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To evaluate the association between a single abnormal value on a 3-h 100 g oral glucose tolerance test (OGTT) results and future type-2 diabetes mellitus (Type-2 DM). Retrospective cohort study of women between 18 and 45 years of age who underwent a 3-h OGTT during pregnancy and delivered in a tertiary medical center between 2007 and 2014. The women were followed for a median period of 64 months postpartum. According to OGTT values, women were divided into three groups: normoglycemic (normal OGTT), single abnormal OGTT value (SAV) and gestational diabetes mellitus (two or more abnormal OGTT values, GDM). General pre-pregnancy characteristics, cardiovascular risk factors and future diagnosis of Type-2 DM, as the primary outcome, were recorded. During the study period, 5295 women underwent an OGTT and were followed for a median period of 64 months (interquartile range of 32). The cohort was divided as following: 3639 (68.73%) were normoglycemic, 854 (16.13%) had a SAV in the OGTT and 802 (15.15%) were diagnosed with GDM. Compared with normoglycemic controls, women with SAV and GDM tended to be older (32.20, 33.10 and 31.35 years for SAV, GDM and controls, respectively, p

Objective To evaluate whether pregnancy outcomes associated with hypertensive disorders of pregnancy in twin pregnancies differ relatively from those in singleton pregnancy. Methods We conducted a retrospective, population-based cohort study of all women with a liveborn singleton or twin hospital birth in Ontario, Canada, between 2012 and 2019. Data were obtained from the Better Outcomes Registry & Network Ontario. Pregnancy outcomes were compared between women with and without hypertensive disorders of pregnancy in twin gestations, and separately in singleton gestations. Adjusted relative risks (aRRs) and 95% CIs were generated using modified Poisson regression and were compared between twins and singletons using relative risk ratios. Results Overall, 932,218 women met the study criteria, of whom 917,542 (98.4%) and 14,676 (1.6%) had singleton and twin gestations, respectively. The incidence of hypertensive disorders of pregnancy was higher in women with twin compared with singleton gestations (14.4% vs 6.4%, aRR 1.85 [1.76-1.94]). Hypertensive disorders of pregnancy were associated with certain adverse outcomes in singleton gestations only and with other adverse outcomes in both the singleton and twin gestations, but the aRR was lower in twins. For example, preterm birth before 37 weeks of gestation (singletons: 15.2% [hypertensive disorders of pregnancy] vs 5.4% [no hypertensive disorders of pregnancy], aRR 2.42; twins: 67.5% [hypertensive disorders of pregnancy] vs 50.4% [no hypertensive disorders of pregnancy], aRR 1.30) and neonatal respiratory morbidity (singletons: 16.3% [hypertensive disorders of pregnancy] vs 8.7% [no hypertensive disorders of pregnancy], aRR 1.50; twins: 39.8% [hypertensive disorders of pregnancy] vs 32.7% [no hypertensive disorders of pregnancy], aRR 1.13). These findings persisted in the subgroups of women with preeclampsia and early-onset preeclampsia. Conclusions Although the absolute risk of adverse maternal and neonatal outcomes is higher in twin compared with singleton pregnancies, the incremental risk of adverse outcomes associated with hypertensive disorders in twin pregnancies is lower than the incremental risk in singleton pregnancies. These findings may be attributed in part to the higher baseline risk of preterm birth and adverse maternal and perinatal outcomes in twin compared with singleton pregnancies.

To explore the role of maternal ethnicity as a risk factor for obstetrical anal sphincter injury (OASI).A retrospective cohort study of all women with singleton gestations who had a vaginal delivery at term, between January 2014 and October 2017, at a single center. OASI was defined as a third-degree perineal tear (anal sphincter complex) or a fourth-degree perineal tear (anorectal mucosa). The characteristics of women with and without OASIs were compared. Multiple logistic regression was performed to account for potential confounders, including ethnicity.During the study period, 11 012 women were eligible for inclusion, of whom 336 (3.1%) had an OASI; 313 (93.1%) had a third-degree tear, and 23 (6.9%) had a fourth-degree tear. Women with OASIs were characterized by younger maternal age (35 years), Asian ethnicity, nulliparity, neonatal birth weight ≥3500 grams, midline and mediolateral episiotomy, second stage of labour lasting ≥60 minutes, and assisted vaginal delivery. After adjusting for potential confounders, Asian ethnicity remained independently associated with increased risk of OASI (adjusted odds ratio 2.07; 95% CI 1.6-2.7) whereas mediolateral episiotomy was independently associated with decreased risk of OASI (adjusted odds ratio 0.64; 95% CI 0.5-0.9).Asian ethnicity is independently associated with increased risk of OASI. Although midline episiotomy increases the risk of OASI, mediolateral episiotomy may protect against OASI, and should be considered in high-risk patients.

To identify risk factors for postpartum hemorrhage (PPH) following cesarean delivery (CD).A retrospective study of all women who underwent CD in a university-affiliated tertiary hospital (2014-15). PPH was defined as any of the following: clinical PPH (≥1000 ml estimated blood loss), hemoglobin (Hb) drop ≥3 g/dl (the difference between pre-CD Hb level within a 24 h prior to the delivery) and post-CD (nadir level during the first 72 h after CD)) or the need for blood products transfusion. The characteristics of women with PPH following CD were compared to a control group of those with CD without PPH.Of the 15,564 deliveries during the study period, 3208 (20.6%) women met inclusion criteria, of them, 307 (9.6%) had PPH and 2901 (90.4%) served as controls. Women in the PPH group were younger (32.6 ± 5.3In women undergoing cesarean section, urgent CD, the duration of the surgery, and the number of the previous CD are associated with the risk of PPH and should be taken into consideration during the postpartum assessment.

To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD. This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries. Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73–8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39–0.97, and aOR 0.49; 95% CI 0.25–0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC. Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.

Objective: The aim of the current study was to identify the optimal cutoff that should define discordance in dichorionic twin gestations through correlation with abnormal placental pathology as a specific measure of fetal growth restriction of the smaller twin. Methods: We performed a retrospective cohort study of all women with dichorionic twin pregnancies who gave birth in a single center between 2002 and 2015. We investigated the association between the level of growth discordance and maternal vascular malperfusion (MVM) pathology in the placenta of the smaller twin, with and without adjustment for whether the smaller twin is small for gestational age (SGA). Results: A total of 1,198 women with dichorionic twin gestation met the study criteria. The rate of MVM pathology in the placenta of the smaller twin increased with the level of discordance and was most obvious for discordance ≥25% (rate of MVM 12.0% compared with 2.8% in cases with discordance Conclusion: Our findings suggest that discordant growth in dichorionic twins should raise the concern of fetal growth restriction of the smaller twin, irrespective of whether the smaller twin is SGA, only when the discordance s ≥25%. The association of lower levels of discordance with abnormal placental pathology is mainly driven by the confounding effect of SGA of the smaller twin.

