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To characterize probabilities of vaginal delivery based on second-stage duration along with maternal and neonatal risks for women undergoing labor after cesarean delivery.This unplanned secondary analysis of the Maternal-Fetal Medicine Units Cesarean Registry, a prospective observational cohort, assessed outcomes in women with a prior uterine scar and included women with a previous cesarean delivery without prior vaginal delivery who reached the second stage of labor. The primary outcome was mode of delivery by second-stage duration. Secondary outcomes included assessment of individual adverse maternal (chorioamnionitis, atony, endometritis, hysterectomy, uterine rupture or dehiscence, and red cell transfusion) and neonatal (cord pH less than 7.10, Apgar score less than 6 at 5 minutes, neonatal intensive care unit admission, and ventilatory support) outcomes.Of 4,579 women with a previous cesarean delivery who reached the second stage of labor, 4,147 (90.6%) delivered vaginally. As second stage increased, successful vaginal delivery rates decreased: 97.3% at less than 1 hour (95% CI 96.6-97.9%), 91.5% at 1 to less than 2 hours (95% CI 89.8-93.1%), 78.5% at 2 to less than 3 hours (95% CI 74.5-82.1%), 62.3% at 3 to less than 4 hours (95% CI 55.2-69.1%), and 45.6% at 4 hours or greater (95% CI 37.7-53.7%). Risk of all adverse maternal outcomes increased with the length of the second stage. Specifically, risk of uterine rupture or dehiscence increased with second-stage length from less than 1 hour (0.7%), 1 to less than 2 hours (1.4%), 2 to less than 3 hours (1.5%), to 3 hours or greater (3.1%) (P.001 for differential risk across the second stage). Risk of neonatal outcomes did not differ significantly by second-stage length.Although many women with a longer second stage (greater than 3 hours) will achieve successful vaginal delivery, these patients may be at increased risk for adverse maternal outcomes and should have close observation of fetal heart rate monitoring, maternal vital signs, and symptoms suggestive of uterine rupture or dehiscence.

BACKGROUND: While there are well-accepted standards for the diagnosis of arrested active-phase labor, the definition of a "failed" induction of labor remains less certain. One approach to diagnosing a failed induction is based on the duration of the latent phase. However, a standard for the minimum duration that the latent phase of a labor induction should continue, absent acute maternal or fetal indications for cesarean delivery, remains lacking. OBJECTIVE: The objective of this study was to determine the frequency of adverse maternal and perinatal outcomes as a function of the duration of the latent phase among nulliparous women undergoing labor induction. METHODS: This study is based on data from an obstetric cohort of women delivering at 25 U.S. hospitals from 2008-2011. Nulliparous women who had a term singleton gestation in the cephalic presentation were eligible for this analysis if they underwent a labor induction. Consistent with prior studies, the latent phase was determined to begin once cervical ripening had ended, oxytocin was initiated and rupture of membranes (ROM) had occurred, and was determined to end once 5 cm dilation was achieved. The frequencies of cesarean delivery, as well as of adverse maternal (e.g., cesarean delivery, postpartum hemorrhage, chorioamnionitis) and perinatal outcomes (e.g., a composite frequency of either seizures, sepsis, bone or nerve injury, encephalopathy, or death), were compared as a function of the duration of the latent phase (analyzed with time both as a continuous measure and categorized in 3-hour increments). RESULTS: A total of 10,677 women were available for analysis. In the vast majority (96.4%) of women, the active phase had been reached by 15 hours. The longer the duration of a woman's latent phase, the greater her chance of ultimately undergoing a cesarean delivery (P

Objective The aim of the study is to evaluate the association of steroid metabolism and respiratory gene polymorphisms in neonates exposed to antenatal corticosteroids (ACS) with respiratory outcomes, small for gestational age (SGA), and response to repeat ACS. Study Design This candidate gene study is a secondary analysis of women enrolled in a randomized controlled trial of single versus weekly courses of ACS. Nineteen single nucleotide polymorphisms (SNPs) in 13 steroid metabolism and respiratory function genes were evaluated. DNA was extracted from placenta or fetal cord serum and analyzed with TaqMan genotyping. Each SNP was evaluated for association via logistic regression with respiratory distress syndrome (RDS), continuous positive airway pressure (CPAP)/ventilator use (CPV), and SGA. Results CRHBP , CRH , and CRHR1 minor alleles were associated with an increased risk of SGA. HSD11B1 and SCNN1B minor alleles were associated with an increased likelihood of RDS. Carriage of minor alleles in SerpinA6 was associated with an increased risk of CPV. CRH and CRHR1 minor alleles were associated with a decreased likelihood of CPV. Conclusion Steroid metabolism and respiratory gene SNPs are associated with respiratory outcomes and SGA in patients exposed to ACS. Risks for respiratory outcomes are affected by minor allele carriage as well as by treatment with multiple ACS.

To compare adipose tissue concentration among obese women receiving 2 g compared with 3 g of precesarean cefazolin prophylaxis.This was a double-blind randomized controlled trial of women with singleton gestations and body mass indexes (BMIs) of 30 or greater at their first prenatal visit undergoing cesarean delivery at term. Women were randomly allocated, stratified by BMI, to receive 2 g or 3 g of cefazolin. Subcutaneous adipose tissue was harvested twice: before (opening) fascial incision and after (closing) fascial closure. The primary outcome was opening adipose tissue cefazolin concentration, measured by high-pressure liquid chromatography.From April 2013 to July 2014, 58 women were enrolled, 57 included in the analysis: 28 in the 2-g group and 29 in the 3-g group. Baseline characteristics were similar between groups. Median opening adipose tissue concentration was similar between the 2-g and 3-g groups (9.4 [interquartile range 5.1-13.4] compared with 11.7 [interquartile range 7-18.3] micrograms/g, P=.12). The percentage of women with opening concentrations above 8 micrograms/g, the minimally inhibitory concentration of cefazolin for Staphylococcus species, was similar (61% compared with 72%, P=.35). All samples were above 2 micrograms/g, the minimally inhibitory concentration for Enterobacteriaceae. Closing adipose tissue concentrations and stratified analyses were consistent with the overall analysis.In obese women undergoing cesarean delivery, prophylaxis with 3 g of cefazolin did not significantly increase adipose tissue concentration. Thus, our data do not support recommendations for 3-g dosing.I.

