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Background: Many cases of placenta accreta spectrum are not diagnosed antenatally, despite identified risk factors and improved imaging methods. Identification of plasma protein biomarkers could further improve the antenatal diagnosis of placenta accreta spectrum ., Objective: The purpose of this study was to determine if women with placenta accreta spectrum have a distinct plasma protein profile compared with control subjects., Study Design: We obtained plasma samples before delivery from 16 participants with placenta accreta spectrum and 10 control subjects with similar gestational ages (35.1 vs 35.5 weeks gestation, respectively). We analyzed plasma samples with an aptamer-based proteomics platform for alterations in 1305 unique proteins. Heat maps of the most differentially expressed proteins (T test, P<.01) were generated with matrix visualization and analysis software. Principal component analysis was performed with the use of all 1305 proteins and the top 21 dysregulated proteins. We then confirmed dysregulated proteins using enzyme-linked immunosorbent assay and report significant differences between placenta accreta spectrum and control cases (Wilcoxon-rank sum test, P<.05)., Results: Many of the top 50 proteins that significantly dysregulated in participants with placenta accreta spectrum were inflammatory cytokines, factors that regulate vascular remodeling, and extracellular matrix proteins that regulate invasion. Placenta accreta spectrum, with the use of the top 21 proteins, distinctly separated the placenta accreta spectrum cases from control cases (P<.01). Using enzyme-linked immunosorbent assay, we confirmed 4 proteins that were dysregulated in placenta accreta spectrum compared with control cases: median antithrombin III concentrations (240.4 vs 150.3 mg/mL; P=.002), median plasminogen activator inhibitor 1 concentrations (4.1 vs 7.1 ng/mL; P<.001), soluble Tie2 (13.5 vs 10.4 ng/mL; P=.02), soluble vascular endothelial growth factor receptor 2 (9.0 vs 5.9 ng/mL; P=.003)., Conclusion: Participants with placenta accreta spectrum had a unique and distinct plasma protein signature., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The association between small-for-gestational-age (birthweight <10th percentile for gestational age) and neonatal morbidity is well established. Yet, there is a paucity of data on the relationship between suspected small for gestational age (sonographic-estimated fetal weight <10th percentile) at 2 thresholds and subsequent neonatal morbidity., Objective: The objective of this study was to determine the relationship between sonographic-estimated fetal weight <5th percentile vs 5-9th percentile and neonatal morbidity., Study Design: This retrospective study involved 5 centers and included nonanomalous, singletons with sonographic-estimated fetal weight <10th percentile for gestational age who delivered from 2009-2012. Composite neonatal morbidity included respiratory distress syndrome, proven sepsis, intraventricular hemorrhage grade III or IV, necrotizing enterocolitis, thrombocytopenia, seizures, or death. Odd ratios were adjusted for center, maternal age, race, body mass index at first visit, smoking status, use of alcohol, use of drugs, and neonatal gender., Results: Of 834 women with suspected small-for-gestational-age fetuses, 513 (62%) had sonographic-estimated fetal weight <5th percentile, and 321 (38%) had sonographic-estimated fetal weight of 5-9th percentile for gestational age. At delivery, 81% of women with a suspected small-for-gestational-age fetus had a confirmed small-for-gestational-age fetus. In the group with a sonographic-estimated fetal weight <5th percentile, 59% of neonates had birthweight <5th percentile; in the group with a sonographic-estimated fetal weight 5-9th percentile, 41% had birthweight <5th percentile, and 36% had birthweight at 5-9th percentile. Neonatal intensive care unit admission differed significantly for those fetuses at <5th percentile (29%) compared with those fetuses at 5-9th percentile (15%; P<.001). The composite neonatal morbidity among the sonographic-estimated fetal weight <5th percentile group was higher than the sonographic-estimated fetal weight of 5-9th percentile group (31% vs 13%; adjusted odds ratio, 2.41; 95% confidence interval, 1.53-3.80). Similar findings were noted when the analysis was limited to sonographic-estimated fetal weight within 28 days of delivery (adjusted odds ratio, 2.22; 95% confidence interval, 1.34-3.67)., Conclusion: Eight of 10 suspected small-for-gestational-age fetuses had birthweight <10th percentile for gestational age; the prediction of actual birthweight