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Introduction: To examine the association of preoperative absent end-diastolic velocity (AEDV) and percent AEDV (%AEDV) in the umbilical artery (UA) with donor twin intrauterine fetal demise (IUFD) after laser surgery for twin-twin transfusion syndrome (TTTS).Methods: We performed a retrospective study of stage III/IV TTTS patients who underwent laser surgery from 2006 to 2016. Donors were classified as having preoperative persistent AEDV (yes/no). %AEDV was calculated for those with AEDV as 100× the proportion of the total cardiac cycle in AEDV. Using multiple logistic regression, we tested for an association between the outcome donor IUFD and AEDV risk factors (part 1) and %AEDV (part 2). We stratified these analyses by estimated fetal weight (EFW) discordance ≥20 versus <20%.Results: Of 344 cases, 153 (44.5%) donors had AEDV. Part 1 did not confirm an independent association between AEDV and donor IUFD. In the part 2 analysis of the 153 patients with AEDV, %AEDV was a positive risk factor for donor IUFD only in those with discordance (n = 129) (OR 1.04, 95% CI 1.01-1.08, p = 0.0278) when adjusting for %EFW discordance, presence of arterioarterial anastomoses, and multiparity.Discussion: Among stage III/IV TTTS patients with AEDV, %AEDV was a risk factor for donor IUFD only in the presence of EFW discordance. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative membrane separation is a complication of selective laser photocoagulation of communicating vessels (SLPCV) for the treatment of twin-twin transfusion syndrome (TTTS).Objective: The aim of this work was to determine whether a quantitative grading system of membrane separation following SLPCV was associated with preterm premature rupture of membranes (PPROM) and preterm delivery (PTD).Methods: Patients with membrane separation after SLPCV on postoperative day 1 were stratified into greatest width of separation <1 cm (Group A) or ≥1 cm (Group B) and compared to patients without separation by the following outcomes: PPROM ≤21 postoperative days, PTD <28 gestational weeks, and PTD <32 gestational weeks.Results: Of 654 patients, 123 (18.8%) had membrane separation. Of these, 120 patients were eligible for study and divided into Groups A (n = 91) and B (n = 29). Multiple logistic regression analysis yielded associations with PPROM ≤21 days for Groups B (OR 8.60, 95% CI 3.38-21.90, p < 0.0001) and A (OR 2.39, 95% CI 1.05-5.40, p = 0.0369) compared to those without membrane separation. In similar models, Group B was associated with PTD <32 weeks (OR 2.41, 95% CI 1.10-5.28, p = 0.0274).Conclusion: Postoperative membrane separation was associated with an increased risk of PPROM ≤21 days. Membrane separation ≥1 cm had a higher risk of PTD <32 weeks. [ABSTRACT FROM AUTHOR]

Background: Umbilical cord occlusion via radiofrequency ablation (RFA) is utilized to maximize outcomes of the co-twin in complicated multifetal monochorionic (MC) gestations. However, post-procedure co-twin fetal demise is of concern.Objective: The aim of this study was to determine risk factors for co-twin fetal demise following RFA.Methods: This is a retrospective study of MC multiples that underwent RFA. Indications for RFA included twin reversed arterial perfusion (TRAP) sequence, selective fetal growth restriction (sFGR) type II, discordant lethal anomalies, and twin-twin transfusion syndrome (TTTS) with proximate placental cord insertion sites. The primary outcome was co-twin fetal demise. Bivariate analyses and multiple logistic regression modeling of identified risk factors were conducted.Results: Of 36 patients studied, surgical indications were: TRAP (n = 15, 41.7%), sFGR (n = 10, 27.8%), discordant anomalies (n = 9, 25.0%), and TTTS (n = 2, 5.6%). Nine patients (25.0%) experienced a co-twin fetal demise. In multiple logistic regression analysis, fetal growth restriction (FGR) of one co-twin was associated with increased risk of co-twin fetal demise (OR = 10.85, 95% CI 1.03-114.48, p = 0.0474) and a preoperative diagnosis of TRAP was protective against fetal demise (OR = 0.06, 95% CI 0.00-0.84, p = 0.0368).Conclusion: Co-twin FGR was associated with an increased risk of post-RFA demise. When compared to other indications, patients with TRAP sequence were less likely to have a co-twin demise. [ABSTRACT FROM AUTHOR]

