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To evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix.This was a retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2015. We included patients at 28 weeks of gestation or less who were diagnosed with a cervical length less than 20 mm. At the time of diagnosis, all patients were prescribed vaginal progesterone. Starting in 2013, they were also offered pessary placement in addition to vaginal progesterone. We compared outcomes between patients who received a pessary and matched women in a control group in a one-to-three ratio. Women in the control group were matched to women in the case group according to cervical length and gestational age (within 5 mm and 1 week, respectively, of the case patient at the time of pessary placement). We excluded patients with cerclage, monochorionic-monoamniotic placentation, major fetal congenital anomalies discovered before or after birth, patients with twin-twin transfusion syndrome, and patients for whom there were no appropriate controls. Chi-square, Fisher exact, and Student's t tests were used, as appropriate. Regression analysis was performed to control for significant differences at baseline.Twenty-one patients received a cervical pessary, and they were compared with 63 matched women in the control group. As expected (as a result of matching), baseline gestational age (25.7±2.1 compared with 25.9±2.1 weeks of gestation, P=.671) and cervical length (10.9±3.6 mm compared with 11.9±4.5 mm, P=.327) were similar between the groups. Patients with a pessary had a significantly lower incidence of delivery at less than 32 weeks of gestation (1/21 [4.8%] compared with 18/63 [28.6%], adjusted P=.05), longer interval to delivery (65.2±16.8 compared with 52.1±24.3 days, adjusted P=.025), and a lower incidence of severe neonatal morbidity (2/21 [9.5%] compared with 22/63 [34.9%], adjusted P=.04).For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.

OBJECTIVE: To evaluate whether a history of preterm birth or small for gestational age (SGA) in a singleton pregnancy is associated with an increased risk of recurrence of the same condition in a subsequent twin pregnancy. METHODS: Retrospective cohort study of twin pregnancies delivered in one maternal–fetal medicine practice from 2005 to 2014. Patients with a history of singleton preterm birth at less than 37 weeks of gestation were compared with patients with a history of singleton term birth and nulliparous patients. A similar analysis was performed for a history of SGA (birth weight less than 10%). RESULTS: Six hundred forty-seven twin pregnancies were included. The prior singleton gestational age at delivery was significantly positively correlated with the twin gestational age at delivery (P,.001), and the prior singleton birth weight was significantly positively correlated with the birth weight of the larger twin (P,.001) and the smaller twin (P,.001). The rate of twin preterm birth before 32 weeks of gestation was 3.5% in patients with a prior term birth, 9.2% in nulliparous patients, and 26% in patients with a prior preterm birth (P,.001). The rate of SGA in patients with a prior birth not complicated by SGA was 42.1%, in nulliparous women it was 54.4%, and in patients with a history of SGA it was 65.2% (P5.007). On regression analysis, prior preterm birth and SGA of a singleton pregnancy were independently associated with recurrence of the same condition in a subsequent twin pregnancy. CONCLUSION: Prior preterm birth and SGA in a singleton pregnancy increase the risk of the same condition in a subsequent twin pregnancy. We postulate that the extrinsic mechanism responsible for the pathophysiology of adverse outcomes in twin pregnancies overlaps with that in singleton pregnancies. (Obstet Gynecol 2015;125:870–5)

To compare the efficacy of tocolytic treatment with indomethacin (I), magnesium sulfate (M) and nifedipine (N) for acute tocolysis in women with advanced cervical dilation (4-6 cm).A single center, randomized trial was carried out involving patients in preterm labor (cervix 1-6 cm). Secondary analysis of women with advanced cervical dilation (cervix 4-6 cm) at 24-32 weeks' gestation who received intravenous M, oral N or I suppositories comprised this study population.Over 38 months, 92 women with advanced cervical dilation were randomized to one tocoloytic type. Days gained in utero (11.7) and percent remaining undelivered at 48 h (60.8%), 72 h (53.1%) and7 days (38.3%) were similar regardless of tocolytic employed (p = 0.923, 0.968, 0.791, 0.802, respectively). Likewise, gestational age at delivery (30.7 ± 3.2) was similar between groups (p = 0.771). Finally, neonatal statistics were not different when stratified by tocolytic treatment.There were no statistical differences between tocolytics in treating women with advanced cervical dilation. All offered significant days gained in utero after therapy, a high percentage remaining undelivered after 48 or 72 h and after 7 days. It would appear from data that there may be advantages to tocolytic treatment even in women with advanced cervical dilation.

Introduction: To evaluate whether maternal serum α-fetoprotein (MSAFP) improves the detection rate for open neural tube defects (ONTDs) and ventral wall defects (VWD) in patients undergoing first-trimester and early second-trimester fetal anatomical survey. Material and Methods: A cohort of women undergoing screening between 2005 and 2012 was identified. All patients were offered an ultrasound at between 11 weeks and 13 weeks and 6 days of gestational age for nuchal translucency/fetal anatomy followed by an early second-trimester ultrasound at between 15 weeks and 17 weeks and 6 days of gestational age for fetal anatomy and MSAFP screening. All cases of ONTD and VWD were identified via query of billing and reporting software. Sensitivity and specificity for detection of ONTD/VWD were calculated, and groups were compared using the Fisher exact test, with p < 0.05 as significance. Results: A total of 23,790 women met the criteria for inclusion. Overall, 15 cases of ONTD and 17 cases of VWD were identified; 100% of cases were diagnosed by ultrasound prior to 18 weeks' gestation; none were diagnosed via MSAFP screening (p < 0.001). First-trimester and early second-trimester ultrasound had 100% sensitivity and 100% specificity for diagnosing ONTD/VWD. Discussion: Ultrasound for fetal anatomy during the first and early second trimester detected 100% of ONTD/VWD in our population. MSAFP is not useful as a screening tool for ONTD and VWD in the setting of this ultrasound screening protocol.

To estimate the association between maternal weight gain and SPTB in twin pregnancies.A case-control study of patients with twin pregnancies and a normal prepregnancy BMI (18.5-24.9 kg/m(2)) in one maternal-fetal medicine practice from 2005 to 2013. We reviewed maternal weight in six time periods: prepregnancy, 12-15 6/7 weeks, 16-19 6/7 weeks, 20-23 6/7 weeks, 24-27 6/7 weeks and 28-31 6/7 weeks. We compared maternal weight gain patterns across pregnancy between patients who did and did not have SPTB32 weeks. Student's t-test and chi-square were used for analysis.In total, 382 patients were included, 29 (7.6%) of whom had SPTB32 weeks. The baseline height, weight and BMI did not differ between the groups, nor did maternal age, IVF status, race or chorionicity. Patients with SPTB32 weeks had significantly less weight gain as early as 15 6/7 weeks (2.9 ± 4.6 versus 7.3 ± 6.6 lb, p 0.001), and this continued until 31 6/7 weeks (25.3 ± 8.7 versus 30.8 ± 10.9 lb, p = 0.037).In twin pregnancies with a normal prepregnancy BMI, there is a significant association between SPTB32 weeks and lower maternal weight gain, particularly prior to 16 weeks. Future studies are needed to test if prepregnancy or early nutritional interventions in twin pregnancies can reduce the risk of preterm birth and improve neonatal outcomes in this high-risk population.

