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Objective: To compare the daily glycemic profile reflected by continuous and intermittent blood glucose monitoring in pregnant women with type 1 diabetes and to compare the treatment protocols based on the two monitoring methods.Methods: The study sample consisted of 34 gravid patients at gestational weeks 16-32, with type 1 diabetes being treated by multiple insulin injections. Data derived from the continuous glucose monitoring system for 72 hours were compared with finger stick glucose measurements performed 6-8 times per day. During the study period, patients documented the time of food intake, insulin injections, and hypoglycemic events. Data on demographics, gravidity, parity, body mass index, hemoglobin A1c, and fructosamine levels were collected for each patient.Results: An average (+/- standard deviation) of 780 +/- 54 glucose measurements was recorded for each patient with continuous glucose monitoring. The mean total time of hyperglycemia (glucose level greater than 140 mg/dL) undetected by the finger stick method was 192 +/- 28 minutes per day. Nocturnal hypoglycemic events (glucose level less than 50 mg/dL) were recorded in 26 patients; in all cases, there was an interval of 1-4 hours before clinical manifestations appeared or the event was revealed by random blood glucose examination. Based on the additional information obtained by continuous monitoring, the insulin therapeutic regimen was adjusted in 24 patients (70%).Conclusion: Continuous glucose monitoring can diagnose high postprandial blood glucose levels and nocturnal hypoglycemic events that are unrecognized by intermittent blood glucose monitoring and may serve as a basis for determining treatment regimens. A large, prospective study on maternal and neonatal outcome is needed to evaluate the clinical implications of this new monitoring technique. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the length of the second stage of labor in twin deliveries and to compare the length of the second stage in twin and singleton gestations., Methods: This is a retrospective cohort study from three large hospitals in Israel. Clinical data were collected from the electronic medical record. The primary outcome was the length of the second stage (the time from documented 10-cm dilation until spontaneous vaginal delivery of the first twin). Multivariable linear regression was used to examine the association of clinical factors with the length of the second stage. The length of the second stage in twin and singleton pregnancies was compared., Results: From 2011 to June, 2020, there were 2,009 twin deliveries and 135,217 singleton deliveries. Of the twin deliveries, 655 (32.6%) of the patients were nulliparous (95th percentile length of the second stage 3 hours and 51 minutes), 1,235 (61.5%) were parous (95th percentile 1 hour 56 minutes), and 119 (5.9%) were grand multiparous (five or more prior deliveries) (95th percentile 1 hour 24 minutes). In women delivering twins, epidural use was associated with a statistically significant increase in the length of the second stage of 40 minutes in nulliparous patients and 15 minutes in parous patients. In all groups, the length of the second stage was longer in patients delivering twins compared with singletons. Second-stage length longer than the 95th percentile in twins was associated with admission to the neonatal intensive care unit and need for phototherapy., Conclusion: Second-stage labor is longer in twins than singletons and is associated with obstetric history. Normal ranges for the second stage may be useful in guiding clinical practice., Competing Interests: Financial Disclosure Abraham Tsur disclosed receiving money from Pregnantech as the medical inventor of the “Lioness” and Anthem AI for MFM precision consulting. Dr. Tsur also disclosed that money was paid to his institution from New Sight. The other authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Information on the cardiac manifestations of coronavirus disease 2019 (COVID-19) is scarce. We performed a systematic and comprehensive echocardiographic evaluation of consecutive patients hospitalized with COVID-19 infection., Methods: One hundred consecutive patients diagnosed with COVID-19 infection underwent complete echocardiographic evaluation within 24 hours of admission and were compared with reference values. Echocardiographic studies included left ventricular (LV) systolic and diastolic function and valve hemodynamics and right ventricular (RV) assessment, as well as lung ultrasound. A second examination was performed in case of clinical deterioration., Results: Thirty-two patients (32%) had a normal echocardiogram at baseline. The most common cardiac pathology was RV dilatation and dysfunction (observed in 39% of patients), followed by LV diastolic dysfunction (16%) and LV systolic dysfunction (10%). Patients with elevated troponin (20%) or worse clinical condition did not demonstrate any significant difference in LV systolic function compared with patients with normal troponin or better clinical condition, but they had worse RV function. Clinical deterioration occurred in 20% of patients. In these patients, the most common echocardiographic abnormality at follow-up was RV function deterioration (12 patients), followed by LV systolic and diastolic deterioration (in 5 patients). Femoral deep vein thrombosis was diagnosed in 5 of 12 patients with RV failure., Conclusions: In COVID-19 infection, LV systolic function is preserved in the majority of patients, but LV diastolic function and RV function are impaired. Elevated troponin and poorer clinical grade are associated with worse RV function. In patients presenting with clinical deterioration at follow-up, acute RV dysfunction, with or without deep vein thrombosis, is more common, but acute LV systolic dysfunction was noted in ≈20%.

