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OBJECTIVE To characterize asthma prevalence and outcomes during U.S. delivery hospitalizations. METHODS For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with asthma were identified in the 2000-2018 National Inpatient Sample, which approximates a 20% stratified sample of all hospitalizations nationally. Temporal trends in asthma were analyzed using joinpoint regression to estimate the average annual percent change with 95% CIs. The association of asthma with other comorbid conditions was analyzed. The relationship between asthma and several adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted odds ratios and adjusted odds ratios (aORs) as measures of effect. Risk for and trends in a composite of rare, but severe, respiratory complications also were analyzed. RESULTS An estimated 73,109,790 delivery hospitalizations from 2000 to 2018 were included in the analysis, of which 2,221,644 (3.0%) had a diagnosis of asthma. (Unweighted, the study sample included 15,213,024 deliveries, of which 462,276 [3.0%] had a diagnosis of asthma.) Asthma diagnoses rose from 1.2% in 2000 to 5.3% in 2018, representing an average annual percent change of 8.3% (95% CI 7.4-9.2%). Asthma was more common among women with obesity and chronic hypertension. In adjusted analyses, asthma was associated with severe maternal morbidity (aOR 1.50, 95% CI 1.45-1.55), preeclampsia and gestational hypertension (aOR 1.29, 95% CI 1.26-1.30), postpartum hemorrhage (aOR 1.21, 95% CI 1.19-1.24), cesarean delivery (aOR 1.16, 95% CI 1.15-1.18), gestational diabetes (aOR 1.20, 95% CI 1.18-1.21), venous thromboembolism (aOR 1.79, 95% CI 1.65-1.95), and preterm delivery (aOR 1.27, 95% CI 1.25-1.29). From 2000 to 2018, severe respiratory complications decreased from 72 per 10,000 deliveries with asthma to 14 per 10,000 deliveries with asthma (average annual percent change -9.4%, 95% CI -13.3% to -5.3%). This decreasing risk was offset on a population level by an increase in the risk of asthma. CONCLUSION Asthma is increasing during deliveries, is associated with adverse maternal outcomes, and is associated with comorbid conditions. Severe respiratory complications are decreasing proportionately among deliveries with asthma, but are stable on a population basis.

OBJECTIVE To characterize trends of an influenza diagnosis at delivery hospitalization and its association with severe maternal morbidity. METHODS We conducted a repeated cross-sectional analysis of delivery hospitalizations using the Nationwide Inpatient Sample from 2000 to 2018. We assessed the association between an influenza diagnosis at delivery hospitalization and severe maternal morbidity excluding transfusion per Centers for Disease Control and Prevention criteria. Secondary outcomes included maternal death and morbidity measures associated with influenza (mechanical intubation and ventilation, sepsis and shock, and acute respiratory distress syndrome [ARDS]) and obstetric complications (preterm birth and hypertensive disorders of pregnancy). We assessed trends of severe maternal morbidity by annual influenza season and the association between influenza and severe maternal morbidity using multivariable log-linear regression, adjusting for demographic, clinical, and hospital characteristics. RESULTS Of 74.7 million delivery hospitalizations, 23 per 10,000 were complicated by an influenza diagnosis. The rate of severe maternal morbidity was higher with an influenza diagnosis compared with those without influenza (86-410 cases vs 53-70 cases/10,000 delivery hospitalizations). Women with an influenza diagnosis at delivery hospitalization were at an increased risk of severe maternal morbidity compared with those without influenza (2.3 vs 0.7%; adjusted risk ratio 2.24, 95% CI 2.17-2.31). This association held for maternal death, mechanical intubation, sepsis and shock, and ARDS-as well as obstetric complications, including preterm birth and hypertensive disorders of pregnancy. CONCLUSION Pregnant women with influenza are at increased risk of severe maternal morbidity, as well as influenza-related maternal and obstetric complications. These results emphasize the importance of primary prevention and recognition of influenza infection during pregnancy to reduce downstream maternal morbidity and mortality.

Objective To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March 2020. Methods We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020. Results Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%). Conclusion During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.