Objectives To evaluate the utility of ultrasound markers in the management of pregnancies complicated by preterm prelabor rupture of membranes (PPROM) between 23 + 0 and 33 + 6 weeks' gestation, and to assess the ability of ultrasound markers to predict adverse neonatal outcomes. Methods This was a retrospective cohort study of all patients with PPROM between 23 + 0 and 33 + 6 weeks' gestation and latency period (PPROM to delivery) > 48 h, who delivered before 34 weeks' gestation at a tertiary referral center between 2005 and 2017. All patients underwent a non-stress test daily and an ultrasound scan twice a week for assessment of amniotic fluid volume, biophysical profile (BPP) and umbilical artery (UA) pulsatility index (PI). In patients with suspected fetal growth restriction, fetal middle cerebral artery (MCA)-PI was also assessed and the cerebroplacental ratio (CPR) calculated. The last ultrasound examination performed prior to delivery was analyzed. We compared the characteristics and outcomes between women who were delivered owing to clinical suspicion of chorioamnionitis and those who were not delivered for this indication. The primary objective was to evaluate the utility of ultrasound in the management of patients with PPROM. The secondary objective was to assess the diagnostic performance of ultrasound markers (BPP score 95th percentile, MCA-PI Results A total of 504 women were included in the study, comprising 120 with suspected chorioamnionitis and 384 without. Women with suspected chorioamnionitis, compared with those without, were less likely to be nulliparous (34.2% vs 45.3%; P = 0.03) and more likely to have fever (50.8% vs 2.6%; P 95th percentile was similar between the two groups. There was a higher incidence of composite adverse neonatal outcome in the group with suspected chorioamnionitis than in the group without (78.3% vs 64.3%, respectively; P = 0.004). However, on logistic regression analysis, none of the ultrasound markers evaluated was found to be associated with chorioamnionitis or composite adverse neonatal outcome, and they all had a poor diagnostic performance for the prediction of chorioamnionitis and composite adverse neonatal outcome. Conclusions Commonly used ultrasound markers in pregnancies complicated by PPROM were similar between women delivered for suspected chorioamnionitis and those delivered for other indications, and performed poorly in predicting composite adverse neonatal outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

To investigate clinical and sonographic features associated with sonographic accuracy for the prediction of small for gestational age (SGA) and macrosomia at birth.The database of a tertiary medical center was retrospectively searched for women who gave birth at term to a singleton healthy neonate in 2007-2014 and underwent sonographic estimated fetal weight (sEFW) evaluation within 3 d before delivery. Fetal growth restriction (FGR) and SGA were defined as sEFW or birth weight10th percentile for gestational age; macrosomia was defined as birth weight4000 grams. Data on maternal age, parity, gestational age, fetal gender, presentation, placental location, diabetes, hypertension, and oligo/polyhydramnios were compared between pregnancies with a false-negative and false-positive diagnosis of SGA or macrosomia.Of the 5425 fetal weight evaluations, 254 (4.7%) deviated by15% from the actual birth weight. Nulliparity, absence of diabetes, neonatal female gender, anterior placenta, lower birth weight, and oligohydramnios were associated with a high deviation. We identified 482 SGA neonates (8.9%) and 633 macrosomic neonates (11.7%). A false-positive diagnosis of FGR was associated with oligohydramnios, absence of diabetes, and posterior placenta, and a false-negative diagnosis, with older maternal age, nulliparity, and male gender. A false-positive diagnosis of macrosomia was associated with older maternal age, multiparity, polyhydramnios, anterior placenta, and lack of hypertensive complications, and a false-negative diagnosis, with diabetes, hypertension, oligohydramnios, and vertex presentation.The accuracy of sEFW is affected by clinical and sonographic pregnancy characteristics. Further analyses should focus on improving accuracy especially at the fetal weight extremes.

Objective Amniotic fluid volume (AFV) plays an important role in early fetal lung development, and oligohydramnios in early pregnancy is associated with pulmonary hypoplasia. The aim of this study was to evaluate the association between AFV at the time of presentation with early preterm prelabor rupture of membranes (PPROM) and severe neonatal respiratory morbidity and other adverse pregnancy outcomes. Methods This was a retrospective study of all women with a singleton pregnancy, admitted to a single tertiary referral center between 2004 and 2014, for expectant management of PPROM at 20 + 0 to 28 + 6 weeks' gestation. The primary exposure was AFV at presentation, classified according to sonographic maximum vertical pocket (MVP) as: normal AFV (> 2 cm), oligohydramnios (≤ 2 cm and > 1 cm) or severe oligohydramnios (≤ 1 cm). The primary outcome was a composite variable of severe respiratory morbidity, defined as either of the following: (1) need for respiratory support in the form of mechanical ventilation using an endotracheal tube for ≥ 72 h and need for surfactant; or (2) bronchopulmonary dysplasia, defined as requirement for oxygen at postmenstrual age of 36 weeks or at the time of transfer to a Level-II facility. Adjusted odds ratios (aOR) and 95% CI for the primary and secondary outcomes were calculated for each AFV-at-presentation group (using normal AFV as the reference), adjusting for gestational age (GA) at PPROM, latency period, birth weight, mode of delivery and chorioamnionitis. Results In total, 580 women were included, of whom 304 (52.4%) had normal AFV, 161 (27.8%) had oligohydramnios and 115 (19.8%) had severe oligohydramnios at presentation. The rates of severe respiratory morbidity were 16.1%, 26.7% and 45.2%, respectively. Compared with normal AFV at presentation, oligohydramnios (aOR, 3.27; 95% CI, 1.84-5.84) and severe oligohydramnios (aOR, 4.11; 95% CI, 2.26-7.56) at presentation were associated independently with severe respiratory morbidity. Other variables that were associated independently with the primary outcome were GA at PPROM (aOR, 0.54; 95% CI, 0.43-0.69), latency period (aOR, 0.94; 95% CI, 0.91-0.98) and Cesarean delivery (aOR, 2.01; 95% CI, 1.21-3.32). Conclusions In women with early PPROM, AFV at presentation, as assessed by the MVP on ultrasound examination, is associated independently with severe neonatal respiratory morbidity. This information may be taken into consideration when counseling women with early PPROM regarding neonatal outcome and management options. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

We retrospectively included women with abnormal FTS analytes and compared outcomes between those with elevated and normal UtA-PI. Out of 582 women with abnormal FTS analytes, 65 (11.2%) had elevated UtA-PI. Neonates of women in this group had higher rates of birth weight3rd, 5th, and 10th percentile. The area under the ROC curve for predicting FGR10th percentile by UtA-PI was 0.584, for FGR5th percentile 0.593, and for FGR3rd percentile 0.720. In women with abnormal FTS, elevated UtA-PI is associated with higher rates of FGR, but its predictability is moderate-to-poor.

