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Objective To determine the utility of fetal echocardiography in diagnosing cardiac defects in fetuses with a single umbilical artery (SUA). Methods A retrospective cohort study of prenatally diagnosed SUA was conducted over a 10-year period at a single institution. Cardiac anatomy on detailed anatomical survey was compared with fetal echocardiogram for fetuses with prenatally diagnosed SUA. A diagnostic meta-analysis of studies comparing fetal anatomical survey to fetal echocardiogram in fetuses with SUA between 2010 to 2019 was also performed. Results Three hundred and twenty fetuses with SUA were identified, 113 of which had completed both ultrasound and echocardiography. There were 36 cases of cardiac defects on prenatal echocardiogram and all had abnormal anatomical ultrasounds. There were zero cases of abnormal cardiac exams (0%) when the cardiac views on anatomical survey were normal. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound were 100%, 77%, 73% and 100%, respectively. A summary ROC curve demonstrated a high predictive value of routine anatomic survey for cardiac defects (AUC: 0.99). Conclusion Anatomic survey is highly predictive in the detection of cardiac defects in fetuses with SUA. Fetal echocardiogram is unnecessary in SUA when cardiac views are normal on ultrasound.

Objective We examined rates of spontaneous and indicated preterm births (S-PTB and I-PTB, respectively) and clinical risk factors for PTB in adolescents.Study Design This is a population-based, retrospective cohort using 2012 U.S. natality data of nulliparous women who delivered a nonanomalous singleton birth between 20 and 42 weeks' gestation. Maternal age included Results In 1,342,776 pregnancies, adolescents were at higher risk for PTB than adults. The rate of total PTB was highest in young adolescents at 10.6%, decreased to 8.3% in older adolescents, and 7.8% in adults. The proportion of S-PTB was highest in the youngest adolescents and decreased toward adulthood; the proportion of I-PTB remained stable across age groups. Risk factors for S-PTB in adolescents included Asian race, underweight body mass index (BMI), and poor gestational weight gain (GWG). In all age groups, carrying a male fetus showed a significant increased S-PTB, and Women, Infants, and Children's (WIC) participation was associated with a significantly decreased risk.Conclusion The higher risk for PTB in adolescents is driven by an increased risk for S-PTB. Low BMI and poor GWG may be potentially modifiable risk factors.Condensation Adolescents have a higher risk for spontaneous PTB than adult women, and risk factors for spontaneous PTB may differ in adolescents.

Objective This study aimed to estimate the effect of antenatal corticosteroid administration on neonatal mortality and morbidity in preterm small-for-gestational age infants through a systematic review and meta-analysis. Data Sources A predefined, systematic search was conducted through Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trial Registry Platform, and ClinicalTrials.gov yielding 5324 articles from 1970 to 2019. Study Eligibility Criteria Eligible studies compared neonatal morbidity and mortality among small-for-gestational age infants delivered preterm who received antenatal corticosteroids with those who did not. Methods The primary outcome was neonatal mortality. Secondary outcomes were respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and periventricular leukomalacia, bronchopulmonary dysplasia or chronic lung disease of prematurity, or neonatal sepsis. We assessed heterogeneity by means of Higgins I2 statistic and Cochran’s Q test and calculated pooled odds ratios with 95% confidence intervals using random effects models. Results A total of 16 observational cohort and case-control studies published from 1995 to 2018 met the selection criteria for the systematic review and included 8989 preterm small-for-gestational age infants. Antenatal corticosteroid administration was explicitly reported among 8376 small-for-gestational age infants; 4631 (55.3%) received antenatal corticosteroids and 3741 (44.7%) did not. Of note, 13 studies including 6387 preterm small-for-gestational age infants were then included in the meta-analysis. Neonatal mortality was significantly lower among infants who received antenatal corticosteroids than those who did not (12 studies: 12.8% vs 15.1%; pooled odds ratio, 0.63; 95% confidence interval, 0.46–0.86), with significant heterogeneity between studies (I2=55.1%; P=.011). There was no significant difference in respiratory distress syndrome (12 studies: odds ratio, 0.89; 95% confidence interval, 0.69–1.15), necrotizing enterocolitis (7 studies: odds ratio, 0.93; 95% confidence interval, 0.70–1.22), intraventricular hemorrhage and periventricular leukomalacia (10 studies: odds ratio, 0.82; 95% confidence interval, 0.56–1.20), bronchopulmonary dysplasia or chronic lung disease of prematurity (8 studies: odds ratio, 1.11; 95% confidence interval, 0.88–1.41), or neonatal sepsis (6 studies: odds ratio, 1.13; 95% confidence interval, 0.86–1.49). Conclusion These data indicate that antenatal corticosteroid administration reduces neonatal mortality in small-for-gestational age infants delivered preterm, with no apparent effect on neonatal morbidity. This supports the use of antenatal corticosteroids to reduce neonatal mortality in pregnancies with small-for-gestational age infants at risk of preterm birth.

Women with diabetes are at increased risk for cesarean delivery, but there is a paucity of data examining practice patterns associated with indication for cesarean delivery among women with and without diabetes. We conducted a secondary analysis of the Consortium on Safe Labor data to evaluate cesarean delivery practices among women with gestational diabetes (GDM) and pregestational diabetes in a large U.S. cohort. Of the 191,174 women, 9,791 (5.1%) had GDM and 2,792 (1.4%) had pregestational diabetes. The overall cohort cesarean delivery rate was 30%. After adjusting for covariates, cesarean delivery rates were higher for women with GDM (28 vs. 45%, aOR 1.44, 95% CI 1.36-1.54) and pregestational diabetes (28 vs. 59%, aOR 2.21, 95% CI 1.99-2.46). Women with GDM and pregestational diabetes were more likely to undergo pre-labor cesarean delivery. Because indications for cesarean delivery may differ by maternal parity, stratified analyses were performed in nulliparous and multiparous women by diabetes type. Elective cesarean delivery and cesarean delivery for macrosomia were more common among women with diabetes, while cesarean delivery for failure to progress was less likely (Table). These data suggest that encouraging an attempt of vaginal delivery in women with diabetes and no contraindications may be one strategy to reduce the risk for cesarean delivery in this high-risk population. Disclosure J. Grasch: None. K. Miller: None. D. Haas: None. M. Tuuli: None. C.M. Scifres: None.

Objective: To test the hypothesis that third-trimester uterine artery Doppler (UAD) predicts adverse pregnancy and neonatal outcomes in a high-risk population.Study design: This is a nested case co...

