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Objective:Patients with pregnancy-associated secondary brain tumors (PASBT) are challenging to manage. Because no guidelines for the management of such patients currently exist, we performed a systematic review of the literature using PRISMA guidelines with a discussion of management from a neurosurgeon’s perspective.Method:Systematic review of the literature using PRISMA guidelines from 1999 to 2018.Results:We identified 301 studies of which 16 publications (22 patients reporting 25 pregnancies, 20 deliveries, 5 early terminations) were suitable for final analysis. The most frequent primary cancers were breast (8/22, 36.36%), skin (6/22, 27.27%), and lung (5/22, 22.73%). Four patients (18.18%) had neurosurgical procedures during their pregnancies. Five patients (22.73%) received neurosurgical resection after their pregnancies. Nine patients (40.91%) received radiation therapy and seven patients (31.82%) received chemotherapy during pregnancy while seven patients (31.82%) received chemotherapy and radiation after pregnancy. There was 1 fetal death (5%) out of 20 healthy deliveries. Five pregnancies (20%) were terminated in the first trimester due to a need for urgent neurosurgical intervention.Conclusion:Management of PASBT remains a challenging issue. Maternal and fetal risks associated with surgical resection and teratogenicity due to adjuvant therapy should be discussed in the context of a multidisciplinary team. Timing of surgery and the use of systemic chemoradiation depends on the gestational age (GA) of the fetus, extent, and control of the mother’s primary and metastatic disease. Guidelines need to be established to help neuro-oncology teams safely and effectively manage this group of patients.

The optimal management of Chiari I malformation during pregnancy remains uncertain. Labor contractions, which increase intracranial pressure, and neuraxial anesthesia both carry the theoretical risk of brainstem herniation given the altered CSF dynamics inherent to the condition. Mode of delivery and planned anesthesia, therefore, require forethought to avoid potentially life-threatening complications. Since the assumed potential risks are significant, we seek to systematically review published literature regarding Chiari I malformation in pregnancy and, therefore, to establish a best practice recommendation based on available evidence. The English-language literature was systematically reviewed from 1991 to 2018 according to PRISMA guidelines to assess all pregnancies reported in patients with Chiari I malformation. After analysis, a total of 34 patients and 35 deliveries were included in this investigation. Additionally, a single case from our institutional experience is presented for illustrative purposes but not included in the statistical analysis. No instances of brain herniation during pregnancy in patients with Chiari I malformation were reported. Cesarean deliveries (51%) and vaginal deliveries (49%) under neuraxial blockade and general anesthesia were both reported as safe and suitable modes of delivery. Across all publications, only one patient experienced a worsening of neurologic symptoms, which was only later discovered to be the result of a previously undiagnosed Chiari I malformation. Several patients underwent decompressive suboccipital craniectomy to treat the Chiari I malformation during the preconception period (31%), during pregnancy (3%), and after birth (6%). Specific data regarding maternal management were not reported for a large number (21) of these patients (60%). Aside from one abortion in our own institutional experience, there was no report of any therapeutic abortion or of adverse fetal outcome. Although devastating maternal complications are frequently feared, very few adverse outcomes have ever been reported in pregnant patients with a Chiari I malformation. The available evidence is, however, rather limited. Based on our survey of available data, we recommend vaginal delivery under neuraxial blockade for truly asymptomatic patients. Furthermore, based on our own experience and physiological conceptual considerations, we recommend limiting maternal Valsalva efforts either via Cesarean delivery under regional or general anesthesia or by choosing assisted vaginal delivery under neuraxial blockade. There is no compelling reason to offer suboccipital decompression for Chiari I malformation during pregnancy. For patients with significant neurologic symptoms prior to conception, decompression prior to pregnancy should be considered.

Objectives Ischemic placental disease (IPD), including preeclampsia, abruption, and fetal growth restriction, often recurs in subsequent pregnancies. Angiogenic factors of placental origin have been implicated in the pathogenesis of preeclampsia, but have not been studied as predictors of IPD in subsequent pregnancies. We hypothesized that elevated angiogenic factors in an index pregnancy would be associated with recurrence of IPD. Study design We conducted a retrospective cohort study of patients undergoing evaluation for preeclampsia who had angiogenic factors measured in an index pregnancy and experienced a subsequent pregnancy at the same institution. Patients with IPD in the index pregnancy were included. A high ratio of soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) was defined as greater than or equal to 85. Main outcome measures The primary outcome was IPD in a subsequent pregnancy. Results We included 109 patients in the analysis. The sFlt1/PlGF ratio was elevated in 30% of participants. Those with an elevated ratio were more likely to be nulliparous in the index pregnancy, and less likely to have chronic hypertension. The recurrence of IPD in the study was 27%, with a non-significant difference in risk based on a high sFlt-1/P1GF ratio RR 0.58 (95% CI 0.21 – 1.6) compared to a low ratio. Conclusions A high sFlt1/P1GF ratio in an index pregnancy is not associated with a higher risk of IPD in a subsequent pregnancy. These data suggest placental angiogenic biomarkers are specific to the pregnancy and not a reflection of maternal predisposition to IPD.