Lateral placentation may compromise placental perfusion, and we aimed to assess whether it impacts pregnancy outcomes. This single-center retrospective study included 1203 singleton pregnancies, categorized into two groups according to placental location. Women with lateral placenta had significantly higher risk of preterm birth

OBJECTIVE To determine maternal and neonatal complications associated with an intrapartum cesarean delivery (CD) with and without a history of a previous CD. METHODS A retrospective cohort study of all women who underwent an unplanned intrapartum CD following a trial of labor in a university-affiliated tertiary hospital, between 2009 and 2016. Perinatal outcomes of women with and without a history of a previous CD were compared. Composite adverse maternal outcome included one or more of the following: postpartum hemorrhage, need for blood transfusion, or cesarean hysterectomy. Composite adverse neonatal outcome included one or more of the following: 5-min Apgar score

The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. Although observational and retrospective data were accumulated, it was not until the publication of the Twin Birth Study that evidence-based recommendations could emerge. However, although some of the most pressing questions were answered by the Twin Birth Study, other questions were left outside the scope of the study. The questions were of great interest and included the following topics: the impact of gestational age, the influence of chorionicity, and the generalizability of the results for women with a previous uterine scar. The current evidence supported a trial of labor in dichorionic-diamniotic or monochorionic-diamniotic twin pregnancies in which the first twin is in cephalic presentation at ≥32 weeks’ gestation. Dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic twins should be delivered at 37 0/7 to 38 0/7, 36 0/7 to 37 0/7, and 32 0/7 to 34 0/7 weeks’ gestation, respectively. Breech extraction done by a competent healthcare provider seemed to offer a higher chance of successful vaginal delivery of the second twin than the external cephalic version. The current data did not allow for a clear recommendation regarding the mode of delivery in very preterm birth of low birthweight twins, but most studies did not demonstrate a clear benefit of cesarean delivery vs trial of labor. Furthermore, a trial of labor seemed safe in women with a previous cesarean delivery. Cesarean delivery is likely beneficial for twin pregnancies with the first twin in breech presentation, monochorionic-monoamniotic twins, and higher-order multiple pregnancies. In all multiple pregnancies, delivery should be performed by an experienced practitioner competent in multiple pregnancy deliveries.

To evaluate whether induction of labor (IOL), as compared with expectant management, in gestational diabetes mellitus (GDM) mothers at term (between 370/7 and 406/7), decreases caesarean section (CS) rate and the rate of adverse composite neonatal outcomes. A retrospective cohort study, of all women with GDM and a singleton gestation who delivered at term in a single, tertiary, university-affiliated medical center (2007–2014). We compared outcomes of women who underwent IOL at each week of gestation between 370/7 and 406/7 weeks with women who were managed expectantly. The primary outcome was CS rate. Overall, 2472 GDM patients included in the study, of which 880 women had IOL. CS rate was not found to be significantly different between the groups at any gestational age. IOL at 37 weeks was associated with adverse composite neonatal outcome (aOR 2.2, 95% CI 1.4–3.6) and NICU admission (aOR 2.5, 95% CI 1.4–4.4). At 38 weeks, with NICU admission (aOR 2.0, 95% CI 1.4–2.9), and at 39 weeks with fracture of the clavicle. In a sub-analysis of nulliparous women, IOL at 37 weeks had higher odds of NICU admission and adverse composite neonatal outcomes, at 38 weeks with CS and at 39 weeks with fracture of the clavicle. IOL in GDM mothers at term does not reduce CS rate and may be associated with increased CS rate among nulliparous women at 38 weeks. It is also associated with increased risk for adverse composite neonatal outcome or NICU admission when done prior to 390/7 weeks.

Objective: We aimed to evaluate the association between second trimester biochemical markers and pathological placentation. Methods: This was a retrospective case-control study (2007–2014) of singleton gestations at a university-affiliated tertiary center. Women with pathologic placentation were subdivided into three groups: placenta accreta (group A), placenta previa (group B), or both (group C). We compared second trimester biochemical screening markers taken between 16 + 0 and 19 + 6 weeks of gestation between groups A, B, and C, and women with normal placentation (group D). Obstetrical and neonatal outcomes, risk factors for pathologic placentation, and second trimester biochemical marker values were compared between groups. Results: Overall, 301 deliveries were evaluated: 64 (21%) in group A, 66 (22%) in group B, 17 (6%) in group C, and 153 (51%) in group D. Each of the pathological placentation groups individually had a higher median alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) multiples of median (MoM) than the controls, with the highest values of AFP and hCG observed among women with placenta accreta and the lowest values among the controls. When a multivariant analysis was applied, the hCG levels remained significantly correlated with pathological placentation. Receiver operation characteristic curves for AFP, hCG, or both were computed. For AFP the area under the ROC curve (AUC) was 0.573 (95% CI 0.515–0.630, p < 0.0274) and a cut-off value above 0.99 MoM demonstrated a sensitivity and specificity of 71 and 46%, respectively, for the prediction of pathological placentation. For hCG, the AUC was 0.662 (95% CI 0.605–0.715, p < 0.0001) and a cut-off value of 1.25 MoM demonstrated a sensitivity and specificity of 53 and 68%. When both markers were plotted, the AUC was 0.668 (95% CI 0.611–0.721, p < 0.0001) and sensitivity and specificity were 63 and 64%, respectively. A percentile MoM cut-off approach distinguished between two groups: a high-risk group (patients with AFP or hCG or both above the 75th percentile, odds ratio (OR) for pathological placentation 2.27, 95% CI 1.42–3.63), and a low-risk group (patients with AFP or hCG or both below the 25th percentile, OR for pathological placentation 0.38, 95% CI 0.24–0.60). Conclusion: Second trimester biomarkers such as hCG and AFP can be used to raise a suspicion towards characterizing women into high-risk and low-risk groups for pathological placentation.

In singletons, the pathogenesis of hypertensive disorders of pregnancy (HDP) is attributed to abnormal placentation, characterized by maternal vascular malperfusion (MVM) lesions. Whether MVM plays a similar role in twin pregnancies is unclear. The purpose of the study was to compared placental pathology findings between dichorionic-twin and singleton pregnancies complicated by HDP.Retrospective cohort study of women with dichorionic-twin or singleton pregnancies complicated by HDP who gave birth in a single tertiary center between 2001 and 2015. Placental abnormalities were classified into lesions associated with MVM, fetal vascular malperfusion, placental hemorrhage and chronic villitis. Placental findings and neonatal outcomes were compared between twin and singleton pregnancies.A total of 144 women with twins and 768 women with a singleton pregnancy met the inclusion criteria. Compared with HDP singletons, twins with HDP had higher mean birth weights, were less likely to be small for gestational age and be born at34 and at32 weeks. Twins had lower odds for placental weight below10th percentile (aOR 0.49, 95%CI 0.33-0.71), for MVM pathology (aOR 0.28, 95%CI 0.20-0.39) and for fetal vascular malperfusion pathology (aOR 0.65, 95%CI 0.45-0.93). These finding remained significant in the subpopulation of early onset HDP (34 weeks) and small for gestational newborn.Our findings support the hypothesis that MVM are less relevant to the pathogenesis of HDP in twin pregnancies and suggest that other placental or non-placental factors are responsible for the increased risk of HDP in twin pregnancies.