The aim of the study was to evaluate associations between fetal growth and weight at 2 years in infants born preterm using a customized approach for birth weight.This is a secondary analysis of a multicenter trial that included a 2-year follow-up of children born prematurely. Customized birth weight percentiles were calculated using the Gardosi model for a U.S. population, and the relation between customized percentile and weight and height at 2 years (adjusted for gender using z-score) was determined using regression analysis and by comparing z-scores for children with birth weight10th versus ≥10th percentile.Weight z-score at 2 years was significantly lower in the10th than in the ≥10th percentile group (median [interquartile range, IQR]: -0.66 [-1.58, -0.01] vs. -0.23 [-1.05, 0.55]; p 0.001), and remained after adjusting for maternal education (p 0.001). A similar relationship was noted for height z-score between groups (median [IQR]: -0.56 [-1.29, 0.19] vs. -0.24 [-0.99, 0.37]; p 0.001). Positive relationships between customized birth weight percentile and weight and height at 2 years were noted (p 0.001 for both), but were not strong (R (2) = 0.04 and 0.02, respectively).Customized birth weight percentile is a minor determinant of weight at 2 years among children born preterm.

Objective To determine whether β2-adrenoceptor (β2AR) genotype is associated with shortening of the cervix or with preterm birth (PTB) risk among women with a short cervix in the second trimester. Design A case–control ancillary study to a multicentre randomised controlled trial. Setting Fourteen participating centres of the Maternal-Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Population Four hundred thirty-nine women, including 315 with short cervix and 124 with normal cervical length. Methods Nulliparous women with cervical length

Objective This study aims to determine whether there is a threshold 3-hour oral glucose tolerance test (OGTT) value associated with accelerated risk of adverse pregnancy outcomes. Study Design In a secondary analysis of a cohort of women with untreated mild gestational glucose intolerance, we used generalized additive models with smoothing splines to explore nonlinear associations between each of the 3-hour OGTT values (fasting, 1-hour, 2-hour, and 3-hour) and adverse pregnancy outcomes, including the study's composite outcome (perinatal mortality, hypoglycemia, hyperbilirubinemia, neonatal hyperinsulinemia, and/or birth trauma), large for gestational age birth weight, small for gestational age birth weight, shoulder dystocia, neonatal hypoglycemia, gestational hypertension (gHTN), and preeclampsia. Results Among the 1,360 eligible women, each timed OGTT value was linearly associated with increased odds of composite adverse outcome. We found evidence of a departure from linearity only for the association between fasting glucose and gHTN/preeclampsia, with a stronger association for values of 85 to 94 mg/dL ( p = 0.03). We found no evidence of departure from linearity for any other OGTT values and measured outcomes (all chi-square test p -values ≥ 0.05). Conclusion In a population of untreated women with mild gestational glucose intolerance and fasting OGTT

This study aims to assess the risk of morbidity associated with maternal lactic acid concentration in women with possible sepsis in pregnancy.Retrospective cohort of pregnant and postpartum patients with signs of sepsis. Morbidity outcomes were compared by lactic acid concentration. Linear regression was used to evaluate the association between lactic acid and adverse outcomes.Out of the 850 women included, 159 had lactic acid measured. Patients with lactic acid measured had higher morbidity: positive blood cultures (16.8 vs. 5.5%, p = 0.04), admission to the intensive care unit (5 vs. 0.1%, p0.01) or acute monitoring unit (17.2 vs. 0.9%, p0.01), longer hospital stay (median 3 vs. 2 days, p0.01), and preterm delivery (18.3 vs. 10.9%, p = 0.05). The mean lactic concentration was higher in patients admitted to the intensive care (2.6 vs. 1.6 mmol/L, p = 0.04) and telemetry unit (2.0 vs. 1.6, p = 0.03), and in those with positive blood cultures (2.2 vs. 1.6, p0.01). Lactic acid was positively associated with intensive care or telemetry unit admission, adjusted odds ratio per 1 mmol/L increase in lactic acid 2.34 (95% confidence interval, 1.33-4.12).Elevated lactic acid in pregnancy is associated with adverse maternal outcomes from presumed sepsis. In this cohort, lactic acid measurement was a marker of more severe infection.

To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity.This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008-2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery.A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36-1.59; Asian adjusted OR 1.26, 95% CI 1.14-1.40; Hispanic adjusted OR 1.17, 95% CI 1.07-1.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Nonapplication of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or cervical ripening did not contribute to increased odds of cesarean delivery for non-Hispanic black and Hispanic women. Compared with non-Hispanic white women, Hispanic women were actually less likely to experience elective cesarean delivery (adjusted OR 0.60, 95% CI 0.42-0.87) or cesarean delivery for arrest of dilation before 4 hours (adjusted OR 0.67, 95% CI 0.49-0.92). Additionally, compared with non-Hispanic white women, Asian women were more likely to experience cesarean delivery for nonreassuring fetal status (adjusted OR 1.29, 95% CI 1.09-1.53) and to have had that cesarean delivery be performed in the setting of a 1-minute Apgar score 7 or greater (adjusted OR 1.79, 95% CI 1.07-3.00). A similar trend was seen among multiparous women with prior vaginal deliveries.Although racial and ethnic disparities exist in the frequency of cesarean delivery, differential use of labor management strategies intended to reduce the cesarean delivery rate does not appear to be associated with these racial and ethnic disparities.

This month we focus on current research in cesarean delivery. Dr. Rouse discusses six recent publications, which are concluded with a "bottom line" that is a take-home message. A complete reference for each can be found on on this page along with direct links to abstracts.