was more accurate in the <5th percentile group. Neonates with sonographic-estimated fetal weight of <5th percentile were more likely to be admitted to the neonatal intensive care unit and have complications than were those neonates with sonographic-estimated fetal weight of 5-9th percentile., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Placenta accreta spectrum is one of the most morbid conditions obstetricians will encounter. The incidence has dramatically increased in the last 20 years. The major contributing factor to this is believed to be the increase in the rate of cesarean delivery. Despite the increased incidence of placenta accreta, most obstetricians have personally managed only a small number of women with placenta accreta. The condition poses dramatic risk for massive hemorrhage and associated complication such as consumption coagulopathy, multisystem organ failure, and death. In addition, there is an increased risk for surgical complications such as injury to bladder, ureters, and bowel and the need for reoperation. Most women require blood transfusion, often in large quantities, and many require admission to an intensive care unit. As a result of indicated, often emergent preterm delivery, many babies require admission to a neonatal care intensive care unit. Outcomes are improved when delivery is accomplished in centers with multidisciplinary expertise and experience in the care of placenta accreta. Such expertise may include maternal-fetal medicine, gynecologic surgery, gynecologic oncology, vascular, trauma and urologic surgery, transfusion medicine, intensivists, neonatologists, interventional radiologists, anesthesiologists, specialized nursing staff, and ancillary personnel. This article highlights the desired features for a center of excellence in placenta accreta, and which patients should be referred for evaluation and/or delivery in such centers., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Ultrasound technology has evolved dramatically in recent years and now includes applications such as 3-dimensional volume imaging, real-time evaluation of pelvic organs (simultaneous with the physical examination), and Doppler blood flow mapping without the need for contrast, which makes ultrasound imaging unique for imaging the female pelvis. Among the many cross-sectional imaging techniques, we should use the most informative, less invasive, and less expensive modality to avoid radiation when possible. Hence, ultrasound imaging should be the first imaging modality used in women with pelvic symptoms., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Noninvasive prenatal testing (NIPT) is a recently developed risk-assessment technique with high sensitivity and specificity for fetal aneuploidy. The effect NIPT has had on traditional screening and diagnostic testing has not been clearly demonstrated. In this study, NIPT uptake and subsequent changes in the utilization of first-trimester screen (FTS), chorionic villus sampling (CVS), and amniocentesis in a single referral center is reported., Study Design: Monthly numbers of NIPT (in high-risk patients), FTS, CVS, and amniocentesis were compared between a 35-month baseline period (April 2009 through February 2012) before introduction of NIPT, and the initial 16 months following NIPT introduction divided in 4-month quarters beginning in March 2012 through June 2013., Results: A total of 1265 NIPT, 6637 FTS, 251 CVS, and 1134 amniocentesis were recorded over the 51-month study period in singleton pregnancies of women who desired prenatal screening and diagnostic testing. NIPT became the predominant FTS method by the second quarter following its introduction, increasing by 55.0% over the course of the study period. Total first-trimester risk assessments (NIPT+FTS) were not statistically different following NIPT (P = .312), but average monthly FTS procedures significantly decreased following NIPT introduction, decreasing by 48.7% over the course of the study period. Average monthly CVS and amniocentesis procedures significantly decreased following NIPT introduction, representing a 77.2% and 52.5% decrease in testing, respectively. Screening and testing per 100 morphological ultrasounds followed a similar trend., Conclusion: NIPT was quickly adopted by our high-risk patient population, and significantly decreased alternate prenatal screening and diagnostic testing in a short period of time., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and magnetic resonance imaging in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost-effectiveness and to identify research opportunities. This article is the executive summary of the workshop., (Published by Mosby, Inc.)