ObjectivesAntenatal corticosteroids (ACS) decrease neonatal mortality and morbidity among preterm neonates, yet there has been concern regarding their long-term safety. We hypothesised that potential long-term adverse effects of ACS may be observed among infants born during the late preterm period (LPT, 340/7–366/7weeks of gestation), when the benefits of ACS are subtle.DesignPopulation-based, retrospective cohort.SettingOntario, Canada, between 2006 and 2011.PatientsAll live singleton infants born during the LPT period with a minimum 5-year follow-up.InterventionsExposure to ACS prior to 340/7weeks of gestation.Main outcome measuresSuspected neurocognitive disorder, audiometry testing or visual testing.ResultsOverall, 25 668 infants were eligible for analysis, of whom 2689 (10.5%) received ACS. Infants in the ACS group had lower mean birth weight and higher rates of birth weight ConclusionIn children born during the LPT period, exposure to ACS prior to 340/7weeks of gestation is associated with an increased utilisation of the healthcare system related to audiometry and visual testing and suspected neurocognitive disorders by 5 years of age.

Background We assessed the association of early term at first birth (ETB) with the risk of preterm birth (PTB) and ETB in women with 3 consecutive deliveries. Methods We conducted a retrospective cohort study of all women with 3 consecutive singleton births at a single institute from 1994 to 2013. The risk of PTB ( Results Of 49,259 women delivered in our center during the study period, 4038 met inclusion criteria. The rate for subsequent PTB, spontaneous PTB and recurrent ETB in the 3rd delivery significantly increased as the number of prior ETBs increased. The order of a single prior ETB in one of the first two deliveries was differently associated with the risk of complications in the 3rd delivery, which was higher when the prior ETB was more recent to the third delivery. Conclusion A history of ETB is associated with the risk of future PTB and recurrent ETB. The risk is related to the number and order of prior ETBs.

Background Estimation of fetal weight (EFW) by ultrasound is useful in clinical decision-making. Numerous formulas for EFW have been published but have not been validated in pregnancies complicated by preterm premature rupture of membranes (PPROM). The purpose of this study is to compare the accuracy of EFW formulas in patients with PPROM, and to further evaluate the performance of the most commonly used formula - Hadlock IV. Methods A retrospective cohort study of women with singleton gestations and PPROM, admitted to a single tertiary center between 2005 and 2017 from 220/7–330/7 (n = 565). All women had an EFW within 14 days of delivery by standard biometry (biparietal diameter, head circumference, abdominal circumference and femur length). The accuracy of previously published 21 estimated EFW formulas was assessed by comparing the Pearson correlation with actual birth weight, and calculating the random error, systematic error, proportion of estimates within 10% of birth weight, and Euclidean distance. Results The mean gestational was 26.8 ± 2.4 weeks at admission, and 28.2 ± 2.6 weeks at delivery. Most formulas were strongly correlated with actual birth weight (r > 0.9 for 19/21 formulas). Mean systematic error was − 4.30% and mean random error was 14.5%. The highest performing formula, by the highest proportion of estimates and lowest Euclidean distance was Ott (1986), which uses abdominal and head circumferences, and femur length. However, there were minimal difference with all of the first 10 ranking formulas. The Pearson correlation coefficient for the Hadlock IV formula was strong at r = 0.935 (p p p Conclusions In women with singleton gestation and PPROM, the Ott (1986) formula for EFW was the most accurate, yet all of the top ten ranking formulas performed quite well. The commonly used Hadlock IV performed quite similarly to Ott’s formula, and is acceptable to use in this specific setting.

Background It has been suggested that women admitted for delivery should have universal PCR testing for SARS‐CoV‐2. Yet, the considerable difference in the incidence of COVID‐19 between different geographic regions may affect screening strategies. Therefore, we aimed to compare questionnaire‐based testing versus universal PCR testing for SARS‐CoV‐2 in women admitted for delivery. Methods A prospective cohort study of women admitted for delivery at a single center during a four‐week period (April 22‐May 25, 2020). All women completed a questionnaire about COVID‐19 signs, symptoms, or risk factors, and a nasopharyngeal swab for PCR for SARS‐CoV‐2. Women who were flagged as suspected COVID‐19 by the questionnaire (questionnaire‐positive) were compared with women who were not flagged by the questionnaire (questionnaire‐negative). Results Overall, 446 women were eligible for analysis, of which 54 (12.1%) were questionnaire‐positive. PCR swab detected SARS‐CoV‐2 in four (0.9%) women: 3 of 392 (0.8%) in the questionnaire‐negative group, and 1 of 54 (1.9%) in the questionnaire‐positive group (P = .43), yielding a number needed to screen of 92 (95% CI 62‐177). In 96% of the cases, the PCR results were obtained only in the postpartum period. No positive PCR results were obtained from neonatal testing for SARS‐CoV‐2. The sensitivity of the questionnaire was 75.0%, and the negative predictive value was 99.7%. Conclusions Although the rate of positive PCR results was not significantly different between the groups, the number needed to screen is considerably high. The use of questionnaire‐based PCR testing in areas with low incidence of COVID‐19 allows for a reasonable allocation of resources and is easy to implement.

Background: We aimed to explore the association of the number, order, gestational age and type of prior PTB and the risk of preterm birth (PTB) in the third delivery in women who had three consecutive singleton deliveries. Methods: A retrospective cohort study of all women who had three consecutive singleton births at a single medical center over a 20-year period (1994&ndash, 2013). The primary outcome was PTB (&lt, 37 weeks) in the third delivery. Results: 4472 women met inclusion criteria. The rate of PTB in the third delivery was 4.9%. In the adjusted analysis, the risk of PTB was 3.5% in women with no prior PTBs, 10.9% in women with prior one PTB only in the first pregnancy, 16.2% in women with prior one PTB only in the second pregnancy, and 56.5% in women with prior two PTBs. A similar trend was observed when the outcome of interest was spontaneous PTB and when the exposure was limited to prior spontaneous or indicated PTB. Conclusions: In women with a history of PTB, the risk of recurrent PTB in subsequent pregnancies is related to the number and order of prior PTBs. These factors should be taken into account when stratifying the risk of PTB.

Background In the Twin Birth Study, women at 320/7–386/7 weeks of gestation, in whom the first twin was in cephalic presentation, were randomized to planned vaginal delivery or cesarean section. The study found no significant differences in neonatal or maternal outcomes in the two planned mode of delivery groups. We aimed to compare neonatal and maternal outcomes of twin gestations without spontaneous onset of labor, who underwent induction of labor or pre-labor cesarean section as the intervention of induction may affect outcomes. Methods In this secondary analysis of the Twin Birth Study we compared those who had an induction of labor with those who had a pre-labor cesarean section. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Secondary outcome was a composite of maternal morbidity and mortality. Trial Registration: NCT00187369. Results Of the 2804 women included in the Twin Birth Study, a total of 1347 (48%) women required a delivery before a spontaneous onset of labor occurred: 568 (42%) in the planned vaginal delivery arm and 779 (58%) in the planned cesarean arm. Induction of labor was attempted in 409 (30%), and 938 (70%) had a pre-labor cesarean section. The rate of intrapartum cesarean section in the induction of labor group was 41.3%. The rate of the primary outcome was comparable between the pre-labor cesarean section group and induction of labor group (1.65% vs. 1.97%; p = 0.61; OR 0.83; 95% CI 0.43–1.62). The maternal composite outcome was found to be lower with pre-labor cesarean section compared to induction of labor (7.25% vs. 11.25%; p = 0.01; OR 0.61; 95% CI 0.41–0.91). Conclusion In women with twin gestation between 320/7–386/7 weeks of gestation, induction of labor and pre-labor cesarean section have similar neonatal outcomes. Pre-labor cesarean section is associated with favorable maternal outcomes which differs from the overall Twin Birth Study results. These data may be used to better counsel women with twin gestation who are faced with the decision of interventional delivery.