OBJECTIVE: To describe risk of Clostridium difficile infection associated with clindamycin and acute kidney injury associated with gentamicin during delivery hospitalizations. METHODS: Women admitted for delivery from January 2006 to March 2015 were analyzed using an inpatient administrative database. Primary outcomes were C. difficile infection and acute kidney injury. Clostridium difficile infection was compared between women receiving clindamycin (with or without other antibiotics) and women receiving antibiotics other than clindamycin. Acute kidney injury was compared between women receiving gentamicin (with or without other antibiotics), women receiving antibiotics other than gentamicin, and women receiving no antibiotics. Unadjusted and adjusted log linear models analyzing the role of patient demographics, mode of delivery, and hospital-level characteristics were created evaluating risk for C. difficile infection and acute kidney injury with risk ratios (RR) and adjusted risk ratios with 95% confidence intervals (CI) as measures of association. A sensitivity analysis for gentamicin and acute kidney injury was performed restricted to women with preeclampsia. RESULTS: Of 5,657,523 women admitted for delivery hospitalization, 266,402 (4.7%) received clindamycin and 165,726 (2.9%) received gentamicin. Clostridium difficile infection was diagnosed in 0.04% of women receiving clindamycin. Compared to women receiving other antibiotics, clindamycin was associated with a nearly three-fold increased risk of C. difficile infection (RR 2.93, 95% CI 2.36, 3.65). Acute kidney injury was diagnosed in 0.24% of women receiving gentamicin. Gentamicin was associated with a three-fold risk of acute kidney injury (RR 3.01, 95% CI 2.71, 3.34) compared to women receiving other antibiotics, while receipt of no antibiotics was associated with significantly lower risk (RR 0.18, 95% CI 0.15, 0.20). In adjusted analyses, these associations retained significance. Significantly increased risk for acute kidney injury was noted with women with preeclampsia receiving gentamicin (RR 2.04, 95% CI 1.64, 2.53). CONCLUSION: Receipt of clindamycin was associated with significantly increased likelihood for C. difficile infection and receipt of gentamicin with significantly increased likelihood of acute kidney injury, although the absolute risk for these complications was low.

OBJECTIVE: To assess trends in use of long-acting opioids during delivery hospitalizations. METHODS: The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioids use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria. RESULTS: Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. While buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than a third of all long-acting opioids used during delivery hospitalizations. By 2015 buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared to other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids. CONCLUSION: Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine are associated with decreased maternal morbidity although causation cannot be presumed from this study model.

OBJECTIVE: To characterize symptoms and disease severity among pregnant women with coronavirus disease 2019 (COVID-19) infection, along with laboratory findings, imaging, and clinical outcomes. METHODS: Pregnant women with COVID-19 infection were identified at two affiliated hospitals in New York City from March 13 to April 19, 2020, for this case series study. Women were diagnosed with COVID-19 infection based on either universal testing on admission or testing because of COVID-19-related symptoms. Disease was classified as either 1) asymptomatic or mild or 2) moderate or severe based on dyspnea, tachypnea, or hypoxia. Clinical and demographic risk factors for moderate or severe disease were analyzed and calculated as odds ratios (ORs) with 95% CIs. Laboratory findings and associated symptoms were compared between those with mild or asymptomatic and moderate or severe disease. The clinical courses and associated complications of women hospitalized with moderate and severe disease are described. RESULTS: Of 158 pregnant women with COVID-19 infection, 124 (78%) had mild or asymptomatic disease and 34 (22%) had moderate or severe disease. Of 15 hospitalized women with moderate or severe disease, 10 received respiratory support with supplemental oxygen and one required intubation. Women with moderate or severe disease had a higher likelihood of having an underlying medical comorbidity (50% vs 27%, OR 2.76, 95% CI 1.26-6.02). Asthma was more common among those with moderate or severe disease (24% vs 8%, OR 3.51, 95% CI 1.26-9.75). Women with moderate or severe disease were significantly more likely to have leukopenia and elevated aspartate transaminase and ferritin. Women with moderate or severe disease were at significantly higher risk for cough and chest pain and pressure. Nine women received ICU or step-down-level care, including four for 9 days or longer. Two women underwent preterm delivery because their clinical status deteriorated. CONCLUSION: One in five pregnant women who contracted COVID-19 infection developed moderate or severe disease, including a small proportion with prolonged critical illness who received ICU or step-down-level care.