To estimate the effects of a brief prenatal behavioral intervention on risk behaviors for maternal cytomegalovirus (CMV) infection.Women were screened with CMV serology during prenatal care before 20 weeks of gestation and followed for at least 10 weeks. Women without serologic evidence of primary CMV infection were approached. Participants were apprised of serostatus and then randomized 2:1 to either a brief behavioral intervention during their prenatal care visit or to standard care (a brochure). The 7- to 10-minute in-office intervention included a video and hygiene education using motivational interviewing. Participants were then given a reminder calendar to take home and weekly text message reminders. The primary outcome was change in behavioral compliance score on a scale of 0-100. Secondary outcomes included process evaluation and domains of behavior change. A sample size of 180 participants was planned to compare the behavioral compliance score change of at least 15% between intervention and control groups with 80% power and 2.5% two-sided α.From April 2013 to October 2014, 197 women were randomized. One hundred eighty-seven (96%) had outcome data available. Mean gestational age at screening and randomization was 9 4/7 and 13 6/7 weeks of gestation, respectively. Primary outcome assessment occurred at a mean of 28 4/7 weeks of gestation. Baseline behavioral compliance scores increased modestly in the intervention group (mean: 7-point increase from 80.7 to 87.7, 95% CI 2.4-5.9) compared with the comparison group (mean: 4-point increase from 79.7 to 84.1, 95% CI 5.9-8.4; mean difference in change score: 3.0, 95% CI, 0.8-5.2; P=.007). Those in the intervention group reported change in risk perception related to perceived severity and susceptibility, self-efficacy, and perceived norms (P.05 for all).A brief behavioral intervention delivered in the prenatal care setting was modestly effective at changing behaviors related to CMV infection risk.ClinicalTrials.gov, NCT01819519.

To compare morbidity among small-for-gestational-age (SGA; birth weight less than the 10th percentile for gestational age), appropriate-for-gestational-age (AGA; birth weight 10th to 90th percentile; reference group), and large-for-gestational-age (LGA; birth weight greater than the 90th percentile) neonates in apparently uncomplicated pregnancies at term (37 weeks of gestation or greater).This secondary analysis, derived from an observational obstetric cohort of 115,502 deliveries, included women with apparently uncomplicated pregnancies of nonanomalous singletons who had confirmatory ultrasound dating no later than the second trimester and who delivered between 37 0/7 and 42 6/7 weeks of gestation. We used two different composite neonatal morbidity outcomes: hypoxic composite neonatal morbidity for SGA and traumatic composite neonatal morbidity for LGA neonates. Log Poisson relative risks (RRs) with 95% CIs adjusted for potential confounding factors (nulliparity, body mass index, insurance status, and neonatal sex) were calculated.Among the 63,436 women who met our inclusion criteria, SGA occurred in 7.9% (n=4,983) and LGA in 8.3% (n=5,253). Hypoxic composite neonatal morbidity was significantly higher in SGA (1.1%) compared with AGA (0.7%; adjusted RR 1.44, 95% CI 1.07-1.93) but similar between LGA (0.6%) and AGA (adjusted RR 0.84, 95% CI 0.58-1.22). Traumatic composite neonatal morbidity was significantly higher in LGA (1.9%) than AGA (1.0%; adjusted RR 1.88, 95% CI 1.51-2.34) but similar in SGA (1.3%) compared with AGA (adjusted RR 1.28, 95% CI 0.98-1.67).Among women with uncomplicated pregnancies, hypoxic composite neonatal morbidity is more common with SGA neonates and traumatic-composite neonatal morbidity is more common with LGA neonates.

OBJECTIVE: To assess the association of subsequent pregnancy with subsequent metabolic syndrome and type II diabetes mellitus after a pregnancy complicated by mild gestational diabetes mellitus (GDM). METHODS: We conducted a prospective observational follow-up study of women with mild GDM randomized from 2002 to 2007 to usual care or dietary intervention and glucose self-monitoring. Women were evaluated 5–10 years after the parent study. Participants were grouped according to the number of subsequent pregnancies (group A, none [reference]; group B, one; group C, two or greater). Serum triglycerides, glucose tolerance, high-density lipoprotein cholesterol, blood pressure, and waist circumference were assessed. Metabolic syndrome was diagnosed by American Heart Association and National Heart Lung and Blood Institute criteria. Multivariable regression was used to estimate adjusted relative risks (RRs) and 95% confidence intervals (CIs). RESULTS: Of 905 eligible women from the original trial, 483 agreed to participate, 426 of whom were included in this analysis. Groups A, B, and C consisted of 212, 143, and 71 women, respectively. Of women with subsequent pregnancies, 32% (69/214) had another pregnancy complicated with GDM. No difference between groups was observed for metabolic syndrome (group A, 34%; group B, 33%; group C, 30%). Subsequent pregnancies were associated with diabetes mellitus outside of pregnancy (group A, 5.2%; group B, 10.5%, RR 2.62, 95% CI 1.16–5.91; group C, 11.3%, RR 2.83, 95% CI 1.06–7.59), and if complicated with GDM (no subsequent GDM pregnancy, RR 1.99, 95% CI 0.82–4.84; subsequent GDM pregnancy, RR 3.75, 95% CI 1.60–8.82). CONCLUSION: In women with prior mild GDM, subsequent pregnancies did not increase the frequency of metabolic syndrome, but subsequent pregnancies with GDM increased the risk of diabetes mellitus outside of pregnancy.

OBJECTIVE To evaluate whether treatment of mild gestational diabetes mellitus (GDM) confers sustained offspring health benefits, including a lower frequency of obesity. RESEARCH DESIGN AND METHODS Follow-up study of children (ages 5–10) of women enrolled in a multicenter trial of treatment versus no treatment of mild GDM. Height, weight, blood pressure, waist circumference, fasting glucose, fasting insulin, triglycerides, and HDL cholesterol were measured. RESULTS Five hundred of 905 eligible offspring (55%) were enrolled. Maternal baseline characteristics were similar between the follow-up treated and untreated groups. The frequencies of BMI ≥95th (20.8% and 22.9%) and 85th (32.6% and 38.6%) percentiles were not significantly different in treated versus untreated offspring (P = 0.69 and P = 0.26). No associations were observed for BMI z score, log waist circumference, log triglycerides, HDL cholesterol, blood pressure, or log HOMA-estimated insulin resistance (HOMA-IR). The effect of treatment was different by sex for fasting glucose and log HOMA-IR (P for interaction = 0.002 and 0.02, respectively) but not by age-group (5–6 and 7–10 years) for any outcomes. Female offspring of treated women had significantly lower fasting glucose levels. CONCLUSIONS Although treatment for mild GDM has been associated with neonatal benefits, no reduction in childhood obesity or metabolic dysfunction in the offspring of treated women was found. However, only female offspring of women treated for mild GDM had lower fasting glucose.

