst possible outcomes guided the enormous successes of modern obstetrics in reducing the morbidity and mortality of childbirth. The challenges of improving the quality of childbirth today has prompted health care providers, policymakers, and patients to ask whether this principle is in fact preventing us from supporting the normal processes of childbirth, resulting in undue intervention and potentially causing harm. In this commentary, we suggest that recognizing the strengths of the medical model of childbirth does not preclude looking outside of it to meet the maternity care needs of the majority of healthy, low-risk women. Obstetricians have the good fortune to have a partner in their work among midwives, who hail from a long tradition of incorporating a perspective of "normalcy" in the care of childbearing women. Given the many evidence-based practices demonstrating the strengths of midwifery to actualize patient-centered, low-intervention birth, we advocate for the explicit establishment of professional standards for team-based physician-midwife care. More than merely introducing midwives into a physician-dominated setting, this means elevating the contributions of midwives and meaningfully incorporating a culture of normalcy to standardize practices such as intermittent auscultation, continuous birth support, nonpharmacologic pain management, and positional flexibility in labor. The literature suggests that a woman's health care provider is the most powerful determinant of her birth outcomes; striking the balance between averting poor outcomes and normalcy compels us to make room at the table for both obstetricians and midwives. [ABSTRACT FROM AUTHOR]

Objective: To characterize pregnancy-associated deaths and examine the relationship between area of residence and pregnancy-associated deaths and pregnancy-related mortality ratios in Georgia from 2010 to 2012.Methods: The cohort of pregnancy-associated deaths was reviewed and categorized as pregnancy-related or resulting from other medical conditions not related to pregnancy, suicide, drug toxicity, homicide, or motor vehicle accident. Georgia Online Analytical Statistical Information System data were used to calculate pregnancy-related mortality ratio by rural, nonrural, and metropolitan Atlanta area and by race. Causes of death and pregnancy-related mortality ratio were compared by area of residence and race using χ tests; a P value <.05 was considered significant.Results: There were 262 pregnancy-associated deaths; 40.1% (n=105) were pregnancy-related. The 2010-2012 pregnancy-related mortality ratio was 26.5 per 100,000 live births and the pregnancy-related mortality ratio did not differ statistically among rural (27.1), nonrural (24.4), and metropolitan Atlanta (27.7) areas (P=.845). Most pregnancy-related deaths were the result of hemorrhage and cardiovascular factors. In aggregate, the pregnancy-related mortality ratio for black women was 49.5 compared with 14.3 for white women (P<.001). The gap in pregnancy-related mortality ratio between black and white women was highest for metropolitan Atlanta (51.6 compared with 12.4, P<.001), less in nonrural areas (50.3 compared with 12.0, P<.001), and comparable in rural areas (39.4 compared with 22.4, P=.281).Conclusion: Although the pregnancy-related mortality ratio was similar for rural, nonrural, and metropolitan Atlanta areas, it was significantly higher for black compared with white women living outside of rural areas. [ABSTRACT FROM AUTHOR]