Objective To report the obstetrical outcomes in patients with twin pregnancies who underwent an emergency/physical exam-indicated cerclage and to compare them to patients with singleton pregnancies undergoing the same procedure. Study design Patients who underwent emergency/physical exam-indicated cerclage in the second trimester in one maternal-fetal medicine practice from July 1997 to March 2012 were reviewed. We defined an emergency/physical exam-indicated cerclage as any cerclage placed in a patient with a dilated cervix on examination or membranes visible at the external cervical os on speculum examination. We compared outcomes between patients with singleton and twin pregnancies using non-parametric testing. Results There were 43 patients (12 twin and 31 singleton pregnancies) who underwent emergency/physical exam-indicated cerclage placement. The median gestational age at cerclage placement, cervical dilation, maternal age, and cerclage type were similar between the groups. Comparing twins to singletons, the median time from cerclage placement to delivery was similar (92 vs. 106 days, p =0.330), as was the median gestational age at delivery (33.5 vs. 35.0 weeks, p =0.244). The likelihood of delivery at >32 weeks (75.0% vs. 71.0%, p >0.999) and the likelihood of neonatal survival to discharge (83.3% vs. 83.9%, p >0.999) were also similar. Conclusions Emergency/physical exam-indicated cerclage in twin pregnancies can be associated with favorable outcomes, including a high likelihood of delivery at >32 weeks and a high likelihood of survival. Their outcomes appear similar to singleton pregnancies. Cerclage should be considered an option for patients with twin pregnancies and a dilated cervix in the second trimester.

OBJECTIVES The purpose of this study was to estimate the prevalence and persistence rate of vasa previa in at-risk pregnancies using a standardized screening protocol. METHODS We conducted a descriptive study of patients with a diagnosis of vasa previa from a single ultrasound unit between June 2005 and June 2012. Vasa previa was defined as a fetal vessel within 2 cm of the internal cervical os on transvaginal sonography. Screening for vasa previa using transvaginal sonography with color flow mapping was performed routinely in the following situations: resolved placenta previa, prior pregnancy with vasa previa, velamentous insertion of the cord in the lower uterine segment, placenta succenturiata in the lower uterine segment, and twin gestations. RESULTS A total of 27,573 patients were referred to our unit for fetal anatomic surveys over the study period. Thirty-one cases of vasa previa were identified, for an incidence of 1.1 per 1000 pregnancies. Twenty-nine cases had full records available for analysis. Five patients (17.2%) had migration and resolution of the vasa previa. When the diagnosis was made during the second trimester (

The objective was to determine if the rate of abnormal biochemical markers is different in pregnancies conceived by donor oocyte versus those conceived by autologous oocytes.This is a retrospective cohort study of patients who underwent risk assessment for aneuploidy. Pregnancies conceived by egg donation were matched with control groups who conceived using their own eggs. The primary outcomes were incidence of low PAPP-A or free bHCG in the first trimester or elevated MSAFP, free bHCG or Inhibin A, or low uE3 in the second trimester.260 singleton gestations were identified who conceived via oocyte donor. There was a significantly higher rate of unexplained elevated MSAFP in pregnancies conceived by egg donation (8% versus 2%, p = 0.028) compared to a control group matched by maternal age. There was also a significantly higher rate of unexplained elevated MSAFP in pregnancies conceived by egg donation (7% versus 2%, p = 0.01) compared to a control group matched by age of the egg donor.Pregnancies conceived by egg donation are more likely to have an unexplained elevation in MSAFP compared to pregnancies not conceived by egg donation regardless of age. Egg donation itself is not associated with other biochemical abnormalities.

To compare the efficacy and maternal side effects of nifedipine (N), magnesium sulfate (M), and indomethacin (I) for acute tocolysis.In this single center randomized trial, women in preterm labor 24-32 weeks' gestation received intravenous M, oral N, or I suppositories. The primary outcomes of interest were arrest of preterm labor (48 h, ≥7 days), gestational age at delivery, and maternal side effects.Over a 38-month period, 301 women were allocated to receive M (90), N (114), or I (90). Gestational age at delivery (p = 0.551) or arrest of labor48 h,7 days were similar between the three groups (p = 0.199, 0.654). Hypotension and tachycardia were more common in N patients compared to women receiving M or I (p = 0.003, 0.009). Patients receiving I had more fetal ductal constriction or oligohydramnios compared to M or N (p = 0.001, 0.020) but, I women were tested more often. There was one case of pulmonary edema in the M group and one with plural effusion in the N group.There were no differences in efficacy or in major maternal safety issues between the three tocolytic agents. Since there is no FDA approved tocolytic to treat preterm labor, clinicians should use the tocolytic that has afforded them the best results with the least maternal/neonatal side effects.

To compare pregnancy outcomes in twin pregnancies based on maternal pre-pregnancy body mass index (BMI).Historical cohort study of all twin pregnancies24 weeks managed by one maternal-fetal medicine practice from 2005 to 2012. We compared pregnancy outcomes between pre-pregnancy obese (BMI ≥ 30 kg/m(2)) and normal weight women (BMI 18.5-24.99 kg/m(2)). We also compared pre-pregnancy normal weight women to overweight women (BMI 25-29.99 kg/m(2)) and underweight women (BMI18.5 kg/m(2)). Chi square, Fisher's exact test, Student's t-test, and one-way ANOVA were used as appropriate. A p value of0.05 was considered significant.Five hundred fourteen patients with twin pregnancies were included. Pre-pregnancy obesity was associated with gestational hypertension (34.1% versus 17.9%, p = 0.011), preeclampsia (27.3% versus 14.4%, p = 0.028), and gestational diabetes (22.2% versus 4.7%, p0.001). Pre-pregnancy overweight was associated with gestational diabetes (13.7% versus 4.7%, p = 0.002). Pre-pregnancy underweight was not associated with any adverse pregnancy outcomes. Comparing outcomes across normal weight, overweight, and obese women, the rates of gestational diabetes and gestational hypertension increased significantly across the three groups.In patients with twin pregnancy, pre-pregnancy obesity is associated with adverse pregnancy outcomes, including gestational diabetes, gestational hypertension, and preeclampsia.

A randomized study published in 2003 by the National Institute of Child Health and Human Development Maternal Fetal Medicine Units network showed efficacy of 17-alpha hydroxyprogesterone caproate (17P) for the prevention of recurrent preterm delivery. Between 2003 and 2011 the drug was often provided by compounding pharmacies. In 2011, the US Food and Drug Administration (FDA) approved the drug for this indication. The objective of this study was to evaluate the impact of FDA approval on physician attitudes and perceptions regarding use of 17P as a drug for preventing recurrent preterm delivery. A 10-min online survey using a structure closed-ended questionnaire format was designed and administered from 17 June 2011 to 7 July 2011 among 401 obstetricians distributed evenly throughout the USA. There is nearly universal awareness of 17P for the prevention of preterm birth (93 %), with a large majority (80 %) of obstetricians having reported prescribing the medication. However, surveyed physicians reported that the average proportion of eligible patients seen in their practice but not prescribed 17P in 2009–2010 was 41 %. Financial and logistical barriers carried the most weight (approximately 75 %) in the decision not to prescribe 17P to an eligible patient. Forty-one percent of respondents cited lack of FDA approval of 17P as a deterrent to prescribing the medication. Thirty-nine percent of respondents had professional liability concerns regarding prescribing compounded 17P. Assuming the same out-of-pocket expense for patients, two-thirds of obstetricians would choose to prescribe Makena®. Awareness of 17P for the prevention of preterm birth among obstetricians is high. FDA-approved medications seem to have physician preference due to enhanced assurance for product efficacy and safety.

