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Objective: To establish a case-adjusted hospital-specific performance evaluation tool using machine learning methodology for cesarean delivery. Data Sources: Secondary data were collected from patients between January 1, 2015 and February 28, 2018 using a hospital's 'Electronic Data Warehouse' database from Illinois, USA. Study Design: The machine learning methodology of optimal classification trees (OCTs) was used to predict cesarean delivery rate by physician group, thereby establishing the case-adjusted benchmarking standards in comparison to the overall hospital cesarean delivery rate. Outcomes of specific patient populations of each participating practice were predicted, as if each were treated in the overall hospital environment. The resulting OCTs estimate physician group expected cesarean delivery outcomes, both aggregate and in specific clinical situations. Data Collection/Extraction Methods: Twelve thousand eight hunderd and forty one singleton, vertex, term deliveries, cared for by practices with [greater than or equal to]50 births. Principal Findings: The overall rate of cesarean delivery was 18.6% (n = 2384), with a range of 13.3%-33.7% amongst 22 physician practices. An optimal decision tree was used to create a prediction model for the hospital overall, which defined 23 patient cohorts divided by 46 nodes. The model's performance for prediction of cesarean delivery is as follows: area under the curve 0.73, sensitivity 98.4%, specificity 16.1%, positive predictive value 83.7%, negative predictive value 70.6%. Comparisons with the overall hospital's specific-case adjusted benchmark groups revealed that several groups outperformed the overall hospital benchmark, and some practice groups underperformed in comparison to the overall hospital benchmark. Conclusions: OCT benchmarking can assess physician practice-specific case-adjusted performance, both overall and clinical situation-specific, and can serve as a valuable tool for hospital self-assessment and quality improvement. KEYWORDS cesarean birth, cesarean delivery, cesarean section, database, machine learning, optimal classification trees, risk analysis/modeling, statistics What is known on this topic * The cesarean delivery rate in the United States for low-risk births is higher than the World Health Organization's target rate and associated with increased maternal morbidity and mortality. * Criticisms of prior benchmarking models are the inclusion of limited patient-related factors, reporting of a single summary measure of hospital performance, and outdated analytical methods to predict risk based only on binary risk factors. * Crude comparison of cesarean delivery rates between hospitals or practice groups may not be appropriate given variation in case mix. What this study adds * Optimal classification trees (OCTs) benchmarking analysis is a novel and nonlinear technology that can assess physician practice-specific case-adjusted performance for cesarean delivery with high sensitivity of 98.4% in this study. * OCT benchmarking analysis can be used to compare practice group performance in cesarean delivery with an area under the curve of 0.73. * OCT benchmarking analysis can compare practice groups and reveal differences in performance in comparison to the overall hospital's performance., 1 | INTRODUCTION The current cesarean delivery (CD) rate in the United States for the most recent data from 2018 was 31.9%, with a low-risk CD rate (nulliparous, term, singleton, [...]

The rate of successful trial of labor after previous cesarean delivery for dystocia is assessed in a large cohort based on the relative birth weights of the two pregnancies. It is likely that increased fetal size relative to previous birth weight plays a significant role in the outcome of a subsequent trial of labor for patients with previous cesarean delivery for dystocia, reducing chances of vaginal delivery.

The success rates of vaginal birth after cesarean (VBAC) delivery, uterine rupture and major maternal/perinatal outcomes are compared between women, with previous cesarean deliveries undergoing trial of labor (TOL) with preterm and term pregnancies, and also maternal and neonatal morbidities in women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD). The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture, and perinatal outcomes are similar with preterm TOL and RCD.

Many of us often encourage laboring patients who choose epidural analgesia to try to hold off receiving it as long as possible, or at least until cervical dilation reaches 4 [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2005.06.050 Byline: Alan M. Peaceman (a), Komal Bajaj (a), Praveen Kumar (b), William A. Grobman (a) Abstract: This study was undertaken to determine whether the benefits of a single course of antenatal steroid treatment for neonatal respiratory morbidity diminish beyond 7 days. Author Affiliation: (a) Departments of Obstetrics and Gynecology and Pediatrics (b) Northwestern University Feinberg School of Medicine, Chicago, IL Article History: Received 1 March 2005; Revised 3 June 2005; Accepted 13 June 2005 Article Note: (footnote) Presented at the Twenty-Fifth Annual Meeting of the Society for Maternal-Fetal Medicine, Reno, Nev, February 7-12, 2005. Reprints not available from the author.