To evaluate the association of duration of magnesium sulfate infusion with stillbirth or death, cerebral palsy, and select adverse maternal and neonatal outcomes.This is a secondary cohort analysis of women randomized to receive magnesium sulfate within a previously reported Maternal-Fetal Medicine Units Network prospective clinical trial. The association of antenatal infusion of magnesium sulfate for less than 12 hours, 12-18 hours, and greater than 18 hours on maternal and perinatal outcomes was compared. The primary outcome was cerebral palsy of any severity or death. Secondary outcomes included cerebral palsy, death, and select maternal and neonatal outcomes. Stratified and logistic regression analyses were used. The models were adjusted for race, gestational age at birth, time since last magnesium sulfate, any magnesium sulfate at delivery, and eligibility criteria as appropriate.Of 933 women available for analysis, 356, 341, and 236 received antenatal magnesium sulfate infusion for a total of less than 12 hours, 12-18 hours, or greater than 18 hours, respectively. Any cerebral palsy or death occurred in 39 women (11.7%) who received magnesium sulfate less than 12 hours, 34 women (10.3%) who received 12-18 hours of magnesium sulfate, and 20 women (8.8%) who received greater than 18 hours of magnesium sulfate. There was no difference in death or cerebral palsy among groups (less than 12 hours as reference; adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 0.60-1.77 for 12-18 hours; adjusted OR 1.08, 95% CI 0.57-2.03 for greater than 18 hours). Select maternal adverse drug affects and neonatal morbidities were also similar across groups.The duration of antenatal magnesium sulfate infusion is not associated with risk of death or cerebral palsy. The optimal treatment duration needed for maximal neuroprotection remains unknown.: II.

Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate nonreassuring fetal heart rate patterns. However, the only 2 randomized trials investigating the use of maternal oxygen supplementation in laboring women do not support that such supplementation is likely to be of benefit to the fetus. And by increasing free radical activity, maternal oxygen supplementation may even be harmful. Based on a review of the available literature, we conclude that until it is studied properly in a randomized clinical trial, maternal oxygen supplementation in labor should be reserved for maternal hypoxia, and should not be considered an indicated intervention for nonreassuring fetal status.

Objective The aim of the article is to determine whether maternal body mass index (BMI) influences the beneficial effects of diabetes treatment in women with gestational diabetes mellitus (GDM). Study Design Secondary analysis of a multicenter randomized treatment trial of women with GDM. Outcomes of interest were elevated umbilical cord c-peptide levels (> 90th percentile 1.77 ng/mL), large for gestational age (LGA) birth weight (> 90th percentile), and neonatal fat mass (g). Women were grouped into five BMI categories adapted from the World Health Organization International Classification of normal, overweight, and obese adults. Outcomes were analyzed according to treatment group assignment. Results A total of 958 women were enrolled (485 treated and 473 controls). Maternal BMI at enrollment was not related to umbilical cord c-peptide levels. However, treatment of women in the overweight, Class I, and Class II obese categories was associated with a reduction in both LGA birth weight and neonatal fat mass. Neither measure of excess fetal growth was reduced with treatment in normal weight (BMI Conclusion There was a beneficial effect of treatment on fetal growth in women with mild GDM who were overweight or Class I and Class II obese. These effects were not apparent for normal weight and very obese women.

To examine the association of elevated early pregnancy hemoglobin A1c (HbA1c) levels with adverse pregnancy outcomes in women with preexisting diabetes mellitus.Retrospective cohort study of 330 women with preexisting diabetes enrolled in a Diabetes in Pregnancy Program at an academic institution between 2003 and 2011 who had an early HbA1c determination. The frequencies of composite maternal adverse pregnancy outcomes (birth at37 weeks, preeclampsia, and medically indicated birth39 weeks), and composite fetal adverse pregnancy outcomes [shoulder dystocia, Apgar scores7 at 5 minutes, small for gestational age (SGA), large for gestational age (LGA), and stillbirth] were compared between HbA1c categories (6.5, 6.5-7.4, 7.5-8.4 and ≥ 8.5%).There was no statistically significant difference between composite adverse maternal pregnancy outcomes and composite adverse fetal pregnancy outcomes as well as other individual outcomes between different HbA1c categories. Of the vaginally delivered women in our cohort, the 37 patients with HbA1c levels of ≥ 8.5% had a significantly higher frequency of fetal shoulder dystocia than the 62 with HbA1c levels of8.5% (24.2 vs. 1.6%, P = 0.002). Neonates of patients with HbA1c ≥ 8.5% were more likely to have low five minute Apgar scores than neonates of patients with HbA1c8.5%, but this was of borderline statistical significance (7.4% vs. 0.5%, P = 0.05).In patients with preexisting diabetes mellitus, HbA1c levels of ≥ 8.5% during early pregnancy are not useful in predicting most adverse outcomes, although there may be an increased risk for shoulder dystocia.

In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

OBJECTIVE: To evaluate the feasibility of salpingectomy compared with standard bilateral tubal ligation at the time of cesarean delivery in women with undesired fertility. METHODS: We included women ≥ 35 weeks of gestation desiring permanent sterilization at the time of cesarean delivery. Patients were randomized after skin incision to bilateral salpingectomy or bilateral tubal ligation by a computer-generated scheme. If salpingectomy was unable to be completed on one or both sides, bilateral tubal ligation was attempted. Primary feasibility outcomes were total operative time and bilateral completion of randomized procedure. Secondary outcomes included clinically estimated blood loss (EBL) and surgical complications up to 6 weeks postpartum. We estimated that 80 patients(40 per group) would provide >80% power to identify a 10-minute difference in the primary outcome (time) with a standard deviation of 15 minutes and 2-sided α of 0.05. Analysis was by intent-to-treat. RESULTS: Of 221 women screened from June 2015 to April 2017, 115 (52%) consented to the study; 80 were randomized, 40 to salpingectomy and 40 to bilateral tubal ligation. Groups were similar at baseline. A total of 27 bilateral salpingectomies were successfully completed compared to 38 bilateral tubal ligations (68% vs. 95%, p = 0.002). Total operative time was on average 15 minutes longer for salpingectomies (75.4 ± 29.1 vs. 60.0 ± 23.3 min, p = 0.004). No adverse outcomes directly related to the sterilization procedure were noted in either group. While EBL of only the sterilization procedure (surgeon estimate) was greater for the salpingectomy group (median 10 [IQR 5–25] vs. 5 [IQR 5–10] cc, p

(Abstracted from Am J Obstet Gynecol 2018;219(3):296.e1–296.e8)Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37 0/7–38 6/7 weeks) even after demonstrated fetal lung maturity when compared with full-term bi

Importance Administration of corticosteroids to women at high risk for delivery in the late preterm period (34-36 weeks’ gestation) improves short-term neonatal outcomes. The cost implications of this intervention are not known.

