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To compare 2 different risk factor models for the prediction of shoulder dystocia.We performed a retrospective study of women with vaginal deliveries at a single institution over an 8-year period. Two distinct multivariable logistic regression models were used to evaluate the occurrence of shoulder dystocia: a traditional model used information based on birthweight and macrosomia, and a clinical model used information based on esti-mated fetal weight and suspected macrosomia.Of the 13,998 deliveries analyzed, there were 221 cases of shoulder dystocia (1.6%). In addition to the macrosomia or suspected macrosomia variables, the final models included prolonged second stage of labor, diabetes status, and oxytocin use. Neither model was highly sensitive or highly specific, and neither demonstrated a cutoff threshold that yielded a clinically viable PPV.Despite the presence of 1 or more risk factors for shoulder dystocia, its occurrence remains largely an unpredictable clinical event.

Although vaccination against the Human Papilloma Virus (HPV) reduces the risk of related morbidities, the vaccine uptake remains low in adolescents. This has been attributed to limited parental knowledge and misconceptions. In this cross sectional study, we assessed the (1) clarity of educational material informing Hispanic mothers about HPV, cervical cancer and the HPV vaccine, (2) determined vaccination acceptability and (3) identified predictors of vaccine acceptance in an underserved health setting. 418 Hispanic mothers received the educational material and completed an anonymous survey. 91 % of participants understood most or all of the information provided. 77 % of participants reported vaccine acceptance for their children; this increased to 84 % when only those with children eligible to receive vaccination were included. Significant positive predictors of maternal acceptance of the HPV vaccine for their children were understanding most or all of the provided information, older age and acceptance of the HPV vaccine for themselves. Concerns about safety and general dislike of vaccines were negatively associated with HPV vaccine acceptance. Prior knowledge, level of education, previous relevant gynecologic history, general willingness to vaccinate and other general beliefs about vaccines were not significantly associated with HPV vaccine acceptance. The majority of participants reported understanding of the provided educational material. Vaccine acceptability was fairly high, but was even higher among those who understood the information. This study documents a cost-effective way to provide Hispanic mothers with easy-to-understand HPV-related information that could increase parental vaccine acceptability and future vaccine uptake among their children.

Objective We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery. Study Design We conducted a retrospective cohort study of 652 infants born between 24 and 30 6/7 weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables. Results Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10–2.90), require intubation (OR, 1.80; 95% CI, 1.12–2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02). Conclusion Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.

Objective: To compare the incidence of histopathological features in placentas from women with cholestasis of pregnancy to healthy individuals without ICP. Methods: Placentas from mothers with and without cholestasis of pregnancy were reviewed by a pathologist masked to the study group. Subjects were excluded if they had medical problems already associated with placental histopathology. Results: Twenty-four cases and 30 controls placentas were reviewed. Seventeen placental histopathological features were found. There was no statistically significant difference between the groups. Amongst patients with cholestasis, there was a decrease in villitis of unknown etiology in those treated with ursodeoxycholic acid. Conclusion: There is no difference in the placental histopathology in cholestasis of pregnancy compared to normal pregnancies, but treatment of patients with cholestasis of pregnancy with ursodeoxycholic acid may decrease findings of villitis of unknown etiology.

The link between depression, obesity, and fertility status is poorly understood among Latina women. The Patient Health Questionnaire 9 (PHQ-9) is routinely administered in the Diabetes and Obesity in Reproductive Age women Clinic. We describe median PHQ-9 score and PHQ-9 score ≥10 [indicative of Major Depressive Disorder (MDD)] by fertility status. Of the 76 eligible new patients seen between June 2008 and 2009, 18.4% (n = 14) had PHQ-9 scores indicative of MDD. Infertile women had marginally significantly higher PHQ-9 scores than non-infertile women (p = 0.08). 26.5% of infertile women and 12.2% of non-infertile women had a PHQ-9 score indicative of MDD (p = 0.14). Number of previous births was inversely correlated with PHQ-9 score (R = -0.34, p = 0.002), those with no previous births had higher PHQ-9 scores (p = 0.001) and were more likely to have a PHQ-9 score indicative of MDD than those with previous births (28.6 vs. 9.8%, p = 0.04). Among non-infertile women, postpartum women had significantly lower PHQ-9 scores than non-postpartum women (p = 0.002). 4.6% of postpartum women and 21.1% of non-postpartum women had a PHQ-9 indicative of MDD (p = 0.19). Further investigation is needed to determine if reproductive success is protective against MDD among overweight and obese urban Latinas. Overall, depression is common among overweight and obese reproductive-age Latinas and thus routine screening is recommended.