Objective: The objective was to determine the rate of neonatal brachial plexus palsy (NBPP) among women with vaginal birth after cesarean delivery (VBAC) and to compare the peripartum characteristics with control subjects., Study Design: The Maternal-Fetal Medicine Unit cesarean registry data were used to identify nonanomalous singleton pregnancies with VBAC and NBPP at gestational age of ≥37 weeks (term) and 4 control subjects (matched for gestational age and diabetes mellitus status but without brachial injury). Odds ratio (OR) and 95% confidence intervals (CIs) were calculated., Results: Among 11,313 VBACs at term, there were 23 women with NBPP (rate of 2.0/1000 women). Newborn infants with NBPP, compared with control infants, were significantly more likely to weigh ≥4000 g (48% vs 10%, respectively; OR, 8.45; 95% CI, 2.58-28.44) and to require admission to the neonatal intensive care unit (30% vs 13%; OR, 12.98; 95% CI, 2.61-72.18)., Conclusion: Women who desire VBAC should be informed about the low rate of NBPP and, if eligible, encouraged to have a trial of labor after cesarean delivery., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: We sought to compare cognitive functioning in children born with birthweight <3% vs ≥3% for gestational age (GA) between 9 months and kindergarten., Study Design: Nonanomalous singletons from the Early Childhood Longitudinal Study-Birth Cohort were included. Associations between weight for GA and cognitive functioning were examined using a series of confounder-adjusted general linear models., Results: Of 3633 cohorts, 585 (16%) were <3% for GA. At 9 months, cognitive performance of newborns <3% was about 12 percentile points lower than their normal counterparts (P < .001). By 2 years, however, no significant cognitive differences between these groups were observed (P = .668). Academic performance at preschool age (around 3.5 years) was not different for reading (P = .245) or math (P = .880), nor different at kindergarten age., Conclusion: Newborns <3% for GA exhibit catch-up cognitive functioning by 2 years, with relatively no decrements in academic functioning observed by kindergarten., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Approximately 16% of twin gestations have discordance of at least 20%. We identified 14 risk factors for divergent growth that can be categorized as maternal, fetal, or placental. Determination of chorionicity and serial ultrasound evaluation with a high index of suspicion for divergent growth is required for the diagnosis and stratification of risk. The highest reported likelihood ratio for detection of discordance was 5.9 during the first trimester examination and 6.0 for the second trimester. Although our ability to identify discordant twins is limited, once suspected and at viable gestational age, these pregnancies should have antepartum testing. Discordant growth alone is not an indication for preterm birth. Although there are multiple publications on the increased morbidity and mortality rates with discordant growth, there is a paucity of reports on how to manage them optimally and deliver them in a timely manner., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: To examine the association between electronic fetal heart rate monitoring and neonatal and infant mortality, as well as neonatal morbidity., Study Design: We used the United States 2004 linked birth and infant death data. Multivariable log-binomial regression models were fitted to estimate risk ratio for association between electronic fetal heart rate monitoring and mortality, while adjusting for potential confounders., Results: In 2004, 89% of singleton pregnancies had electronic fetal heart rate monitoring. Electronic fetal heart rate monitoring was associated with significantly lower infant mortality (adjusted relative risk, 0.75); this was mainly driven by the lower risk of early neonatal mortality (adjusted relative risk, 0.50). In low-risk pregnancies, electronic fetal heart rate monitoring was associated with decreased risk for Apgar scores <4 at 5 minutes (relative risk, 0.54); in high-risk pregnancies, with decreased risk of neonatal seizures (relative risk, 0.65)., Conclusion: In the United States, the use of electronic fetal heart rate monitoring was associated with a substantial decrease in early neonatal mortality and morbidity that lowered infant mortality., (Copyright © 2011 Mosby, Inc. All rights reserved.)

The rate of twin pregnancies in the United States has stabilized at 32 per 1000 births in 2006. Aside from determining chorionicity, first-trimester screening and second-trimester ultrasound scanning should ascertain whether there are structural or chromosomal abnormalities. Compared with singleton births, genetic amniocentesis-related loss at <24 weeks of gestation for twin births is higher (0.9% vs 2.9%, respectively). Selective termination for an anomalous fetus is an option, although the pregnancy loss rate is 7% at experienced centers. For singleton and twin births for African American and white women, approximately 50% of preterm births are indicated; approximately one-third of these births are spontaneous, and 10% of the births occur after preterm premature rupture of membranes. From 1989-2000, the rate of preterm twin births increased, for African American and white women alike, although the perinatal mortality rate has actually decreased. As with singleton births, tocolytics should be used judiciously and only for a limited time (<48 hours) in twin births. Administration of antenatal corticosteroids is an evidence-based recommendation., (Copyright © 2010 Mosby, Inc. All rights reserved.)