The aim of the study is to determine if umbilical cord serum concentrations of interleukin-6 (IL-6), C-reactive protein (CRP), and myeloperoxidase (MPO), in pregnancies at risk for preterm birth (PTB), are associated with neonatal morbidities and/or altered neurodevelopmental outcomes in the children.Umbilical cord serum samples were collected at birth from 400 newborns delivered within a multicenter randomized controlled trial of repeated versus single course of antenatal corticosteroids (ACs), in women at increased risk for PTB. Newborns were followed through discharge and were evaluated between 36 and 42 months corrected age with neurological examination and Bayley Scales of Infant Development. Umbilical cord serum concentrations of IL-6, CRP, and MPO were determined using enzyme-linked immunoassays. Multivariate logistic regression analyses explored the relationship between umbilical cord serum IL-6, CRP, and MPO levels, adverse newborn outcomes, and PTB 32 weeks of gestational age (GA).Univariate analysis revealed that umbilical cord IL-6 above the 75th percentile was associated with increased respiratory distress syndrome (RDS) and chronic lung disease (CLD), but not with necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), or neonatal sepsis; however, this association was not significant after adjusting for GA at delivery and treatment group. No significant associations between CRP or MPO and RDS, CLD, NEC, sepsis, or IVH were evident. Regression analysis revealed that CRP above the 75th percentile was associated with a decreased risk of CLD (odds ratio, 0.10; 95% confidence interval, 0.02-0.41). No associations between umbilical cord IL-6, CRP, or MPO and MDI 70 or PDI 70 were evident. Umbilical cord serum concentrations of IL-6, CRP, and MPO, above the 75th percentile, were associated with more frequent PTB 32 weeks of GA.Elevated umbilical cord serum concentration of CRP is associated with reduced risk for CLD even after adjusting for GA at delivery. Occurrence of levels 75th percentile of IL-6, CRP, and MPO in umbilical cord serum was associated with PTB 32 weeks of GA. Elevated umbilical cord serum concentrations of IL-6, CRP, and MPO at birth were not associated with poor neurodevelopmental outcomes.

Background While there are well-accepted standards for the diagnosis of arrested active-phase labor, the definition of a “failed” induction of labor remains less certain. One approach to diagnosing a failed induction is based on the duration of the latent phase. However, a standard for the minimum duration that the latent phase of a labor induction should continue, absent acute maternal or fetal indications for cesarean delivery, remains lacking. Objective The objective of this study was to determine the frequency of adverse maternal and perinatal outcomes as a function of the duration of the latent phase among nulliparous women undergoing labor induction. Study Design This study is based on data from an obstetric cohort of women delivering at 25 US hospitals from 2008 through 2011. Nulliparous women who had a term singleton gestation in the cephalic presentation were eligible for this analysis if they underwent a labor induction. Consistent with prior studies, the latent phase was determined to begin once cervical ripening had ended, oxytocin was initiated, and rupture of membranes had occurred, and was determined to end once 5-cm dilation was achieved. The frequencies of cesarean delivery, as well as of adverse maternal (eg, postpartum hemorrhage, chorioamnionitis) and perinatal (eg, a composite frequency of seizures, sepsis, bone or nerve injury, encephalopathy, or death) outcomes, were compared as a function of the duration of the latent phase (analyzed with time both as a continuous measure and categorized in 3-hour increments). Results A total of 10,677 women were available for analysis. In the vast majority (96.4%) of women, the active phase had been reached by 15 hours. The longer the duration of a woman’s latent phase, the greater her chance of ultimately undergoing a cesarean delivery (P 40% of women whose latent phase lasted ≥18 hours still had a vaginal delivery. Several maternal morbidities, such as postpartum hemorrhage (P Conclusion The large majority of women undergoing labor induction will have entered the active phase by 15 hours after oxytocin has started and rupture of membranes has occurred. Maternal adverse outcomes become statistically more frequent with greater time in the latent phase, although the absolute increase in frequency is relatively small. These data suggest that cesarean delivery should not be undertaken during the latent phase prior to at least 15 hours after oxytocin and rupture of membranes have occurred. The decision to continue labor beyond this point should be individualized, and may take into account factors such as other evidence of labor progress.

The twin birth rate has been steadily increasing in the United States over the past 10 years attributable in large part to the increased use of reproductive technologies. Despite advancements in the prevention of preterm labor for singletons, the overall rate of preterm birth has decreased only minimally. Several interventions to prevent preterm birth in twins have been studied, but none has proven effective. Inpatient bedrest has not been shown to be effective and can cause significant maternal morbidity. Although intramuscular 17α-hydroxyprogesterone caproate is effective in decreasing the risk of recurrent preterm delivery in singletons, neither it nor cerclage is effective in twin gestations, even in those with a short cervix. However, small trials, subgroup analyses, and a meta-analysis suggest that vaginal progesterone and the Arabin cervical pessary may reduce rates of preterm birth in twins of mothers with a short cervix. Given the current lack of effective therapies to prevent preterm birth in twins, large multicenter trials are needed to assess the effectiveness of vaginal progesterone and pessary in twins of mothers with a short cervix.

We reviewed recent data on the prevalence, risk factors, complications, and management of trauma during pregnancy. Using the terms "trauma" and "pregnancy" along with specified mechanisms of injury, we queried the PubMed database for studies reported from Jan. 1, 1990, through May 1, 2012. Studies with the largest number of patients for a given injury type and that were population-based and/or prospective were included. Case reports and case series were used only when more robust studies were lacking. A total of 1164 abstracts were reviewed and 225 met criteria for inclusion. Domestic violence/intimate partner violence and motor vehicle crashes are the predominant causes of reported trauma during pregnancy. Management of trauma during pregnancy is dictated by its severity and should be initially geared toward maternal stabilization. Minor trauma can often be safely evaluated with simple diagnostic modalities. Pregnancy should not lead to underdiagnosis or undertreatment of trauma due to unfounded fears of fetal effects. More studies are required to elucidate the safest and most cost-effective strategies for the management of trauma in pregnancy.