Objective To evaluate the association between in vitro fertilization (IVF) and ischemic placental disease (IPD), stratified by gestational age. Design We performed a secondary analysis of a retrospective cohort study of deliveries. Setting Deliveries were performed over 15 years at a single tertiary hospital. Patient(s) We included all parturients who had a live born infant or an intrauterine fetal demise (IUFD). Intervention(s) We compared pregnancies resulting from IVF cycles to non-IVF pregnancies. Main Outcome Measure(s) The primary outcomes were preterm and term IPD (preeclampsia, placental abruption, small-for-gestational age infant [SGA], or an intrauterine fetal demise [IUFD] due to placental insufficiency). Result(s) Of the 69,084 deliveries during the study period, 3,763 (5.4%) were conceived with IVF. The incidence of preterm delivery was 32.6% in IVF pregnancies and 10.8% in non-IVF pregnancies. Multiple gestations were more common in IVF pregnancies. Compared to non-IVF pregnancies, IVF pregnancies were more likely to develop both preterm and term IPD, even after adjustment for maternal age and parity. The risk of preterm IPD was 4 times higher (95% confidence interval, 3.7–4.4) in patients who underwent IVF compared with those who did not undergo IVF. Among parturients who delivered at ≥37 weeks of gestation, IVF pregnancies had 1.7 times the risk of term IPD (95% confidence interval, 1.6–1.9) compared with non-IVF pregnancies. Conclusion(s) IVF was strongly associated with preterm IPD. We found a similar, but attenuated, association between IVF and term IPD. The stronger association with preterm IPD suggests an association between IVF and placental insufficiency.

There is a strong correlation between the level of circulating female sex hormones and the parturient growth of meningiomas. As a result, rapid changes in meningioma size occur during pregnancy, putting both the mother and fetus at risk. Large, symptomatic meningiomas require surgical resection, regardless of the status of pregnancy. However, the preferred timing of such complex intervention is a matter of debate. The rarity of this clinical scenario and the absence of prospective trials make it difficult to reach evidence-based conclusions. The aim of this study was to create evidence-based management guidelines for timing of surgery for pregnancy-related intracranial meningiomas. The English literature from 1990 to 2016 was systematically reviewed according to PRISMA guidelines for all surgical cases of pregnancy–related intracranial meningiomas. Cases were divided into two groups: patients who have had surgery during pregnancy and delivered thereafter (group A) and patients who delivered first (group B). Groups were compared for demographic, clinical and radiological features, as well as for neurosurgical, obstetrical and neonatological outcomes. Statistical analysis was performed to assess differences. A total of 104 surgical cases were identified and reviewed, of which 86 were suitable for comparison and statistical analysis. Thirty-five patients (40%) underwent craniotomy for resection during pregnancy or at delivery (group A) and 51 patients (60%) underwent surgery after delivery (group B). Groups showed no significant differences in characteristics such as age at diagnosis, number of gestations, presenting symptoms, tumor site and tumor size. Despite a comparable distribution over the gestational trimesters, group A had significantly more patients diagnosed prior to the 27th gestational week (46 vs 17.5%, p = 0.0075). Group A was also associated with a significantly higher rate of both emergent craniotomies (40 vs 19.6%, p = 0.0048) and emergent Caesarian deliveries (47 vs 17.8%, p = 0.00481). The time from diagnosis to surgery was significantly longer in group B (11 weeks vs 1 week in group A, p = 0.0013). The rate of premature delivery was high but similar in both groups (∼70%). Risks of maternal mortality or fetal mortality were associated with group A (odds ratio = 14.7), but did not reach statistical significance. While surgical resection of meningioma during pregnancy may be associated with increased maternal and fetal mortalities, the overall neurosurgical, obstetrical and neonatological outcomes, as well as many clinical characteristics, are similar to patients undergoing resection postpartum. We believe that fetal survival chances have a significant impact on decision-making, as patients diagnosed at a later stage in pregnancy (≥27th week of gestation) were more likely to undergo delivery first. This complicated clinical scenario requires the close cooperation of multiple disciplines. While the mother’s health and well-being should always be paramount in guiding management, we hope that the overall good outcomes observed by this systematic review will encourage colleagues to aim for term pregnancies whenever possible in order to reduce prematurity-related problems.