Objective: To identify factors associated with continuity of care and human immunodeficiency virus (HIV) virologic suppression among postpartum women diagnosed with HIV during pregnancy in New York State.Methods: This retrospective cohort study was conducted among 228 HIV-infected women diagnosed during pregnancy between 2008 and 2010. Initial receipt of HIV-related medical care (first CD4 or viral load test after diagnosis) was evaluated at 30 days after diagnosis and before delivery. Retention in care (2 or more CD4 or viral load tests, 90 days or greater apart) and virologic suppression (viral load 200 copies/mL or less) were evaluated in the 12 months after hospital discharge.Results: Most women had their initial HIV-related care encounter within 30 days of diagnosis (74%) and before delivery (87%). Of these women, 70% were retained in the first year postpartum. Women waiting more than 30 days for their initial HIV-related care encounter were more likely diagnosed in the first (29%) compared with the third (11%) trimester and were of younger (younger than 25 years, 32%) compared with older (35 years or older, 13%) age. Loss to follow-up within the first year was significantly greater among women diagnosed in the third compared with the first trimester (adjusted relative risk 2.21, 95% confidence interval [CI] 1.41-3.45) and among women who had a cesarean compared with vaginal delivery (adjusted relative risk 1.76, 95% CI 1.07-2.91). Of the 178 women with one or more HIV viral load test in the first year postpartum, 58% had an unsuppressed viral load.Conclusion: Despite the high proportion retained in care, many women had poor postpartum virologic control. Robust strategies are needed to increase virologic suppression among newly diagnosed postpartum HIV-infected women. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Gestational diabetes mellitus (GDM) is a common complication of pregnancy associated with an increased incidence of pregnancy complications, adverse pregnancy outcomes, and maternal and fetal risks of chronic health conditions later in life. Physical activity has been proposed to reduce the risk of GDM and is supported by observational studies, but experimental research assessing its effectiveness is limited and conflicting. We aimed to use meta-analysis to synthesize existing randomized controlled studies of physical activity and GDM. DATA SOURCES: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and ClinicalTrials. gov for eligible studies. METHODS OF STUDY SELECTION: The following combination of keywords was used: (pregnant or pregnancy or gestation or gestate or gestational or maternity or maternal or prenatal) AND (exercise or locomotion or activity or training or sports) AND (diabetes or insulin sensitivity or glucose tolerance) AND (random* or trial). Eligibility was restricted to studies that randomized participants to an exercise-only-based intervention (ie, separate from dietary interventions) and presented data regarding GDM risk. Two authors performed the database search, assessment of eligibility, and abstraction of data from included studies, and a third resolved any discrepancies. A total of 469 studies was retrieved, of which 10 met inclusion criteria and could be used for analysis (3,401 participants). TABULATION, INTEGRATION, AND RESULTS: Fixed-effects models were used to estimate summary relative risk (RR) and 95% confidence interval (CI) and I² to assess heterogeneity. There was a 28% reduced risk (95% CI 9-42%) in the intervention group compared with the control group (RR 0.72, P=.005). Heterogeneity was low (I² = 12%) and nonsignificant (P=.33). CONCLUSION: The results from this meta-analysis suggest that physical activity in pregnancy provides a slight protective effect against the development of GDM. Studies evaluating type, timing, duration, and compliance of physical activity regimens are warranted to best inform obstetric guidelines. [ABSTRACT FROM AUTHOR]

OBJECTIVE: "Catch-up vaccination" is vaccination outside of the recommended schedule and may occur between 13 and 26 years of age for human papillomavirus vaccines. We aimed to characterize those adolescents and young women who were most likely to complete the three-vaccine series on a catch-up schedule. METHODS: We performed a retrospective review of adolescents and young women aged 13-26 years who initiated human papillomavirus vaccination between January 2007 and April 2009 and followed them through April 2010 for vaccine completion (n=310). Completion was defined as receipt of three doses of the human papillomavirus vaccine. We used log binomial regression to investigate characteristics associated with vaccine completion. The main exposure was pregnancy occurring within 1 year of initiating the series. Other exposure var-iables included age, race, insurance, and clinical site. RESULTS: Fifty-six percent of participants completed the vaccine series with a mean follow-up of 2 years. After adjusting for age and site of vaccination, those who became pregnant (n=31) were significantly less likely than those who did not to complete the series (22.6% compared with 59.9%, respectively, adjusted relative risk 0.42, 95% confidence interval [CI] 0.21-0.81). Race or ethnicity was also independently associated with com-pletion, with black patients having the lowest completion rate (48% compared with 72.1% among white patients, adjusted relative risk 0.71, 95% CI 0.54-0.91). CONCLUSION: Human papillomavirus vaccination completion is low among adolescents and females receiving vaccination on a catch-up schedule. Those who become pregnant may not resume the series after pregnancy. Vaccine initiation is an opportunity for contraceptive provision for adolescents and young women. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the potential risk of perinatal morbidity outcomes in small-gestational-age (SGA) pregnancies on a population-based birth weight standard and a customized fetal growth standard. It shows that the prematurity rates in the SGA population-based pregnancies were 4.8% and SGA customized cohorts 64.5%, while neonatal death ratios in both pregnancies were 4.8% and 2.9%, respectively. It notes that customized standards may not improve risk identification.