The choice of fetal growth chart to be used in antenatal screening for fetal growth restriction (FGR) has an important impact on the proportion of fetuses diagnosed as small for gestational age (SGA), and on the detection rate for FGR. We aimed to compare diagnostic accuracy of SGA diagnosed using four different common fetal growth charts [Hadlock, Intergrowth-21st (IG21), World Health Organization (WHO), and National Institute of Child Health and Human Development (NICHD)], for abnormal placental pathology.A secondary analysis of data from a prospective cohort study in low-risk nulliparous women. The exposure was SGA (birthweight10th centile for gestational age) using each of the four charts. The outcomes were one of three types of abnormal placental pathology associated with fetal growth restriction: maternal vascular malperfusion (MVM), chronic villitis, and fetal vascular malperfusion.A total of 742 nulliparous women met the study criteria. The proportion of SGA was closest to the expected rate of 10% using the Hadlock chart (12.7%). The detection rates (DR) and false positive rates (FPR) for MVM pathology were similar for the Hadlock (DR = 53.1%, FPR = 10.8%), WHO (DR = 59.4%, FPR = 14.2%), and NICHD (DR = 53.1%, FPR = 12.3%) charts, and each was superior when compared to the IG21 chart (DR = 34.4%, FPR = 3.8%, p 0.001). The diagnosis of SGA was associated with increased risks of preeclampsia and preterm birth for all four charts.The selection of fetal growth chart to be used in screening programs for FGR has important implications with regard to the false positive and detection rate for FGR.

OBJECTIVE To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m2 who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS). DESIGN A retrospective cohort study of births between April 2012 and March 2014. SETTING A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada. POPULATION A cohort of 8752 women with a BMI of ≥35 kg/m2 who had a singleton birth at 38-42 weeks of gestation. METHODS Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS. MAIN OUTCOME MEASURE A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5-minute Apgar score of

OBJECTIVE The value of using customized birth-weight centiles to improve the diagnostic accuracy for fetal growth restriction (FGR), in comparison with using population-based charts, remains a matter of debate. One potential explanation for the conflicting data is that most studies used measures of perinatal mortality and morbidity as proxies for placenta-mediated FGR, many of which are not specific and may be confounded by other factors such as prematurity. The aim of this study was to compare the diagnostic accuracy of small-for-gestational age (SGA) at birth, defined according to customized vs population-based charts, for associated abnormal placental pathology. METHODS This was a secondary analysis of data from a prospective cohort study on risk factors for placenta-mediated complications and abnormal placental pathology in low-risk nulliparous women. All placentae were sent for detailed histopathological examination by two perinatal pathologists. The primary exposure was SGA, defined as birth weight

ObjectiveThe aim of this study was to investigate the effect of short or long interpregnancy interval (IPI) with placental mediated pregnancy complications after already complicated first delivery.MethodsWe performed a retrospective cohort analysis of all women with singleton pregnancies who delivered their first three consecutive deliveries in one university-affiliated medical center (1994–2013). Placental mediated complications included placental abruption, small for gestational age, preeclampsia, gestational hypertension, or preterm delivery. Following first complicated delivery, IPI was compared stratified by second delivery outcome. Following two complicated deliveries, IPI was compared stratified by third delivery outcome. IPI was evaluated as continuous or categorical variable (>18, 18–60, >60 months). Related samples Cochrans’ Q test and Mann-Whitney analysis were used as appropriate.ResultsOverall, 4310 women entered analysis. Of them, 18.3%, 10.5%, and 9.3% had complicated first, second, and third delivery, consecutively. Evaluated continuously, longer IPI, but not short IPI, was associated with higher rates of complicated second delivery. Stratified to categories, IPI had no effect on recurrent complications evaluated separately or as composite.ConclusionOur results suggest that long IPI may increase risk for placental mediated pregnancy complications. Further studies are needed to evaluate this effect.

Background The Twin Birth Study, a multicenter randomized controlled trial, found no differences in neonatal outcomes in women with twins randomized to planned cesarean or vaginal delivery. Nevertheless, women who present in spontaneous labor might expect a better outcome following a trial of vaginal delivery than undergoing cesarean delivery. In this secondary analysis, we aimed to compare neonatal outcomes of women who presented in spontaneous labor in the two arms of the Twin Birth Study. Methods Women in whom the first twin was in the cephalic presentation were randomized between 32 + 0 and 38 + 6 weeks to planned vaginal delivery or cesarean. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Results Of the 2804 women included in the Twin Birth Study, 823 women in the planned vaginal delivery arm and 612 in the planned cesarean arm presented in spontaneous labor. Although the odds ratio favored planned vaginal delivery, there was no statistically significant difference in the rate of primary outcome between the vaginal delivery and cesarean arms (1.8% vs 2.7%, respectively; P = 0.16; OR 1.49; 95% CI, 0.87-2.55). Similarly, the rates of the individual components of the primary outcome and of maternal adverse outcome were similar between the two arms. Conclusion In women with twins who present in spontaneous labor between 32 + 0 and 38 + 6 weeks' gestation, where the first twin is cephalic, a policy of planned vaginal delivery or cesarean is not associated with significant differences in neonatal or maternal outcomes.

Objective: To evaluate the relationship between adipocytokines and glycemic control.Study design: Prospective observational trial of gestations with gestational diabetes mellitus (GDM). Fasting glucose (FG), insulin, adiponectin, leptin, chemerin, retinol-binding protein 4 (RBP-4), osteocalcin, and resistin were measured. HomeOstasis model assessment of insulin resistance (HOMA-IR) and QUantitative insulin sensitivity ChecK Index (QUICKI) were calculated. Women who required medications for glycemic control were compared to women using nutritional therapy only.Results: Overall, 75 women were included -26 (34.7%) required medications to achieve good glycemic control. Factors associated with poor control are as follows: low resistin (aOR 0.84), HOMA-IR (aOR 1.96), QUICKI (aOR 0.62), first trimester FG (aOR 1.43), and maternal age (aOR 1.26). HOMA-IR and QUICKI performed highest for prediction. Resistin, first trimester FG, maternal age, and QUICKI had an AUC of 0.878, sensitivity and specificity of 87.5% for the prediction of the need for medications.Conclusions: Low resistin is associated with poor control. A model utilizing maternal age, first trimester fasting glucose, and first visit QUICKI yields good predictability.

Objective: To evaluate the outcomes of vacuum-assisted vaginal deliveries (VAD) among neonates of mothers with gestational diabetes mellitus (GDM).Study design: Retrospective cohort study of women ...