PURPOSE: Assess the risk of ischemic placental disease (IPD) among in vitro fertilization (IVF; donor and autologous) pregnancies compared with non-IVF pregnancies. METHODS: This was a retrospective cohort study of deliveries from 2000 to 2015 at a tertiary hospital. The exposures, donor, and autologous IVF, were compared with non-IVF pregnancies and donor IVF pregnancies were also compared with autologous IVF pregnancies. The outcome was IPD (preeclampsia, placental abruption, small for gestational age (SGA), or intrauterine fetal demise due to placental insufficiency). We defined SGA as birthweight

OBJECTIVE: To compare the incidence of Group B Streptococcus (GBS) conversion from a negative antepartum to a positive intrapartum culture among women who self-identify as non-Hispanic black, Hispanic, or non-Hispanic white. STUDY DESIGN: This was a prospective cohort study of women with a negative rectovaginal GBS culture within 35 days of enrollment. An intrapartum rectovaginal swab was collected and cultured for GBS. Data were compared with chi-square, Fisher’s exact, or Wilcoxon rank-sum test. Modified Poisson regression was used. RESULTS: We enrolled 737 women; 75.4% were non-Hispanic white, 17.6% were non-Hispanic black, and 6.9% were Hispanic. Non-Hispanic black women were more likely to convert to GBS positive than non-Hispanic white women, 9.2% as compared to 5.3% (RR: 2.0; 95% CI: 1.02–3.8). CONCLUSION: The increased incidence of positive intrapartum GBS cultures among non-Hispanic black women suggests that non-Hispanic black race is a risk factor for GBS conversion in the late third trimester.

Objective: Admissions to acute care hospitals represent a significant portion of healthcare utilization. Little is known regarding hospitalization in the first postpartum year beyond the traditional 6 weeks of the puerperium. We sought to investigate whether there are identifiable risk factors for hospital readmission during this time period. Study Design: We conducted a retrospective population-based study using all California birth records between 1999 and 2003. These records were linked with hospital discharge data for all admissions to California hospitals in the first 365 days after delivery. For women with a first birth during the study period, we assessed the likelihood of readmission to an acute care hospital between 42 and 365 days post-delivery. Univariate and multivariable logistic regression were used to determine risk factors for these “late postpartum” admissions. Results: Of 951,570 maternal birth admissions during the time period, 15,727 (1.7%) women were admitted in the late postpartum period. Women with an early postpartum readmission, antepartum admission, extremes of maternal age, black race, diabetes, hypertension, early preterm delivery and cesarean delivery had higher rates of late postpartum readmission. Of women with an antepartum admission for gestational diabetes or pre-existing diabetes, 6.6% and 18.5% of these women experienced a late postpartum admission for a diabetes-related diagnosis. Conclusion: Hospital readmission rates in the first year postpartum, remote from delivery, are significant. Women are at a higher risk of requiring hospital admission in the first year postpartum with select demographics and pregnancy-related diagnoses.

In medical school, students learn that the diagnostic criteria for preeclampsia are new-onset hypertension and proteinuria after 20 weeks of gestation. An accurate diagnosis is essential, because preeclampsia is a leading cause of iatrogenic prematurity; the sole known “cure” for preeclampsia is delivery of the placenta. However, in clinical practice, the diagnosis of preeclampsia may be more nuanced than the classic textbook presentation. In a subset of patients, severe preeclampsia and even eclampsia (i.e., the presence of seizures) may present atypically in the absence of either hypertension or proteinuria. Diagnosing preeclampsia is further complicated by the fact that signs and symptoms of preeclampsia overlap with those of other medical conditions seen in pregnancy, such as liver disease, renal disease, chronic hypertension, and idiopathic thrombocytopenic purpura. Moreover, the standard clinical diagnostic criteria, such as hypertension or proteinuria, are not sufficiently accurate to predict adverse outcomes associated with the disease. The American College of Obstetricians and Gynecologists recently released new guidelines modifying the diagnostic criteria for preeclampsia that broaden the inclusion criteria to further reflect the heterogeneity of the clinical presentation (1). Current emphasis on overdiagnosis may improve maternal outcomes but may also lead to worse neonatal outcomes, because iatrogenic preterm delivery could result from significant misclassification of the disease. Preeclampsia is a leading cause of maternal mortality in developed and developing countries, making an improved diagnostic tool that is linked to the pathogenesis of the disease an important goal and a crucial step toward developing new treatments. Basic research has implicated a major pathogenic role for angiogenic imbalance in the placenta in the onset and progression of preeclampsia. High circulating concentrations of antiangiogenic factors such as soluble fms-like tyrosine kinase 1 (sFlt1)3 and low concentrations of proangiogenic factors such as placental growth factor (PlGF) released by the placenta contribute to …