To compare the maternal and neonatal risks of elective repeat cesarean delivery compared with pregnancy continuation at different gestational ages, starting from 37 weeks.We analyzed the composite maternal and neonatal outcomes of repeat cesarean deliveries studied prospectively over 4 years at 19 U.S. centers. Maternal outcome was a composite of pulmonary edema, cesarean hysterectomy, pelvic abscess, thromboembolism, pneumonia, transfusion, or death. Composite neonatal outcome consisted of respiratory distress, transient tachypnea, necrotizing enterocolitis, sepsis, ventilation, seizure, hypoxic-ischemic encephalopathy, neonatal intensive care unit admission, 5-minute Apgar of 3 or lower, or death. Outcomes after elective repeat cesarean delivery without labor at each specific gestational age were compared with outcomes for all who were delivered later as a result of labor onset, specific obstetric indications, or both.Twenty-three thousand seven hundred ninety-four repeat cesarean deliveries were included. Elective delivery at 37 weeks of gestation had significantly higher risks of adverse maternal outcome (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.06-2.31), whereas elective delivery at 39 weeks of gestation was associated with better maternal outcome when compared with pregnancy continuation (OR 0.51, 95% CI 0.36-0.72). Elective repeat cesarean deliveries at 37 and 38 weeks of gestation had significantly higher risks of adverse neonatal outcome (37 weeks OR 2.02, 95% CI 1.73-2.36; 38 weeks OR 1.39 95% CI 1.24-1.56), whereas delivery at 39 and 40 weeks of gestation presented better neonatal outcome as opposed to pregnancy continuation (39 weeks OR 0.79, 95% CI 0.68-0.92; 40 weeks OR 0.57, 95% CI 0.43-0.75).In women with prior cesarean delivery, 39 weeks of gestation is the optimal time for repeat cesarean delivery for both mother and neonate.

Clinical trials support the efficacy and safety of magnesium sulfate for cerebral palsy prevention. We evaluated the implementation of a clinical protocol for the use of magnesium for cerebral palsy prevention in our large women's hospital, focusing on uptake, indications, and safety.We performed a review of selected gravidas with threatened or planned delivery before 32 weeks of gestation from October 2007 to February 2011. The primary study outcome was the change in the rate of predelivery administration of magnesium sulfate over this time period.Three hundred seventy-three patients were included. In 2007, before guideline implementation, 20% of eligible gravidas (95% confidence interval [CI] 9.1-35.6%) received magnesium before delivery compared with 93.9% (95% CI 79.8-99.3%) in the final 2 months of the study period (P.001). Dosing did not vary significantly over the 4 study years: the median number of treatments was one, the total predelivery median dose ranged from 15 to 48 g, and the median duration of therapy ranged from 3 to 12 hours. After 3 years, magnesium administration was almost universal among patients diagnosed with preeclampsia, preterm labor, or preterm premature rupture of membranes (95.4%), whereas patients delivered preterm for fetal growth restriction were significantly less likely to receive predelivery magnesium (44%, P.001). No maternal or perinatal magnesium-attributable morbidity was noted. Among patients eligible for the protocol who received magnesium, 84.2% delivered before 32 weeks of gestation.It is feasible to implement a magnesium sulfate cerebral palsy prevention protocol into clinical practice.III.

Children exposed to gestational diabetes mellitus (GDM) in utero have greater risk for obesity and comorbid health problems as compared to children from non-diabetic mothers (1-3). This effect is believed to be at least partially attributable to altered intrauterine programming of metabolism and body weight regulation. Gut hormones play an important role in the regulation of body weight homeostasis via signaling of hunger and satiety. To date, however, there are no published studies that have examined the concentrations and activity of gut hormones among offspring of women with gestational diabetes (OGD) versus those from a non-diabetic intrauterine environment (CTRL). Ghrelin is a hormone secreted in the stomach and to date, is the only peripheral signal that is known to stimulate food intake (4). Secretion of ghrelin increases prior to a meal and is suppressed following a meal (5). Among obese adults, fasting concentrations of ghrelin tend to be lower, and the post-prandial suppression of ghrelin is blunted (6; 7). Although it appears paradoxical for obese individuals to have lower fasting ghrelin, it has been hypothesized that this pattern is consequent to increased insulin, which is inversely associated with ghrelin, or is an adaptive response to positive energy balance in obese adults (6). Despite consistent findings in studies of adults, studies of lean versus obese children, have yielded less consistent results (8; 9). Glucagon-like peptide 1 (GLP-1) and peptide-tyrosine-tyrosine (PYY) are anorectic hormones that are secreted from L-cells in the ileum of the small intestine in response to feeding. Circulating concentrations of GLP-1 tend to be lower among obese adults and children (10; 11), and the acute increase in GLP-1 following meal consumption may be suppressed in obese states (12). There are two endogenous forms of PYY: 1-36 and 3-36; the latter of these has been more strongly implicated in feeding. Some, but not all (9), studies have shown lower fasting concentrations of PYY3-36 among obese individuals (13; 14). Furthermore, obesity has been consistently associated with suppression of the usual increase in PYY3-36 concentration that occurs following a meal (9; 13; 14). Previous research has not examined whether the response of GLP-1 and PYY to a meal challenge is perturbed among children of women with GDM. The main objective of this study was to compare fasting and postprandial concentrations of ghrelin, GLP-1 and PYY3-36 among children with and without intrauterine exposure to maternal GDM. The secondary objective was to examine whether associations of these hormones with children’s usual food intake differed by group. Differences in body composition, energy intake, physical activity, insulin sensitivity and secretion among OGD versus CTRL from this cohort have been reported previously (2). We hypothesized that, similar to obese individuals, OGD would have lower fasting concentrations of ghrelin, GLP-1, and PYY3-36, and an attenuated postprandial response of these gut hormones. These hypotheses were tested among 5-10 year-old children with and without intrauterine exposure to GDM.

Objective To estimate the cost-effectiveness of a trial of labor after one previous cesarean delivery (TOLAC). Study Design A model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Probabilistic estimates were obtained from women matched on their baseline characteristics using propensity scores. Cost data, quality-adjusted life-years (QALYs), and data on cerebral palsy were incorporated from the literature. Results The TOLAC strategy dominated the ERCD strategy at baseline, with $138.6 million saved and 1703 QALYs gained per 100,000 women. The model was sensitive to five variables: the probability of uterine rupture, the probability of successful TOLAC, the QALY of failed TOLAC, the cost of ERCD, and the cost of successful TOLAC without complications. When the probability of TOLAC success was at the base value, 68.5%, TOLAC was preferred if the probability of uterine rupture was 4.2% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 42.6% or more. Conclusion A TOLAC is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics.