To assess the effect of intravenous versus oral iron on hematologic indices and clinical outcomes for iron-deficiency anemia (IDA) in pregnancy. Searches in Ovid Medline, Embase, SCOPUS, Cochrane Database, and ClinicalTrials.gov identified randomized-controlled trials comparing intravenous to oral iron for treating IDA in pregnancy. Primary outcomes were maternal hematologic indices at delivery. Secondary outcomes were blood transfusion, cesarean delivery, neonatal outcomes, and medication reactions. Of 15,637 studies, 20 randomized trials met inclusion criteria and were analyzed. Mean hemoglobin at delivery (9 studies: WMD 0.66 g/dL (95% confidence Interval 0.31 –1.02 g/dL)) was significantly higher after intravenous iron therapy. Intravenous iron was associated with higher birthweight (8 studies: WMD 58.25 g (95% CI: 5.57–110.94 g)) but no significant differences in blood transfusion, cesarean delivery, or neonatal hemoglobin. There were fewer medication reactions with intravenous iron (21 studies: RR 0.34% (95% CI: 0.20–0.57)). Intravenous iron therapy is associated with higher maternal hemoglobin at delivery with no difference in blood transfusion and fewer mild medication reactions.

OBJECTIVE To investigate the association between elevated umbilical arterial lactate at birth and electronic fetal monitoring (EFM) characteristics at admission and in the beginning of the active phase of labor. STUDY DESIGN Nested case-control study within a prospective cohort of laboring patients at term who achieved active labor. Neonates with umbilical arterial lactate ≥ 4 mmol/L (cases, n = 119), were matched 1:1 to controls with lactate

Background Maternal oxygen administration is a widely used intrauterine resuscitation technique for fetuses with category II electronic fetal monitoring patterns, despite a paucity of evidence on its ability to improve electronic fetal monitoring patterns. Objective This study investigated the effect of intrapartum oxygen administration on Category II electronic fetal monitoring patterns. Study Design This is a secondary analysis of a randomized trial conducted in 2016–2017, in which patients with fetuses at ≥37 weeks’ gestation in active labor with category II electronic fetal monitoring patterns were assigned to 10 L/min of oxygen by face mask or room air until delivery. Trained obstetrical research nurses blinded to allocation extracted electronic fetal monitoring data. The primary outcome was a composite of high-risk category II features including recurrent variable decelerations, recurrent late decelerations, prolonged decelerations, tachycardia, or minimal variability 60 minutes after randomization to room air or oxygen. Secondary outcomes included individual components of the composite high-risk category II features, resolution of recurrent decelerations within 60 minutes of randomization, and total deceleration area. The outcomes between the room air and oxygen groups were compared using univariable statistics. Time-to-event analysis was used to compare time to resolution of recurrent decelerations between the groups. Paired analysis was used to compare the pre- and postrandomization outcomes within each group. Results All 114 randomized patients (57 room air and 57 oxygen) were included in this analysis. There was no difference in resolution of recurrent decelerations within 60 minutes between the oxygen and room air groups (75.4% vs 86.0%; P=.15). The room air and oxygen groups had similar rates of composite high-risk category II features including recurrent variable decelerations, recurrent late decelerations, prolonged decelerations, tachycardia, and minimal variability 60 minutes after randomization. Time to resolution of recurrent decelerations and total deceleration area were similar between the room air and oxygen groups. Among patients who received oxygen, there was no difference in the electronic fetal monitoring patterns pre- and postrandomization. Similar findings were observed in the electronic fetal monitoring patterns pre- and postrandomization in room air patients. Conclusion Intrapartum maternal oxygen administration for category II electronic fetal monitoring patterns did not resolve high-risk category II features or hasten the resolution of recurrent decelerations. These results suggest that oxygen administration has no impact on improving category II electronic fetal monitoring patterns.

Background Maternal oxygen (O2) administration is a commonly performed intrauterine resuscitation technique though to improve fetal oxygenation. However, hyperoxygenation is known to be harmful in both neonates and adults. Currently, there are no formal recommendations on whether a certain dose or duration of O2 may be most helpful in improving umbilical cord gases or neonatal outcomes. Objective We tested the hypothesis that prolonged supplemental O2 exposure during labor is associated with increased umbilical cord O2 concentrations. Study Design This was a planned secondary analysis of a randomized noninferiority trial comparing O2 with room air in laboring patients. Patients were randomized to receive either 10 L/min O2 or room air at any point during active labor when they developed a category II fetal heart tracing that would otherwise require resuscitation. The primary outcome variable for this analysis was partial pressure of O2 in the umbilical vein. The secondary outcome variable was partial pressure of O2 in the umbilical artery. These outcome variables were compared between patients with short durations of O2 exposure and those with long durations of O2 exposure, defined as Results Among the 99 patients with paired and validated cord gases who were included in this analysis, the partial pressure of O2 in the umbilical vein was significantly lower in patients who received O2 supplementation for longer durations than in those who received O2 for shorter durations (median interquartile range 25.5 [21.5–33] vs 32.5 [26.5–37.5] mm Hg; P Conclusion Longer durations of O2 exposure are not associated with a higher partial pressure of O2 in the umbilical cord. In fact, patients with longer durations of O2 exposure had lower partial pressure of O2 in the umbilical vein, suggesting impaired placental O2 transfer with prolonged O2 exposure.

Objective Our aim was to estimate the incidence of unintentional hysterotomy extension at the time of cesarean delivery and to identify associated risk factors and maternal morbidity. Study Design We conducted a secondary analysis of a randomized controlled trial evaluating chlorhexidine-alcohol versus iodine-alcohol for skin antisepsis in women undergoing cesarean delivery. We included patients with a low transverse hysterotomy. The primary outcome was the incidence of unintentional hysterotomy extension. Logistic regression was performed to identify independent factors associated with hysterotomy extension. Maternal morbidity was compared between patients with and without extension. Results Of 1,038 patients meeting the inclusion criteria, 71 (6.8%; 95% confidence interval [CI]: 5.4–8.5%) experienced a hysterotomy extension. Of several potential risk factors assessed, the second stage of labor was the only independent predictor of hysterotomy extension (adjusted odds ratio: 10.2; 95% CI: 2.6–39.8). Hysterotomy extension was associated with increased operative time (73 vs. 55.3 minutes; p< 0.01), need for blood transfusion (relative risk: 5; 95% CI: 1.6–15.2), and rate of additional surgical injury (RR: 17; 95% CI: 6.9–41.8). Conclusion Hysterotomy extensions are not infrequent at the time of cesarean delivery and are associated with increased maternal morbidity. Cesarean delivery during the second stage of labor is the main independent risk factor for hysterotomy extension.

