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(Am J Obstet Gynecol.2023;228:588.e1–588.e13)Managing late preterm prelabor rupture of membranes (PPROM) between 34+0 and 36+6 weeks’ gestation helps balance the advantages of extending the pregnancy with the risk of intra-amniotic infection. Two Dutch PPROM Expectant Management Versus Induction of Labor (PPROMEXIL) trials were conducted between 2007 and 2011. These randomized controlled studies analyzed induction of labor (IOL) compared to expectant management (EM) in pregnant women with late PPROM. While neonatal sepsis risks were similar between both groups, children at 2 years of age did show slightly higher neurodevelopmental delays with EM compared to IOL. Long-term data on child development beyond age 2 in children born after late PPROM are lacking. The aim of this PPROMEXIL follow-up study was to evaluate the effects of IOL versus EM on child outcomes.

(Aust N Z J Obstet Gynaecol. 2019;59:677–683)Instrumental vaginal delivery is a relatively common obstetric procedure in both Australia and the UK, accounting for ∼10% to 13% of deliveries. It is typically performed in cases of prolonged second stage of labor, fetal compromise, or limited ability of the mother to push. While instrumental deliveries are performed when obstetricians believe the benefits outweigh the risks, there are numerous potential side effects for both mother and fetus. These include maternal soft tissue tears and anal and urinary sphincter dysfunction as well as fetal trauma injuries, such as intracranial and subgaleal bleeding, lacerations, and cranial nerve injuries. Researchers have been concerned about the potential long-term neurodevelopmental effects of instrumental vaginal delivery, but previous studies have not adequately compared the development of children who were born via spontaneous vaginal delivery versus those born via instrumental vaginal delivery. This study was conducted to determine whether vacuum extraction, forceps, or normal vaginal deliveries had an effect on academic performance at 8 years of age.

(BMJ. 2021;374:n2103)Preterm preeclampsia affects 10% of all women with preeclampsia worldwide. Although preeclampsia prevention is attempted with therapies including low-dose aspirin, there are no current treatments for preeclampsia once diagnosed other than delivery. Preterm preeclampsia causes increased risk for both maternal and neonatal morbidity and mortality, especially in developing areas without adequate obstetric or NICU care.

(Int J Gynaecol Obstet. 2021t;155:8–12)Iatrogenic preterm delivery, also known as provider-initiated preterm birth, is a planned delivery before 37 weeks of gestation. As the science of obstetrical and neonatal care practice progresses, globally iatrogenic preterm delivery has increased. Now, iatrogenic preterm delivery constitutes nearly 50% of preterm births and is increasing worldwide. Provider-initiated birth may be induction of labor or cesarean delivery without rupture of membranes or spontaneous labor. Reasons for iatrogenic preterm delivery include obstetric complications of both maternal and fetal nature. Maternal conditions include such comorbidities as hypertensive disorders of pregnancy, antepartum hemorrhage, and abnormal placentation conditions. Maternal medical conditions such as heart disease, cancer, nephropathy, and sepsis are increasing in frequency. Fetal causes such as fetal growth restriction, fetal distress, and structural malformations; and nonmedical causes may prompt iatrogenic preterm delivery. Maternal factors and provider behavior may play a role in the increasing rate of iatrogenic preterm delivery, which has led researchers to consider strategies that could decrease preterm birth rates.

(Obstet Gynecol. 2021;137:72–81. doi: 10.1097/AOG.0000000000004149)Progress has been made recently to predict and diagnose preeclampsia in pregnant women. Angiogenic and antiangiogenic biomarkers such as placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) have been examined and recently implemented clinically as predictive measurements of preeclampsia. This study aims to review and analyze sFlt-1, PlGF, and the sFLt-1/PlGF ratio and their ability to predict time to delivery and adverse outcomes in patients with preeclampsia.