OBJECTIVE: To determine if prophylactic cerclage improves pregnancy outcomes in women with twin pregnancies without a history of cervical insufficiency. STUDY DESIGN: Women with twin pregnancies who received outpatient preterm labor surveillance services between January 1990 and May 2004 for ≥1 day beginning at < 28.0 weeks' gestation were identified from a database. Patients with previous preterm delivery or a diagnosis of cervical incompetence in a previous or in the index pregnancy were excluded. Twin pregnancies managed with prophylactic cerclage were compared with twin pregnancies in which cerclage was not placed. The primary outcome was incidence of preterm birth prior to 32 weeks. Groups were compared using Fisher exact and Mann-Whitney U test statistics. RESULTS: Overall, 8,218 twin pregnancies met inclusion criteria, of which 146 women (1.8%) received prophylactic cerclage. Patients who received prophylactic cerclage had a significantly higher incidence of preterm birth before 32 weeks and infants with lower mean birth weight and longer nursery stays. No significant difference was seen in mean gestational age at delivery. This study had 80% power to detect a 7% reduction in the primary outcome. CONCLUSION: Prophylactic cerclage was not associated with a lower risk of preterm birth and adverse neonatal outcomes in twin pregnancies without history of cervical insufficiency.

To evaluate the clinical utility of a novel means of assessing the cervix by measuring the angle of the curvature and to evaluate the performance of this technique as well as two other commonly used techniques of cervical length assessment in predicting spontaneous preterm birth (SPTB).This was a retrospective cohort analysis of singleton gestations with a history of SPTB. Transvaginal ultrasound images of cervical length obtained between 20 and 23 6/7 weeks were re-measured using three techniques: (1) straight linear distance between the internal and external os, (2) sum of two contiguous linear segments tracing the internal to the external os, and (3) measurement of the angle of the curve within the cervix using an electronic protractor. A short cervical length was defined as ≤25 mm.A total of 181 women were included. The relative risk (RR) for SPTB by cervical angle ≤160° was 1.2 (95% CI 0.7-2.0) and the ROC curve revealed an area under the curve of 0.54 (95% CI 0.44-0.63). The RR for SPTB by short cervical length measured by the straight technique was 2.3 (95% CI 1.3-4.0) and by the segmental technique 2.1 (95% CI 1.2-3.8). There was a 99.4% agreement between the two techniques with an intraclass Kappa coefficient of 0.96.In women with a history of SPTB, cervical angle measurement does not correlate with the risk of SPTB. Cervical length measured via straight and segmental techniques had excellent agreement in identifying short cervix, and both identified a short cervix predictive of SPTB.

We sought to assess the association between maternal height and the risk of preterm birth, fetal growth restriction and mode of delivery in twin gestations.Cohort study of patients with twin pregnancies delivered from 2005 to 2014. We compared pregnancy outcomes between patients of short stature ≤159 cm to those of normal stature ≥160 cm. Patients with monoamniotic twins and major fetal anomalies were excluded. Pearson's correlation, Chi-square and Student's t-test were used as appropriate.Six hundred and sixty-six patients were included, 159 (23.9%) of whom had short stature (mean height 155.8 ± 2.5 cm) and 507 (76.1%) of whom had normal stature (mean height 167.2 ± 5.5 cm). There were no differences in outcomes between the groups in regards to preterm birth, gestational age (GA) at delivery, birth weight of either twin, preeclampsia, gestational diabetes or cesarean section rate. Results were similar when the groups were stratified by parity. As a continuous variable, maternal height did not correlate with GA at delivery (p= 0.388), cesarean delivery (p = 0.522) nor the birth weight of the larger (p = 0.206) or smaller (p = 0.307) twin.In twin pregnancies, maternal short stature is not associated with preterm birth, fetal growth restriction or cesarean section rate. This suggests that although anthropometric measurements have long been used to counsel patients in regards to outcomes, patients of short stature should be reassured that their height does not appear to lead to adverse twin pregnancy outcomes.

Objective: Detail adverse neonatal effects in pregnancies treated with indomethacin (I), magnesium sulfate (M) or nifedipine (N). Methods: Women in acute preterm labor with cervical dilatation 1–6 cm were randomized to receive one of three first-line tocolytic drugs. Results: There were 317 neonates (I = 103, M = 95, N = 119) whose mothers were treated with tocolytic therapy. There was no difference in gestational age at randomization (average 28.6 weeks’ gestation) or at delivery (31.6 weeks’ gestation, p = 0.551), birth weight (p = 0.871) or ventilator days (p = 0.089) between the three groups. Neonatal morbidity was not different between the three groups; respiratory distress syndrome (p = 0.086), patent ductus arteriosus (p = 0.592), sepsis (p = 0.590), necrotizing enterocolitis (p = 0.770), intraventricular hemorrhage (p = 0.669) and periventricular leukomalacia (p = 0.124). Conclusions: There were no statistically significant differences between the three tocolytics as far as composite neonatal morb...

To estimate the likelihood of cesarean delivery and length of labor in twin pregnancies undergoing induction of labor as compared with singleton pregnancies.This was a retrospective cohort study of 100 patients with twin pregnancy in one maternal-fetal medicine practice undergoing induction of labor from 2005 to 2012. The control group was 100 randomly selected patients in the same practice with a singleton pregnancy undergoing induction of labor over the same time period. The primary outcome was mode of delivery (vaginal or cesarean).The likelihood of cesarean delivery did not differ between the groups (19% in twins compared with 21% in singletons, P=.724) nor did the time from induction to vaginal delivery (median and interquartile time 9.7 [5.5-12.5] hours in twins compared with 10.4 [6.6, 14.1] hours in singletons, P=.255). Results were not different when we looked at nulliparous patients only or multiparous patients only. On adjusted analysis of risk factors for cesarean delivery in patients undergoing induction, twin pregnancy was not independently associated with cesarean delivery.Patients with twin pregnancies undergoing induction of labor have a similar risk of cesarean delivery and a similar length of labor as patients with singleton pregnancies undergoing induction of labor.II.

To estimate the association between fetal fibronectin (fFN), cervical length (CL), and spontaneous preterm birth (SPTB) in asymptomatic women with triplet pregnancies.A cohort of 39 consecutive women with triplet pregnancies managed in one Maternal-Fetal medicine practice from 2005-2011 was analyzed. Combined fFN and CL testing was performed every 2 weeks from 22-32 weeks. A short CL was defined as ≤ 20 mm.A positive fFN was significantly associated with SPTB28 weeks,30 weeks,32 weeks, and34 weeks. A short CL was significantly associated with SPTB32 weeks. On combined testing, having both tests positive was associated with the highest likelihood of SPTB at all gestational ages. As a screening test for SPTB32 weeks, having both a positive fFN and a short CL had a sensitivity of 62.5%, specificity of 90%, positive predictive value of 62.5%, negative predictive value of 90%, positive likelihood ration of 2.98 and negative likelihood ratio of 0.88. Combined fFN and CL outperformed fFN alone, CL alone, or either test being positive alone.In asymptomatic women with triplet pregnancies, fFN and CL are each significantly associated with SPTB. For the prediction of SPTB, combined fFN and CL testing outperforms either test alone.