OBJECTIVE: To evaluate whether administration of antenatal late-preterm betamethasone is cost-effective in the immediate neonatal period. STUDY DESIGN: Cost-effectiveness analysis of late-preterm betamethasone administration with a time horizon of 7.5 days was conducted using a health-system perspective. Data for neonatal outcomes, including respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), and hypoglycemia, were from the Antenatal Betamethasone for Women at Risk for Late Preterm Delivery trial. Cost data were derived from the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality, and utilities of neonatal outcomes were from the literature. Outcomes were total costs in 2017 United States dollars and quality-adjusted life-years (QALYs) for each individual infant as well as for a theoretical cohort of the 270,000 late-preterm infants born in 2015 in the United States. RESULTS: For an individual patient, compared to withholding betamethasone, administering betamethasone incurred a higher total cost ($6,592 versus $6,265) and marginally lower QALYs (0.02002 QALYS versus 0.02006 QALYs) within the studied time horizon. For the theoretical cohort of 270,000 patients, administration of betamethasone was $88 million more expensive ($1,780 million versus $1,692 million) with lower QALYs (5,402 QALYs versus 5,416 QALYs), compared to withholding betamethasone. For administration of betamethasone to be cost-effective, the rate of hypoglycemia, RDS, or TTN among late-preterm infants receiving betamethasone would need to be less than 20.0%, 4.5%, and 2.4%, respectively. CONCLUSION: Administration of betamethasone in the late-preterm period is likely not cost-effective in the short-term.

The optimal management of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) with primary surgical versus non-surgical treatment is unclear. The objective of this systematic review was to evaluate the literature and compare survival for primary surgical versus non-surgical treatment of HPV-positive OPSCC. We performed a comprehensive literature search of multiple electronic databases for relevant articles up to February, 2017. Studies reporting mortality or hazard ratio (HR) for overall survival (OS) in primary HPV-positive OPSCC patients were eligible. Seventy-three articles were eligible, of which 66 included single-modality (19 surgical, 47 non-surgical), and 7 included both surgical and non-surgical modalities. There were no randomized studies comparing outcomes between both modalities. In a meta-analysis of both-modality studies, OS with surgical treatment was not significantly different from non-surgical treatment (pooled HR 1.12; 95% CI: 0.35, 3.57). There was significant heterogeneity between studies (I2 = 82.4%). Among single-modality studies, the mortality rate was lower with surgical [pooled proportion 0.15 (95% CI: 0.09, 0.21)] versus non-surgical treatment [0.20 (95% CI:0.15, 0.24)]. In a subgroup analysis, OS was higher for HPV-positive versus HPV-negative OPSCC, irrespective of the treatment modality. We conclude that there is an absence of high-quality studies that compare survival for HPV-positive OPSCC treated with primary surgical versus non-surgical approach. The available data suggest no statistical or clinically meaningful difference in survival between the two approaches. HPV-positivity was a key prognostic factor irrespective of treatment modality. Further high-quality studies with consistent data reporting are needed to inform the choice for optimal treatment modality for HPV-positive OPSCC.

Objective To estimate the risk of perioperative morbidity with increasing number of cesareans. Study Design We conducted a retrospective cohort study from 2004 to 2010. Patients delivered by cesarean were included. Outcome measures were a composite organ injury (bowel or bladder), hysterectomy, hemorrhage requiring transfusion, severe morbidity, or surgical site complications. The Cochran–Armitage's test of trend was used to assess increasing incidence of each morbidity with number of prior cesareans. Multivariable logistic regression was used to estimate adjusted risks for each morbidity with increasing number of cesareans compared with primary cesarean. Results Of the 15,872 women in the cohort, 5,144 had cesarean delivery: 3,113 primary, 1,310 one prior, 510 two prior, and 211 three or more prior cesareans. There was a significant increase in organ injury, hysterectomy, and surgical site complications with increasing number of cesareans. In multivariable analysis, the risk of organ injury and hysterectomy was increased compared with primary cesarean after two prior cesareans, and after three or more cesareans for hemorrhage requiring transfusion and surgical site complications. Conclusion The risks of organ injury and hysterectomy are increased after two or more prior cesareans, and risks of hemorrhage and surgical site complications are increased after three or more cesareans.

Objective: Determine the association between electronic fetal monitoring and neonatal outcomes in the setting of a true knot at delivery. Study Design: This was a planned secondary analysis of a prospective cohort of 8,580 women. Patients with and without a true knot were compared and the primary outcome was repetitive late decelerations occurring with at least 50% of contractions. Confounders were adjusted for using logistic regression. Results: 8,580 patients met inclusion criteria and 49 (0.57%) had a TK. There was no significant difference in the rate of repetitive late decelerations in patients with TK (aOR 1.04; 95% confidence interval [CI] 0.25–4.40),other electronic fetal monitoring parameters, or neonatal outcomes. Conclusion: Neonates with true knots who are delivered at term have similar electronic fetal monitoring characteristics compared to those without true knots and no detectable difference in neonatal morbidity; thus, calling into question the clinical significance of a true knot at term.

Objective: To measure the impact of group prenatal care (GPC) on diabetes-specific peer support and depressive symptoms in women with pregnancies complicated by diabetes.Materials and methods: This...

Objective To investigate the association between the intraoperative diagnosis of placenta accreta at the time of cesarean hysterectomy and pathological diagnosis. Study Design This is a retrospective cohort study of all patients undergoing cesarean hysterectomy for suspected placenta accreta from 2000 to 2016 at Barnes-Jewish Hospital. The primary outcome was the presence of invasive placentation on the pathology report. We estimated predictive characteristics of clinical diagnosis of placenta accreta using pathological diagnosis as the correct diagnosis. Results There were 50 cesarean hysterectomies performed for suspected abnormal placentation from 2000 to 2016. Of these, 34 (68%) had a diagnosis of accreta preoperatively and 16 (32%) were diagnosed intraoperatively at the time of cesarean delivery. Two patients had no pathological evidence of invasion, corresponding to a false-positive rate of 4% (95% confidence interval [CI]: 0.5%, 13.8%) and a positive predictive value of 96% (95% CI: 86.3%, 99.5%). There were no differences in complications among patients diagnosed intraoperatively compared with those diagnosed preoperatively. Conclusion Most patients undergoing cesarean hysterectomy for placenta accreta do have this diagnosis confirmed on pathology. However, since the diagnosis of placenta accreta was made intraoperatively in nearly a third of cesarean hysterectomies, intraoperative vigilance is required as the need for cesarean hysterectomy may not be anticipated preoperatively.