Uterine activity plays a crucial role in labor, especially when utero-tonic materials are administered. We aimed to determine the electrical responsiveness of the uterine musculature to labor augmentation with oxytocin using electrical uterine myography (EUM) technology, and to assess whether the kinetics of the EUM device may serve as a predictor for successful vaginal delivery. EUM prospectively measured electrical uterine activity in women with singleton gestations at term (≥ 37 + 0 weeks) undergoing labor augmentation by oxytocin administration. The results were reported as the EUM index, which represented the mean electrical activity in 10-min intervals and measured in units of microwatt per second (mW/s). Measurements were performed at least 30 min before oxytocin initiation and until at least four contractions per 10 min were recorded by standard tocodynamometry. The delta EUM index was defined as the difference between the mean EUM index before and after the initiation of oxytocin. The mean EUM index increased significantly during oxytocin augmentation in all the parturients (P

Amniotic fluid embolism (AFE) is a rare and potentially lethal obstetric complication, commonly occurring during labor, delivery, or immediately postpartum. There is a paucity of data regarding incidence, risk factors, and clinical management. Our primary objective in this study was to evaluate clinical presentation of AFE and delineate anesthesia management of these cases.This 10 years retrospective multi-center cohort study was performed in five tertiary university-affiliated medical centers, between the years 2005 and 2015. All documented cases of AFE identified according to the ICD guidelines were reviewed manually to determine eligibility for AFE according to Clark's criteria. All cases confirming Clark's diagnosis were included in the cohort.Throughout the study period, 20 cases of AFE were identified, with an incidence of 4.1 per 100,000 births. Average age at presentation was 35 ± 5 years. Seventy percent of cases presented during vaginal delivery, 20% occurred throughout a cesarean delivery, and 10% occurred during a dilation and evacuation procedure. The most common presenting symptom was sudden loss of consciousness in 12 parturients (66.7%), fetal bradycardia in 11 parturients (55%), and shortness of breath in 10 parturients (50%). Perimortem cesarean section was performed in 55% of cases, although only one case was performed in the delivery suite, while all others were performed in the operating room. Echocardiography was performed in 60% of the cases and all were pathological. Furthermore, 20% of cases were connected to an extracorporeal membrane oxygenation machine. There was a 15% mortality rate of 15%. A further 15% suffered major neurological disability, 25% suffered minor neurological morbidity, and 45% survived without severe complications.AFE is associated with significant maternal morbidity. This study highlights the importance of providing advanced training for the delivery suite staff for cases of maternal cardiovascular collapse secondary to AFE and increasing awareness for this rare and devastating obstetric condition.

Intrapartum fetal heart rate (FHR) monitoring is well recommended during labor to assess fetal wellbeing. Though commonly used, the external Doppler and fetal scalp electrode monitor have significant shortcomings. Lately, non-invasive technologies were developed as possible alternatives.The objective of this study is to compare the accuracy of FHR trace using novel Electronic Uterine Monitoring (EUM) to that of external Doppler and fetal scalp electrode monitor.A comparative study conducted in a single tertiary medical center. Intrapartum FHR trace was recorded simultaneously using three different methods: internal fetal scalp electrode, external Doppler, and EUM. The latter, a multichannel electromyogram (EMG) device acquires a uterine signal and maternal and fetal electrocardiograms. FHR traces obtained from all devices during the first and second stages of labor were analyzed. Positive percent of agreement (PPA) and accuracy (by measuring root means square error between observed and predicted values) of EUM and external Doppler were both compared to internal scalp electrode monitoring. A Bland-Altman agreement plot was used to compare the differences in FHR trace between all modalities. For momentary recordings of fetal heart rate110 bpm or160 bpm level of agreement, sensitivity, and specificity were also evaluated.Overall, 712,800 FHR momentary recordings were obtained from 33 parturients. Although both EUM and external Doppler highly correlated with internal scalp electrode monitoring (rIntrapartum FHR using EUM is both valid and accurate, yielding higher correlations with internal scalp electrode monitoring than external Doppler. As such, it may provide a good framework for non-invasive evaluation of intrapartum FHR.

Intertwin size discordance is an independent risk factor for adverse neonatal outcomes in twin pregnancies. However, size discordance at a given point in gestation fails to take into consideration information, such as the timing of onset and the rate of progression of discordance, that may be of prognostic value.In this study, we aimed to identify distinct patterns of discordant fetal growth in twin pregnancies and to determine whether these patterns are predictive of adverse pregnancy outcomes.This was a retrospective cohort study of women with twin pregnancies in a single tertiary referral center between January 2011 and April 2020, who had at least 3 ultrasound examinations during pregnancy that included assessment of fetal biometry. Size discordance was calculated at each ultrasound examination, and pregnancies were classified into 1 of 4 predetermined patterns based on the timing of onset and the progression of discordance: pattern 1, no significant discordance group (referent); pattern 2, early (24 weeks' gestation) progressive discordance group; pattern 3, early discordance with plateau group; or pattern 4, late (≥24 weeks' gestation) discordance group. The associations of discordance pattern (using pattern 1 as referent) with preterm birth, preeclampsia, size discordance at birth, and birthweight10th percentile were expressed as adjusted relative risk with 95% confidence intervals and were compared with those observed for a single measurement of size discordance at 32 weeks' gestation.Of 2075 women with a twin gestation who were identified during the study period, 1059 met the study criteria. Of the 1059 women, 599 (57%) were classified as no significant discordance (pattern 1), 23 (2%) as early progressive discordance (pattern 2), 160 (15%) as early discordance with plateau (pattern 3), and 277 (26%) as late discordance (pattern 4). The associations of discordance pattern with preterm birth at34 weeks' gestation and preeclampsia were strongest for pattern 2 (rates of 43% [adjusted relative risk, 3.43; 95% confidence interval, 2.10-5.62] and 17% [adjusted relative risk, 5.81; 95% confidence interval, 2.31-14.60], respectively), intermediate for pattern 3 (rates of 23% [adjusted relative risk, 1.82; 95% confidence interval, 1.28-2.59] and 6% [adjusted relative risk, 2.08; 95% confidence interval, 1.01-4.43], respectively), and weakest for pattern 4 (rates of 12% [adjusted relative risk, 0.96; 95% confidence interval, 0.65-1.42] and 4% [adjusted relative risk, 1.41; 0.68-2.92], respectively). In contrast, a single measurement of size discordance at 32 weeks' gestation showed no association with preeclampsia and only a weak association with preterm birth at34 weeks' gestation.We identified 4 distinct discordance growth patterns among twins that demonstrated a dose-response relationship with adverse outcomes and seemed to be more informative than a single measurement of size discordance.