Objectives To estimate the association between the cervical length (CL) measurement at 30–32 weeks and the mode of delivery in twin pregnancies. Methods This was a retrospective study of a cohort, from 2005–2010, of 265 twin pregnancies with a CL measurement at 30–32 weeks. We compared the CL measurement at 30–32 weeks based on mode of delivery. We then analyzed our data across four subgroups, based on the CL measurement quartiles at 30–32 weeks. We performed this analysis in all patients, and also performed a planned subgroup analysis of 130 patients who attempted a vaginal delivery. Results In all patients, including those who attempted a vaginal delivery, the mean CL at 30–32 weeks was significantly shorter in women who delivered vaginally compared with women who had a Cesarean section. The likelihood of Cesarean delivery increased significantly with increasing CL measurement across the groups defined by measurement quartiles. On adjusted analysis controlling for maternal age, race, in-vitro fertilization, chorionicity, induction of labor and prior vaginal delivery, the CL measurement at 30–32 weeks was independently associated with mode of delivery. Conclusions In twin pregnancies, the CL at 30–32 weeks is significantly associated with the likelihood of Cesarean delivery. A longer CL may represent underdevelopment of the uterus, leading to a higher risk of Cesarean delivery in labor at term. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM).Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI ≥ 30 kg/m(2)) and non-obese (pre-pregnancy BMI30 kg/m(2)) women and for women across five increasing pre-pregnancy BMI categories.A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes.In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

Please cite this paper as: Fox N, Saltzman D, Roman A, Klauser C, Moshier E, Rebarber A. Intravaginal misoprostol versus Foley catheter for labour induction: a meta-analysis. BJOG 2011;118:647–654. Background There are a number of agents used for cervical ripening prior to the induction of labour. Two commonly used agents are intravaginal misoprostol and a transcervical Foley catheter. Objective To review the evidence comparing misoprostol and transcervical Foley catheter placement for induction of labour, and perform a meta-analysis comparing these two induction agents. Search strategy We conducted database searches of PubMed, Embase, the Cochrane Library Database, and the ClinicalTrials.gov website. Bibliographies of all relevant articles were reviewed. Selection criteria Prospective, randomised trials comparing the use of intravaginal misoprostol and transcervical Foley catheter for the purpose of cervical ripening and induction of labour were included. We excluded studies in which the patients in these two intervention groups also received other induction agents concurrently, such as oral misoprostol, oxytocin, or other prostaglandins. Data collection and analysis The primary outcomes selected were time to delivery, and the rates of caesarean section, uterine tachysystole, and chorioamnionitis. Random-effects generalised linear models with a poisson distribution and log link function were used to compare the two induction agents across the studies. Main results Nine studies (1603 patients) were identified as eligible to be included in this meta-analysis. There were no significant differences in the mean time to delivery (mean difference 1.08 ± 2.19 hours shorter for misoprostol, P = 0.2348), the rate of caesarean delivery (RR 0.991; 95% CI 0.768, 1.278), or in the rate of chorioamnionitis (RR 1.130; 95% CI 0.611, 2.089) between women who received misoprostol compared with transcervical Foley catheter. Patients who received misoprostol had significantly higher rates of tachysystole compared with women who received a transcervical Foley catheter (RR 2.844; 95% CI 1.392, 5.812). Conclusions Intravaginal misoprostol and transcervical Foley catheter have similar effectiveness as induction agents. Transcervical Foley catheter is associated with a lower incidence of tachysystole.

We sought to estimate the association of several maternal risk factors with intrauterine growth restriction (IUGR) in twin pregnancies. This is a case-control study of 313 patients with twin pregnancies delivered greater than 24 weeks between June 2005 and January 2010. We used three definitions of IUGR: (1) either twin with a birth weight < 10th percentile for gestational age; (2) either twin with a birth weight < 5th percentile for gestational age; and (3) birth-weight discordance ≥ 20%. Using each definition of IUGR, we estimated the association between IUGR and maternal age, weight, monochorionicity, in vitro fertilization, pregnancy reduction, thrombophilia, hypertension, and diabetes. Overall, 47% of patients delivered at least one twin with a birth weight

Objective. The purpose of this study was to define normal second-trimester cervical length (CL) measurements and to estimate the association between second-trimester CL and spontaneous preterm birth (SPTB) in twin pregnancies. Methods. A retrospective cohort of 309 asymptomatic patients with twin pregnancies who had routine outpatient CL assessment in the second trimester was studied. We looked at the gestational age periods of 16 to 17 6/7, 18 to 19 6/7, 20 to 21 6/7, and 22 to 23 6/7 weeks. We estimated the association between the CL measurement during each period and SPTB. A short CL was defined both as a CL at or below the 10th percentile for gestational age and 25 mm or less. We also performed regression analyses controlling for a number of clinically important factors: maternal age, chorionicity, in vitro fertilization, multifetal reduction, prior term births, prior preterm births, prepregnancy body mass index, and cerclage. Results. The CL measurement at 16 to 17 6/7 weeks was not associated with gestational age at delivery or SPTB. At 18 to 19 6/7 and 20 to 21 6/7 weeks, the CL measurement was not significantly associated with gestational age at delivery or SPTB before 28 and 32 weeks. There was an association with SPTB before 35 weeks. At 22 to 23 6/7 weeks, the CL measurement had a significant association with gestational age at delivery and SPTB before 28, 32, and 35 weeks (P < .05). A short CL at 22 to 23 6/7 weeks was significantly associated with SPTB before 32 and 35 weeks (P < .05). Conclusions. In second-trimester twin pregnancies, the strongest association between CL and SPTB is at 22 to 23 6/7 weeks.

We evaluated the added benefit of a comprehensive counseling protocol for first-trimester aneuploidy risk assessment. We performed a prospective cohort study surveying patients referred for first-trimester aneuploidy risk assessment. We compared responses between women who underwent serum testing done in advance of their ultrasound such that their final risk assessment was given to them the same day as their ultrasound (comprehensive) versus women who underwent serum testing the same day as their ultrasound and who therefore received their final risk assessment later (standard). Response rate was 94.8%. The comprehensive group was significantly more likely to receive counseling in accordance with recommended American College of Obstetricians and Gynecologists (ACOG) guidelines, had significantly greater reduction in anxiety and increased satisfaction, and was more likely to report an increased understanding of their results. The comprehensive group scored significantly higher on test-style questions about aneuploidy risk assessment. Comprehensive aneuploidy risk assessment counseling including same-day results is associated with increased patient understanding and satisfaction, decreased anxiety, and increased adherence to ACOG guidelines.

Objective To estimate whether the weight gain recommendations for twin pregnancies in the 2009 Institute of Medicine (IOM) guidelines are associated with improved perinatal outcomes. Methods A cohort of 297 twin pregnancies was identified from a single practice with measured prepregnancy body mass index (BMI) and weight gain during pregnancy. Recommended IOM guidelines were applied to our cohort based on prepregnancy BMI categories (normal weight, overweight, obese). Pregnancy outcomes were compared between patients whose weight gain met or exceeded the IOM recommendations and patients who did not meet these recommendations. Results Patients with normal prepregnancy BMIs whose weight gain met the IOM recommendations had significantly improved outcomes compared with patients who did not meet the IOM recommendations. They were less likely to have preterm birth before 32 weeks (5.0% compared with 13.8%) and spontaneous preterm birth before 32 weeks (3.4% compared with 11.5%). They also delivered significantly larger neontates (larger twin birth weight 2,582.1+/-493.4 g compared with 2,370.3+/-586.0 g; smaller twin birth weight 2,277.0+/-512.1 g compared with 2,109.3+/-560.9 g) and were significantly more likely to have both neonates weigh more than 2,500 g (38.8% compared with 22.5%) and more than 1,000 g (97.5% compared with 91.2%) and were less likely to deliver any twin with a birth weight lower than the fifth percentile for gestational age (21.5% compared with 35.0%). Conclusion In women with twin pregnancies and normal starting BMIs, weight gain during pregnancy is significantly associated with improved outcomes, including a decreased risk of prematurity and larger birth weights. Level of evidence II.