Objectives: Amniopatch is a proposed treatment of iatrogenic preterm premature rupture of membranes (iPPROM). We studied characteristics associated with successful amniopatch treatment of iPPROM after fetoscopic laser surgery for twin-twin transfusion syndrome.Methods: Patients with iPPROM within 15 days of laser surgery treated with an amniopatch were studied. Factors associated with amniopatch success (i.e. cessation of leakage with normalization of amniotic fluid volume) were tested univariately and in multivariate logistic regression models. Continuous variables are expressed as median (range).Results: Of 1124 patients undergoing laser surgery, 19 (1.7%) had iPPROM and subsequent amniopatch. Twelve (63.2%) were successful. Latency in days from iPPROM to delivery was greater in the successful group (114.0 [87.0-141.0]) versus (44.0 [3.9-88.0], p = 0.0005), which translated into greater gestational age (GA) (weeks) at delivery (35.1 [30.9-39.4] versus 28.1 [22.0-31.0], p = 0.0005). The 30-day survival of the affected recipient twin was improved (100% versus 57.1%, p = 0.0361). After multivariate testing, GA < 20 weeks at the time of the amniopatch placement was the only variable that remained associated with successful sealing of the membranes.Conclusions: Treatment of iPPROM via amniopatch was successful in almost two-thirds of cases and was associated with higher GA at delivery and improved perinatal survival. [ABSTRACT FROM AUTHOR]

Introduction: We examined placental weight characteristics associated with donor selective intrauterine growth restriction (SIUGR) among patients with twin-twin transfusion syndrome (TTTS) who underwent laser surgery.Materials and Methods: Fresh placental specimens were studied. Pregnancies with higher-order multiples, fetal demise, or disrupted or nonsubmitted placental specimens were excluded. Placental characteristics prospectively collected included total placental weight, individual placental weight, and placental share. Data were compared between pregnancies with SIUGR (TTTS + SIUGR group) and those without SIUGR (TTTS-only group).Results: Of 369 consecutive patients who underwent laser surgery for TTTS, 155 (42%) met inclusion criteria: 91 with TTTS + SIUGR and 64 with TTTS-only. Compared to the TTTS-only group, patients in the TTTS + SIUGR group had a lower total placental weight (608 ± 163 vs. 687 ± 224 g, p = 0.012), with a lower donor individual placental weight (237 ± 91 vs. 291 ± 124 g, p = 0.002), but no apparent difference in the individual placental weight of recipient twins (371 ± 109 vs. 396 ± 133 g, p = 0.211). Donor placental share was smaller in those pregnancies affected by SIUGR (38.7 ± 9.6 vs. 42.3 ± 9.8%, p = 0.029).Discussion: TTTS patients with SIUGR had a lower total placental weight and a lower donor individual placental weight compared to those without SIUGR. These findings suggest that differences in donor individual placental weights for SIUGR gestations may not solely be related to differences in placental share. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of selective intrauterine growth restriction (SIUGR) on monochorionic multiples treated with selective laser photocoagulation of communicating vessels (SLPCVs) for twin-twin transfusion syndrome (TTTS). Methods: Perinatal survival was compared among TTTS patients with and without SIUGR. The TTTS + SIUGR group was defined as TTTS patients with donor twin weight <10th percentile. Multivariable logistic regression analyses identified factors associated with 30-day survival. Results: Of 369 patients, 65% (N = 241) had TTTS + SIUGR. Thirty-day donor twin survival for the TTTS-only group was 84% versus 75% in the TTTS + SIUGR group (p = 0.0348). Stage III donor involved (stage III donor, donor/recipient) TTTS + SIUGR patients (N = 110) had 66% 30-day donor survival. Multivariable logistic regression demonstrated that the TTTS-only group was twice as likely to achieve donor survival compared to the TTTS + SIUGR group (OR 2.01, 95% CI 1.11–3.66,p = 0.0214). In the TTTS + SIUGR group, patients not classified as stage III donor-involved were twice as likely to achieve donor survival as stage III donor-involved patients (OR 2.02, 95% CI 1.10–3.71,p = 0.0226). Conclusions: SIUGR, present in two-thirds of TTTS patients, was a risk factor for decreased donor survival. Patients with donor SIUGR and umbilical artery persistent or reversed end-diastolic flow (Quintero Stage III Donor-involved) were especially at risk. [ABSTRACT FROM AUTHOR]