The sonographic prediction of fetal macrosomia affects obstetrical decision regarding the timing and mode of delivery. We aimed to compare the accuracy of various formulas for prediction of macrosomia at different thresholds. This was a retrospective cohort study of singleton gestations at term, with fetal biometrical measurements taken up to 7 days prior to delivery (2007 to 2014). Sonographic estimated fetal weight was calculated using 20 previously published formulas. Macrosomia prediction was evaluated for every formula utilizing: (1) measures of accuracy (sensitivity, specificity and so on); (2) comparison of the systematic and random errors (SE and RE), and the proportion of estimates within 10% of actual birth weight for macrosomic and non-macrosomic neonates. Performance measurements were evaluated for different macrosomia thresholds: 4000, 4250 and 4500 g. Best performing formula for every threshold was defined as the one with the lowest Euclidean distance (=SQRT(SE2+RE2)). Out of 7977 women who met the inclusion criteria, 754 (9.4%) delivered a neonate weighing ⩾4000 g, 266 (3.3%) delivered a neonate weighing⩾4250 g and 75 (0.9%) delivered a neonate weighing⩾4500 g. Considerable variability was noted between the accuracy parameters of the different formulas, with Woo’s formula integrating Abdominal circumference (AC) and femur length (FL) as the most sensitive formula with the highest negative predictive value for all thresholds and Woo’s formula using AC, FL and biparietal diameter (BPD) as the most specific for all thresholds. The same formula also demonstrated the best overall accuracy. Regardless of threshold chosen, 80% or more of formulas demonstrated negative systematic error, meaning lower EFW than actual birthweight. As for the Euclidean distance, Hadlock’s formula (AC, FL and BPD) ranked the highest for the 4000 and 4250 g thresholds, whereas Shepard’s formula (AC and BPD) ranked the highest for the 4500 g threshold. Considerable variability exist between formulas for prediction of neonatal macrosomia. Formulas by Hadlock’s and Shepard’s utilizing AC, BPD±FL were most accurate for macrosomia prediction at 4000, 4250 and 4500 g thresholds, respectively.

We sought to evaluate perinatal outcomes in women with epilepsy.We performed a retrospective cohort study between 2007 and 2014, at a tertiary, university-affiliated medical center. All women with singleton gestation who delivered during the study period were included, except for pregnancies in which fetuses with chromosomal or structural anomalies were diagnosed. Perinatal outcome was compared between two groups: women diagnosed with epilepsy and women without epilepsy.Out of 62,102 deliveries during the study period, 61,455 met the inclusion criteria, of whom 206 (0.3%) had epilepsy. The only difference found in maternal demographics was higher rate of nulliparity in the epilepsy group (p = .02). As for maternal adverse outcome, higher rates of placental abruption and longer postpartum admission were found in women with epilepsy (p = .02 and p .001, respectively). Comparing neonatal outcomes between the two groups, higher rates of neonatal intensive care unit admission (16.5 versus 9.2%), seizures (1.9 versus 0.4%), transient tachypnea of the newborn (2.4 versus 1.0%) and respiratory distress syndrome (1.9 versus 0.4%) were significantly higher to newborns of women with epilepsy (p .05 for all). On multivariable logistic regression, epilepsy was found to be independently and significantly associated with placental abruption (OR 4.04, 95%CI 1.27-12.83, p = .02), neonatal intensive care unit (NICU) admissions (OR 1.84, 95%CI 1.25-2.70, p = .002), seizures (OR 4.33, 95%CI 1.60-11.77, p = .004), transient tachypnea of the newborn (OR 2.47, 95%CI 1.005-6.05, p = .049) and respiratory distress syndrome (OR 7.16, 95%CI 2.47-20.76, p .001).Epilepsy in pregnant women is associated with adverse perinatal outcomes, including neonatal seizures, placental abruption and respiratory problems.

PURPOSE To develop and evaluate an algorithm for computerized evaluation and measurement of the endometrial-myometrial junction (EMJ). MATERIALS AND METHODS The advanced image processing toolbox of the Matlab software package was used for identificiation and quantitative analysis of the EMJ area on three-dimensional (3D) rendered coronal plane uterine images, with clear-cut borders of the EMJ. The algorithm was used to process the images and calculate the geometric parameters characterizing the identified EM The manual measurements of the maximum thickness of the EMJ were compared to automated measurements performed by the algorithm on the same images. RESULTS For all three interfaces, the mean maximum manual measurement was less than the mean maximui computed measurement. The differences between the two measurements were not statistically significant (p = 0.275, 0.608 and 0.41 for the right wall, left wall, and fundus, respectively). The mean systematic and random errors ranged from 5.4% tol9.3% and 20.4 to 48.6%, respectively. Pearson correlations for the right wall, left wall and fundus (r = 0.642, p = 0.001; r = 0.730, p < 0.001, and r 0.694, p < 0.001, respectively) were good. CONCLUSIONS Maximum EMJ thickness measurements performed by the innovative Matla software algorithm are as accurate as manual measurements, and have the potential to reduce inter-observer variability.

To estimate the association between intrapartum fever and adverse perinatal outcome.A retrospective cohort study of women attempting vaginal delivery at term in a tertiary hospital (2012-2015). Perinatal outcome of deliveries complicated by intrapartum fever (≥38.0 °C) were compared to women with no intrapartum fever matched by parity and gestational age at delivery in a 1:2 ratio. Maternal outcome included cesarean section (CS), operative vaginal delivery (OVD), retained placenta or post-partum hemorrhage. Neonatal outcome included 5-minute Apgar score7, umbilical artery pH7.1, meconium aspiration syndrome, need for mechanical ventilation or hypoxic ischemic encephalopathy.Overall, 309 women had intrapartum fever and 618 served as controls. Women with intrapartum fever had higher rates of OVD (34.3 versus 19.6%, p .001) and CS (20.7 versus 8.7%, p .001). In multivariate analysis, intrapartum fever was independently associated with adverse maternal (3.75, 95%CI 2.65-5.30, p .001) and neonatal outcome (3.39, 95%CI 1.78-6.45, p .001). In febrile women, fever duration was related to maternal complications, specifically to CS. In addition, maternal bacteremia and positive placental cultures were risk factors for neonatal complications compared to those with negative cultures (23.3 versus 9.8%, p = .01).Intrapartum fever was associated with adverse perinatal complications. The duration of intrapartum fever, maternal bacteremia, and positive cultures further increase this risk.

Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p .001), increased blood components transfusions (p .001), and significant increase in cesarean hysterectomy rate (p .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p .001).Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.

Objective To compare the accuracy of various sonographic estimation of fetal weight (sEFW) formulas for breech-presenting fetuses. Methods A retrospective analysis of sEFW performed within 3 days of delivery in a tertiary medical center in Israel between July 2007 and December 2014 was conducted. Breech-presenting singleton fetuses were matched by sex and birth weight to vertex-presenting fetuses. sEFW was calculated using 21 formulas. Systematic and random errors, proportion of estimates (POE) within 10% of actual birth weight, and reliability analysis were used to compare sonographic accuracy. The best performing formula was determined by Euclidean distance. Results Both groups contained 274 fetuses. Systematic error was lower for breech fetuses when compared with control fetuses in 17 of 21 formulas; there was no significant difference in random error between the breech and vertex groups. For vertex fetuses, Euclidean distance was smaller in 17 of 21 formulas, and POE within 10% of birth weight was higher in most formulas. Cronbach α value was higher for vertex fetuses than for breech fetuses in all formulas. The formulas of Combs et al. and Hadlock et al. were highest ranking for breech-presenting fetuses. Conclusion sEFW might be more accurate for vertex than for breech fetuses. This article is protected by copyright. All rights reserved.