Our objectives were to develop an ovine model for Escherichia coli -induced preterm delivery, and monitor E. coli (lux modified for photonic detection) invasion of the fetal environment—ewes (124 ± 18 d of gestation) received intrauterine inoculations using E. coli -lux as follows: control ( n = 5), 1.2 × 10 6 CFU/ml ( n = 5), 5.6 × 10 6 CFU/ml ( n = 5) E. coli -lux. Preterm delivery occurred between 48 and 120 h post-inoculation in 60%, 60% of ewes infected with 1.2, and 5.6 × 10 6 CFU/ml E. coli -lux, respectively, with presence of emitting bacteria confirmed by real-time imaging of lamb tissues. In summary, preterm delivery and/or fetal distress were observed in a majority of inoculated ewes. Finally, the use of photonic bacteria with imaging was a feasible means to monitor bacterial presence ex vivo .

The insulin (INS) and IGF 2 (IGF2) genes are in close proximity to each other and undergo maternal imprinting during fetal growth. We investigated the association between maternal and umbilical cord IGF 2 protein (IGF-II) levels and single nucleotide polymorphisms (SNPs) in the INS and IGF2 genes in 207 healthy African-American mother-newborn pairs. No association was found between maternal IGF-II levels and polymorphism in the INS-IGF2 locus. A significant association was found between newborn IGF-II levels and two SNPs (rs3842738 and rs689) at the 5' end of the INS-IGF2 locus. Analyses of haplotypes inferred from these two SNPs demonstrate a significant relationship between paternally transmitted haplotypes and newborn IGF-II levels, but no association with maternally transmitted haplotypes.

To test the association between small for gestational age and polymorphisms in the insulin gene in newborns and their mothers, as well as the effect of the parental transmission of haplotypes. Pairs of healthy African-American full-term newborns (N=207) and mothers were recruited from Memphis TN and Jackson MS with birth weights ranging from 2210 to 4735 g. Six single nucleotide polymorphisms (SNPs) located in the insulin (INS) and insulin-like growth factor 2 (IGF2) genes were genotyped in mothers and newborns. Haplotypes composed of three SNPs in the 5′ region of the INS–IGF2 locus were computationally inferred. Odds ratios for risk of small for gestational age (SGA) birth were calculated for individual SNPs and inferred haplotypes in the newborns and in the mothers using logistic regression. For 162 mother – newborn pairs the parental transmission of the haplotypes could be inferred, and the risks for SGA birth were calculated for the three common haplotypes in this sample. Three INS SNPs exhibited significant association with risk for SGA birth. The SNP alleles associated with increased risk for SGA were opposite in the maternal and newborn genomes, implying opposing influences on the rate of fetal growth. Consistent with these results, haplotypes composed of complementary nucleotide sequences (CAC at rs3842738, rs689 and rs3842748, respectively, in the newborn versus GTG in the mother) were significantly associated with risk for SGA birth. In analyses of haplotypes according to parental transmission, the same trend in risk for SGA was observed for both maternally and paternally transmitted haplotypes, although a significant difference in risk was observed only for paternally transmitted haplotypes. Polymorphisms near the 5′ end of the INS–IGF2 locus are significantly associated with risk for SGA birth with a major effect due to the paternally transmitted haplotype, which is preferentially expressed due to imprinting.

OBJECTIVE The objective of this study was to determine if first- and second-trimester biochemical markers for aneuploidy have an association with adverse pregnancy outcomes in twin gestations. STUDY DESIGN A retrospective cohort study of patients who presented with dichorionic diamniotic twin gestations was performed. Patients with first-trimester low pregnancy-associated plasma protein A (PAPP-A) or low free β human chorionic gonadotropin (β-hCG), or second-trimester elevated α-fetoprotein (AFP), elevated inhibin A, elevated hCG, or low unconjugated estradiol were identified. The rates of adverse pregnancy outcomes were compared between patients with or without abnormal analytes with p

Objectives To estimate the risk of spontaneous preterm birth in twin pregnancies based on transvaginal sonographic cervical length, fetal fibronectin (fFN) testing, and the gestational age at which these tests were performed. Methods Women with twin pregnancies, cervical length assessment, and fFN testing between 22 weeks and 31 weeks 6 days in a single maternal-fetal medicine practice from 2005 to 2013 were included. All testing was done on asymptomatic women on an out-patient basis. Women with monochorionic monoamniotic twins and twin-twin transfusion were excluded. Logistic regression analysis was used to estimate the risk of spontaneous preterm birth before 35, 32, and 28 weeks. Results Six hundred eleven patients were included and underwent a total of 2406 cervical length measurements and 2279 fFN tests over the course of the study period. The likelihood values for spontaneous preterm birth before 35, 32, and 28 weeks were 19.1%, 6.3%, and 2.3%, respectively. The risk of spontaneous preterm birth before 35 weeks increased with a decreasing cervical length (coefficient for the log of the odds ratio [OR coefficient], −0.13; P < .01; 95% confidence interval [CI], −0.22 to −0.037), a positive fFN result (OR coefficient, 1.04; P < .01; 95% CI, 0.45 to 1.64), as well as earlier gestational ages at testing (OR coefficient, −0.214; P < .01; 95% CI, −0.33 to −0.10). Similar results were seen for spontaneous preterm birth before 32 and 28 weeks. Conclusions In asymptomatic patients with twin pregnancies, the cervical length, fFN, and gestational age are all significantly associated with spontaneous preterm birth.

Objectives-The nonstress test is currently the most widely used modality for antenatal surveillance in twin pregnancies, with a quoted false-positive rate of 11%-12%. Our objective was to report our experience with the sonographic portion of the biophysical profile in twin pregnancies as the primary screening modality.Methods-Women with twin pregnancies delivered by a single maternal-fetal medicine practice from 2005 to 2013 were included. We excluded monoamniotic twins. Twin pregnancies began weekly sonography for the biophysical profile starting at 32 to 33 weeks, or earlier if indicated. The nonstress test was performed if the sonographic biophysical profile score was less than 8 of 8. We reviewed biophysical profile scores and outcomes for all patients who delivered at 33 weeks or later to assess the false-positive rate for the biophysical profile, as well as the incidence of intrauterine fetal death (IUFD) after initiation of antenatal surveillance.Results-A total of 539 twin pregnancies were included. The incidence of IUFD per patient was 2 per 539 (0.4%; 95% confidence interval [CI], 0.1%-1.3%), and the incidence of IUFD per fetus was 2 per 1078 (0.19%; 95% CI, 0.05%-0.7%). The overall positive screen rate was 24 per 539 (4.45%; 95% CI, 3.0%-6.5%). The false-positive screen rate, defined as an abnormal biophysical profile that did not diagnose an IUFD or lead to delivery, was 10 per 539 (1.9%; 95% CI, 1.0%-3.4%).Conclusions-In twin pregnancies the use of the sonographic biophysical profile for routine antenatal surveillance has a low false-positive rate, with a very low incidence of IUFD. The sonographic biophysical profile should be considered as a primary mode for antenatal surveillance in twin pregnancies, with a reflex nonstress test for an abnormal score.