To evaluate the effect of placenta previa location (anterior vs posterior) on cesarean morbidity.Retrospective cohort of women undergoing cesarean for placenta previa. The rate of hysterectomy and blood transfusion in the setting of anterior previa was compared with posterior previa. Planned stratified analysis based on delivery history was performed. Logistic regression was performed to control for potential confounders.Two hundred and eighty-five women undergoing cesarean delivery for placenta previa were identified. Women undergoing primary cesareans with an anterior previa had higher rates of blood transfusion (adjusted odds ratio (aOR) 3.13 95% confidence interval (CI) (1.18 to 8.36) and hysterectomy (7.4% vs 0, P=0.001) compared with those with a posterior previa; similarly, women undergoing repeat cesarean with anterior previa had higher rates of hysterectomy (aOR 4.60 95% CI (1.02 to 20.7). The majority of hysterectomies (93.8%) were due to abnormal placentation.An anterior placenta previa increases the risk of hysterectomy for both primary and repeat cesareans due to abnormal placentation. In the absence of accreta, blood transfusion remained a significant cause of maternal morbidity in both anterior and posterior placenta previas. This information may be useful for operative planning.

Background Our goal is to study triggers of spontaneous preterm delivery using a case-crossover design.

Preeclampsia, a hypertensive disorder of pregnancy, affects 5-8% of women. Large studies demonstrate a strong association between preeclampsia and future cardiovascular disease (CVD). Despite CVD being the leading cause of mortality for women, there has been little education for internal medicine physicians or obstetrician-gynecologists (ob-gyns) about this association; published guidelines do not include preeclampsia as a risk factor for future CVD. Therefore, women with a history of preeclampsia may not receive adequate risk-reduction counseling for CVD. It is unclear whether primary care physicians are aware of the association; thus, we sought to determine whether primary care providers at our institution were aware of preeclampsia's association with future CVD and whether they were providing appropriate counseling.An anonymous online survey was sent to all internists and (ob-gyns) at our hospital.Although most internists (95%) and (ob-gyns) (70%) provide routine cardiovascular risk-reduction counseling, a substantial proportion of them were unaware of any health risk associated with a history of preeclampsia. Many internists were unsure or did not know whether preeclampsia is associated with ischemic heart disease (56%), stroke (48%), and decreased life expectancy (79%). The corresponding proportions for (ob-gyns) were 23, 38, and 77%, respectively. Only 9% of internists and 38% of obstetrician-gynecologists were providing cardiovascular risk-reduction counseling to women with a history of preeclampsia.There is limited knowledge of the association between preeclampsia and future CVD; this deficiency may limit the application of this risk factor to clinical care.

Preeclampsia (PE) is diagnosed using clinical criteria and in atypical cases the diagnosis may be inaccurate as there are no specific tests to confirm or exclude PE. This study sought to evaluate the utility of angiogenic biomarkers, sFlt1, sEng and PlGF to distinguish patients with gestational thrombocytopenia and immune thrombocytopenic purpura (ITP) from patients with thrombocytopenia resulting from the HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome, a complication of severe PE.Serum was collected and the angiogenic biomarkers of patients with ITP and gestational thrombocytopenia (N = 9) were compared to patients with HELLP (N = 11) and PE (N = 11). Circulating levels of these angiogenic biomarkers were also compared by gestational age to 1564 randomly selected normotensive women from the Calcium for Preeclampsia Prevention study.Patients with non-HELLP thrombocytopenia had lower sFlt1 (7.3 +/- 3.8 ng/ml vs. 15.5 +/- 5 ng/ml, P0.001), lower sEng (8.7 +/- 3.6 vs. 34 +/- 17, P0.001) and higher PlGF (484 +/- 412 vs. 66.3 +/- 44, P = 0.003) than patients with HELLP syndrome. Angiogenic factor abnormalities in patients with PE were similar to patients with HELLP syndrome, suggesting a common pathogenesis. Patients with non-HELLP thrombocytopenia had angiogenic profiles similar to normotensive controls, whereas patients with HELLP syndrome had levels higher than the 90th percentile for sFlt1 and sEng and lower than the 10th percentile for PlGF.Angiogenic biomarkers may be useful in excluding conditions that mimic PE.