Objective: To design a clinically based predictive model for the likelihood of successful external cephalic version (ECV)., Methods: This single-center retrospective study was conducted from February 2016 to July 2018 and included all candidates for ECV between 36 and 41 weeks of gestation. Variables with a potential effect on ECV success were collected. These variables include: body mass index, amniotic fluid index, gestational age, parity, location of placenta, fetal trunk posture, time in breech presentation before the procedure and the ultrasonographically measured size of the amniotic fluid preceding the fetal presenting part (fore-bag). Variables' association with ECV success was evaluated using a multivariate logistic regression and a decision tree predicting ECV outcome was developed using 75% of the patients and validated on the remaining 25%., Results: Overall, 250 pregnant women were identified and opted for a trial of ECV by a single operator, with a success rate of 64.8%. Body mass index, size of fore-bag, and parity were independent determinants of the version success, whereas other variables had no statistically significant effect on the success rate. Our decision tree model divided the cohort into five subgroups according to various combinations of the three variables. When evaluated on the internal validation set, the C-Index of the tree was 0.933 (0.863-1) and the prediction accuracy was 91.9% (86.5%-97.3%)., Conclusion: A prediction model composed of three easily measurable variables enables accurate prediction of successful ECV at term. Fore-bag was identified as the most important discriminator. Our model holds in internal validation and it can be used to support patient counseling and decision making for ECV but should be externally validated.

Background: Paroxysmal atrial fibrillation (AF) can be caused by gain-of-function mutations in genes, encoding the cardiac potassium channel subunits KCNJ2, KCNE1, and KCNH2 that mediate the repolarizing potassium currents I k1 , I ks , and I kr , respectively., Methods: Linkage analysis, whole-exome sequencing, and Xenopus oocyte electrophysiology studies were used in this study., Results: Through genetic studies, we showed that autosomal dominant early-onset nocturnal paroxysmal AF is caused by p.S447R mutation in KCND2, encoding the pore-forming (α) subunit of the Kv4.2 cardiac potassium channel. Kv4.2, along with Kv4.3, contributes to the cardiac fast transient outward K + current, I to . I to underlies the early phase of repolarization in the cardiac action potential, thereby setting the initial potential of the plateau phase and governing its duration and amplitude. In Xenopus oocytes, the mutation increased the channel's inactivation time constant and affected its regulation: p.S447 resides in a protein kinase C (PKC) phosphorylation site, which normally allows attenuation of Kv4.2 membrane expression. The mutant Kv4.2 exhibited impaired response to PKC; hence, Kv4.2 membrane expression was augmented, enhancing potassium currents. Coexpression of mutant and wild-type channels (recapitulating heterozygosity in affected individuals) showed results similar to the mutant channel alone. Finally, in a hybrid channel composed of Kv4.3 and Kv4.2, simulating the mature endogenous heterotetrameric channel underlying I to , the p.S447R Kv4.2 mutation exerted a gain-of-function effect on Kv4.3., Conclusions: The mutation alters Kv4.2's kinetic properties, impairs its inhibitory regulation, and exerts gain-of-function effect on both Kv4.2 homotetramers and Kv4.2-Kv4.3 heterotetramers. These effects presumably increase the repolarizing potassium current I to , thereby abbreviating action potential duration, creating arrhythmogenic substrate for nocturnal AF. Interestingly, Kv4.2 expression was previously shown to demonstrate circadian variation, with peak expression at daytime in murine hearts (human nighttime), with possible relevance to the nocturnal onset of paroxysmal AF symptoms in our patients. The atrial-specific phenotype suggests that targeting Kv4.2 might be effective in the treatment of nocturnal paroxysmal AF, avoiding adverse ventricular effects.