Women with a twin or triplet pregnancy whose uterine cervix is a normal length at 24 weeks and who don't have fetal fibronectin in their vaginal secretions have a low risk of premature birth. This was the conclusion of a study of 109 women who had a twin or triplet pregnancy.

Intravenous immune globulin for the treatment of antiphospholipid syndrome in pregnant women may prevent fetal growth restriction. Beyond that, it did not improve neonatal outcomes compared to heparin and low-dose aspirin. Antiphospholipid syndrome is an autoimmune disease that can affect the fetus.

Vaginal delivery of triplets may be as safe as delivery by cesarean section. Researchers compared the outcome of 33 triplets born vaginally with 33 triplets born by elective cesarean section. Vaginal deliveries were successful in 29 cases, while four cases required cesarean sections during labor complications. Newborns delivered by cesarean section were more likely to develop respiratory distress syndrome than those delivered vaginally.

A fibronectin test result appears to be a reliable factor in planning for a premature birth. Fibronectin tests were performed vaginally on 763 women in early labor, dilated more than three centimeters, whose membranes had not broken and had not been given medication to stop the contractions. Women with positive fibronectin test results were 25.9 times more likely to deliver within a week and 20.4 times more likely to deliver within two weeks than those with negative results. Nearly all of the women with a negative test result did not deliver within two weeks of the test.

Byline: Alan M. Peaceman, Michael L. Socol Keywords: Active management of labor; cesarean section; dystocia Abstract: Active management of labor was first instituted as a program to shorten the length of nulliparous labor. Numerous institutions have found that implementation of this program decreased rates of cesarean section. Two randomized trials have evaluated this program, with both showing that labor was shortened by approximately 2 hours and maternal infectious morbidity was decreased by approximately 50%. Although one trial demonstrated a significant reduction in the rate of cesarean birth, the other did not. No users have reported any increase in neonatal morbidity. For some institutions implementation of active management of labor principles may be one approach to decrease operative deliveries for dystocia. (Am J Obstet Gynecol 1996;175:363-8.) Author Affiliation: Chicago, Illinois Article Note: (footnote) [star] From the Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Medical School., [star][star] Reprints not available from the authors., a 0002-9378/96 $5.00 + 0 6/1/73368

Aspirin therapy may prevent recurrent miscarriages caused by antiphospholipid antibodies by inhibiting the production of thromboxane. Lupus anticoagulant and anticardiolipin antibody are two antiphospholipid antibodies associated with recurrent miscarriage. Thromboxane causes blood vessels to constrict and causes platelets to clot. Researchers compared the effects of aspirin and of indomethacin, two nonsteroidal anti-inflammatory drugs, on lupus anticoagulant in placental tissue samples from normal pregnancies. Indomethacin inhibited prostacyclin but not thromboxane production. Aspirin inhibited thromboxane production. Aspirin may prevent recurrent miscarriage and lessen preeclampsia by inhibiting thromboxane production in the placenta.

Two soluble tumor necrosis factor receptors, p55 and p75, may be present in the blood of pregnant women and in amniotic fluid in the second and third trimesters of pregnancy. Soluble tumor necrosis factor receptors are thought to prevent harmful effects of tumor necrosis factor, such as producing too many diseased cells, which happens in tumors. Tumor necrosis factor may be beneficial during pregnancy as it facilitates growth and control functions related to the fetus and placenta. Researchers analyzed blood samples from 61 healthy pregnant women taken at the time of amniocentesis and at delivery. Concentrations of soluble tumor necrosis factor receptors rose from the second to the third trimester, perhaps to counter the increase in tumor necrosis factor during the same period.

Preeclampsia appears to increase fetal fibronectin levels. Preeclampsia is known to be a factor in abnormal placental development. Fetal fibronectin is believed to play a role in the adherence of the placental cells to the uterine lining cells. Three groups were compared: 20 first-time mothers with severe preeclampsia, 20 healthy first-time mothers not in labor and matched to the preeclamptic women for gestational length, and 20 healthy first-time mothers in early labor with term fetuses. Maternal blood samples were drawn, amniotic fluid samples were taken from the healthy laboring mothers and from the preeclamptic mothers when they went into labor, and fetal blood samples were taken from the umbilical cord after birth. Fetal fibronectin concentrations were elevated in maternal blood of preeclamptic women before labor and after birth compared with healthy women. Amniotic fluid levels of fetal fibronectin were also higher in preeclamptic women. Fetal blood levels were similar between preeclamptic and healthy mothers. This suggests that excess fetal fibronectin originates at the junction of maternal and fetal tissues and not within the fetus.