To evaluate the success of a multidisciplinary approach to policy change regarding timing of antibiotic administration for the prevention of surgical-site infection after cesarean delivery.After review of the evidence, our multidisciplinary Obstetrics Leadership Committee decided to change policy on the timing of antibiotic prophylaxis for cesarean delivery. Using a combination of meetings, email communications, and local champions, 100% compliance with the new policy was achieved in 5 weeks. The effect of this policy change was investigated through a prospective cohort study of consecutive patients undergoing cesarean delivery at one institution from January 2009 through May 2009. Approximately halfway through the study period our department implemented a practice change that required antibiotic administration before skin incision rather than after clamping the umbilical cord. We compared the incidence of surgical-site infection, including endometritis, cellulitis, and total infectious morbidity, among women who received antibiotics before skin incision to those who received antibiotics after umbilical cord clamp.There were 533 consecutive women who underwent cesarean delivery during the study period. Two hundred forty (45.0%) women received antibiotics after cord clamping, and 285 (53.5%) women received antibiotics before skin incision; timing could not be determined for 8 (1.5%) women. Within 5 weeks of the policy change, 100% of the women undergoing cesarean delivery received perioperative prophylactic antibiotics before skin incision. The incidence of infectious morbidity fell from 5.4 to 2.5% when antibiotics were given before skin incision. Compared to the administration of antibiotics before skin incision, receiving antibiotics after cord clamp yielded a crude relative risk (RR) of 2.21 (95% CI 0.89-5.44) for total infectious morbidity and 3.56 (95% CI 0.73-17.49) for endometritis. Although not statistically significant, there was an increased risk of cellulitis (RR 1.66; 95% CI 0.53-5.17) when antibiotics were administered after cord clamping.A multidisciplinary approach was successful in achieving 100% adherence to our institution's policy change regarding timing of prophylactic antibiotics. This approach was necessary in order to incorporate this type of change into the labor and delivery workflow and may serve as a paradigm for success in implementing labor and delivery quality improvement projects. In addition, administration of prophylactic antibiotics before skin incision resulted in fewer surgical-site infections following cesarean delivery. As the clinical and economic impact of surgical-site infections is considerable, the once common practice of administering antibiotics after cord clamping should be avoided.

Background. Preeclampsia is difficult to diagnose in patients with underlying renal disease and proteinuria. Prior studies show that there is an angiogenic factor imbalance with elevated levels of antiangiogenic proteins soluble fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (sEng) and reduced levels of the proangiogenic protein, placental growth factor (PlGF) in women with preeclampsia. These angiogenic biomarkers may be useful in distinguishing preeclampsia from other conditions of pregnancy, which may present with overlapping clinical characteristics.Cases. Case 1: A multiparous woman at 18 weeks gestation with nephrotic syndrome presented with hypertensive emergency and worsening renal insufficiency. She underwent induction of labor for severe preeclampsia. Her sFlt1 and sEng levels were at the 97 percentile while her PlGF level was undetectable (less than the 1st percentile). Case 2: A nulliparous woman with lupus nephritis at 22 weeks gestation presented with fetal demise and heart failure. Three weeks previously, the patient had developed thrombocytopenia and hypertensive urgency. She underwent dilation and evacuation. Her angiogenic profile was consistent with severe preeclampsia.Conclusion. Angiogenic factors may provide evidence to support a diagnosis of preeclampsia in patients with preexisting renal disease and proteinuria, conditions in which the classical definition of hypertension and proteinuria cannot be used.