Objectives. We examined trends in maternal comorbidities in California. Methods. We conducted a retrospective cohort study of 1 551 017 California births using state-linked vital statistics and hospital discharge cohort data for 1999, 2002, and 2005. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify the following conditions, some of which were preexisting: maternal hypertension, diabetes, asthma, thyroid disorders, obesity, mental health conditions, substance abuse, and tobacco use. We estimated prevalence rates with hierarchical logistic regression models, adjusting for demographic shifts, and also examined racial/ethnic disparities. Results. The prevalence of these comorbidities increased over time for hospital admissions associated with childbirth, suggesting that pregnant women are getting sicker. Racial/ethnic disparities were also significant. In 2005, maternal hypertension affected more than 10% of all births to non-Hispanic Black mothers; maternal diabetes affected nearly 10% of births to Asian/Pacific Islander mothers (10% and 43% increases, respectively, since 1999). Chronic hypertension, diabetes, obesity, mental health conditions, and tobacco use among Native American women showed the largest increases. Conclusions. The prevalence of maternal comorbidities before and during pregnancy has risen substantially in California and demonstrates racial/ethnic disparity independent of demographic shifts. [ABSTRACT FROM AUTHOR]

Objective Shoulder dystocia (SD) and brachial plexus palsy (BPP) are complications of childbirth that can result in significant long-term sequelae. The purpose of the present study was to analyze risk factors in cases of SD and BPP. Methods We performed a retrospective study of laboring women who delivered a singleton, term, live-born infant at the Los Angeles County + University of Southern California Medical Center from 1995 to 2004. Multivariable logistic regression models were used to analyze risk factors among SD cases with and without BPP. Results Of the 13,998 deliveries that met inclusion criteria, 221 (1.6%) had SD. Of these, 42 (19.0%) had BPP. After testing for association with multiple potential risk factors, including maternal demographic variables, diabetes, hypertension, prior cesarean delivery, uterine abnormalities, induction of labor, prolonged second stage (adjusted by parity and epidural use), assisted vaginal delivery, and neonatal birth weight, no statistical association of BPP with any specific risk factor was identified. Conclusion In the present study, we were unable to identify any reliable risk factors for BPP among deliveries with or without SD. SD and BPP remain unpredictable complications of childbirth. [ABSTRACT FROM AUTHOR]