Immunoreactive tumor necrosis factor-alpha (TNF-alpha) is found in elevated amounts in maternal plasma during the second trimester of pregnancy. TNF-alpha regulates cell growth and proliferation. Fifty-five healthy women undergoing a second trimester amniocentesis had blood drawn as well. Blood was also drawn from 21 healthy women in the third trimester and from 22 healthy nonpregnant women of reproductive age. Blood and amniotic fluid samples were analyzed for TNF-alpha. In the second trimester, TNF-alpha was detected in maternal plasma of 78% of women but not in amniotic fluid. The median concentration was 135 pg/ml (range 0 to 625 pg/ml). Among third trimester women, TNF-alpha was found in the blood serum of 33% of women and the median concentration was 0 pg/ml (range 0 to 110 pg/ml). TNF-alpha was not found in nonpregnant women. During the second trimester, placental blood vessels are invasively growing and proliferating in maternal tissue. TNF-alpha may be helping to regulate this growth.

Tumor necrosis factor-alpha (TNF-alpha) levels may be elevated in the plasma and amniotic fluid of pregnant women with severe preeclampsia. Preeclampsia is a metabolic disorder of late pregnancy marked by high blood pressure, fluid retention, and protein in the urine. TNF-alpha is a cytokine, a chemical messenger involved in immune system regulation. Researchers analyzed blood and amniotic fluid samples from 21 women with severe preeclampsia and 36 healthy pregnant women, 16 of whom were not in labor and 20 of whom were. Plasma and amniotic fluid levels of TNF-alpha were higher in women with preeclampsia than in the comparison group. This finding suggests that abnormal immune system activation may induce preeclampsia, and TNF-alpha may be released to combat the damage produced by preeclampsia. The elevated TNF-alpha levels were not thought to result from infection. TNF-alpha and interleukin-1-beta, another cytokine, have been noted in the plasma and amniotic fluid of women in labor, but they are not usually present before labor and, in this study, were more highly concentrated during labor and elevated before labor.

Exposing placental tissue to antiphospholipid antibody from lupus patients appears to result in increased thromboxane production. Lupus anticoagulant is an antibody produced in the body against phospholipids. Phospholipids are components of cell membranes. Lupus anticoagulant has been associated with a high rate of pregnancy complications. Immunoglobulin G (IgG) is produced in the body in response to bacteria, fungi and viruses. IgG from lupus patients and non-lupus patients was incubated with placental tissue taken from normal pregnancies. Prostacyclin and thromboxane production were measured for 48 hours. Thromboxane is produced in the body and constricts blood vessels. Prostacyclin is a hormone-like fatty acid associated with blood vessel dilation. Prostacyclin levels were similar in all samples regardless of IgG dose. Thromboxane production increased when incubated with IgG from lupus patients. This increase occurred within 20 hours of incubation. This suggests that thromboxane increases triggered by lupus anticoagulant may play a role in the high rate of pregnancy complications in patients with antiphospholipid antibodies.

Physicians may not be responsible for the higher cesarean section rate among women over 35 years old. A combination of both fetal and maternal factors may affect usage in older patients. Researchers compared the labor of 74 women over 35 years old to that of 275 women between 20 and 29 years old. Twenty-two percent of the older women had a cesarean section, compared with 10% of the younger women. A birth weight over 3,600 grams increased the likelihood of a cesarean section more among the older women than among the younger women. Other factors that increased the likelihood of a cesarean section in the older patients included a higher oxytocin requirement, maternal age and epidural anesthesia. No significant differences in the patients' physicians could be found between the two groups.

Women who have active management of labor may have different risk factors for cesarean section than those who have traditional management. The proportion of women who have a cesarean section has increased significantly since the 1970s. Among 700 pregnant women, 346 had active management of labor and 354 had traditional management. Ten percent of the patients with active management had a cesarean section, compared with 14% of those with traditional management. Risk factors for women actively managed included position of the fetus, augmentation of labor with oxytoxin, response to oxytoxin, epidural anesthesia and inflammation of fetal membranes. Risk factors for women traditionally managed were maternal age, height, health insurance status and infant birth weight.