Objective To evaluate the clinical utility of dilation and curettage (D&C) in diagnosing ectopic pregnancy (EP). Design Retrospective cohort study. Setting University hospital. Patient(s) Clinically stable women (n = 321) who underwent a diagnostic D&C with no visible intrauterine pregnancy (IUP) on transvaginal ultrasound or those with an abnormal hCG trend. Intervention(s) None. Main Outcome Measure(s) EP or IUP made by final pathologic review. Result(s) Overall, 73.2% of the patients were ultimately diagnosed with EP and 26.8% were found to have a nonviable IUP. Those with EPs had significantly lower initial hCGs than those with nonviable IUPs and were more likely to have had a history of an EP. On ultrasound, the overall impression, the presence of free fluid, and the endometrial echo complex correlated well with the final diagnoses but did not have 100% predictive value. Conclusion(s) D&C remains valuable to differentiate EP from nonviable IUP and to avoid misdiagnosis and unnecessary exposure to methotrexate. Low initial hCG values and ultrasound findings such as a thin endometrial echo complex and the presence of free fluid are associated with but are not diagnostic of an ectopic pregnancy.

To compare time to delivery between two induction procedures. The Foley balloon is a mechanical method for cervical ripening. However, the device may also result in endogenous prostaglandin release following separation of the chorionic membrane and decidua. Prolonged Foley placement may therefore be unnecessary for successful labor induction. Randomized controlled trial of labor induction at LAC+USC Medical Center between 2010 and 2013. Subjects were assigned to either (a) standard placement of the Foley balloon or (b) Foley balloon insufflation and immediate removal. Oxytocin was administered to all subjects not in active labor after 12 h. Delivery information and neonatal outcomes were documented and all patients were followed for 6 weeks for adverse events. A total of 79 women were included in the analysis (37 standard and 42 immediate). Induction time was 8.6 h longer in the immediate removal group (23.5 vs 32.1, P=0.002), but the difference in delivery within 24 h did not meet the statistical significance (46.0 vs 28.6%, P=0.11). Similar rates of cesarean delivery, epidural use and abnormal APGAR scores were observed. After controlling for number of vaginal exams and duration of rupture, a decreased risk of infection was observed in the immediate removal group (odds ratio=0.08, 95% confidence interval=0.007 to 0.93, P=0.04). Further, when the analysis was stratified by parity, differences in induction time only persisted in nulliparous women. Immediate removal of the Foley balloon may lead to longer overall induction time, but a lower risk of infection. Parous women may be particularly good candidates for this type of induction.

To compare the obstetrical outcomes of term pregnancies induced with one of four commonly used labor induction agents.This is a retrospective cohort study of induced deliveries between 1 August 1995 and 31 December 2007 occurring at the Los Angeles County + University of Southern California Medical Center. Viable, singleton, term pregnancies undergoing induction were identified. Exclusion criteria included gestational age less than 37 weeks, previous cesarean delivery, breech presentation, stillbirth, premature rupture of membranes, and fetal anomaly. Induction methods studied were oxytocin, misoprostol, dinoprostone and Foley catheter. Our primary outcome was cesarean delivery rate among the four induction agents. Secondary outcomes included rate of failed induction, obstetrical complications, and immediate neonatal complications.A total of 3707 women were included in the study (1486 nulliparous; 2221 multiparous). Outcomes were compared across induction methods using Chi-square Tests (Pearson or Fisher's, as appropriate). Among the nulliparous patients, there was no statistical difference among the four induction agents with regards to cesarean delivery rate (p = 0.51), frequency of failed inductions (p = 0.49), the cesarean delivery frequency for "fetal distress" (p = 0.82) and five minute Apgar score7 (p = 0.24). Among parous patients, the cesarean delivery rate varied significantly by induction method (p 0.001), being lowest among those receiving misoprostol (10%). Those receiving oxytocin and transcervical Foley catheter had cesarean rates of 22%, followed by dinoprostone at 18%. The rate of failed inductions was 2% among those receiving misoprostol, compared to 7-8% among those in the other groups (p 0.01). Although cases of "fetal distress" between the four induction agents was not significantly different amongst multipara women, the cesarean delivery indication for "fetal distress" was higher among multipara receiving misoprostol (p = 0.004). There was no difference among the different induction agents with regards to five minute Apgar7 (p = 0.34).Among nulliparous women, all induction methods have similar rate of cesarean delivery. The use of misoprostol appears to be associated with a lower risk of cesarean birth among parous women induced at our institution.