INTRODUCTION The INTERGROWTH-21st project (IG-21) was recently performed aiming to provide a universal benchmark for comparing fetal growth across different ethnicities. Our aim was to compare the IG-21 with a customized standard for predicting pregnancies at risk for neonatal small-for-gestational age (SGA) and adverse outcomes. MATERIAL AND METHODS This was a prospective cohort study including singleton pregnancies presenting for fetal growth assessment between 26 and 36 weeks of gestation. Fetal growth restriction was defined as estimated fetal weight

Objective To estimate the natural history of cervical effacement in labor. Study Design This is a retrospective cohort study of term, vertex, singletons who reached 10 cm of cervical dilation from 2010 to 2014. Interval-censored regression was used to estimate the median number of hours between changes in effacement (measured in centimeters of the residual cervix) and to estimate the median effacement at a given cervical dilation. Analysis was stratified by parity and labor type. Results In total, 7,319 patients were included. Multiparas had faster effacement from 1 cm to complete effacement than nulliparas, but nulliparas were significantly more effaced at each cervical dilation. Patients in spontaneous labor had faster effacement and were significantly more effaced at each centimeter of cervical dilation than those who were induced or augmented. Once active labor was established (>6 cm of cervical dilation), 95% of patients had an effacement of 1 cm or less. By 8 cm of cervical dilation, 50% of all patients were completely effaced. Conclusion There is a wide range in the normal length of time for the progression of cervical effacement. However, once a patient is in active labor, 95% of patients have effaced to 1 cm or less.

IMPORTANCE: It is unclear whether the timing of second stage pushing efforts affects spontaneous vaginal delivery rates and reduces morbidities. OBJECTIVE: To evaluate whether immediate or delayed pushing results in higher rates of spontaneous vaginal delivery and lower rates of maternal and neonatal morbidities. DESIGN, SETTING, AND PARTICIPANTS: Pragmatic randomized clinical trial of nulliparous women at or beyond 37 weeks’ gestation admitted for spontaneous or induced labor with neuraxial analgesia between May 2014 and December 2017 at 6 US medical centers. The interim analysis suggested futility for the primary outcome and recruitment was terminated with 2414 of 3184 planned participants. Follow-up ended January 4, 2018. INTERVENTIONS: Randomization occurred when participants reached complete cervical dilation. Immediate group participants (n = 1200) began pushing immediately. Delayed group participants (n = 1204) were instructed to wait 60 minutes. MAIN OUTCOMES AND MEASURES: The primary outcome was spontaneous vaginal delivery. Secondary outcomes included total duration of the second stage, duration of active pushing, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, chorioamnionitis, endometritis, perineal lacerations (≥second degree), and a composite outcome of neonatal morbidity that included neonatal death and 9 other adverse outcomes. RESULTS: Among 2414 women randomized (mean age, 26.5 years), 2404 (99.6%) completed the trial. The rate of spontaneous vaginal delivery was 85.9% in the immediate group vs 86.5% in the delayed group, and was not significantly different (absolute difference, −0.6% [95% CI, −3.4% to 2.1%]; relative risk, 0.99 [95% CI, 0.96 to 1.03]). There was no significant difference in 5 of the 9 prespecified secondary outcomes reported, including the composite outcome of neonatal morbidity (7.3% for the immediate group vs 8.9% for the delayed group; between-group difference, −1.6% [95% CI, −3.8% to 0.5%]) and perineal lacerations (45.9% vs 46.4%, respectively; between-group difference, −0.4% [95% CI, −4.4% to 3.6%]). The immediate group had significantly shorter mean duration of the second stage compared with the delayed group (102.4 vs 134.2 minutes, respectively; mean difference, −31.8 minutes [95% CI, −36.7 to −26.9], P

OBJECTIVES To identify the incidence and resolution rates of a low-lying placenta or placenta previa and to assess the optimal time to perform follow-up ultrasonography (US) to assess for resolution. METHODS We conducted a retrospective cohort study of women with a diagnosis of a low-lying placenta or placenta previa at routine anatomic screening. Follow-up US examinations were reviewed to estimate the proportion of women who had resolution. A Kaplan-Meier survival curve was generated to estimate the median time to resolution. The distance of the placental edge from the internal cervical os was used to categorize the placenta as previa or low-lying (0.1-10 or ≥ 10-20 mm). A time-to-event analysis was used to estimate predictive factors and the time to resolution by distance from the os. RESULTS A total of 1663 (8.7%) women had a diagnosis of a low-lying placenta or placenta previa. The cumulative resolution for women who completed 1 or more additional US examinations was 91.9% (95% confidence interval, 90.2%-93.3%). The median time to resolution was 10 (interquartile range [IQR], 7-13) weeks. The distance from the internal cervical os was known for 658 (51.0%) women. The probability of resolution was inversely proportional to the distance from the internal os: 99.5% (≥10-20 mm), 95.4% (0.1-10 mm), and 72.3% (placenta previa; P

Racial and ethnic disparities in maternal morbidity and mortality rates are an important public health problem in the United States. Because racial and ethnic minorities are expected to comprise more than one-half of the US population by 2050, this issue needs to be addressed urgently. Research suggests that the drivers of health disparities occur at 3 levels: patient, provider, and system. Although we have recognized this issue and identified elements that contribute to it, knowledge must be converted into action to address it. In addition, despite available funding and databases, research directed towards understanding and reducing these disparities is lacking. This document summarizes findings of a workshop convened at the 2016 Society for Maternal-Fetal Medicine's 36th Annual Pregnancy meeting in Atlanta, GA, to review and make recommendations about immediate actions in clinical care and research that will serve to reduce racial and ethnic disparities in maternal morbidity and mortality rates in the United States.