A drop in the rate of cesarean sections occurred after initiation of a three-step process to encourage vaginal delivery at a university hospital. Cesarean sections accounted for 27.3% of all deliveries at Northwestern Memorial Hospital in Illinois in 1986. Under a new system introduced in 1987, doctors were required to document that they had offered a trial of labor to a woman who had previously had one cesarean section. In 1988, the number of cesarean sections performed by each obstetrician was circulated to other physicians. A new protocol for dealing with labor complications was developed in 1990 to encourage more active management of labor before resorting to surgery. As result, the hospital was able to reduce cesarean section rates by up to 42% over six years. At the same time the newborn mortality rate dropped from 10.3 in 1986 to 3.8 in 1991.

OBJECTIVE: Because of the widespread use of antiphospholipid antibody testing in the evaluation of patients with recurrent pregnancy loss, we evaluated the consistency of results among laboratories testing for anticardiolipin antibody and the upus anticoagulant. STUDY DESIGN: A questionnaire regarding methods used and samples of blood from 20 patients were sent to five university-based and five commercial facilities for antiphospholipid antibody testing. RESULTS: The responses of the participating laboratories to the questionnaires revealed significant differences in methods, standardization, and units of reporting. For anticardiolipin antibody, the number of specimens found to be positive for any isotype (immunoglobulin G, M, or A) varied considerably among laboratories, with a range of 5 to 13. All laboratories were in agreement (i.e., at least one isotype was present or all were absent) for only 5 of 20 specimens (25%). in contrast, lupus anticoagulant results were more reproducible, although one facility reported results markedly discordant from the other four laboratories. CONCLUSION: These observations suggest that significant interlaboratory variation exists in antiphospholipid antibody, and particularly anticardiolipin antibody, testing and might lead to unnecessary therapeutic interventions. (Am J OBSTET GYNECOL 1992;166:1780-7.) Key words: Antiphospholipid antibodies, lupus anticoagulant, anticardiolipin antibody, recurrent pregnancy loss

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2008.12.009 Byline: Alan M. Peaceman, Lindsay Kuo, Joe Feinglass Keywords: cesarean section; infant mortality; twin gestation Abstract: To compare infant outcomes for twin gestations delivered vaginally with those with cesarean delivery by using a large national dataset containing birth certificate data. Author Affiliation: Departments of Obstetrics and Gynecology and Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL Article History: Received 20 August 2008; Revised 16 October 2008; Accepted 5 December 2008 Article Note: (footnote) This study was supported by the Friends of Prentice Distinguished Physician Award., Reprints not available from the authors., Cite this article as: Peaceman AM, Kuo L, Feinglass J. Infant morbidity and mortality associated with vaginal delivery in twin gestations. Am J Obstet Gynecol 2009;200:462.e1-462.e6.

IMPORTANCE: Administration of corticosteroids to women at high risk for delivery in the late preterm period (34-36 weeks’ gestation) improves short-term neonatal outcomes. The cost implications of this intervention are not known. OBJECTIVE: To compare the cost-effectiveness of treatment with antenatal corticosteroids with no treatment for women at risk for late preterm delivery. DESIGN, SETTING, AND PARTICIPANTS: This secondary analysis of the Antenatal Late Preterm Steroids trial, a multicenter randomized clinical trial of antenatal corticosteroids vs placebo in women at risk for late preterm delivery conducted from October 30, 2010, to February 27, 2015. took a third-party payer perspective. Maternal costs were based on Medicaid rates and included those of betamethasone, as well as the outpatient visits or inpatient stay required to administer betamethasone. All direct medical costs for newborn care were included. For infants admitted to the neonatal intensive care unit, comprehensive daily costs were stratified by the acuity of respiratory illness. For infants admitted to the regular newborn nursery, nationally representative cost estimates from the literature were used. Effectiveness was measured as the proportion of infants without the primary outcome of the study: a composite of treatment in the first 72 hours of continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation. This secondary analysis was initially started in June 2016 and revision of the analysis began in May 2017. EXPOSURES: Betamethasone treatment. MAIN OUTCOMES AND MEASURES: Incremental cost-effectiveness ratio. RESULTS: Costs were determined for 1426 mother-infant pairs in the betamethasone group (mean [SD] maternal age, 28.6 [6.3] years; 827 [58.0%] white) and 1395 mother-infant pairs in the placebo group (mean [SD] maternal age, 27.9 [6.2] years; 794 [56.9%] white). Treatment with betamethasone was associated with a total mean (SD) woman-infant–pair cost of $4681 ($5798), which was significantly less than the mean (SD) amount of $5379 ($8422) for women and infants in the placebo group (difference, $698; 95% CI, $186-$1257; P = .02). The Antenatal Late Preterm Steroids trial determined that betamethasone use is effective: respiratory morbidity decreased by 2.9% (95% CI, −0.5% to −5.4%). Thus, the cost-effectiveness ratio was −$23 986 per case of respiratory morbidity averted. Inspection of the bootstrap replications confirmed that treatment was the dominant strategy in 5000 samples (98.8%). Sensitivity analyses showed that these results held under most assumptions. CONCLUSIONS AND RELEVANCE: The findings suggest that antenatal betamethasone treatment is associated with a statistically significant decrease in health care costs and with improved outcomes; thus, this treatment may be an economically desirable strategy.