I read with interest a recent manuscript and letter to the editor by Baba et al.1 on a similar topic as our manuscript ‘Does previa location matter? Surgical morbidity associated with location of a placenta previa.’2 Baba et al. similarly found that anterior placenta previas are associated with massive hemorrhage (defined as >90th percentile of bleeding for the cohort) compared to posterior placenta previas. The primary end points in our manuscript (hysterectomy and blood transfusion) differ from the outcomes in Baba et al.’s manuscript of hemorrhage >2400 cc; however, both author groups tried to investigate the same question. We found that the majority of women requiring blood transfusion and hysterectomy were women with an anterior placenta who had a pathology-confirmed placenta accreta. Baba et al. noted that even when excluding placenta accretas women with an anterior placenta previa continued to have statistically higher blood loss compared to women with posterior placenta previas when controlling for select confounders. Although the exact cause of this finding remains speculative, taken in combination, the collective data indicate that placenta previa location in addition to cesarean delivery history is an important piece of information for clinicians preparing for a cesarean for placenta previa.

Hernias commonly coexist with pregnancy; however, an incarcerated hernia with bowel obstruction is rare at advanced gestation and requires urgent intervention.A multiparous woman with a known large incisional hernia presented at 33 weeks and 5 days gestational age with acute-onset, upper abdominal pain and nausea. The patient was diagnosed with small bowel obstruction secondary to an incarcerated hernia. She was managed with serial abdominal exams until her repeat cesarean section and simultaneous hernia repair were performed 24 h after admission and betamethasone administration. The patient and infant did well postoperatively.Bowel incarceration through an incisional hernia can occur during pregnancy and result in favorable maternal and neonatal outcomes with simultaneous delivery and surgical repair.

Objective Toll-like receptors (TLRs) are integral parts of the innate immune system and have been implicated in complications of pregnancy. The longitudinal expression of TLRs on dendritic cells in the maternal circulation during uncomplicated pregnancies is unknown. The objective of this study was to prospectively evaluate TLRs 1-9 as expressed on dendritic cells in the maternal circulation at defined intervals throughout pregnancy and postpartum. Study Design This was a prospective cohort of 30 pregnant women with uncomplicated pregnancies and 30 nonpregnant controls. TLRs and cytokine expression was measured in unstimulated dendritic cells at 4 defined intervals during pregnancy and postpartum. Basal expression of TLRs and cytokines was measured by multicolor flow cytometry. The percent-positive dendritic cells for each TLRs were compared with both nonpregnant and postpartum levels with multivariate linear regression. Results TLRs 1, 7, and 9 were elevated compared with nonpregnant controls with persistent elevation of TLR 1 and interleukin-12 (IL-12) into the postpartum period. Concordantly, levels of IL-6, IL-12, interferon alpha, and tumor necrosis factor alpha increased during pregnancy and returned to levels similar to nonpregnant controls during the postpartum period. The elevated levels of TLR 1 and IL-12 were persistent postpartum, challenging notions that immunologic changes during pregnancy resolve after the prototypical postpartum period. Conclusion Normal pregnancy is associated with time-dependent changes in TLR expression compared with nonpregnant controls; these findings may help elucidate immunologic dysfunction in complicated pregnancies.

This chapter presents the background for new code for simulating self-priming siphon-weirs within the Extended Transport (EXTRAN) module of the Stormwater Mana…

This chapter presents an approach to analysing combined sewer systems with dynamic sluice and radial gates for real-time flow control. New code was developed f…

New code developed for radial gates and siphon-weirs is suitable for handling unsteady flow conditions occurring in real sewer systems. RGEXTRAN is described i…

Objective We sought to evaluate an intrapartum nucleic acid amplification test (NAAT) for group B streptococcus (GBS). Study Design This was a prospective cohort study of 559 women comparing intrapartum GBS culture with antepartum culture and intrapartum NAAT. Results GBS prevalence was 19.5% by antepartum culture and 23.8% by intrapartum culture. Compared with intrapartum culture, antepartum culture had 69.2% sensitivity (60.6-76.9%) and 96.0% specificity (93.7-97.7%). The NAAT demonstrated sensitivity of 90.8% (84.6-95.2%), specificity of 97.6% (95.6-98.8%), and predictive values >92%. The incidence of discordant cultures was 10.4%. Of the women with negative antepartum and positive intrapartum cultures, only 1 (2.4%) received intrapartum antibiotics. Compared with white women, black ( P = .02) and Hispanic ( P = .02) women were more likely to have discordant cultures. Conclusion This intrapartum NAAT has excellent characteristics. It may be superior to antepartum culture for detecting intrapartum GBS–allowing more accurate management of laboring mothers and reducing neonatal GBS sepsis.