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

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

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

Video abstract summary This video reviews the surgical management of adnexal torsion in early and late pregnancy. We discuss imaging and diagnosis, and present an approach focusing on the preoperative, intraoperative, and postoperative considerations.

Objectives An isthmocele is a cesarean section scar defect with a depth of >2mm, and can cause both obstetric and gynecologic complications. To date, no study has determined the impact of a locked versus unlocked double-layer uterine closure technique on isthmocele prevention. The primary objective of this study is to evaluate protocol feasibility amongst our own patients and physicians, with the ultimate goal of a larger-scale randomized controlled trial (RCT). Secondary objectives include determining: (a) isthmocele incidence; (b) isthmocele measurements on postoperative transvaginal ultrasound; and (c) adverse surgical outcomes related to suture technique. Methods This is a single-centre parallel-group pilot RCT enrolling 50 participants (25 per arm) including all term singleton pregnant women >18 years old undergoing primary cesarean section. Exclusion criteria include previous uterine hysterotomy, known uterine anomalies, active labour, known bleeding disorders, and maternal connective tissue disorders. Subjects are randomized to locked versus unlocked first layer uterine closure, followed by an unlocked second layer. Women will undergo transvaginal ultrasound to evaluate isthmocele formation six months postoperatively. Results At time of submission 31 subjects have been recruited. Data will be analyzed on an intention-to-treat basis. Demographic data will be reported using descriptive statistics. Rates of isthmocele will be compared between groups using chi-square analysis; subgroup analysis of the variable suture material will be performed. Other outcomes will be assessed using a t test (continuous variables) or chi-square test (categorical variables) as appropriate. Conclusions This study design appears feasible at this time. Further outcome data will be reported once the study is complete.

Objectives Estimated fetal weight (EFW) helps inform clinical decision making in patients with preterm premature rupture of membranes (PPROM). The Hadlock IV formula is the most commonly used calculation of EFW using biparietal diameter, head circumference, abdominal circumference, and femur length. The study objective was to assess the accuracy of the Hadlock IV calculation in patients with PPROM. Methods We performed a retrospective cohort study of singleton gestations with PPROM admitted between 220–330 weeks gestational age (GA) to a single, university-affiliated, tertiary hospital between 2003–2017. All women had a sonographic EFW performed within 14 days of delivery calculated by Hadlock IV formula. The Pearson correlation was calculated to determine the association between EFW and birthweight (BW). Results Five-hundred-sixty-five women were included. Mean GA was 26.8±2.4 at admission, and 28.2±2.6 at delivery. The median EFW-to-delivery interval was three days (0–14 days, intraquartile range 5 days), mean BW 1154±418 grams, and mean EFW 1078±382 grams. Overall, 49.4% of women had maximal vertical pocket (MVP) Conclusions The study shows that Hadlock IV provides an accurate EFW in patients with PPROM, regardless of fetal sex or amniotic fluid levels.

Objective To prospectively examine whether children of women with a pregnancy affected by severe pre-eclampsia (PE), compared to children of women without a PE-affected pregnancy, have differences in neurodevelopmental performance up to 5 years of age. Design Prospective cohort study. Setting Tertiary care centre. Participants Women were recruited following a PE-affected pregnancy. After each PE participant was recruited, the next normotensive woman without a prior history of PE and matched by parity, maternal age and race was invited to participate. Women with a history of chronic hypertension, diabetes or renal disease were excluded. Total enrolment included 129 PE-affected and 140 normotensive mothers. Outcome measures The primary outcome measure was failure of the Ages and Stages Questionnaire (ASQ). The ASQ was completed yearly, until age 5. Results A significant difference was found in the proportion of ASQ categories failed in year 3 (p

There are a number of different anticoagulation options for pregnant women with mechanical heart valves. The purpose of this study was to examine maternal thromboembolic complications in women with mechanical valves treated with low-molecular weight heparin (LMWH) throughout pregnancy. This was a substudy of a larger prospective cohort study of pregnant women with heart disease followed from 1998 to 2008. All pregnant women with mechanical left-sided valves who were treated with LMWH throughout pregnancy were included. Maternal thromboembolic events were defined as valve thrombosis, need for valve replacement, or stroke during pregnancy or postpartum (up to 6 months). Twenty-three pregnancies (17 women) occurred in women treated with LMWH and low-dose aspirin: 15 in women with mechanical mitral valves, 9 in women with mechanical aortic valves, and 1 in a woman with both. There was 1 maternal thromboembolic event (4%), which resulted in maternal and fetal death. Five women (22%) developed other adverse cardiac events during pregnancy. Nine pregnancies (43%) had fetal or neonatal adverse events, 5 of which had favorable outcomes. Three pregnancies were complicated by postpartum hemorrhage. In conclusion, carefully monitored LMWH may be a suitable anticoagulation strategy in pregnant women with mechanical heart valves who are unwilling to use warfarin. However, this group of women remains at risk for maternal cardiac and fetal complications. The occurrence of valve thrombosis resulting in maternal death despite therapeutic anti-Xa levels highlights current limitations with anticoagulation in this population.