No Prophylactic treatment with vaginal progesterone did not reduce the incidence of preterm birth (i.e., birth at 32 weeks' gestation or earlier) in women who had a history of spontaneous […]

Magnesium sulfate is given to pregnant women to prevent early (preterm) labor and to prevent seizures from high blood pressure. The higher doses of magnesium sulfate needed to prevent early labor may cause depression of the central nervous system. The drug can pass through the placenta from the mother's blood and enter the blood of the fetus. Biophysical measurements of the fetus such as heart rate, breathing movements, body tone, degree of movement, and the amount of amniotic fluid surrounding the fetus can be used to measure its well-being. To determine whether magnesium sulfate used to prevent preterm labor can affect the biophysical profile of the fetus, 22 fetuses born to 16 women were evaluated before and after treatment. Upon admission to the hospital, all the fetuses had normal non-stress tests, an indicator of fetal well-being, and 21 (95 percent) had normal sustained breathing movements. After administration of magnesium sulfate, 50 percent of the fetuses had nonreactive (abnormal) non-stress tests and only 18 percent (4 of 22) had sustained breathing movements. Other biophysical factors were unchanged by the use of magnesium sulfate. It was found that the baseline heart rate among the fetuses increased after magnesium sulfate use and the overall biophysical profile of the fetus was reduced. It is suggested that the effects of magnesium sulfate do not compromise the well-being of the fetus, but rather the test results are due to pharmacologic central nervous system depression.

(Abstracted from JAMA2017;317(10):1047–1056)Prediction of spontaneous preterm birth, a leading cause of infant mortality, depends in practice largely on a history of previous birth, and the risk for first time mothers and nulliparous women is more difficult to assess. The aim of this study was to assess the reliability of serial transvaginal cervical length (CL) and quantitative fetal fibronectin (fFN) measurements in predicting spontaneous preterm birth (before 37 weeks) in a large, prospective cohort of nulliparous women.

(Abstracted from N Engl J Med2016;374:1311–1320)Infants born during the late preterm period (34 weeks 0 days to 36 weeks 6 days) are more likely to suffer neonatal and childhood complications than newborns born at term (37 weeks or later). A randomized, multicenter trial was undertaken (between 2010 and 2015) at 17 university-based clinical centers participating in the Maternal-Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) to assess whether the administration of betamethasone to women who are likely to deliver in the late preterm period would decrease the risks of neonatal morbidities.

Risk-adjustment of cesarean birthrates has been hampered by inadequacies in the existing secondary data sources or by the need for extensive chart review. This study presents an efficient risk-adjustment model for cesarean birth, based on easily retrievable ICD-9 codes and clinical risk factors least influenced by physician practice style. Data are presented for mothers undergoing 7322 deliveries from 1997-1998 at a large academic medical center with a cesarean birth rate of 15.9%. Multiple logistic regression was used to predict the likelihood of cesarean delivery controlled for maternal age, 10 risk factors identified through ICD-9 coding, and 3 additional clinical variables (nulliparity, birth weight, and gestational age) derived from a perinatal (birth certificate) database. All risk factors were significant predictors of cesarean birth, producing an area under the receiver-operating characteristic curve of 0.86 and a 60-fold increase in cesarean delivery from highest to lowest deciles of predicted risk. This methodology can be used widely for quality improvement without the need for extensive chart review.

Objective: This analysis was undertaken to better understand the costs and health consequences of a trial of labor after cesarean when compared with a policy of routine elective repeat cesarean delivery.