Objective: To estimate the risk of placenta-mediated complications in women in their third delivery according to their obstetric history in the first and second deliveries., Methods: A retrospective cohort study of all women with singleton pregnancies who delivered their first three consecutive deliveries in a single medical center over a 20-year period (1994-2013). The risk of placenta-mediated complications in the third delivery, that is, hypertensive disorders such as preeclampsia or gestational hypertension, placental abruption, and small for gestational age (SGA less than the 10th percentile), was assessed according to the presence or absence of complications in previous deliveries. Pregnancies complicated by multiple gestations or fetal anomalies were excluded., Results: Of the 121,728 deliveries during the study period, 4,472 women (13,416 deliveries [11.0%]) met inclusion criteria. The rate of placenta-mediated complications in the third delivery was 5.9% (n=264). The most prevalent placenta-mediated complication was SGA. The risk of each placenta-mediated complication was greater the higher the incidence of placenta-mediated complications in prior pregnancies. In multivariate analysis, that risk was significantly associated with the number and order of complications in previous deliveries in a dose-dependent pattern: with no complications in either their first or second deliveries as a reference (n=3,650), the adjusted odds ratio (and 95% confidence intervals) was 4.35 (3.03-6.24) for complications in the first delivery but not the second delivery (n=532); 6.41 (3.95-10.38) for complications in the second delivery but not the first delivery (n=179); and 8.28 (4.72-14.58) for complications in both first and second deliveries (n=111), (P<.001)., Conclusion: The number and order of previous placenta-mediated complications in the first two deliveries are major risk factors for recurrence in the third delivery. Previous SGA was the strongest risk factor for recurrence of SGA and other placenta-mediated complications.

Objective: To evaluate pregnancy outcome among women with isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation., Methods: Retrospective cohort study at a tertiary medical center between 2007 and 2012. Isolated polyhydramnios was defined as amniotic fluid index (AFI) greater than 25 cm at admission in the absence of gestational or pregestational diabetes mellitus or fetal structural or chromosomal anomalies. Women with isolated polyhydramnios were compared with women with a normal AFI (5-25 cm)., Results: Overall, 31,376 women were eligible for analysis, of whom 215 (0.7%) had isolated polyhydramnios and 31,161 normal AFI. Women with isolated polyhydramnios had higher rates of labor induction (7.9% compared with 4.8%, P=.04) and cesarean delivery (12.1% compared with 5.1%, P<.001). They also had higher rates of placental abruption (0.9% compared with 0.2%, P=.02), abnormal or intermediate fetal heart rate (FHR) tracings (7.0% compared with 3.2%, P=.002), and prolonged first stage of delivery (6.0% compared with 1.4%, P<.001). Isolated polyhydramnios was also associated with higher rates of shoulder dystocia (1.9% compared with 0.3%, P<.001) and respiratory distress syndrome (0.5% compared with 0.03%, P=.001). On a multiple logistic regression model, isolated polyhydramnios was an independent risk factor for labor induction (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.01-2.8), cesarean delivery (adjusted OR 2.6, 95% CI 1.7-4.0), prolonged first stage of delivery (adjusted OR 3.6, 95% CI 1.97-6.7), abnormal or intermediate FHR tracings (adjusted OR 2.6, 95% CI 1.6-4.5), placental abruption (adjusted OR 8.4, 95% CI 2.00-35.4), shoulder dystocia (adjusted OR 3.4, 95% CI 1.2-9.7), and respiratory distress syndrome (adjusted OR 38.9, 95% CI 4.6-332.6). Mild isolated polyhydramnios (AFI 25.1-30.0) was independently associated with cesarean delivery, prolonged first stage of delivery, placental abruption, abnormal or intermediate FHR tracings, and shoulder dystocia., Conclusion: Isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation is associated with adverse obstetric and neonatal outcomes.