Objective Placental insufficiency is associated with neonatal neurologic morbidity and late-term gestations (410/7–416/7 weeks). Whether late-term infants are at increased risk of neurologic morbidity compared with term infants (390/7–406/7 weeks) remains unclear. We aim to compare risk of neurologic morbidity among late-term and term infants. Study Design This secondary analysis of a single-institution prospective cohort study included all liveborn, nonanomalous singleton term and late-term infants, with data on adverse neonatal outcomes up until 28 days of life. The primary outcome was a neonatal neurologic morbidity composite, defined by having one of these conditions: neonatal seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, and neonatal hypothermic therapy. Secondary outcomes were the composite's individual components and nonneurologic neonatal morbidity. Multivariable logistic regression adjusted for delivery mode, nulliparity, and labor type. Results Of 5,529 infants included, 747 were late term and 4,782 were term. The risk of composite neurologic morbidity was not significantly different among late-term or term infants (0.5 vs. 0.6%; adjusted odds ratio: 0.59, 95% confidence interval: 0.21–1.71). Overall neonatal morbidity was not significantly different in the two groups, though late-term infants had a nonsignificantly higher prevalence of respiratory distress syndrome (5.5 vs. 3.3%) and meconium aspiration syndrome (0.7 vs. 0.2%). Conclusion Neonatal neurologic morbidity is uncommon after 39 weeks. Risk does not increase after 41 weeks.

Objective The objective of this study was to investigate the relationship between umbilical cord partial pressure of oxygen (pO2) at delivery and neonatal morbidity. Study Design This is a secondary analysis of a prospective cohort study of term deliveries with universal cord gas collection between 2010 and 2014. The primary composite outcome of neonatal morbidity included neonatal death, meconium aspiration syndrome, intubation, mechanical ventilation, hypoxic-ischemic encephalopathy, and hypothermia treatment. Umbilical artery (UA), vein (UV), UV minus UA (Δ) pO2, and hypoxemia (pO2 ≤ fifth percentile) were compared between patients with and without neonatal morbidity. Areas under the receiver-operating characteristic curves were used to assess the predictive ability of pO2. Results Of 7,789 patients with paired umbilical cord pO2, 106 (1.4%) had the composite neonatal morbidity. UA pO2 was significantly lower in patients with neonatal morbidity compared with those without (median [interquartile range]: 16 (12, 21) vs. 19 (15, 24) mm Hg, p Conclusion Although UA pO2 is significantly lower in patients with neonatal morbidity, it is a poor predictor of neonatal morbidity at term.

To estimate the risk of adverse perinatal outcomes among women with isolated fetal growth restriction from 17 to 22 weeks of gestation.This was a retrospective cohort study of all singleton, nonanomalous pregnancies undergoing ultrasonography to assess fetal anatomy between 17 and 22 weeks of gestation at a single center from 2010 to 2014. After excluding patients with fetal structural malformations, chromosomal abnormalities, or identified infectious etiologies, we compared perinatal outcomes between pregnancies with and without fetal growth restriction, defined as estimated fetal weight less than the 10th percentile for gestational age. Our primary outcome was small for gestational age (SGA) at birth, defined as birth weight less than the 10th percentile. Secondary outcomes included preterm delivery at less than 37 and less than 28 weeks of gestation, preeclampsia, abruption, stillbirth, neonatal death, neonatal intensive care unit admission, intraventricular hemorrhage, need for respiratory support, and necrotizing enterocolitis.Of 12,783 eligible patients, 355 (2.8%) had early second-trimester fetal growth restriction. Risk factors for growth restriction were African American race and tobacco use. Early second-trimester growth restriction was associated with a more than fivefold increase in risk of SGA at birth (36.9% compared with 9.1%, adjusted odds ratio [OR] 5.5, 95% CI 4.3-7.0), stillbirth (2.5% compared with 0.4%, OR 6.2, 95% CI 2.7-12.8), and neonatal death (1.4% compared with 0.3%, OR 5.2, 95% CI 1.6-13.5). Rates of indicated preterm birth at less than 37 weeks of gestation (7.3% compared with 3.3%, OR 2.3, 95% CI 1.5-3.5) and less than 28 weeks of gestation (2.5% compared with 0.2%, OR 10.8, 95% CI 4.5-23.4), neonatal need for respiratory support (16.9% compared with 7.8%, adjusted OR 1.6, 95% CI 1.1-2.2), and necrotizing enterocolitis (1.4% compared with 0.2%, OR 7.7, 95% CI 2.3-20.9) were also significantly higher for those with growth restriction. Rates of preeclampsia, abruption, and other neonatal outcomes were not significantly different.Although fetal growth restriction in the early second trimester occurred in less than 3% of our cohort and most of those with isolated growth restriction did not have adverse outcomes, it is a strong risk factor for SGA, stillbirth, neonatal death, and indicated preterm birth.

Objective The objective of this study was to compare the rates of spontaneous labor onset and its progression in obese and nonobese women after 37 weeks. Study Design We performed a secondary analysis of a retrospective cohort of all women who were admitted for delivery at ≥ 37 weeks of gestation at a university-based tertiary care center between 2004 and 2010. The cohort was stratified by weeks of gestation at which the patient presented for delivery. The rates of spontaneous labor, vaginal delivery, and augmentation with oxytocin were compared between obese (body mass index [BMI] ≥ 30) and nonobese (BMI Results Obese women had lower rates of spontaneous labor than nonobese women at every gestational week (37 weeks, 6.1 vs. 9.3%, p Conclusion Obese women at or beyond 37 weeks are less likely to experience spontaneous labor compared with nonobese women. In addition, obese women presenting in spontaneous labor are less likely that nonobese women to have a vaginal delivery at 37 to 40 weeks, even after oxytocin augmentation.

Objectives This study aims to evaluate the implementation of a delayed umbilical cord clamping (DCC) protocol for neonates Study Design Retrospective cohort study from November 2014 to March 2016 of patients delivered by 316/7 weeks. In 2014, an institutional protocol for DCC at Results Of the 185 patients included in the study, 90 underwent DCC, and 72% of potentially eligible patients appropriately received DCC. There was no significant difference in the maternal hemorrhage composite outcome between DCC and immediate cord clamping (23.3 vs. 36.8%, adjusted odds ratio = 0.64, 95% confidence interval = 0.33, 1.26). There was also no significant difference in the ability to obtain a single or paired umbilical cord blood gas result. Conclusion Implementation of a DCC protocol for preterm neonates is feasible and was successful. We did not find an increase in maternal risk or a decrease in the ability to obtain umbilical cord blood gases following DCC.