Objective To determine the preoperative pelvic ultrasonographic characteristics of postmenopausal women diagnosed with endometrial cancer (EC) at our institution. Methods Postmenopausal women with EC who underwent preoperative transvaginal pelvic ultrasound from 1999–2009 were identified from our institutional database. The histologic diagnosis was based on pathologic findings in the hysterectomy specimen. Endometrial echo complex (EEC) thickness was abstracted from ultrasound reports. In all instances, ultrasound preceded the biopsy by a maximum of 3months. Means with standard deviations were calculated for all categorical data. Differences between type 1 and type 2 ECs were determined using Mann–Whitney U tests and Chi squared/Fisher's exact tests, as appropriate. A p-value of Results Among 250 patients with postmenopausal EC, 156 had type 1 EC while 94 had type 2 EC. Thirty-six percent of the cohort had an EEC ≤4mm, including 37% of patients with type 1 EC and 34% of patients with type 2 EC (p=0.63). There were no significant differences between type 1 and type 2 ECs in any demographic characteristic, other than likelihood of postmenopausal bleeding. Conclusions Current expert opinion recommends no further diagnostic procedure in a woman with postmenopausal bleeding and an EEC ≤4mm. These results indicate that a sizable proportion of women with EC have EECs ≤4mm during their initial evaluation. An EEC ≤4mm does not completely rule out endometrial cancer and cannot supplant histologic evaluation.

Objective To evaluate the interobserver reliability of fetal heart rate (FHR) pattern definition and interpretation assessed by physicians at various levels of training using standard Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) definitions and standard principles of interpretation. Study Design We conducted an interrater reliability study of the intrapartum FHR tracings of 32 singleton term pregnancies at Los Angeles County–University of Southern California (LAC + USC) Medical Center. Analysis included the 5 hours immediately preceding delivery, divided into 10- minute segments. A medical student, resident, and three attending physicians evaluated the same set of FHR tracings. Interobserver agreement was assessed using the free-marginal kappa coefficient. Results Reviewers demonstrated substantial to excellent agreement on baseline rate (κ = 0.97), moderate variability (κ = 0.80), accelerations (κ = 0.62), decelerations (κ = 0.63), category (κ = 0.68), and the ability to identify the presence of either moderate variability or accelerations (κ = 0.82). Conclusions Interobserver agreement was significantly higher on all components of FHR definition and interpretation than previously expected. Standardization of FHR definitions and interpretation may improve interobserver reliability and patient safety.

Objective To determine the current status of oocyte cryopreservation across the United States, and the perceived indications for its use. Design Cross-sectional survey of all IVF Centers in the United States. Setting Telephone and fax based survey of all IVF practice or laboratory directors, conducted March to June of 2009. Patient(s) None. Intervention(s) None. Main Outcome Measure(s) Prevalence of oocyte cryopreservation, acceptable indications and age groups, number of oocyte cryopreservation cycles performed and thawed, fertilization and pregnancy rates, number of live births. Result(s) Of 442 centers contacted, 282 (64%) responded in 49 states. In these centers 143 (51%) programs currently offer oocyte cryopreservation, with a geographic trend toward the western-located clinics. Of all programs, 36% offer oocyte cryopreservation only for cancer patients or as an alternative to embryo cryopreservation after IVF, whereas 64% of programs offer it electively in women of advancing maternal age. For elective indications, 87% of programs accept patients aged 35–37 years, 49% consider age 38–40 years as acceptable, whereas only 26% of programs cryopreserve oocytes beyond age 40 years. Three hundred thirty-seven live births resulting from 857 thawed cycles (39.3% pregnancy rate [PR]) were reported across all centers. Conclusion(s) Oocyte cryopreservation is offered in more than 50% of ART clinics in the United States. Most programs that perform oocyte cryopreservation for cancer indications offer it for elective delay of childbearing as well. These data suggest a growing acceptance for this technology within our field.