Purpose of Review: To address the recent evidence regarding the association between hyperglycemia during pregnancy and adverse short-term and long-term outcome for both mothers and offspring., Recent Findings: Recent data suggest a relationship between hyperglycemia during pregnancy and adverse short-term fetal outcomes, mainly those associated with excessive fetal growth. The degree of hyperglycemia plays an important role in risk stratification. Moreover, the long-term effect of hyperglycemia during pregnancy is expressed mainly as cardiometabolic morbidity and increased risk for the development of metabolic syndrome both maternal and in early adolescence. Alternation in DNA methylation and gene expression of metabolic pathways were found in association with hyperglycemia in utero, supporting the 'developmental origins of disease' hypothesis., Summary: The effect of hyperglycemia on the early life metabolic environment may contribute to the subsequent risk of cardiovascular or metabolic morbidity later in life. It is also a sign of future maternal metabolic alternation. Several future randomized trials, hopefully will help to determine if early intervention could decrease the risk for gestational diabetes and whether long term adverse outcome are preventable and importantly the association with degree of maternal hyperglycemia in pregnancy and future morbidity.

The various strategies to diagnose gestational diabetes mellitus (GDM), starting from O'sullivan, followed by numerous opinions and recommendations and up to the recently published International association of diabetes and pregnancy study groups criteria, have been and still are the subject of extensive and ongoing debate, since the 1960s, and holding, fiercely than ever, nowadays. In this review we shall provide an overlook on the history of GDM diagnosis, concentrating on the interpretation of the hyperglycemia and adverse pregnancy outcome results into clinical guidelines, and the pros and cons for changing the criteria for GDM diagnosis.

Objective: To assess the predictive role of ultrasonographic cervical length for preterm delivery in women with threatened preterm labor., Methods: A retrospective cohort study of women with singleton pregnancies who presented with preterm labor before 34 weeks of gestation and underwent ultrasonographic measurement of cervical length in a tertiary medical center. Women with cervical cerclage, cervical dilatation greater than 3 cm at presentation, and pregnancies complicated by placental abruption, clinical chorioamnionitis, stillbirth, or major fetal anomalies were excluded. The predictive accuracy of cervical length for preterm delivery was analyzed using both fixed thresholds and outcome-specific thresholds, which are associated with a detection rate of 90%, false-positive rate of 10%, or the inflexion point of the receiver operator characteristic curve., Results: Between 2007 and 2012, 1,077 women presented with preterm labor and met the study criteria. The correlation between cervical length and the time interval to delivery was significant but weak (r=0.293, P<.001). Cervical length was independently associated with the risk of preterm delivery at less than 37, 35, and 32 weeks of gestation and within 14 and 7 days from presentation (a 4-7% decrease in the risk for each additional millimeter of cervical length) as well as with the time interval between presentation and delivery (each additional 2 mm was associated with an increase of 1 day). Overall, the accuracy of cervical length in predicting preterm delivery was relatively poor., Conclusion: Although cervical length is an independent predictor of preterm delivery in women with preterm labor, its predictive accuracy as a single measure is relatively limited., Level of Evidence: : II.

Objective: To estimate the association between fetal sex and pregnancy outcome in dichorionic twin pregnancies and the effect of male and female fetuses on their opposite-sex co-twin., Methods: This was a retrospective study of all dichorionic twin pregnancies at a tertiary hospital from 1995 to 2006. Pregnancies were classified into three groups according to fetal sex: female-female, male-female, and male-male. Pregnancy outcome was compared for the three groups. Neonatal outcome of female neonates from female-female pregnancies was compared with that of female neonates from male-female pregnancies. Similarly, the outcome of male neonates from male-female pregnancies was compared with that of male neonates from male-male pregnancies., Results: Two thousand seven hundred four twin pregnancies were included in the study, of which there were 436 (16.1%) female-female pregnancies, 1,878 (69.5%) male-female pregnancies, and 390 (14.4%) male-male pregnancies. The risk of preterm delivery at less than 31 and 28 weeks of gestation was highest in the male-male group (9.2%, odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.6 and 4.1%, OR 2.3, 95% CI 1.3-4.2, respectively) and intermediate in the male-female group (7.5%, OR 1.4, 95% CI 1.1-1.9 and 3.2%, OR 1.8, 95% CI 1.2-3.0, respectively) using the female-female group as reference (5.5% and 1.8%, respectively). Male neonates in male-male twin pairs were characterized by a lower mean birth weight and a lower growth rate when compared with male neonates in male-female pairs. Female neonates from male-female pregnancies had a rate of respiratory and neurologic morbidity similar to that of male neonates and significantly higher than that of female neonates from female-female pregnancies., Conclusion: In twins, pregnancy outcome is enhanced when the fetus (male or female) shares the womb with a female rather than with a male co-twin. Analysis of neonatal outcome for preterm twin neonates identifies a male-offending factor., Level of Evidence: II.