Background Classifying preterm birth as spontaneous or indicated is critical both for clinical care and research, yet the accuracy of classification based on different data sources is unclear. We examined the accuracy of preterm birth classification as spontaneous or indicated based on birth certificate data. Methods This is a retrospective cohort study of 123 birth certificates from preterm births in Missouri. Correct classification of spontaneous or indicated preterm birth subtype was based on multi-provider (RN, MFM Fellow, MFM attending) consensus after full medical record review. A categorisation algorithm based on clinical data available in the birth certificate was designed a priori and classification was performed by a single investigator according to the algorithm. Accuracy of birth certificate classification as spontaneous or indicated was compared to the consensus classification. Errors in misclassification were explored. Results Classification based on birth certificates was correct for 66% of preterm births. Most errors in classification by birth certificate occurred in classifying a birth as spontaneous when it was in fact indicated. The vast majority of errors occurred when preterm rupture of membranes (≥12 h) was checked on the birth certificate causing classification as spontaneous when there was a maternal or fetal indication for delivery. Conclusions Birth certificate classification overestimated spontaneous preterm birth and underestimated indicated preterm birth compared to classification performed from medical record review. Revisions to birth certificate clinical data would allow more accurate population level surveillance of preterm birth subtypes.

Importance Two-thirds of women in labor receive supplemental oxygen to reverse perceived fetal hypoxemia and prevent acidemia. Oxygen is routinely administered for category II fetal heart tracings, a class of fetal tracing used to designate intermediate risk for acidemia. This liberal use of oxygen may not be beneficial, particularly because neonatal hyperoxygenation is harmful. Objective To test the hypothesis that room air is noninferior to oxygen in improving fetal metabolic status among patients with category II fetal heart tracings. Design, Setting, and Participants This was a randomized, unblinded noninferiority clinical trial conducted between June 2016 and July 2017 in the labor and delivery ward of a single tertiary care center. Women with singleton pregnancies at 37 weeks’ gestational age or more who were admitted for delivery were eligible. Of those who met inclusion criteria, the patients who developed category II tracings in labor that necessitated intrauterine resuscitation were randomized in a 1:1 ratio to room air or oxygen. Analyses were intention-to-treat. Interventions The oxygen group received 10 L of oxygen per minute by nonrebreather facemask until delivery. The room air group was exposed to room air only without a facemask. Main Outcomes and Measures The primary outcome was umbilical artery lactate, a marker of metabolic acidosis and neonatal morbidity. Noninferiority was defined as a mean difference between groups of less than 9.0 mg/dL (1.0 mmol/L). Secondary outcomes were other umbilical artery gases, cesarean delivery for nonreassuring fetal status, and operative vaginal delivery. Results Of the 705 patients who met inclusion criteria, 277 (39.3%) were enrolled on admission. During labor, 114 patients (41.2% of the enrolled patients) developed category II tracings and were randomized to room air (57 patients; 50.0% of the randomized patients) or oxygen (57 patients; 50.0% of the randomized patients). A total of 99 patients (86.8% of the randomized patients) with paired cord gases were included in the modified intention-to-treat analysis. The 99 patients included 76 African American women (77%); mean (SD) age was 27.3 (6.3) years in the oxygen group and 27.8 (5.3) years in the room air group. There was no difference in umbilical artery lactate between the group on oxygen and the group on room air (mean, 30.6 mg/dL [95% CI, 27.0 to 34.2 mg/dL] vs 31.5 mg/dL [95% CI, 27.9 to 36.0 mg/dL]);P = .69). The mean difference in lactate was 0.9 mg/dL (95% CI, −4.5 to 6.3 mg/dL), which was within the noninferiority margin. There was no difference in other umbilical artery gas components or mode of delivery between groups. Conclusions and Relevance Among patients with category II fetal heart tracings, intrauterine resuscitation with room air is noninferior to oxygen in improving umbilical artery lactate. The results of this trial challenge the efficacy of a ubiquitous obstetric practice and suggest that room air may be an acceptable alternative. Trial Registration ClinicalTrials.gov Identifier:NCT02741284

Background Intrapartum electronic fetal monitoring is the most commonly used tool in obstetrics in the United States; however, which electronic fetal monitoring patterns predict acidemia remains unclear. Objective This study was designed to describe the frequency of patterns seen in labor using modern nomenclature, and to test the hypothesis that visually interpreted patterns are associated with acidemia and morbidities in term infants. We further identified patterns prior to delivery, alone or in combination, predictive of acidemia and neonatal morbidity. Study Design This was a prospective cohort study of 8580 women from 2010 through 2015. Patients were all consecutive women laboring at ≥37 weeks’ gestation with a singleton cephalic fetus. Electronic fetal monitoring patterns during the 120 minutes prior to delivery were interpreted in 10-minute epochs. Interpretation included the category system and individual electronic fetal monitoring patterns per the Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria as well as novel patterns. The primary outcome was fetal acidemia (umbilical artery pH ≤7.10); neonatal morbidities were also assessed. Final regression models for acidemia adjusted for nulliparity, pregestational diabetes, and advanced maternal age. Area under the receiver operating characteristic curves were used to assess the test characteristics of individual models for acidemia and neonatal morbidity. Results Of 8580 women, 149 (1.7%) delivered acidemic infants. Composite neonatal morbidity was diagnosed in 757 (8.8%) neonates within the total cohort. Persistent category I, and 10-minute period of category III, were significantly associated with normal pH and acidemia, respectively. Total deceleration area was most discriminative of acidemia (area under the receiver operating characteristic curves, 0.76; 95% confidence interval, 0.72–0.80), and deceleration area with any 10 minutes of tachycardia had the greatest discriminative ability for neonatal morbidity (area under the receiver operating characteristic curves, 0.77; 95% confidence interval, 0.75–0.79). Once the threshold of deceleration area is reached the number of cesareans needed-to-be performed to potentially prevent 1 case of acidemia and morbidity is 5 and 6, respectively. Conclusion Deceleration area is the most predictive electronic fetal monitoring pattern for acidemia, and combined with tachycardia for significant risk of morbidity, from the electronic fetal monitoring patterns studied. It is important to acknowledge that this study was performed in patients delivering ≥37 weeks, which may limit the generalizability to preterm populations. We also did not use computerized analysis of the electronic fetal monitoring patterns because human visual interpretation was the basis for the Eunice Kennedy Shriver National Institute of Child Health and Human Development categories, and importantly, it is how electronic fetal monitoring is used clinically.