OBJECTIVE: To clarify how race is associated with adverse maternal outcomes and risk for women aged 40 years or older. METHODS: This retrospective cohort study used the Nationwide Inpatient Sample (NIS) for the years 1998 to 2014. Women aged 40 to 54 years were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Temporal trends in severe maternal morbidity and overall comorbid risk by race in women aged ≥40 years were evaluated as were common pregnancy complications including preeclampsia, gestational diabetes, and cesarean delivery. Adjusted models were created to assess factors associated with severe morbidity. RESULTS: A total of 1,724,694 deliveries were included in this analysis. Severe maternal morbidity increased over the study period from 1.6% in 1998–2000 to 3.0% from 2013–2014. Black women had the highest rates of severe morbidity at both the beginning (2.4% in 1998–2000) and the end (4.9% in 2013–2014) of the study period. During this same period, comorbid risk based on medical conditions and other factors increased overall and individually by race. Black women also experienced the absolute largest increase from 1998–2003 to 2010–2014 in risk for acute renal failure, disseminated intravascular coagulation, transfusion, and hysterectomy. Pregnancy complications including preeclampsia, cesarean delivery, and gestational diabetes were more common at the end compared to the beginning of the study for black, white, and Hispanic women. The adjusted risk ratio for overall severe morbidity for black compared to white race was 1.81 (95% CI 1.76–1.87). Black women had a substantially higher risk of death than white women (RR 4.71, 95% CI 3.36–6.61), while Hispanic women were at more than twice the risk of death (RR 2.13, 95% CI 1.48–3.07) as white women. DISCUSSION: While black women older than 40 years were at increased risk for adverse outcomes and severe morbidity, this differential was of smaller magnitude than reported mortality risk.

OBJECTIVE: To evaluate temporal trends in use of antihypertensive medications during delivery hospitalizations complicated by preeclampsia and risk of maternal stroke over the same time period. METHODS: The Perspective database was used to perform a retrospective cohort study evaluating antihypertensive drugs dispensed during delivery hospitalizations complicated by preeclampsia from 2006 to the first quarter of 2015. Medications evaluated included nifedipine, hydralazine, and oral and intravenous labetalol. Adjusted models for receipt of antihypertensive agents accounting for demographic and hospital factors were created. Hospital-level rates of antihypertensive administration for women with severe preeclampsia were analyzed. Risk of stroke during delivery hospitalization was evaluated. RESULTS: A total of 239,454 patients with preeclampsia were included in the analysis including 126,595 women with mild, 31,628 with superimposed, and 81,231 with severe preeclampsia. Overall, 105,409 women received a hypertensive agent. From 2006 to 2014, for all patients with preeclampsia, receipt of oral labetalol increased from 20.3% to 31.4%, intravenous labetalol from 13.3% to 21.4%, hydralazine from 12.8% to 16.9%, nifedipine from 15.0% to 18.2%, and more than one medication from 16.5% to 25.8%. The proportion of patients with preeclampsia receiving any antihypertensive medication rose from 37.8% in 2006 to 49.4% in 2015. In adjusted models, temporal trends retained significance. Rates of antihypertensive administration for severe preeclampsia varied significantly by hospital. For severe preeclampsia, the risk for stroke decreased from 13.5 per 10,000 deliveries in 2006–2008 (n=27) to 9.7 in 2009–2011 (n=25) to 6.0 in 2012–2014 (n=20) (p=0.02). CONCLUSION: Use of multiple antihypertensive agents to treat preeclamptic women increased over the study period for women with mild, superimposed, and severe preeclampsia. There was substantial hospital variation in use of antihypertensive agents. This trend was associated with decreased risk of maternal stroke.

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death

In 2004, leaders in first-trimester aneuploidy screening and a multidisciplinary group of experts established the Nuchal Translucency Quality Review Program, a national program to standardize education, credentialing, and quality monitoring of nuchal translucency. Since its inception, the program has credentialed more than 6,600 physician and ultrasonographer participants and collected more than 2.4 million nuchal translucency measurements. Ongoing quality monitoring is conducted through statistical analysis comparing the distribution and standard deviation of participants' nuchal translucency measurements against those obtained from a standard referent curve. Results of these analyses are distributed to participants quarterly and are used to track each participant's performance and to trigger performance improvement activities or mandatory remediation. This program could serve as a template for future education and credentialing programs that include partnerships with academic leaders, national professional organizations, and industry.