Objective: : To assess pregnancy outcome and risk factors for repeat operative vaginal delivery in women with previous operative vaginal delivery., Methods: : This was a case-control study of all nulliparous women who underwent operative vaginal delivery in a tertiary care medical center from 1993-2006 (n=4,153). The control group included nulliparous women who underwent spontaneous vaginal delivery during the same period in a 2:1 ratio (n=8,306). The women in each group who had a subsequent delivery at our center were identified (n=1,396 and n=2,591, respectively), and the outcome of the subsequent delivery was recorded., Results: : Compared with the women in the spontaneous vaginal delivery group, women who underwent operative vaginal delivery in the index pregnancy had a higher rate of operative vaginal delivery (4.7% compared with 1.2%, P<.006) and cesarean delivery (8.5% compared with 4.6%, P<.001) in the subsequent pregnancy. The rate of neonatal birth injury (1.5% compared with 0.6%, P=.005) and third-degree or fourth-degree lacerations (0.7% compared with 0.2%, P=.01) was significantly higher in the group of women with a previous operative vaginal delivery. Risk factors for repeat operative vaginal delivery were as follows: failed vacuum extraction and prolonged second stage as the indication for operative vaginal delivery in the index pregnancy; prolonged interval (more than 3 years) between pregnancies; higher fetal weight, persistent occipitoposterior position, and use of epidural analgesia in the subsequent pregnancy. The presence of epidural analgesia in the index operative vaginal delivery was not associated with a decreased risk of repeat operative vaginal delivery., Conclusion: : Nulliparous women undergoing operative vaginal delivery are at increased risk of operative vaginal delivery and cesarean delivery in their subsequent pregnancy. Risk stratification based on the identified risk factors may assist clinicians in predicting the likelihood of repeat operative vaginal delivery and in counseling patients accordingly., Level of Evidence: : II.

Objective: To estimate the effect of gestational age on short-term neonatal morbidity in cases of spontaneous, low-risk singleton late preterm deliveries and to identify predictors of adverse neonatal outcome., Methods: This was a retrospective study of all spontaneous, low-risk late preterm deliveries (34 0/7 to 36 6/7 weeks of gestation) during the years 1997 to 2006 (n=2,478). Multiple gestations and pregnancies complicated by preterm premature rupture of membranes (PROM) or maternal or fetal complications were excluded. Short-term neonatal outcome was compared with a control group of full-term deliveries in a 3:1 ratio (n=7,434). Logistic regression analysis was used to identify risk factors for neonatal morbidity among late preterm infants., Results: Compared with full-term infants, spontaneous late preterm delivery was independently associated with an increased risk of neonatal morbidity, including respiratory distress syndrome (4.2% compared with 0.1%, P<.001), sepsis (0.4% compared with 0.04%, P<.001), intraventricular hemorrhage (0.2% compared with 0.02%, P<.001), hypoglycemia (6.8% compared with 0.4%, P<.001), and jaundice requiring phototherapy (18% compared with 2.5%, P<.001). Cesarean delivery (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.6-2.6), male sex (OR 1.4, 95% CI 1.1-1.8), and multiparity (OR 2.2, 95% CI 1.7-2.8) were independent risk factors for neonatal respiratory morbidity in cases of late preterm deliveries. The relationship between gestational age and neonatal morbidity was of continuous nature with a nadir at about 39 weeks rather than a term-preterm threshold phenomenon and was unrelated to birth weight., Conclusion: Late prematurity is associated with significant neonatal morbidity in cases of spontaneous low-risk singleton deliveries. This information is important for appropriate counseling and should stimulate efforts to decrease the rate of late preterm deliveries., Level of Evidence: II.