Gestational diabetes mellitus (GDM) affects 2 to 5% of pregnancies depending on the population; some groups have an incidence as high as 14%.1,2 The American College of Obstetricians and Gynecologists states all pregnant women should be screened for GDM either by history, clinical risk factors, or laboratory screening tests.3 Several recent large studies have evaluated the effects of maternal hyperglycemia and pregnancy outcomes. These trials demonstrated treatment of even mild GDM reduced the risks of fetal macrosomia, large-for-gestational-age infants, shoulder dystocia, cesarean delivery, and hypertensive disorders.4,5 There have been fewer research studies examining the impact of maternal hypoglycemia on pregnancy outcomes, but this could potentially impact fetal growth. Several placental hormones including growth hormone, corticotropin-releasing hormone, chorionic somatomammotropin, and progesterone contribute to insulin resistance in pregnancy. Cytokines and tumor necrosis factor-α also contribute to insulin resistance in pregnancy.6 Metabolic changes in pregnancy reflect a patient’s pregravid metabolic status, and therefore the glucose loading test (GLT) may give insight on metabolic profiles outside of pregnancy.7 Altered glucose production and insulin resistance have been studied in hyperglycemic pregnancy states and their relationship to maternal and neonatal outcomes, but less is known about the converse state. Table 1 shows a summary of previous work examining hypoglycemia and the outcomes. Early studies stratified study and control groups by those with intrauterine growth restriction or low-birth-weight infants and then studied their glucose test results.8–10 More recent studies have looked at outcomes of those with mild hypoglycemia, but both studies included those with elevated values on the glucose test in their control group.11,12 However, women with even a single abnormal value on the glucose tolerance test are at risk for macrosomia, neonatal morbidity, cesarean delivery, and preeclampsia, which could complicate the comparison between a low GLT value and other values.13,14 The objective of this study was to evaluate the relationship between a low value (less than 90 mg/dL) on the maternal GLT and maternal and neonatal morbidity outcomes compared with women with a GLT value 90 to 119 mg/dL. Table 1 Summary of previous work examining the effects of maternal hypoglycemia

Venous thromboembolism, a serious complication comprising deep vein thrombosis and pulmonary embolism, occurs infrequently during pregnancy and the postpartum period, with an estimated incidence of 1–2 per 1,000 deliveries.1 This incidence is substantially higher in women with prior venous thromboem

Despite major advances in neonatal care, the burden of preterm birth remains high. This is not unexpected since strategies to identify and treat risk factors in early pregnancy have not been very effective in reducing the preterm birth rate. Initial studies suggested a potential benefit for 17-alpha-hydroxyprogesterone caproate (17-OHPC) in decreasing the risk of recurrent preterm birth women with a singleton gestation. However, the use of 17-OHPC has not conferred benefit for other categories of women at high risk for preterm delivery (twins, triplets, and short cervical length). The increasing body of evidence suggests that preterm birth is a complex condition with variable mechanisms of disease and significant individual heterogeneity. This review will examine the plausibility of 17-OHPC in preventing preterm birth and the investigation of its clinical efficacy. We will also highlight factors to explain variations in clinical trial outcomes and outline the trajectory needed for future investigations.

To estimate the associations between the duration of active pushing during the second stage of labor and maternal and neonatal outcomes.We performed an observational study in which data were obtained by trained abstractors from maternal and neonatal charts of deliveries at 25 hospitals over a 3-year period. In this secondary analysis, women with no prior cesarean delivery who had a term, singleton, cephalic gestation and reached complete dilation were analyzed. The duration of pushing, defined as the time from initiation of pushing to either vaginal delivery or the decision to proceed with a cesarean delivery, was determined. The primary maternal outcome was cesarean delivery and the primary neonatal outcome was a composite that included: mechanical ventilation, proven sepsis, brachial plexus palsy, clavicular fracture, skull fracture, other fracture, seizures, hypoxic-ischemic encephalopathy, or death. Nulliparous and parous women were analyzed separately in univariable and then multivariable analyses.A total of 53,285 women were analyzed. In both nulliparous and parous women, longer duration of pushing was associated with increased odds of both cesarean delivery and the neonatal adverse outcome composite. Nevertheless, even after 4 hours of pushing, approximately 78% of nulliparous women who continued with active pushing had a vaginal delivery and more than 97% did not have the composite adverse neonatal outcome. Similarly, after more than 2 hours of pushing, approximately 82% of parous women who continued active pushing delivered vaginally and more than 97% did not have the adverse neonatal outcome.A longer duration of pushing is associated with an increased relative risk, but small absolute difference in risk, of neonatal complications. Approximately 78% of nulliparous women delivered vaginally even after 4 hours of pushing.

Twin pregnancies are at increased risk of stillbirth. Uncomplicated twin pregnancies are commonly delivered earlier to prevent stillbirth; however, there is a risk of neonatal complications associated with being born prior to 39 weeks’ gestation. The optimal gestational age for delivery in twin pregnancies is unknown and likely varies by chorionicity. The present study aimed to determine the prospective risk of stillbirth in women with uncomplicated monochorionic and dichorionic twin pregnancies, and neonatal mortality risks, when delivered beyond 34 weeks of gestation. Data on twin pregnancies that reported rates of stillbirth were obtained from MEDLINE, EMBASE, and Cochrane Library. Separate analyses for risks of stillbirth and neonatal death in monochorionic and dichorionic twin pregnancies were undertaken from 34 weeks’ gestation and further and early preterm (