To characterize contemporary practice patterns for postcesarean thromboembolism prophylaxis and determine whether opportunities to substantially decrease maternal mortality and morbidity in this clinical setting are being missed.A commercial hospitalization database that includes procedure and diagnosis codes, health care provider and hospital information, and patient demographic data were used to analyze use of venous thromboembolism prophylaxis after cesarean delivery in the United States between 2003 and 2010. The analysis evaluated whether patients received pharmacologic prophylaxis, mechanical prophylaxis, combined prophylaxis, or no prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression models evaluating prophylaxis administration.We identified 1,263,205 women who underwent cesarean delivery. Within the cohort, 75.7% (n=955,787) received no thromboembolism prophylaxis, 22.1% (n=278,669) received mechanical prophylaxis alone, 1.3% (n=16,639) received pharmacologic prophylaxis, and 1.0% (n=12,110) received combination prophylaxis. The rate of prophylaxis increased from 8.4% in 2003 to 41.6% in 2010. Prophylaxis rates varied significantly by geographic region. Medical risk factors for thromboembolism were associated with only modest increases in prophylaxis.Although our findings demonstrated increased adoption of postcesarean venous thromboembolism prophylaxis, fewer than half of patients received recommended care as of 2010, and significant variation was present. Thromboembolism prophylaxis is underused and represents a major opportunity to reduce maternal morbidity and mortality. Risk assessment tools and thromboprophylaxis guidelines are needed to assure high-quality, uniform care.: III.

To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality.We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use.Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures.The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations.II.

OBJECTIVE:To estimate the relationship between nuchal translucency thickness and abnormal karyotype, major congenital anomaly, perinatal loss, and composite abnormal outcome in fetuses with first-trimester nuchal cystic hygroma.METHODS:We performed a retrospective cohort study of first-trimester fet

Objective To estimate the relationship between thyroid antibodies and placental abruption. Methods This cohort study assesses thyroperoxidase and thyroglobulin antibodies in relation to placental abruption among 10,062 women with singleton viable pregnancies (from the First and Second Trimester Risk of Aneuploidy [FaSTER] trial). A thyroperoxidase antibody cutoff of 50 international units/mL is used for comparison with published data from another cohort. Results Women with elevated thyroperoxidase antibody levels in the first and second trimesters have a higher rate of placental abruption than antibody-negative women. This relationship is less strong in the first trimester (1.51% compared with 0.83%; odds ratio [OR], 1.83; 95% confidence interval [CI], 0.99-3.37) than in the second trimester (1.78% compared with 0.82%; OR, 2.20; 95% CI, 1.21-3.99). A similar, but weaker, relationship is present for thyroglobulin antibodies. Sixty-four of 782 thyroperoxidase antibody-positive pregnancies without abruption become negative by the second trimester; one pregnancy with abruption becomes antibody-positive. Odds ratios for pregnancies with both thyroperoxidase and thyroglobulin antibody elevations are also higher (first trimester: OR, 2.10; 95% CI, 0.91-4.86; second trimester: OR, 2.73; 95% CI, 1.17-6.33). Conclusion The present data confirm an association between thyroid antibody elevations and placental abruption described in a recent report. These findings, however, do not provide support for recommending routine testing for thyroid antibodies during pregnancy. Level of evidence II.

In contrast to the generally encouraging trend regarding global maternal mortality, there has been an apparent increase in the maternal mortality ratio in the United States. Although maternal death remains a relatively rare adverse event in this country, programs to reduce maternal mortality also will result in a reduction in maternal morbidity, which is a far more prevalent problem. Progress in the field of maternal-fetal medicine over the past several decades has been largely attributable to improvements in fetal and neonatal medicine. We need to develop an organized, national approach focused on reducing maternal mortality and morbidity. The goal will be to outline a specific plan for clinical, educational, and research initiatives to put the "M" back in maternal-fetal medicine.

To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality.We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios.Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10-0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated at low-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47-0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34-0.83).Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings.II.

Fetomaternal hemorrhage refers to the entry of fetal blood into the maternal circulation before or during delivery. Antenatal fetomaternal hemorrhage is a pathological condition with a wide spectrum of clinical variation. Secondary to the resultant anemia, fetomaternal hemorrhage may have devastating consequences for the fetus such as neurologic injury, stillbirth, or neonatal death. Presentation is frequently without an evident precipitating factor. Recognition may become apparent only after injury has occurred, if at all. The most common antenatal presentation is decreased fetal activity and a heightened index of suspicion is warranted in cases of persistent maternal perception of decreased fetal movements. The diagnostic standard, the Kleihauer-Betke screen, has several limitations. Management remains challenging. When detected antenatally, cordocentesis with intrauterine transfusion may be attempted to correct the anemia; however, repeat intrauterine transfusion or delivery may be necessitated to correct ongoing bleeding. Although the occurrence of large antenatal fetomaternal hemorrhage is fortunately rare, this entity likely remains underreported and underrecognized. A national registry should be created to advance our learning across institutions by reviewing the clinical presentations of fetomaternal hemorrhage, the variety of fetal heart rate tracings observed, the management strategies undertaken, and the outcomes achieved.