In 2005, the Food and Drug Administration approved the use of fetal electrocardiographic (ECG) ST-segment analysis (STAN) as an adjunct to conventional electronic fetal heart rate monitoring. However, evidence that such monitoring reduces the rates of neonatal encephalopathy, acidemia, and operative delivery is lacking. This study assesses the effects of using fetal ECG STAN on perinatal outcomes. For this trial, women with a singleton fetus at more than 36 weeks of gestation planning for a vaginal delivery and with cervical dilation of 2 to 7 cm were invited. A total of 11,108 women were randomly assigned to “masked” (5576 women) or “open” (5532 women) monitoring. Masked monitoring functioned as conventional electronic fetal heart rate monitors, and monitoring in the open mode displayed additional information used for detecting and interpreting uncertain fetal heart rate patterns. In addition, those randomized to “open” had some specific algorithms related to the fetal STAN information. The primary study outcomes were intrapartum fetal death, neonatal death, an Apgar score of 3 or less at 5 minutes, neonatal seizure, an umbilical-artery blood pH of 7.05 or less with a base deficit of 12 mmol/L or more, intubation for ventilation at delivery, or neonatal encephalopathy. No significant differences in baseline characteristics were seen between the 2 groups. The primary outcome occurred in 52 neonates (0.9%) born to women in the open group and in 40 neonates (0.7%) delivered by women in the masked group (relative risk, 1.31; 95% confidence interval, 0.87–1.98; P= 0.20). With respect to the incidences of individual components of the primary outcome, the only difference between the groups was that the frequency of an Apgar score of 3 or less at 5 minutes was higher among neonates of patients in the open group than among neonates of patients in the masked group (0.3% vs 0.1%; P= 0.02). There were no significant differences between the 2 groups in the overall rates of cesarean delivery (16.9% vs 16.2%; P= 0.30) or any operative delivery (22.8% vs 22.0%; P= 0.31). This large, randomized trial showed that ST-segment analysis as an adjunct to continuous electronic fetal monitoring (EFM) neither improved neonatal outcomes nor reduced the rates of cesarean delivery or operative vaginal delivery.

The cesarean section (CS) rate in the United States peaked at 24.7% in 1988. Contributing factors to the increase in abdominal delivery over the preceding 2 decades include electronic fetal heart rate monitoring, 28a change in philosophy toward breech presentation and the use of forceps, 3epidural analgesia, 29physician practice styles, 8,10and the medicolegal climate. 27The leading indications for CS now are dystocia and prior CS, with malpresentation and fetal heart rate abnormalities contributing to a lesser degree. 9Strategies to decrease operative delivery for dystocia range from patience and patient support in labor 11to the active management of labor protocol. 14Repeat operative rates decrease by decreasing primary CSs and encouraging vaginal birth after CS (VBAC) in appropriate candidates.

Until recently, estimating the frequency of loss of twin gestations has been difficult, partly because of the fact that, until sensitive human chorionic gonadotropin (hCG) assays were developed, the loss rate before the first missed menses was speculative. Moreover, any calculation of the total rate of pregnancy loss in twins must include not only complete pregnancy loss, but also spontaneous resorption of one twin. The frequency of the latter circumstance, popularly known as the "vanishing twin" phenomenon, only has become quantifiable in recent years after the development of ultrasound. In this article, we will review contemporary studies that allow a determination of the total rate of loss of twin pregnancy through the first two trimesters. In addition, we will consider possible etiologies of loss and methods to improve survival.

Objective: To expand on prior investigations and further evaluate the fetal risk associated with vaginal birth after cesarean (VBAC) by examining the incidence not only of a depressed Apgar score at 5 minutes but also of fetal acidemia.

We evaluated the risk factors associated with cesarean delivery in laboring twin gestations at least 36 completed weeks.

Prostaglandin metabolites, including thromboxane, prostacyclin, and platelet-activating factor, may participate as intermediaries in the pathophysiology of the primary antiphospholipid syndrome (PAPS). In order to determine safe and effective therapies for patients with PAPS, we must improve our knowledge base and specific understanding of the mechanisms that link circulating antiphospholipid antibodies to decidual vasculopathy and fetal death. A review of current research is presented along with an evaluation of medical therapy whose rationale for use is consistent with current evidence.