To compare the utility of maximum vertical pocket versus amniotic fluid index for predicting adverse perinatal outcomes. Systematic review of randomized clinical studies comparing these two ultrasound techniques and random-effects meta-analysis to quantify a range of perinatal outcomes. Six studies with 4278 women were eligible. Use of the maximum vertical pocket reduced the rate of diagnosis of oligohydramnios (pooled relative risk 0.38; 95% confidence interval 0.27, 0.53). Use of the maximum vertical pocket was associated with significantly lower rates of non-reassuring fetal heart tracing, cesarean delivery for fetal distress, and induction of labor for oligohydramnios. There were no differences in the rates of cesarean delivery, presence of meconium, umbilical artery pH

Objective This study aimed to estimate second stage duration and its effects on labor outcomes in obese versus nonobese nulliparous women. Study Design This was a secondary analysis of a cohort of nulliparous women who presented for labor at term and reached complete cervical dilation. Adjusted relative risks (aRR) were used to estimate the association between obesity and second stage characteristics, composite neonatal morbidity, and composite maternal morbidity. Effect modification of prolonged second stage on the association between obesity and morbidity was assessed by including an interaction term in the regression model. Results Compared with nonobese, obese women were more likely to have a prolonged second stage (aRR: 1.48, 95% CI: 1.18–1.85 for ≥3 hours; aRR: 1.65, 95% CI: 1.18–2.30 for ≥4 hours). Obesity was associated with a higher rate of second stage cesarean (aRR: 1.78, 95% CI: 1.34–2.34) and cesarean delivery for fetal distress (aRR: 2.67, 95% CI: 1.18–3.58). Obesity was also associated with increased rates of neonatal (aRR: 1.38, 95% CI: 1.05–1.80), but not maternal morbidity (aRR: 1.06, 95% CI: 0.90–1.25). Neonatal morbidity risk was not modified by prolonged second stage. Conclusion Obesity is associated with increased risk of neonatal morbidity, which is not modified by prolonged second stage of labor.

Summary Background WHO recommends daily iron supplementation for pregnant women, but adherence is poor because of side-effects, effectiveness is low, and there are concerns about possible harm. The iron-regulatory hormone hepcidin can signal when an individual is ready-and-safe to receive iron. We tested whether a hepcidin-guided screen-and-treat approach to combat iron-deficiency anaemia could achieve equivalent efficacy to universal administration, but with lower exposure to iron. Methods We did a three-arm, randomised, double-blind, non-inferiority trial in 19 rural communities in the Jarra West and Kiang East districts of The Gambia. Eligible participants were pregnant women aged 18–45 years at between 14 weeks and 22 weeks of gestation. We randomly allocated women to either WHO's recommended regimen (ie, a daily UN University, UNICEF, and WHO international multiple-micronutrient preparation [UNIMMAP] containing 60 mg iron), a 60 mg screen-and-treat approach (ie, daily UNIMMAP containing 60 mg iron for 7 days if weekly hepcidin was

OBJECTIVE: To compare the role of UA Doppler versus CPR in the prediction of neonatal SGA and short term adverse neonatal outcome in a high-risk population. STUDY DESIGN: We conducted a prospective study on women referred for fetal growth ultrasounds between 26 and 36 weeks of gestation and with an EFW < 20(th) percentile by Hadlock standard. UA and middle cerebral artery (MCA) Doppler assessments were performed. Abnormal UA doppler was defined as: pulsatility index (PI) above the 95th percentile and absent or reverse end diastolic flow. The CPR, calculated as a ratio of the MCA PI by the UA PI, was defined as low if < 1.08. The primary outcome was the sensitivity and specificity of the two Doppler assessments to predict neonatal SGA, defined as birthweight < 10(th) percentile by using Alexander curves. The secondary outcomes included umbilical cord arterial pH < 7.10, APGARS at 5 minutes < 7, NICU admission, respiratory distress syndrome (RDS), hypoglycemia or a composite including any of these secondary outcomes. Chi square was performed for statistical analysis. RESULTS: Of 199 women meeting inclusion criteria, 94 (47.2%) had SGA and 68 (34.2%) had a composite adverse outcome. A total of 7 pregnancies with FGR had a low CPR. Abnormal UA Doppler showed a better sensitivity for predicting SGA and adverse neonatal outcomes, with comparable specificity to low CPR. The area under the ROC curve (AUC) using abnormal UA Doppler for predicting SGA was 0.54, 95% CI 0.50–0.58; and 0.51, 95% CI 0.48–0. 53 for low CPR. The AUC for predicting a composite adverse neonatal outcome are: 0.60, 95% CI 0.51– 0.68 for abnormal UA Doppler; and 0.54, 95% CI 0.47– 0.84 for low CPR. CONCLUSION: The CPR did not improve our ability to predict neonatal SGA or other short-term adverse outcomes.

Objective Electronic fetal monitoring (EFM) is intended to assess fetal well-being during labor. Our objective was to test the hypothesis that findings of a category I tracing at any time in the 60 minutes prior to delivery would rule out neonatal acidemia. Study Design This was a planned secondary analysis of a single-center prospective cohort study of 8,580 singleton pregnancies undergoing labor with nonanomalous infants at term. Monitoring was reviewed by obstetric research nurses at 10-minute intervals in the 60 minutes prior to delivery. The primary outcome was acidemia, defined as an umbilical cord arterial pH of 7.10 or less. Results Of the 4,274 patients included, 42 (0.98%) infants had acidemia at birth. Of the 42 infants with acidemia, 13 (31%) had category I tracings in the 30 minutes prior to delivery. Three (7%) infants had neonatal acidemia despite category I tracing for >40 minutes in the 60 minutes prior to delivery. Conclusion Even in the presence of category I tracing in the 60 minutes prior to delivery, neonatal acidemia can still occur. Periods of category I should be interpreted within the clinical context of a priori risk for acidemia, knowing that it does not completely rule out acidemia.