Objective The purpose of this study was to determine the clinical role of fetal pulse oximetry to reduce cesarean delivery for a nonreassuring fetal heart rate tracing. Study design Singletons ≥28 weeks were randomized to fetal pulse oximetry plus electronic fetal heart rate monitoring (monitoring+fetal pulse oximetry) or monitoring alone. Results Overall, 360 women in labor were recruited: 150 cases with monitoring+fetal pulse oximetry and 177 cases with monitoring alone were analyzed. Most demographic, obstetric, and neonatal characteristics were similar. Specifically, the gestational age, cervical dilation, and station of the fetal head were not differential factors. In addition, cesarean delivery for nonreassuring fetal heart rate tracing was not different between the group with monitoring+fetal pulse oximetry (29%) and the group with monitoring alone (32%; relative risk, 0.95; 95% CI, 0.75, 1.22). Likewise, cesarean delivery for arrest disorder was similar between the group with monitoring+fetal pulse oximetry (22%) and the group with monitoring alone (23%; relative risk, 1.05; 95% CI, 0.79, 1.44). However, the decision-to-incision time was shorter for the group with monitoring+fetal pulse oximetry (17.8 ± 8.2 min) than for the group with monitoring alone (27.7 ± 13.9 min; P Conclusion The use of fetal pulse oximetry with electronic fetal heart rate monitoring does not decrease the rate of cesarean delivery, although it does alter the decision-to-incision time.

OBJECTIVE We compared maternal outcomes for patients with severe preeclampsia who were managed postpartum with or without adjunctive intravenous dexamethasone. METHODS This study was a randomized, blinded placebo-controlled clinical trial comparing the use of dexamethasone postpartum (10 mg-10 mg-5 mg-5 mg intravenously every 12 hours) with a saline control in patients with severe preeclampsia. The Student t and chi(2) tests were used for data analysis, with P < .05 considered significant. RESULTS Data from 157 patients (77 patients receiving dexamethasone, 80 patients receiving placebo) who were treated during 2000-2003 were analyzed. Demographics, diagnostic criteria, baseline laboratory values, and postpartum outcomes were similar between groups. Although dexamethasone-treated patients had fewer returns (6.5% compared with 11.3%) to the labor/delivery/recovery unit for uncontrolled hypertension than control patients, no significant differences were found in blood pressure, antihypertensive requirements, laboratory values, length of hospitalization, interval urine output at 48 hours postpartum, or major maternal morbidity. Two control patients developed hemolysis, elevated liver enzymes, low platelets syndrome. CONCLUSION Adjunctive use of intravenous dexamethasone for postpartum patients with severe preeclampsia does not reduce disease severity or duration. LEVEL OF EVIDENCE I.

To estimate the association between maternal obesity and adverse outcomes in patients without placenta previa or accreta undergoing a tertiary or higher cesarean delivery.Retrospective cohort of patients cared for by a single MFM practice undergoing a tertiary or higher cesarean delivery from 2005 to 2013. Patients attempting vaginal delivery and patients with placenta accreta and/or placenta previa were excluded. We estimated the association of maternal obesity (prepregnancy BMI ≥ 30 kg/m(2)) and maternal outcomes. The primary outcome was a composite of severe maternal morbidity (uterine rupture, hysterectomy, blood transfusion, cystotomy requiring repair, bowel injury requiring repair, intensive care unit admission, thrombosis, re-operation, or maternal death).Three hundred and forty four patients met inclusion criteria, 73 (21.2%) of whom were obese. The composite outcome was significantly higher in the obese group (6.8% versus 1.8%, p = 0.024, aOR 4.36, 95% CI 1.21, 15.75). The incidence of several individual adverse outcomes were also increased in obese women, including blood transfusion (4.1% versus 0.7%, p = 0.033, aOR 7.36, 95% CI 1.19, 45.34), wound separation or infection (20.5% versus 5.9%, p 0.001, aOR 4.05, 95% CI 1.75, 9.36) and 1-min Apgar score less than 7 (6.8% versus 1.9%, p = 0.024, aOR 4.40, 95% CI 1.21, 15.94).In patients undergoing a tertiary or higher cesarean delivery without placenta previa or accreta, obesity increases the risk of adverse outcomes. Obese patients are at risk for blood transfusion, low 1-min Apgar scores and postoperative wound complications.

Objective The objective of this study was to evaluate the ideal cutoff for the glucose challenge test (GCT) in twin pregnancies undergoing screening for gestational diabetes mellitus (GDM). Study Design A historical cohort of patients with twin pregnancies were identified from 1 maternal-fetal medicine practice from 2005 through 2013. All patients were administered a 1-hour, 50-g GCT between 24-28 weeks’ gestation. All patients with a GCT of ≥130 mg/dL underwent a 3-hour, 100-g oral glucose tolerance test. The diagnosis of GDM was made if 2 of the 4 values on the oral glucose tolerance test were abnormal (Carpenter and Coustan). The testing characteristics of the GCT for diagnosis of GDM were evaluated using 3 selected cutoffs: ≥130, ≥135, and ≥140 mg/dL. We excluded all patients diagnosed with GDM Results In all, 475 patients with twin pregnancies underwent a GCT between 24-28 weeks. The incidence of GDM was 6.5%. The positive screen rate using the 3 selected cutoffs were: ≥130 mg/dL, 34.7%; ≥135 mg/dL, 28.6%; and ≥140 mg/dL, 23.4%. A GCT cutoff of ≥135 mg/dL maintained 100% sensitivity, with a specificity of 76.4%. Using this cutoff, the positive predictive value was 22.8% and the negative predictive value was 100%. Compared to a cutoff of ≥130 mg/dL, a cutoff of ≥135 mg/dL resulted in 6.1% less patients testing positive while maintaining the same 100% sensitivity. Conclusion In twin pregnancies, the optimal 1-hour, 50-g GCT screening cutoff appears to be ≥135 mg/dL.

We sought to estimate the association between cervical length (CL) and fetal fibronectin (fFN) and each pathway leading to preterm birth in twin pregnancies.Cohort study of 560 patients with twin pregnancies who underwent routine serial CL and fFN screening from 22 to 32 weeks in one maternal fetal medicine practice during 2005-2013. We calculated the association between a short CL (≤20 mm) or positive fFN with overall preterm birth32 weeks, and then subdivided the analysis into preterm birth32 weeks from preterm labor, preterm premature rupture of membranes (PPROM) and indicated causes. We excluded cases of monochorionic-monoamniotic placentation, vasa previa, twin-twin transfusion and patients with cerclage.The overall rate of preterm birth32 weeks was 6.9% (3.9% from preterm labor, 1.6% from PPROM and 1.4% indicated). A short cervix was associated with preterm birth32 weeks arising from preterm labor (12.4% versus 2.0%, p 0.001), but not PPROM (1.9% versus 1.3%, p = 0.651). Positive fFN was associated with preterm birth32 weeks both from preterm labor (17.0% versus 2.4%, p 0.001) as well as from PPROM (5.7% versus 1.0%, p = 0.034). Neither was significantly associated with preterm birth32 weeks from indicated causes.The mechanism leading toward preterm influences the accuracy of screening tests chosen to assess risk in twin pregnancies. A shortened cervical length and positive fFN is associated with spontaneous preterm labor and birth32 weeks. However, PPROM does not appear to be preceded by a short cervix, but is preceded by a positive fFN. Neither test is associated with an indicated preterm birth.