This study describes a retrospective analysis of all women admitted for induction of labour (IoL), carrying a viable singleton foetus, after 34 + 0 weeks of gestation. We aimed to evaluate if foetal sex has an impact on the rate of caesarean delivery following labour induction. Our results demonstrate that among the 1062 women who met the inclusion criteria, 49% (521/1062) were carrying a male foetus. Other than a lower rate of Oxytocin use for the female sex pregnancies, there were no significant differences in pre-labour and labour characteristics between male or female sex pregnancies. There was no difference in caesarean delivery rate between groups (14.4% vs. 14.2%, male vs. female, respectively, p = .505). We concluded conclude that foetal sex does not impact the caesarean delivery rate among women undergoing IoL, regardless of the indication for induction and the indication for the caesarean delivery. Impact statement Male sex foetuses are at increased risk for adverse perinatal outcomes including, among others, an increased risk for caesarean delivery. The possible contribution of male sex to caesarean delivery after labour induction has not been specifically explored. Following induction of labour, there is no difference in failed induction or caesarean delivery rate between male and female sex pregnancies. Induction of labour may be safely employed for both male and female foetuses.

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 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.

Objectives Early and late hypertensive disorders in pregnancy (HDP) are different entities in singleton gestations, with earlier onset associated with higher rates of placental maternal vascular malperfusion lesions (MVMs). It is still not known if this distinction apply for twin gestations as well. Methods Retrospective study of women with DCDA twin gestations and HDP (2001–2015), with a placental pathology evaluation. Placental lesions were classified according to the Amsterdam criteria. Pregnancies with early onset HDP (≤34 weeks) were compared with pregnancies with late onset HDP (>34 weeks). Results Out of 1655 twin deliveries, 161 (9.7%) were complicated by HDP: 77 (47.8%) had preeclampsia, and 84 (52.2%) had gestational hypertension. Forty patients (24.8%) had early onset HDP. Early HDP was associated with a higher rate of 1 MVMs (p=0.01), ≥2 MVMs (p=0.009) and with a lower rate of chronic villitis (p=0.02). In multivariable analysis, using late HDP as reference, early HDP was associated with a higher prevalence of ≥1 MVMs (aOR 1.9, 95% CI 1.1–3.5, p=0.03) and ≥2 MVMs (aOR 2.6, 95% CI 1.05–6.3, p=0.04). Early HDP was also less associated with chronic villitis (aOR 0.2, 95% CI 0.05–0.9), as chronic villitis is usually associated with a more advanced gestational age. Conclusions While the mechanism underlying HDP in singleton and twins’ gestations may be different, similar to singleton pregnancies, early onset (≤34 weeks gestation) of HDP in twins’ gestation is associated with a higher prevalence of MVM's, suggesting of reduced placental perfusion in early onset HDP in twins.

Objectives Numerous formulas for estimated fetal weight (EFW) calculations have been proposed over the years but have not been validated in patients with preterm premature rupture of membranes (PPROM). The study objective was to compare the accuracy of the various sonographic EFW formulas in patients with PPROM. Methods This was a retrospective cohort study of women with PPROM and singleton gestations who were admitted between 220–330 weeks to a single, university-affiliated tertiary referral centre between 2003–2017. All women had a sonogram for EFW within 14 days of delivery by standard biometry (biparietal diameter, head circumference, abdominal circumference, and femur length). We compared the accuracy of 21 previously published EFW formulas in the setting of PPROM by comparing the correlation with actual birth weight and calculating the systematic error (SE), random error (RE), proportion of estimates (POE) within 10% of birth weight and Euclidean distance. Results Overall, 565 women were included in the study. Most formulas had strong correlation with actual birth weight (19/21 formulas with r >0.9). The mean SE was -4.30% and mean RE 14.48%. The formula that performed the best, by the highest POE and lowest Euclidean distance was that of Ott (1986), utilizing abdominal and head circumferences, and femur length, yet all of the first 10 ranking formulas (including the mostly used Hadlock IV) performed quite similarly with minimal differences between them. Conclusions Most formulas accurately calculation EFW in PPROM patients, but the Ott (1986) formula ranked highest, thus it may be the preferred formula to use in this population.

To determine the association between the myometrial electrical activity in the active and second stages of labor at term using electrical uterine myography (EUM).A prospective observational study of 47 singleton deliveries at term in a tertiary hospital. All women were assessed using noninvasive 9-channel surface electrodes of the EUM during labor. EUM index (EUMi) was calculated as the mean electrical activity during a 30 min monitoring period and expressed as microjouls (MJ). Mean EUMi of the active and second stages of labor were compared accordingly.Mean EUMi during the active phase was 3.53 ± 0.43 MJ, whereas mean EUMi in the second stage was 3.66 ± 0.48 MJ (p = 0.02). Correlation analysis between mean EUMi of the active and second stages of labor produced rA positive correlation of myometrial electrical activity exists between active phase and second stage of labor. However, while EUMi was associated with the duration of the active phase, no correlation was found between EUMi and the duration of the second stage.

BACKGROUND Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.

Controversy surrounds the definition of "normal" and "abnormal" labor.In this study, we used contemporary labor charts to explore labor patterns in large obstetric population (2011-2016).Detailed information from electronic medical records of live singleton deliveries at term (≥37 weeks of gestation) was extracted. Cases of elective cesarean deliveries, nonvertex presentation, and cesarean deliveries during the first stage of labor were excluded.Overall, 35,146 deliveries were included, of whom 15,948 deliveries (45.3%) were of nulliparous women. Median cervical dilation at admission was not significantly different between nulliparous (median, 4 cm; interquartile range, 3-5 cm) and multiparous women (median, 4 cm; interquartile range, 3-6 cm). In all, 99.3% of the women delivered vaginally. For nulliparous women, the median duration of the first stage of labor was 274 minutes (interquartile range, 145-441 minutes; 95th percentile, 747.5 minutes). Likewise, for multiparous women, the corresponding duration was 133 minutes (interquartile range, 56-244 minutes; 95th percentile, 494 minutes). During the latent phase (cervical dilation at admission, ≤4 cm), the time elapsed to the second stage of labor was 120-140 minutes longer in nulliparous women, whereas the gap between the groups decreased dramatically with advanced cervical dilation on admission. Nulliparous and multiparous women appeared to progress at a similar pace during the latent phase; however, after 5 cm, labor accelerated faster in multiparous women. Epidural anesthesia lengthens duration first and second stages of labor in all parities. Partograms according to cervical dilation at presentation are proposed.Cervical dilation rate is relatively constant between nulliparous and multiparous pregnant women during the latent phase. Time interval of the first stage was far slower than previously described, which allowed labor to continue for a longer period during this stage. These findings may reduce the rate of intrapartum iatrogenic interventions.