Objective: To determine the composite risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. Methods: In a retrospective study of laboring women delivering singleton, term neonates, we defined 3 groups of patients by estimated fetal weight (EFW) in grams, using ultrasound: (1) <4000, (2) 4000-4499, and (3) 4500+, and tested them for association with a composite outcome using multivariable logistic regression models. The measure of composite morbidity included: shoulder dystocia, third/fourth degree perineal laceration, postpartum hemorrhage, maternal length of stay (LOS)≥ 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal LOS ≥ 5 days. Because of potential interactions between diabetes and birthweight, women with maternal diabetes were examined separately. Results: Of 8,843 deliveries, the proportion with composite morbidity by group was: (1): 26.2%, (2): 41.2%, and (3): 63.6% ( p < 0.0001). The OR (95% CI) for groups (2) and (3) were: 1.9 (1.2-2.9) and 2.1 (0.6-7.2), for diabetics (9.7% of the final study population), and 2.3 (1.9-2.7) and 3.9 (2.2-6.9), for non-diabetics. Conclusions: Suspected fetal macrosomia appeared associated with increased risk for a composite measure of childbirth morbidity. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to analyze the relationship of 1-h post-glucola (PG) screening results and the need for insulin therapy in women with gestational diabetes (GDM). Methods. The study group was comprised of women with GDM treated at a single institution during calendar years 2000--2004. Women with singleton, term (≥≥37 weeks gestation), liveborn fetuses were included. The association of 1-h PG results and other perinatal risk factors to the need for subsequent insulin therapy was analyzed using multivariable logistic regression models. Results. Of the 1451 women were included in the analysis, 18.1%% required insulin treatment. The mean 1-h PG result was 170.0 ±± 26.1 mg/dl (range 140--414 mg/dl). We determined that a 1-h PG ≥≥ 190 mg/dl ( p < 0.0001), an obese body mass index (BMI) ( p < 0.0001), an overweight BMI ( p == 0.0019), prior GDM ( p == 0.0019), and prior macrosomia ( p == 0.0210) were each highly associated with the need for subsequent insulin therapy during the pregnancy. Conclusions. A 1-h PG ≥≥ 190 mg/dl was strongly associated with the need for insulin therapy in women with GDM. These data may be helpful in counseling and managing women with GDM. [ABSTRACT FROM AUTHOR]

Background: Under value-based payment programs, patient-reported experiences and outcomes can impact hospital and physician revenue. To enable obstetrical providers to improve the childbirth experience, a framework for understanding what women expect and desire during childbirth is needed.Objective: The purpose of this study was to identify key predictors of childbirth hospital satisfaction with the use of the Childbirth Experiences Survey.Study Design: This study builds on a larger effort that used Patient-Reported Outcomes Management Information System methods to develop a childbirth-specific preliminary patient-reported experiences and outcomes item bank. These efforts led to the development of an antepartum and postpartum survey (Childbirth Experiences Survey Parts 1 and 2). All phases of the study were conducted with the participation of a community-based research team. We conducted a prospective observational study using national survey response panels that was organized through Nielsen to identify women's antepartum values and preferences for childbirth (Childbirth Experiences Survey Part 1). Eligible participants were pregnant women in the United States (English or Spanish speaking) who were ≥18 years old and ≥20 weeks pregnant. Women were recontacted and invited to participate in a postpartum follow-up survey to collect information about their childbirth patient-reported experiences and outcomes, which included childbirth satisfaction (Childbirth Experiences Survey Part 2). In bivariate analyses, we tested whether predisposing conditions (eg, patient characteristics or previous experiences), values and preferences, patient-reported experiences and outcomes, and the "gaps" between values and preferences and patient-reported experiences and outcomes were predictors of women's satisfaction with hospital childbirth services. Multivariable logistic regression models were fitted to examine the simultaneous effect of predictors on hospital satisfaction, which were adjusted for key predisposing conditions.Results: From 500 women who anticipated a vaginal delivery at the time of the antepartum survey, who labored before delivery, and who answered the postpartum survey, key findings included the following responses: (1) the strongest predictors of women's satisfaction with hospital childbirth services were items in the domains of staff communication, compassion, empathy, and respect, and (2) 23 childbirth-specific patient-reported experiences and outcomes were identified. Examples of these patient-reported experiences and outcomes (such as being told about progress in labor and being involved in decisions regarding labor pain management) appeared especially relevant to women who experienced childbirth. A final model that predicted women's satisfaction with hospital childbirth services included a total of 8 items that could be optimized by doctors, midwives, and hospitals. These included the patient's report of how well she coped with labor pain, whether the hospital provided adequate space and food for their support person, and whether she received practical support for feeding the newborn infant.Conclusion: This study identified 23 childbirth-specific patient-reported experiences and outcomes that were predictors of childbirth hospital satisfaction. The implementation of the Childbirth Experiences Survey Parts 1 and 2 in a multihospital setting may lead to the development of childbirth hospital performance measures and strategies for improvement of the childbirth experience. [ABSTRACT FROM AUTHOR]