Over the past decade, prenatal diagnosis has shifted rapidly from the second trimester into the first trimester. Although the nuchal-translucency scan may detect a small proportion of fetal structural malformations, fetal anatomy is not routinely assessed until the fetal anatomical survey is performed in the second trimester between 18 and 22 weeks. The recent development of high-frequency transvaginal ultrasound transducers has led to vastly improved ultrasound resolution and improved visualization of fetal anatomy earlier in gestation. Several pilot studies of a first-trimester anatomic survey have reported detection rates comparable with those achieved in the routine second-trimester anatomic survey. As advanced ultrasound technology becomes more available, there is an urgent need to evaluate the diagnostic ability of a first-trimester anatomic survey and to determine the role of a first-trimester anatomic survey in the current screening paradigm.

To assess the impact of birth defects on preterm birth and low birth weight.Data from a large, prospective multi-center trial, the First and Second Trimester Evaluation of Risk (FASTER) Trial, were examined. All live births at more than 24 weeks of gestation with data on outcome and confounders were divided into two comparison groups: 1) those with a chromosomal or structural abnormality (birth defect) and 2) those with no abnormality detected in chromosomes or anatomy. Propensity scores were used to balance the groups, account for confounding, and reduce the bias of a large number of potential confounding factors in the assessment of the impact of a birth defect on outcome. Multiple logistic regression analysis was applied.A singleton liveborn infant with a birth defect was 2.7 times more likely to be delivered preterm before 37 weeks of gestation (95% confidence interval [CI] 2.3-3.2), 7.0 times more likely to be delivered preterm before 34 weeks (95% CI 5.5-8.9), and 11.5 times more likely to be delivered very preterm before 32 weeks (95% CI 8.7-15.2). A singleton liveborn with a birth defect was 3.6 times more likely to have low birth weight at less than 2,500 g (95% CI 3.0-4.3) and 11.3 times more likely to be very low birth weight at less than 1,500 g (95% CI 8.5-15.1).Birth defects are associated with preterm birth and low birth weight after controlling for multiple confounding factors, including shared risk factors and pregnancy complications, using propensity scoring adjustment in multivariable regression analysis. The independent effects of risk factors on perinatal outcomes such as preterm birth and low birth weight, usually complicated by numerous confounding factors, may benefit from the application of this methodology, which can be used to minimize bias and account for confounding. Furthermore, this suggests that clinical and public health interventions aimed at preventing birth defects may have added benefits in preventing preterm birth and low birth weight.II.

Objective To estimate whether nuchal translucency assessment is a useful screening tool for major congenital heart disease (CHD) in the absence of aneuploidy. Methods Unselected patients with singleton pregnancies at 10(3/7) to 13(6/7) weeks of gestation were recruited at 15 U.S. centers to undergo nuchal translucency sonography. Screening characteristics of nuchal translucency in the detection of major CHD were determined using different cutoffs (2.0 or more multiples of the median [MoM], 2.5 or more MoM, 3.0 or more MoM). Results A total of 34,266 euploid fetuses with cardiac outcome data were available for analysis. There were 224 cases of CHD (incidence 6.5 per 1,000), of which 52 (23.2%) were major (incidence 1.5 per 1,000). The incidence of major CHD increased with increasing nuchal translucency: 14.1 per 1,000, 33.5 per 1,000, and 49.5 per 1,000 at 2.0 or more MoM, 2.5 or more MoM, and 3.0 or more MoM cutoffs, respectively. Sensitivity, specificity, and positive predictive values were 15.4%, 98.4%, and 1.4% at 2.0 or more MoM; 13.5%, 99.4%, and 3.3% at 2.5 or more MoM; and 9.6%, 99.7%, and 5.0% at 3.0 or more MoM. Nuchal translucency of 2.5 or more MoM (99th percentile) had a likelihood ratio (95% confidence interval) of 22.5 (11.4-45.5) for major CHD. Based on our data, for every 100 patients referred for fetal echocardiography with a nuchal translucency of 99th percentile or more, three will have a major cardiac anomaly. Conclusion Nuchal translucency sonography in the first trimester lacks the characteristics of a good screening tool for major CHD in a large unselected population. However, nuchal translucency of 2.5 or more MoM (99th percentile or more) should be considered an indication for fetal echocardiography. Level of evidence II.