OBJECTIVE: Growth restricted fetuses have been excluded from many randomized trials of prostaglandin for labor induction. As prostaglandins, particularly misoprostol, are associated with increased rates of cesarean delivery for non-reassuring fetal heart tracing, it is important to assess their safety in pregnancies at higher risk of this complication. The objective of this study was to estimate the association between use of prostaglandins for labor induction in term singleton pregnancies complicated by delivery of small for gestational age (SGA) neonates and the risk of cesarean delivery for non-reassuring fetal status (NRFS). MATERIALS AND METHODS: Retrospective cohort study of singleton deliveries ≥37 weeks following induction of labor in patients with SGA (birthweight

While percutaneous umbilical cord blood sampling (PUBS) and intrauterine transfusion (IUT) are the standards of care for the management of significant fetal anemia, the neonatal complications resultant from these procedures remain poorly understood. Thus, we aimed to compare neonatal outcomes of the patients undergoing percutaneous umbilical cord blood sampling (PUBS) for intrauterine transfusion (IUT) to gestational age- and sex-matched controls with no indication for and not undergoing PUBS.This was a retrospective matched cohort study at a single institution from 2000 to 2017. Clinical and demographic data were abstracted from the medical record of patients undergoing PUBS. Neonatal outcomes from pregnancies undergoing PUBS for suspected fetal anemia and from randomly selected gestational age- and sex-matched controls were collected. Neonatal outcomes were compared using matched pairs analysis.There were 64 patients who underwent a total of 178 PUBS with 157 IUT. The most common etiology of fetal anemia was anti-D alloimmunization. On an average, patients undergoing PUBS underwent two procedures (IQR 1,4). There were available neonatal outcomes in 40 patients. The median gestational age at delivery was 34 weeks in both neonates who underwent PUBS and controls. In matched pairs analysis, neonates who underwent PUBS were at higher risk for neonatal complications compared to control neonates (92.5 vs. 55%, OR 4.5, 95% CI 4.5, ∞) . Specifically, neonates who underwent PUBS were more likely to experience respiratory complications compared to controls despite a higher uptake of antenatal corticosteroids.We found that neonates who underwent PUBS experience a higher occurrence of complications which does not appear to be secondary to prematurity alone. Despite higher uptake of antenatal corticosteroids in neonates who underwent PUBS as compared to control neonates, neonates who underwent PUBS had a higher risk of respiratory complications. This study can help to inform patients undergoing PUBS/IUT on the anticipated neonatal outcomes and anticipate needed neonatology resources. While PUBS/IUT is the best treatment known to date for management of fetal anemia, our study highlights the need for further research into the subsequent neonatal complications and how to prevent them.

Objective This study aimed to determine the association between nuchal cord, electronic fetal monitoring parameters, and adverse neonatal outcomes. Study Design This was a prospective cohort study of 8,580 singleton pregnancies. Electronic fetal monitoring was interpreted, and patients with a nuchal cord at delivery were compared with those without. The primary outcome was a composite neonatal morbidity index. Logistic regression was used to adjust for confounders. Result Of 8,580 patients, 2,071 (24.14%) had a nuchal cord. There was no difference in the risk of neonatal composite morbidity in patients with or without a nuchal cord (8.69 vs. 8.86%; p = 0.81). Nuchal cord was associated with category II fetal heart tracing and operative vaginal delivery (OVD) (6.4 vs. 4.3%; p Conclusion Nuchal cord is associated with category II electronic fetal monitoring parameters, which may drive increased rates of OVD. However, there is no significant association with neonatal morbidity.

To estimate the clinical effectiveness, as determined by positive pregnancy test, of letrozole compared with clomiphene citrate for ovarian stimulation in patients with unexplained infertility.We conducted a systematic review and meta-analysis of data from electronic databases including Ovid-MEDLINE, EMBASE, Scopus, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and ClinicalTrials.gov.We searched for concepts of unexplained infertility, letrozole, clomiphene citrate, and clinical outcomes including pregnancy and live birth. Studies were included if they were randomized controlled trials (RCTs) comparing clomiphene citrate with letrozole in patients with unexplained infertility. Eight RCTs including 2,647 patients with unexplained infertility were included. Primary outcome was positive pregnancy test per patient. Secondary outcomes included positive pregnancy test per cycle, clinical pregnancy, live birth, spontaneous miscarriage, twin gestation, mean serum estradiol (E2), endometrial thickness, and number of dominant follicles. The Cochrane Q test and Higgin's I were used to assess heterogeneity. Random effects models were used to obtain pooled relative risks (RR) and 95% CIs.In analysis per patient, there was no significant difference in positive pregnancy test between patients treated with letrozole compared with clomiphene citrate (24% vs 23%, pooled RR 1.08, 95% CI 0.85-1.36). Significant heterogeneity was noted between studies (I=60.8%). There were no significant differences in clinical pregnancy (pooled RR 1.15, 95% CI 0.71-1.85), live birth (pooled RR 0.94, 95% CI 0.83-1.08), spontaneous miscarriage (pooled RR 0.92, 95% CI 0.61-1.38), or twin gestation (pooled RR 0.81, 95% CI 0.39-1.68). Mean serum E2 was significantly lower in the letrozole group than in the clomiphene citrate group.Although limited by heterogeneity, studies of ovarian stimulation in women with unexplained infertility show no difference in clinical outcomes between letrozole and clomiphene citrate.

Objective: To compare the INTERGROWTH-21st Century growth standard to the Hadlock standard in predicting small for gestational age (SGA) and adverse neonatal outcomes. Method: This is a prospective cohort study on women with singleton gestations referred for fetal growth ultrasound between 26.0 and 36.6 weeks gestational age (GA). The primary outcome is prediction of neonatal SGA. Neonatal SGA was defined as birthweight Results: Among 1054 patients who met inclusion criteria, 139 (13.2%) had neonatal SGA. The mean interval between estimated fetal weight and birthweight was 6.7 ± 3.1 weeks. Composite adverse neonatal outcome was seen in 300 (28.4%) patients. The sensitivity for identifying SGA neonates was higher for Hadlock compared with INTERGROWTH-21st standard (41.7 vs. 24.5%); AUC (95% CI) were 0.69 (0.65–0.73) and 0.62 (0.58–0.65), respectively. Both standards were comparable in predicting the composite adverse neonatal outcomes; AUC (95% CI) were 0.52 (0.50–0.53) and 0.52 (0.50–0.54), respectively; p = .28. Conclusions: The Hadlock standard had a moderate but higher discriminatory ability for predicting neonatal SGA compared to the INTERGROWTH-21st project standard. However, the two standards were poor predictors of early adverse neonatal outcomes. Rationale: The Intergrowth-21st project was recently introduced with the goal of providing a universal benchmark for comparing growth across different ethnicity. We performed a prospective cohort study to compare the Intergrowth-21st standard with the commonly used Hadlock standard for predicting pregnancies at risk for neonatal SGA and adverse outcomes. Hadlock fetal growth standard is moderately superior at predicting neonatal SGA compared to the Intergrowth-21st standard. Both standards are poor at predicting adverse neonatal outcomes. These findings, however, need further validation.