Although preterm birth37 weeks' gestation is the leading cause of neonatal morbidity and mortality in the United States, the majority of data regarding preterm neonatal outcomes come from older studies, and many reports have been limited to only very preterm neonates. Delineation of neonatal outcomes by delivery gestational age is needed to further clarify the continuum of mortality and morbidity frequencies among preterm neonates.We sought to describe the contemporary frequencies of neonatal death, neonatal morbidities, and neonatal length of stay across the spectrum of preterm gestational ages.This was a secondary analysis of an obstetric cohort of 115,502 women and their neonates who were born in 25 hospitals nationwide, 2008 through 2011. All liveborn nonanomalous singleton preterm (23.0-36.9 weeks of gestation) neonates were included in this analysis. The frequency of neonatal death, major neonatal morbidity (intraventricular hemorrhage grade III/IV, seizures, hypoxic-ischemic encephalopathy, necrotizing enterocolitis stage II/III, bronchopulmonary dysplasia, persistent pulmonary hypertension), and minor neonatal morbidity (hypotension requiring treatment, intraventricular hemorrhage grade I/II, necrotizing enterocolitis stage I, respiratory distress syndrome, hyperbilirubinemia requiring treatment) were calculated by delivery gestational age; each neonate was classified once by the worst outcome for which criteria was met.In all, 8334 deliveries met inclusion criteria. There were 119 (1.4%) neonatal deaths. In all, 657 (7.9%) neonates had major morbidity, 3136 (37.6%) had minor morbidity, and 4422 (53.1%) survived without any of the studied morbidities. Deaths declined rapidly with each advancing week of gestation. This decline in death was accompanied by an increase in major neonatal morbidity, which peaked at 54.8% at 25 weeks of gestation. As frequencies of death and major neonatal morbidity fell, minor neonatal morbidity increased, peaking at 81.7% at 31 weeks of gestation. The frequency of all morbidities fell32 weeks. After 25 weeks, neonatal length of hospital stay decreased significantly with each additional completed week of pregnancy; among babies delivered from 26-32 weeks of gestation, each additional week in utero reduced the subsequent length of neonatal hospitalization by a minimum of 8 days. The median postmenstrual age at discharge nadired around 36 weeks' postmenstrual age for babies born at 31-35 weeks of gestation.Our data show that there is a continuum of outcomes, with each additional week of gestation conferring survival benefit while reducing the length of initial hospitalization. These contemporary data can be useful for patient counseling regarding preterm outcomes.

To evaluate the relationships among excessive gestational weight gain, neonatal adiposity, and adverse obstetric outcomes in women with mild gestational diabetes mellitus.This is a secondary analysis of a multicenter randomized clinical trial of women with mild gestational diabetes mellitus. Based on self-reported prepregnancy body weight, gestational weight gain was categorized as excessive if it was greater than 2009 Institute of Medicine guidelines. Maternal outcomes and neonatal anthropomorphic characteristics were compared between women with excessive weight gain and those without excessive weight gain. Multiple linear and logistic regression analyses were performed to adjust for confounding factors.We studied 841 women who participated in the main trial and had prepregnancy body mass index (BMI) and delivery information available (n=431 treatment group, n=410 no treatment). After adjustment for factors including treatment and prepregnancy BMI, excessive weight gain remained associated with large for gestational age (adjusted odds ratio [OR] 2.94, 95% confidence interval [CI] 1.81-4.93), birth weight greater than 4,000 g (adjusted OR 2.56, 95% CI 1.54-4.40), preeclampsia (adjusted OR 2.96, 95% CI 1.35-7.03), and cesarean delivery for labor arrest (adjusted OR 2.37, 95% CI 1.30-4.44). In addition, excessive weight gain was independently associated with increased total neonatal fat (P.001) and birth weight (P.001).In women with both treated and untreated mild gestational diabetes mellitus, excessive gestational weight gain was independently associated with both greater birth weight and adiposity.

Please cite this paper as: Thorp J, Camargo C, McGee P, Harper M, Klebanoff M, Sorokin Y, Varner M, Wapner R, Caritis S, Iams J, Carpenter M, Peaceman A, Mercer B, Sciscione A, Rouse D, Ramin S, Anderson G. Vitamin D status and recurrent preterm birth: a nested case–control study in high-risk women. BJOG 2012;119:1617–1623. Objective To determine whether vitamin D status is associated with recurrent preterm birth, and any interactions between vitamin D levels and fish consumption. Design A nested case–control study, using data from a randomised trial of omega-3 fatty acid supplementation to prevent recurrent preterm birth. Setting Fourteen academic health centres in the USA. Population Women with prior spontaneous preterm birth. Methods In 131 cases (preterm delivery at

A randomized clinical trial (RCT) noted that sonographic examination in the third trimester, in conjunction with delivery at term for abnormalities of fetal growth, significantly decreased the likelihood of small-for-gestational-age (SGA) neonates in uncomplicated pregnancies. We identified 15 characteristics of screening tests and attempted to determine if there is evidence to routinely obtain sonographic estimates of fetal weight in the third trimester and decrease rates of SGA. Of the 15 suggested characteristics, currently 10 (67%) are fulfilled, two are uncertain (sonographic examination is cost-effective or reliable), and one (the test must do its job) is possibly valid. Due to the lack of RCTs demonstrating reduction in morbidity, there is potential for lead-time and length bias. To observe a 36% decrease (from 4.1 to 2.6%) decrease in composite perinatal morbidity, 6000 women need to be randomized to at least two sonographic examinations in the third trimester versus routine prenatal care. Such an RCT is warranted and justified.

To evaluate whether neonates born to women who previously had received antenatal corticosteroids and then delivered a late-preterm-birth neonate had less respiratory morbidity compared with those not exposed to antenatal corticosteroids.This is a secondary analysis from a multicenter observational study regarding mode of delivery after previous cesarean delivery. We compared women who received one course of antenatal corticosteroids with unexposed parturients and evaluated various respiratory outcomes among those having a singleton, late-preterm-birth neonate. We controlled for potential confounders including gestational age at delivery, diabetes, mode of delivery, and maternal race.Five thousand nine hundred twenty-four patients met the inclusion criteria; 550 received steroids and 5,374 did not. In the univariable model, compared with unexposed women, those who received antenatal corticosteroids appeared more likely to have neonates who required ventilatory support (11.5% compared with 8.6%, P=.022), had respiratory distress syndrome (RDS) (17.1% compared with 12.2%, P=.001), developed transient tachypnea of the newborn (12.9% compared with 9.8%, P=.020), or required resuscitation in the delivery room (55.8% compared with 49.7%, P=.007). After controlling for confounding factors, we found no significant differences among the groups regarding all of the above outcomes with an odds ratio for RDS of 0.78 (95% confidence interval, 0.60-1.02) and ventilator support of 0.75 (95% confidence interval, 0.55-1.03).Exposure to antenatal corticosteroids does not significantly affect respiratory outcomes among those with a subsequent late-preterm birth.