Screening for the risk of fetal aneuploidy can be effectively performed in either the first or second trimester. When obtained independently, the interpretation of those data is straightforward. However, the effectiveness of screening can be enhanced by combining studies performed in each trimester in a variety of ways. In this commentary we will define and discuss both the advantages and disadvantages of using integrated, stepwise, sequential or contingency screening for risk assessment of fetal aneuploidy.

OBJECTIVE:To assess obstetricians’ practice patterns and knowledge regarding screening for Down syndrome.METHODS:A questionnaire was mailed to 1,105 American College of Obstetricians and Gynecologists Fellows and Junior Fellows in 2004.RESULTS:Sixty percent of questionnaires were returned. Statistic

The Management of Myelomeningocele Study is a multicenter randomized controlled trial of in utero compared with postnatal repair of isolated spina bifida. Referral of potential patients to the Management of Myelomeningocele Study trial will provide the pregnant woman with substantial information about the fetal condition as well as the trial. The referral rate has been very slow. Possible reasons for this are physicians' and the public's belief that in utero surgery has already been proven to be better than postnatal repair or conversely to offer no benefit over standard therapy; that the trial does not address fundamental issues of maternal and fetal outcomes and safety; and that trial is not well designed. These beliefs are ill-founded. The practicing obstetrician has a fundamental role to inform potential patients about this and other research trials.

The objective was to estimate the effect of maternal age on obstetric outcomes. A prospective database from a multicenter investigation of singletons the FASTER trial was studied. Subjects were divided into 3 age groups: 1) less than 35 years 2) 35–39 years and 3) 40 years and older. Multivariable logistic regression analysis was used to assess the effect of age on outcomes after adjusting for race parity body mass index education marital status smoking medical history use of assisted conception and patient’s study site. A total of 36056 women with complete data were available: 28398 (79%) less than 35 years of age; 6294 (17%) 35–39 years; and 1364 (4%) 40 years and older. Increasing age was significantly associated with miscarriage (adjusted odds ratio {adjOR}2.0 and 2.4 for ages 35–39 years and age 40 years and older respectively) chromosomal abnormalities (adjOR 4.0 and 9.9) congenital anomalies (adjOR 1.4 and 1.7) gestational diabetes (adjOR 1.8 and 2.4) placenta previa (adjOR 1.8 and 2.8) and cesarean delivery (adjOR 1.6 and 2.0). Patients aged 35–39 years were at increased risk for macrosomia (adjOR 1.4). Increased risk for abruption (adjOR 2.3) preterm delivery (adjOR 1.4) low birth weight (adjOR 1.6) and perinatal mortality (adjOR 2.2) was noted in women aged 40 years and older. Increasing maternal age is independently associated with specific adverse pregnancy outcomes. Increasing age is a continuum rather than a threshold effect. (authors)

Screening for Down syndrome is an important part of routine antenatal care. The most common screening method in the United States involves the assessment of a combination of factors: maternal age, multiple second-trimester serum markers, and second-trimester ultrasonography (as a so-called “genetic sonogram”). More recently, however, there has been significant interest in first-trimester methods of screening, including screening for first-trimester serum markers and the sonographic measurement of fetal nuchal translucency. Multiple studies have demonstrated that fetal nuchal translucency has the potential of being a very powerful predictor of fetal aneuploidy. However, for clinicians a large void remains between this knowledge and the practical issues that must be addressed prior to endorsing this form of screening for widespread use. This article provides an objective assessment of the literature describing nuchal translucency, as well as some adjunct first-trimester sonographic techniques, such as ductus venosus flow and nasal bone studies. Additionally, a detailed description of practical problems that might limit the implementation of this form of screening is presented.