Objective To report obstetric outcomes in a series of women with prior uterine rupture or prior uterine dehiscence managed with a standardized protocol. Methods Series of patients delivered by a single maternal-fetal medicine practice from 2005 to 2013 with a history of uterine rupture or uterine dehiscence. Uterine rupture was defined as a clinically apparent, complete scar separation in labor or before labor. Uterine dehiscence was defined as an incomplete and clinically occult uterine scar separation with intact serosa. Patients with prior uterine rupture were delivered at approximately 36-37 weeks of gestation or earlier in the setting of preterm labor. Patients with prior uterine dehiscence were delivered at 37-39 weeks of gestation based on obstetric history, clinical findings, and ultrasonographic findings. Patients with prior uterine rupture or uterine dehiscence were followed with serial ultrasound scans to assess fetal growth and lower uterine segment integrity. Outcomes measured were severe morbidities (uterine rupture, hysterectomy, transfusion, cystotomy, bowel injury, mechanical ventilation, intensive care unit admission, thrombosis, reoperation, maternal death, perinatal death). Results Fourteen women (20 pregnancies) had prior uterine rupture and 30 women (40 pregnancies) had prior uterine dehiscence. In these 60 pregnancies, there was 0% severe morbidity noted (95% confidence interval [CI] 0.0-6.0%). Overall, 6.7% of patients had a uterine dehiscence seen at the time of delivery (95% CI 2.6-15.9%). Among women with prior uterine rupture, the rate was 5.0% (95% CI 0.9-23.6%), whereas among women with prior uterine dehiscence, the rate was 7.5% (95% CI 2.6-19.9%). Conclusion Patients with prior uterine rupture or uterine dehiscence can have excellent outcomes in subsequent pregnancies if managed in a standardized manner, including cesarean delivery before the onset of labor or immediately at the onset of spontaneous preterm labor.

Preeclampsia and intrauterine growth restriction (IUGR) are correlated in singleton pregnancies. The objective of this study was to estimate their relationship in twin pregnancies.Cohort of 578 patients with twin pregnancies delivered by 1 maternal fetal medicine practice from 2005-2013. Patients with chronic hypertension, monochorionic-monoamniotic placentation, twin-twin transfusion, and major congenital anomalies were excluded. Standard definitions were used for gestational hypertension and preeclampsia. We defined IUGR as any twin birthweight less than the 5th percentile for gestational age, as well as any twin birthweight less than the 10th percentile for gestational age.The incidence of preeclampsia was 14.9%, the incidence of birthweight10% was 50.0%, and the incidence of birthweight5% was 27.5%. Comparing patients with and without preeclampsia, the rate of birthweight5th percentile did not differ (27.9% vs 27.4%, P = .929), nor did the rate of birthweight10th percentile (48.8% vs 50.2%, P = .815). We had 80% power with an alpha error of 5% to show a difference in the likelihood of IUGR10th percentile from 50% to 66% and a difference in the likelihood of IUGR5th percentile from 27% to 42% in patients without and with preeclampsia.In patients with twin pregnancy, there is no correlation between preeclampsia and IUGR. This suggests that in twin pregnancies, as opposed to singleton pregnancies, the pathophysiology may differ between these 2 common conditions.

The use of 17-alpha-hydroxyprogesterone caproate (17 P) has been shown to reduce preterm delivery in women who have had a prior preterm birth. The role of 17 P in women with arrested preterm labor is less certain.To compare the preterm birth rate and neonatal outcome in women with arrested preterm labor randomized to receive 17 P or placebo.Women with arrested preterm labor were randomized to weekly injections of either 17 P (250 mg) or placebo. Maternal and neonatal outcome were evaluated.Forty-five singleton pregnancies were randomized after successful tocolysis; 22 received 17 P while 23 got placebo. Gestational age at delivery (p = 0.067) and the interval from treatment to delivery (p = 0.233) were not affected by 17 P. Significantly less women in the 17 P group delivered at34 weeks (14 versus 21, p = 0.035). There was also a significant reduction in the risk of neonatal sepsis (p = 0.047) and gr III/IV intraventricular hemorrhage (IVH) (p = 0.022) in the 17 P group.In this study, 17 P did not delay the interval to delivery after successful preterm labor, but births34 weeks as well as neonatal sepsis and IVH were reduced by 17 P treatment.

Objective To estimate the effect of oocyte donation on pregnancy outcomes in patients with twin pregnancies conceived via IVF. Design Retrospective cohort study. Setting Patients with IVF twin pregnancies delivered by one maternal–fetal medicine practice from 2005 to 2013. Patient(s) Fifty-six patients with IVF twin pregnancies who had oocyte donation and 56 age-matched controls with IVF twin pregnancies who used autologous oocytes. We excluded women aged >50 years because there were no age-matched controls aged >50 years using autologous oocytes. Intervention(s) None. Main Outcome Measure(s) Gestational hypertension, pre-eclampsia. Result(s) The baseline characteristics were similar between the groups, including maternal age, race, parity, chorionicity, and comorbidities. The mean (±SD) age was 43.0 ± 6.0 vs. 41.9 ± 1.7 years. There were no differences in outcomes between the groups in regard to preterm birth, birth weight, or gestational diabetes. There was a greater incidence of gestational hypertension (32.1% vs. 13.0%) and pre-eclampsia (28.3% vs. 13.0%) in the group that underwent IVF with donor oocytes. Conclusion(s) In patients who conceive twin pregnancies using IVF, oocyte donation increases the risk of gestational hypertension and pre-eclampsia. However, this did not translate into increased rates of preterm birth or low birth weight. Patients who require oocyte donation should be carefully counseled regarding the increased risk for pre-eclampsia and gestational hypertension but should be reassured that oocyte donation does not seem to lead to other adverse outcomes.

In singleton pregnancies, a uterine anomaly is a known risk factor for preterm birth and fetal growth restriction. Data on outcomes of twin pregnancies with uterine anomalies is limited to case reports. The objective of this study was to compare outcomes in twin pregnancies based on the presence or not of a uterine anomaly.This was a retrospective cohort of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2012. Patients with monoamniotic twins and twin-twin transfusion syndrome were excluded. Pregnancy outcomes were compared between patients with and without a uterine anomaly. Nonparametric tests (Fisher's exact test, Mann-Whitney U) were used for analysis. A p value of ≤ 0.05 was considered significant.Five hundred and fifty-six twin pregnancies were included, 17 (3.1%) of whom had a known uterine anomaly (nine septate uterus, three bicornuate, three arcuate, one unicornuate and one didelphys). Patients with a uterine anomaly had significantly worse outcomes, including cerclage, preterm birth and lower median birth weights. Birth weight less than the 10th or 5th percentile for gestational age was not more common in patients with a uterine anomaly, nor was there an increase in birth weight discordancy.In patients with twin pregnancies, the presence of a uterine anomaly is associated with an increased risk of cerclage, preterm birth and lower birth weights, but not fetal growth restriction.

Objective To estimate the effectiveness of antepartum surveillance and delivery at 41 weeks in reducing the risk of stillbirth in advanced maternal age (AMA) patients. Study design Retrospective cohort study of all patients managed in one maternal–fetal medicine practice from June 2005 to May 2012. We included all singleton pregnancies delivered at ≥20 weeks of gestation. All AMA patients (age ≥35 years at their estimated delivery date) underwent weekly biophysical profile testing beginning at 36 weeks, as well as planned delivery at 41 weeks, or sooner if indicated. We compared the rate of fetal death at ≥20 weeks and fetal death at ≥36 weeks in AMA vs. non-AMA patients. Fetal deaths due to lethal and chromosomal abnormalities were excluded. Results 4469 patients met the inclusion criteria: 1541 (34.5%) were AMA and 2928 (65.5%) were non-AMA. Using our AMA protocol for surveillance and timing of delivery, the incidence of stillbirth was similar to the non-AMA population (stillbirth ≥20 weeks: 3.9 per 1000 vs. 3.4 per 1000, p = 0.799; stillbirth ≥36 weeks: 1.4 per 1000 vs. 1.1 per 1000, p = 0.773). When looking at women age

To describe pregnancy characteristics associated with the occurrence of spontaneous version in twin pregnancies from 20 weeks until delivery.Review of ultrasound and pregnancy data for all twin pregnancies delivered24 weeks by one Maternal-Fetal Medicine practice from June 2005-May 2012. For each 4-week gestational age window, fetal presentations were recorded, as well as the likelihood of the final presentation being vertex for Twin A and vertex for both twins. Case-control analysis was performed to estimate associations between pregnancy characteristics and spontaneous version of Twin A.A total of 491 twin pregnancies were included. The distribution of fetal presentations changed significantly from 20 weeks to delivery, but the presentation at each gestational age interval was significantly associated with the final position of Twin A and the likelihood of vertex-vertex presentation at delivery. The likelihood of spontaneous version of Twin A decreased from 27.9% after 24-27 6/7 weeks, to 18.8% after 28-31 6/7 weeks, to 8.2% after 32-35 6/7 weeks. Pregnancy characteristics associated with spontaneous version of Twin A were a prior vaginal delivery and increased fetal size of either twin.The likelihood of spontaneous version of Twin A decreases as pregnancy advances. Parity and increased fetal size are associated with spontaneous version.