(Obstet Gynecol. 2021;137:72–81)Progress has occurred recently to predict and diagnose preeclampsia in pregnant women. Angiogenic and antiangiogenic biomarkers such as placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were recently examined. In addition these factors have been implemented clinically as predictive measurements of preeclampsia. This study aims to review and analyze sFlt-1, PlGF, and the sFLt-1/PlGF ratio and their ability to predict time to delivery and adverse outcomes in patients with preeclampsia.

Background:Intrauterine insemination with ovarian stimulation (IUI-OS) is a first-line treatment for couples with unexplained infertility. Individual participant data meta-analysis (IPD-MA) is the gold standard for evidence synthesis.Aim:To compare the effectiveness and safety of ovarian stimulation with gonadotrophin, Letrozole and clomiphene citrate (CC) and to explore treatment-covariate interactions for important baseline characteristics in women undergoing IUI.Method:We searched electronic databases including PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL). We included randomised controlled trials (RCTs) comparing IUI-OS with gonadotropins, Letrozole or CC among couples with unexplained infertility. We excluded dose comparing studies of the same drug. We contacted the authors of eligible RCTs to share the IPD and established the IUI IPD-MA collaboration. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. We used a one-stage approach using a random effects model.Results:Six RCTs (n= 2299) provided IPD. Gonadotropins increased the chance of a live birth compared to both CC (5 RCTs, 1946 women, RR 1.28, 95%CI 1.10 to 1.49, I2 = 25%, moderate-quality evidence) whereas there was insufficient evidence of a difference between Letrozole and CC (1 RCT, 599 women, RR 0.77 95%CI 0.58 to 1.03). Gonadotropins increased the risk of a multiple pregnancy compared to both CC (4 RCTs, 1696 women, RR 2.17, 95%CI 1.33 to 3.55, I2 = 69%, low-quality evidence) whereas there was insufficient evidence of a difference between Letrozole and CC (1 RCT, 599 women, RR 0.71, 95%CI 0.33 to 1.56). No strong evidence on the treatment-covariate interactions (female age, BMI or primary versus secondary infertility) was found.Conclusion:Gonadotropins increased the chance of a live birth compared to both CC and Letrozole but also increased the chance of a multiple pregnancy. Further RCTs comparing Letrozole and other interventions in couples with unexplained infertility are needed.

(BJOG. 2019;126:1118–1126)While physicians strive to avoid unnecessary cesarean sections, they must weigh this goal with the possible risks of hemorrhage in patients with low-lying placentas. Guidelines and recommendations vary widely on whether patients with low-lying placentas should deliver by cesarean delivery. The Royal College of Obstetricians and Gynaecologists states patients with a low-lying placenta should deliver via cesarean, while in the Netherlands, vaginal delivery is suggested for patients with an internal os distance (IOD) of >10 mm. This systematic review and meta-analysis aimed to evaluate the possibility of successful vaginal delivery with a low-lying placenta.

(Int J Obstet Anesth. 2019;39:22–28)Although epidural analgesia remains the preferred method of labor analgesia, remifentanil patient-controlled analgesia (PCA) is a popular alternative due to its quick onset and rapid metabolic properties. Remifentanil PCA has been used in Europe for several years, but its safety has been questioned by some due to concerns about potential serious side effects, such as respiratory depression for both mother and neonate. Since the current rate of serious adverse events (SAEs) connected to remifentanil PCA use during labor is unknown, the current investigators conducted this study to measure the frequency of SAEs, as well as examine the clinical circumstances associated with SAEs and the management of those events.

The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (∼3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.

The aim of the fertility work-up is to exclude recognised causes of infertility and to distinguish those couples who have good spontaneous pregnancy prospects from those who have poor prospects. Information gathered by medical history, clinical findings and results of the diagnostic tests should help the clinician in counselling subfertile couples. The initial diagnostic tests for infertility should include a basal body temperature chart or midluteal phase progesterone level, a semen analysis and a test for tubal patency. Ovarian reserve tests can be used in selected cases. More research is needed in the predictive value of the outcome of diagnostic tests in reproductive medicine.