Objective To evaluate the prospective risk of fetal death in singleton, twin, and triplet pregnancies and to compare this risk with fetal and neonatal death rates. Methods We analyzed 11,061,599 singleton, 297,622 twin, and 15,375 triplet gestations drawn from the 1995–1998 National Center for Health Statistics linked birth and death files. Prospective risk of fetal death was expressed as a proportion of all fetuses still at risk at a given gestational age and compared with fetal death rate. Fetal death risk and neonatal death rates were represented graphically for singletons, twins, and triplets. Results The prospective risk of fetal death at 24 weeks was 0.28 per 1000, 0.92 per 1000, and 1.30 per 1000 for singletons, twins, and triplets, respectively. At 40 weeks, the corresponding risk was 0.57 per 1000 and 3.09 per 1000 for singletons and twins, respectively and, at 38 or more weeks, 13.18 per 1000 for triplets. Plots of gestation-specific prospective risk of fetal death and neonatal mortality converged for singletons and twins at term but crossed for triplets at approximately 36 weeks' gestation. Conclusion Prospective risk of fetal death is greater for triplets and twins than for singletons and greater for triplets than for twins during the third trimester. The pattern corroborates with uteroplacental insufficiency as a suspected underlying mechanism. When prospective risk of fetal death exceeds neonatal mortality risk, delivery might be indicated. When this model is used, this data set suggests that it might be reasonable to consider delivery of twins by 39 weeks and triplets by 36 weeks to improve perinatal outcome.

Objective: To use serial echocardiography to evaluate prospectively the cardiac dysfunction in twin–twin transfusion syndrome and determine its clinical course and outcome. Methods: Twin pregnancies presenting in the second trimester with sonographic evidence of twin–twin transfusion syndrome were managed with therapeutic reduction amniocenteses. Gestational age at diagnosis and delivery, number of amniocenteses performed, volume of amniotic fluid withdrawn, placentation, birth weight, hemoglobin at delivery, and perinatal outcome were recorded. Serial fetal echocardiography was carried out in a single tertiary center. Echocardiographic assessments included cardiac anatomy, chamber size, cardiothoracic ratio, interventricular septal thickness, ventricular systolic function, and the presence and severity of atrioventricular valve regurgitation. Postnatal echocardiograms were obtained on the surviving twins. Results: Twelve cases of twin–twin transfusion syndrome were evaluated with serial echocardiography. Evidence of cardiac dysfunction was present prenatally in 10 recipient twins. All of the donor twins had normal fetal echocardiographic assessments. The most common abnormalities detected prenatally in recipient twins were decreased ventricular function, tricuspid regurgitation, and cardiac chamber enlargement. A deterioration of cardiac function was observed in seven recipient twins with increasing gestational age. Four of the eight surviving recipient twins had persistent postnatal echocardiographic abnormalities on follow-up examinations after the first 28 days of life. Conclusion: Prenatal cardiac dysfunction is common in recipient twins and can be transient, progressive, or persistent beyond the neonatal period.

Objective: To establish whether first-trimester obstetric ultrasonography interpreted by a live video telemedicine link is comparable to an established videotape review network in a low-risk patient population. Methods: An integrated services digital network was established from three satellite offices to our central prenatal diagnostic center. All patients had a sonographic evaluation of the uterus, adnexa, and gestational sac recorded onto videotape by a trained sonographer. A live, interactive video telemedicine link was established, and a perinatologist directed the sonographer through the scan. Subsequently, a different perinatologist, blinded to the telemedicine interpretation, reviewed the original videotaped examination. The reports generated from both modalities then were compared by means of a score of 12 sonographic characteristics. Results: The first 100 patients were included. The mean gestational age (± standard deviation) was 8.9 ± 2.3 weeks (range 5.7–14.4), and the mean duration for telemedicine scans was 7.8 ± 2.9 minutes (range 3.8–20.1). Telemedicine and videotape review scores were the same in 95 cases, and the final diagnosis was identical in 98 cases. This study had 80% power to detect a 10% difference in diagnosis at a significance level of .05. The ability to detect abnormalities was equivalent using both systems. Conclusion: The interpretation of first-trimester obstetric ultrasonography using live video telemedicine is equivalent to a system of videotape review. Obstetric telemedicine may prove to be a useful tool for providing sonographic imaging for low-risk obstetric patients.

Background: Acute fatty liver is reported to be more common in twin than in singleton pregnancies. We report three cases of biopsy-proven acute fatty liver in triplet gestations. Cases: In all three cases of acute fatty liver complicating triplet pregnancies, the presenting features were vague abdominal complaints with elevated hepatic aminotransferase levels. A liver biopsy was performed in each case, and cesareans were performed immediately after the diagnosis was confirmed histologically. Clinical resolution occurred in all cases, and all infants did well in the neonatal period. Conclusion: Patients with triplet gestations should be monitored closely for the early signs of acute fatty liver. Triplet gestations may contribute to the onset of acute fatty liver by further stressing the fatty acid oxidation capabilities of the susceptible woman.