The risk of neonatal adverse respiratory outcomes is higher among infants delivered before 39 weeks’ gestation than after 39 weeks’, and among infants delivered by prelabor cesarean compared to those delivered vaginally. Thus, elective cesarean section before 39 weeks is discouraged in the absence of fetal lung maturity. This prospective study compared neonatal outcomes among infants delivered by elective cesarean delivery at 37, 38, and 39 weeks’ gestation. The study cohort was pregnant women with viable singleton pregnancies undergoing repeat cesarean delivery at 19 academic medical centers. The women were delivered before onset of labor and had no medical or obstetrical indications for delivery before 39 weeks. The primary study outcome was a composite of any adverse neonatal outcome or death. Adverse outcomes included respiratory complications, admission to the neonatal intensive care unit (ICU), newborn sepsis, treated hypoglycemia, and hospitalization for 5 days or longer. Logistic regression models were used to calculate adjusted odds ratios for the association between neonatal outcomes and gestational age at birth relative to 39 completed weeks.

Early preterm birth is associated with approximately one third of all cases of cerebral palsy and is a risk factor. A case–control study was the first to show a decrease in the incidence of cerebral palsy in the offspring of women who were given magnesium sulfate before preterm delivery. This randomized, placebo-controlled, double-blind trial tested the hypothesis that antenatal administration of magnesium sulfate would reduce the incidence of cerebral palsy in the children of women at high risk for early preterm delivery.

As recently as 2004, 12.5% of all live-born infants in the United States were delivered preterm, before 37 completed weeks of gestation. A recent trial showed that women with a previous spontaneous preterm birth who received weekly injections of 17 alpha-hydroxyprogesterone caproate (17P) had a one-third lower risk of recurrent preterm birth, but whether 17P can lower the rate in women with other risk factors is not clear. This placebo-controlled, double-blind, randomized, multicenter trial evaluated 17P in women carrying twins. Cases with serious fetal anomalies, detected by ultrasonography at 12–21 weeks' gestation, were excluded. Participants included 325 women given weekly intramuscular injections of 250 mg of 17P, starting at 16–20 weeks' gestation and ending at 35 weeks; and 330 placebo recipients. The primary outcome was delivery (or fetal death) before 35 weeks' gestation.

Fewer women today are attempting vaginal delivery after a previous cesarean delivery, mostly because of concern about its safety. This prospective cohort study, carried out at 19 academic medical centers, compared outcomes in 17,898 women with a history of cesarean section who attempted vaginal delivery and 15,801 others who had elective repeat cesarean section without labor. Women having a trial of labor were more likely than those having elective repeat cesarean delivery to be less than 30 years of age, black, unmarried, and nonobese. They also were likelier to have both preterm and delayed delivery.

The pregnancy of a patient with Bernard-Soulier syndrome is described. Coagulation abnormalities were encountered, as well as isoimmunization from previous transfusions. Immune suppression was achieved with steroids and intravenous gamma globulin, and plasmapheresis was performed to allow platelet transfusion. (Obstet Gyne'col 73 457,1989)

(Abstracted from N Engl J Med2017;376:815–825)Subclinical hypothyroidism (SCH) during pregnancy has been associated with impaired fetal neuropsychological development. Several organizations recommend treatment of subclinical thyroid dysfunction, although the Controlled Antenatal Thyroid Screening study found mothers who were treated with levothyroxine for hypothyroidism or hypothyroxinemia did not have children with improved cognitive function compared with controls.

Although there is little evidence that the screening, identification, and treatment of mild gestational diabetes during pregnancy is beneficial, a number of professional organizations have recommended screening for this disorder in most pregnant women. The aim of this multicenter randomized trial was to determine whether treatment of women with mild gestational diabetes mellitus reduces perinatal and obstetrical complications. The participants were 958 women between 24 and 31 weeks of gestation who met criteria for mild gestational diabetes mellitus. They were randomly assigned to receive either formal nutritional counseling, diet therapy, and self-monitoring of blood glucose, together with insulin if required (treatment group, n 485) or usual prenatal care (control group, n 473). The primary study outcome was a composite outcome that included perinatal mortality (stillbirth or neonatal death) and neonatal complications that have been associated with maternal hyperglycemia: hypoglycemia, hyperbilirubinemia, neonatal hyperinsulinemia, and birth trauma.

Apart from embolism, hemorrhage remains the commonest cause of pregnancy-related death in the U.S. This prospective observational study, conducted at 19 universities, assessed the factors associated with intraoperative and postoperative packed red blood cell transfusion in women having primary or repeat cesarean delivery in the years 1999–2000.