OBJECTIVES The purpose of this study was to evaluate the gestational age at sonographic detection of placenta previa as a predictor of previa persistence until delivery in twin gestations. METHODS A retrospective cohort of twin pregnancies with placenta previa in a single ultrasound unit was analyzed from 2005 to 2010. Pregnancies were ascertained from a database. Diagnoses were confirmed by transvaginal imaging. Previa was categorized as complete if the placenta completely covered the internal os or marginal if the inferior placental edge reached within 2 cm. Gestational ages were grouped into intervals from 15 to 35 weeks. The study outcome was placenta previa at delivery. Only twin pregnancies at 25 weeks' gestation and later were analyzed using nonparametric statistics as appropriate, with P < .05 as significant. RESULTS Placenta previa was detected in 120 twin pregnancies in the second trimester: 32 complete and 88 marginal. Of those with placenta previa at 15 to 19, 20 to 23, 24 to 27, 28 to 31, and 32 to 35 weeks, previa persisted until delivery in 8.3%, 19.2%, 50%, 75%, and 92.5%, respectively. Only at 15- to 19- and 20- to 23-week intervals was complete previa more likely to persist than marginal previa (P < .001). CONCLUSIONS The likelihood of placenta previa persistence in twins is dependent on the gestational age at sonographic detection. Only at earlier gestations does the type of previa affect its persistence. As gestational age advances, the likelihood of resolution of placenta previa diminishes regardless of the type noted.

To assess the diagnostic accuracy of vaginal fetal fibronectin (fFN) sampling for predicting preterm birth in asymptomatic women carrying triplet gestations.An historical cohort of patients carrying triplet gestations between 1998 and 2010 was identified from a single practice by chart review. All patients were screened with fFN testing at 2-3 week intervals from 22 weeks to 32 weeks of gestation. Outcomes evaluated were spontaneous preterm birth prior to 28, 30, and 32 weeks' gestation and delivery within 2 and 3 weeks of testing.There were 56 pregnancies that met criteria for inclusion. For delivery prior to 30 weeks' gestation, the test had a sensitivity of 75%, a specificity of 85.4%, a positive predictive value of 46.2%, a negative predictive value of 95.3%, positive likelihood ratio of 5.13, and a negative likelihood ratio of 0.29 (p0.0001). For delivery within 3 weeks of a single fFN assessment, the test had a sensitivity of 53.3%, a specificity of 95.8%, a positive predictive value of 53.3%, a negative predictive value of 95.8%, positive likelihood ratio of 12.7 and negative likelihood ratio of 0.48 (p0.0001).Fetal fibronectin testing provides moderate to high prediction of spontaneous preterm birth in triplet gestations.

To estimate the risk of preterm birth in asymptomatic women with twin pregnancies with a normal cervical length (CL) and a positive fetal fibronectin (fFN), we reviewed a retrospective cohort of twin pregnancies delivered in our practice from 2005 to 2010. Patients were screened from 22 to 32 weeks with CL and fFN at 2- to 4-week intervals. We examined 244 patients with twin pregnancies and a normal CL (>25 mm) between 22 and 32 weeks and compared outcomes based on the fFN result. Fourteen (5.7%) patients had a positive fFN and 230 (94.3%) patients had a negative fFN. Positive fFN was associated with an increased the risk of spontaneous preterm birth < 37 weeks (85.7% versus 38.3%, p = 0.001), < 35 weeks (50% versus 11.8%, p < 0.001), < 34 weeks (35.7% versus 6.9%, p < 0.001), and < 32 weeks (21.4% versus 2.2%, p < 0.001). On adjusted analysis, a positive fFN was independently associated with preterm birth < 32 weeks (odds ratio 6.8, 95% confidence interval 1.42, 32.2) and gestational age at delivery (p = 0.001). In the setting of a normal CL, a positive fFN is significantly associated with preterm birth in asymptomatic twin pregnancies. Contingency model screening of fFN in asymptomatic twin pregnancies solely based on CL evaluation may fail to identify a cohort of at-risk patients.

OBJECTIVES The purpose of this study was to estimate the association between second-trimester estimated fetal weight and fetal growth restriction in twin pregnancies. METHODS A historical cohort of 306 twin pregnancies from a single center was analyzed. Estimated fetal weight and discordance at 18 to 24 weeks were calculated. Patients with a fetus whose second-trimester estimated fetal weight was below the 10th percentile were compared to patients with both fetuses at or above the 10th percentile. Also, patients with second-trimester discordance of 15% or greater were compared to patients with discordance of less than 15%. RESULTS Second-trimester discordance was significantly smaller than birth weight discordance (mean discordance ± SD, 7.41% ± 6.06% versus 11.43% ± 9.6%, respectively; P < .001). Patients with second-trimester discordance of 15% or greater were significantly more likely to deliver a twin with a birth weight below the 10th percentile for gestational age (67.7% versus 44.1%; P = .012) and below the 5th percentile for gestational age (41.9% versus 22.8%; P = .019). Patients with a second-trimester estimated fetal weight below the 10th percentile were significantly more likely to deliver a twin with a birth weight below the 10th percentile for gestational age (65.5% versus 44.5%; P = .031) and below the 5th percentile for gestational age (55.2% versus 21.5%; P < .001). CONCLUSIONS In twin pregnancies, second-trimester estimated fetal weight below the 10th percentile and discordance of 15% or greater are associated with fetal growth restriction.

We examined treatment outcomes in women with severe nausea and vomiting of pregnancy (NVP) receiving outpatient nursing support and either subcutaneous metoclopramide or subcutaneous ondansetron via a microinfusion pump. Among women receiving outpatient nursing services, we identified those diagnosed with severe NVP having a Pregnancy-Unique Quantification of Emesis (PUQE) score of greater than 12 at enrollment and prescribed either metoclopramide (N = 355) or ondansetron (N = 521) by their physician. Maternal characteristics, response to treatment, and start versus stop values were compared between the medication groups. Allocation to group was based on intention-to-treat protocol. Maternal characteristics were similar between the groups. Days to reduction in PUQE score levels were similar (median 2 days, metoclopramide; 3 days, ondansetron; P = 0.206). Alteration from metoclopramide to ondansetron (31.8%) was more frequent than alteration from ondansetron to metoclopramide (4.4%; P < 0.001). Improvement of NVP symptoms and reduced need for hospitalization was noted with both medications. Treatment with either metoclopramide or ondansetron resulted in significant improvement of NVP symptoms with half of women showing a reduction from severe symptoms to moderate or mild symptoms within 3 days of treatment initiation. Alteration in treatment was significantly greater in patients initially prescribed metoclopramide.