Objective To determine whether there is a gender discrepancy in severe twin-twin transfusion syndrome. Methods All cases of twin-twin transfusion syndrome evaluated between 1989 and 1996 were reviewed retrospectively. The following sonographic criteria were used: a single placenta, a thin membrane, the same gender, a combination of polyhydramnios-oligohydramnios, a stuck twin and an estimated weight discordance exceeding 20%. At least five of six sonographic criteria were required for inclusion in the study. Only severe cases, which were defined as early onset (before 30 weeks' gestation), a combination of polyhydramnios and oligohydramnios, a stuck twin, fetal hydrops, fetal death, or the requirement of medical or invasive treatment, were included. Chorionicity was confirmed by placental examination when available. Results Thirty-seven twin pregnancies met the above criteria, of which 33 (89%) twin pairs were female. The median gestational age at presentation was 19 weeks (range 15–29; standard deviation, 5.6). A single placenta, thin membrane same gender, and polyhydramnios-oligohydramnios were present in every case. A stuck twin was noted in 34 of 37 cases (92%), and a growth discordance exceeding 20% was present in 26 of 36 (72%). Placental pathology, which was available in 31 (84%) cases, confirmed a monochorionic placentation in 29. Twenty-five (68%) cases had reduction amniocentesis, two were treated with indomethacin, one underwent a cord ligation, and in four cases, fetal death occurred before treatment was instituted. Conclusion There is a significant female preponderance in pregnancies complicated by severe twin-twin transfusion syndrome. The reasons for this are unclear, but they may be related to either placental or fetal gender-specific differences affecting a subset of monochorionic twin pregnancies.

Background Reports suggest that perinatal infection with Brucella abortus does not cause poor obstetric outcomes, because of protective mechanisms in the human, not seen in animal species. Case We report a case of maternal brucellosis resulting in preterm labor, chorioamnionitis, placental abruption, and delivery of a live-born infant at 25 weeks' gestational age. Both maternal blood cultures and amniotic fluid cultures were positive for B abortus species, and delivery occurred despite aggressive antibiotic and tocolytic therapy. Conclusion Maternal infection with B abortus during pregnancy can lead to significant perinatal morbidity, casting doubt on reports that human pregnancy is resistant to such infection.

OBJECTIVE: To determine whether the use of assisted reproductive technology (ART) is associated with an increase in chromosomal abnormalities, fetal malformations, or adverse pregnancy outcomes. METHODS: A prospective database from a large multicenter investigation of singleton pregnancies, the First And Second Trimester Evaluation of Risk trial, was examined. Subjects were divided into 3 groups: no ART use, use of ovulation induction (with or without intrauterine insemination), and use of in vitro fertilization (IVF). Multivariate logistic regression analysis was used to assess association between ART and adverse pregnancy outcomes (significance of differences was accepted at P < .05). RESULTS: A total of 36,062 pregnancies were analyzed : 34,286 (95.1%) were spontaneously conceived, 1,222 (3.4%) used ovulation induction, and 554 (1.5%) used IVF. There was no association between ART and fetal growth restriction, aneuploidy, or fetal anomalies after adjustment for age, race, marital status, years of education, prior preterm delivery, prior fetal anomaly, body mass index, smoking history, and bleeding in the current pregnancy. Ovulation induction was associated with a statistically significant increase in placental abruption, fetal loss after 24 weeks, and gestational diabetes after adjustment. Use of IVF was associated with a statistically significant increase in preeclampsia, gestational hypertension, placental abruption, placenta previa, and risk of cesarean delivery. CONCLUSION: Patients who undergo IVF are at increased risk for several adverse pregnancy outcomes. Although many of these risks are not seen in patients undergoing ovulation induction, several adverse pregnancy outcomes are still increased in this group. There was no increased incidence of fetal chromosomal or structural abnormalities in the women who used any type of ART compared with the women who conceived spontaneously. (Obstet Gynecol 2005;106:1039–45)

Background : Lumbar disk herniation is rare in pregnancy. We report on three pregnant women with this disorder seen over 2 years. Cases : Three women were seen with progressive back pain, paresthesias, and urinary retention. In all three cases, magnetic resonance imaging confirmed the diagnosis. All failed conservative treatment and required surgery. All did well postoperatively, with improvement of symptoms and delivery at or near term. Conclusion : Lumbar disk herniation should be considered in pregnant women presenting with considerable back or leg pain. Magnetic resonance imaging is a useful diagnostic tool. Most patients can be treated conservatively, but those with incapacitating pain, progressive neurologic deficits, or bowel or bladder dysfunction may require surgical treatment.