The article focuses on the Institute of Medicine (IOM) gestational weight gain recommendations. It states that the IOM recommendations of single standard weight gain for obese women are in question due to its basis of a non-evident theoretical relation of gestational weight gain and birth weight. It says that the recommendation was suggested to be more individualized, particular to obese women, due to complication risks pose by excessive gestational weight gain during pregnancy.

The article presents a study on the severe obstetric complications in the delivery and post-partum periods of hospitalized pregnant women with cardiomyopathy and other myocardial disorders. It discloses that 1.33 per 1,000 deliveries in pregnancy hospitalizations have myocardial disorders with 0.46 for cardiomyopathy and 0.87 for other disorders. It reveals on the important contribution of cardiomyopathy and other myocardial disorders to severe obstetric complications.

The article presents a study which investigates the association of prothrombin gene G2010A mutation with pregnancy loss, preeclampsia and small for gestational age (SGA) infants. It finds that 157 of the total respondents are carriers of prothrombin gene mutation and it has the same rates in pregnancy loss, preeclampsia and SGA infants with noncarriers. It also concludes that prothrombin gene mutation is not related to the above mentioned pregnancy disorders.

The article presents a study which investigates the relation of assisted reproductive technology (ART) with the risk of placenta-mediated pregnancy complications including preeclampsia, placental abruption and stillbirth. Participants include about 2,118 who were exposed to different types of ART including vitro fertilization, while about 8,420 conceived naturally. It was found out that ART is not related to the increased risk of placenta-mediated pregnancy complications on singleton pregnancies.

The article discusses a historical cohort study of pregnant women that was designed to establish the role of clinical chorioamnionitis as an independent risk factor for recurrence in a subsequent pregnancy. Results suggest that women delivering vaginally who were diagnosed with chorioamnionitis during their first pregnancy are at risk for chorioamnionitis in a subsequent pregnancy. The concept of predisposition to chorioamnionitis deserves further investigation.

The article discusses a population-based study in Nova Scotia that identified risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Eight percent was the overall admission rate for hyperemesis among 157,922 deliveries between 1988 and 2002. Hyperthyroid disorders, psychiatric illness, previous molar pregnancy, preexisting diabetes, gastrointestinal disorders and asthma were statistically significant risk factors for hyperemesis.

The overwhelming majority of morbidity and mortality attributable to pertussis infection occurs in infants who are 3 months and younger. Infants do not begin their own vaccine series against pertussis until approximately 2 months of age. This leaves a window of significant vulnerability for newborns, many of whom contract serious pertussis infections from family members and caregivers, especially their mothers, or older siblings, or both. In 2013, the Advisory Committee on Immunization Practices published its updated recommendation that a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) should be administered during each pregnancy, irrespective of the prior history of receiving Tdap. The recommended timing for maternal Tdap vaccination is between 27 weeks and 36 weeks of gestation. To maximize the maternal antibody response and passive antibody transfer and levels in the newborn, vaccination as early as possible in the 27-36-weeks-ofgestation window is recommended. However, the Tdap vaccine may be safely given at any time during pregnancy if needed for wound management, pertussis outbreaks, or other extenuating circumstances. There is no evidence of adverse fetal effects from vaccinating pregnant women with an inactivated virus or bacterial vaccine or toxoid, and a growing body of robust data demonstrate safety of such use. Adolescent and adult family members and caregivers who previously have not received the Tdap vaccine and who have or anticipate having close contact with an infant younger than 12 months should receive a single dose of Tdap to protect against pertussis. Given the rapid evolution of data surrounding this topic, immunization guidelines are likely to change over time, and the American College of Obstetricians and Gynecologists will continue to issue updates accordingly. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 33-year-old pregnant woman with a history of endometrial ablation for menorrhagia, complained with severe right-sided abdominal pain during 26th week of gestation. Cesarean operation was performed in which she was discovered to have spontaneous uterine rupture. The article concludes that endometrial ablation can induce the risk of morbidity during pregnancy and that gynecologists must counsel women regarding the importance of contraception.