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Objective The frequency of intrahepatic cholestasis of pregnancy (ICP) peaks during the third trimester of pregnancy when plasma progesterone levels are the highest. Furthermore, twin pregnancies are characterized by higher progesterone levels than singletons and have a higher frequency of cholestasis. Therefore, we hypothesized that exogenous progestogens administered for reducing the risk of spontaneous preterm birth may increase the risk of cholestasis. Utilizing the large IBM MarketScan Commercial Claims and Encounters Database, we investigated the frequency of cholestasis in patients treated with vaginal progesterone or intramuscular 17α-hydroxyprogesterone caproate for the prevention of preterm birth. Study Design We identified 1,776,092 live-born singleton pregnancies between 2010 and 2014. We confirmed second and third trimester administration of progestogens by cross-referencing the dates of progesterone prescriptions with the dates of scheduled pregnancy events such as nuchal translucency scan, fetal anatomy scan, glucose challenge test, and Tdap vaccination. We excluded pregnancies with missing data regarding timing of scheduled pregnancy events or progesterone treatment prescribed only during the first trimester. Cholestasis of pregnancy was identified based on prescriptions for ursodeoxycholic acid. We used multivariable logistic regression to estimate adjusted (for maternal age) odds ratios for cholestasis in patients treated with vaginal progesterone, and in patients treated with 17α-hydroxyprogesterone caproate compared with those not treated with any type of progestogen (the reference group). Results The final cohort consisted of 870,599 pregnancies. Among patients treated with vaginal progesterone during the second and third trimester, the frequency of cholestasis was significantly higher than the reference group (0.75 vs. 0.23%, adjusted odds ratio [aOR]: 3.16, 95% confidence interval [CI]: 2.23–4.49). In contrast, there was no significant association between 17α-hydroxyprogesterone caproate and cholestasis (0.27%, aOR: 1.12, 95% CI: 0.58–2.16) Conclusion Using a robust dataset, we observed that vaginal progesterone but not intramuscular 17α-hydroxyprogesterone caproate was associated with an increased risk for ICP. Key Points

Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.

Cesarean delivery is one of the most common surgeries performed in the United States. In 2012, over 1.2 million cesarean deliveries were performed, accounting for 32.8% of all deliveries.1 Cesarean delivery has been implicated as an important explanatory factor for increasing rates of maternal morbidity, which includes venous thromboembolism, shock, and hemorrhage.2 As a consequence, multiple large-scale initiatives have been promoted by leading obstetric figures and organizations to reduce rates of maternal morbidity.3–5 Postoperative length of stay (LOS) after nonobstetric surgery has been identified as an important quality indicator of inpatient care.6–8 LOS after cesarean delivery may also be an important metric for evaluating the quality of peripartum and postpartum obstetric care. Unfortunately, studies investigating risk factors associated with prolonged LOS after a cesarean delivery are lacking. Such data could assist ongoing efforts aimed at reducing maternal morbidity after cesarean delivery and could be useful for evaluating postcesarean LOS as a quality measure related to obstetric practice. The primary aim of this study was to identify risk factors for prolonged postpartum LOS after cesarean delivery. Moreover, we sought to analyze the contribution of potentially modifiable risk factors on prolonged LOS to highlight areas where improvements in perioperative care could be made. We also performed a secondary analysis to identify risk factors for prolonged LOS for the entire delivery hospitalization period including the intrapartum period.