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Objective Our objective was to determine the accuracy of ultrasound at the time of the fetal anatomy survey in the diagnosis of velamentous cord insertion (VCI). Study design This retrospective case-control study identified placentas with VCI (cases) and randomly selected placentas with normal placental cord insertion (PCI) (controls) as documented by placental pathology for mothers delivered from 2002 through 2015. Archived ultrasound images for PCI at the time of the fetal anatomy survey were reviewed. Data analysis was by calculation of sensitivity, specificity, and accuracy and their 95% CI for the ultrasound diagnosis of VCI. Results The prevalence of VCI was 1.6% of placentas submitted for pathologic examination. There were 122 cases of VCI and 347 controls with normal PCI. The performance criteria calculated for the diagnosis of VCI at the time of fetal anatomy survey were as follows: sensitivity 33.6%; 95% CI: 25.3, 42.7; specificity 99.7%; 95% CI: 98.4, 99.9 and accuracy 82.5; 95% CI: 80.5, 82.9. Conclusion The identification of a VCI at the time of fetal anatomy survey is highly specific for the presence of a VCI as documented by placental pathology. The sensitivity in this study was less than expected. Sensitivity could be improved by reducing the number of nonvisualized PCIs, creating an awareness of risk factors for VCI, and obtaining more detailed images in the case of an apparent marginal PCI.

Objective To investigate the relationship between maximal placental thickness during routine anatomy scan and birthweight at delivery. Methods This retrospective descriptive study analyzed 200 term, singleton deliveries in 2016 at Penn State Hershey Medical Center. We measured maximal placental thickness in the sagittal plane from the ultrasound images of the placenta obtained at the 18–21-week fetal anatomy screen. The relationship between placental thickness and neonatal birthweight was assessed using Pearson’s correlation coefficient (r) with 95% confidence interval (CI). Logistic regression was used to assess the association between placental thickness and secondary binary outcomes of neonatal intensive care unit (NICU) admission and poor Apgar scores. Two-sample t-tests, or exact Wilcoxon rank-sum test for non-normally distributed data, were used to assess for differences attributable to medical comorbidities (pre-gestational diabetes, gestational diabetes, chronic hypertension, gestational hypertension, preeclampsia and eclampsia). Results Placental thickness had a positive correlation with neonatal birthweight [r=0.18, 95% CI=(0.05, 0.32)]. The mean placental thickness measured 34.2±9.7 mm. The strength of the correlation remained similar when adjusting for gestational age (r=0.20) or excluding medical comorbidities (r=0.19). There was no association between placental thickness and NICU admission, Apgar scores Conclusion Our study demonstrated a positive correlation between sonographic placental thickness and birthweight. Future prospective studies are warranted in order to further investigate whether a clinically significant correlation exists while adjusting for more covariates.

Maternal intake of high fat diet (HFD) increases risk for obesity and metabolic disorders in offspring. Developmental programming of taste preference is a potential mechanism by which this occurs. Whether maternal HFD during pregnancy, lactation, or both, imposes greater risks for altered taste preferences in adult offspring remains a question, and in turn, was investigated in the present study. Four groups of offspring were generated based on maternal HFD access: (1) HFD during pregnancy and lactation (HFD), (2) HFD during pregnancy (HFD-pregnancy), (3) HFD during lactation (HFD-lactation), and (4) normal diet (ND) during pregnancy and lactation (ND). Adult offspring 70 days of age underwent sensory and motivational taste preference testing with various concentrations of sucrose and Intralipid solutions using brief-access automated gustometers (Davis-rigs) and 24 h two-bottle choice tests, respectively. To control for post-gestational diet effects, offspring in all experimental groups were weaned on ND, and did not differ in body weight or glucose tolerance at the time of testing. Offspring exposed to maternal HFD showed increased sensory taste responses for 0.3, 0.6, 1.2 M sucrose solutions in HFD and 0.6 M in HFD-pregnancy groups, compared to animals exposed to ND. Similar effects were noted for lower concentrations of Intralipid in HFD (0.05, 0.10%) and HFD-pregnancy (0.05, 0.10, 0.5%) groups. The HFD-lactation group showed an opposite, diminished responsiveness for sucrose at the highest concentrations (0.9, 1.2, 1.5 M), but not for Intralipid, compared to ND animals. Extended-access two-bottle tests did not reveal major difference across the groups. Our study shows that maternal HFD during pregnancy and lactation has markedly different effects on preferences for palatable sweet and fatty solutions in adult offspring and suggests that such developmental programing may primarily affect gustatory mechanisms. Future studies are warranted for determining the impact of taste changes on development of obesity and metabolic disorders in a &ldquo, real&rdquo, food environment with food choices available, as well as to identify specific underlying mechanisms.

Context The first exposure to opioids for many women of reproductive age follows childbirth. Current data show a significant correlation between the number of days supplied and continued use/abuse of opioids. The number of women with opioid dependency in pregnancy is steadily increasing, and opioid use is directly linked to an increase in maternal and neonatal morbidity and mortality. However, there are no clear opioid-prescribing guidelines for the postpartum period. Objective To compare the number of opioid pills prescribed with the number used by patients in the postpartum period. Methods Patients were recruited to this pilot study at the time of admission to the labor and delivery unit at a community hospital in Oklahoma City, Oklahoma; 84 patients gave informed consent to participate. Medical records were reviewed to determine the number of opioids prescribed. Phone surveys were conducted 4 to 6 weeks after discharge to identify the number of opioids used during the postpartum period. Welch t test was used to determine P values. Results After exclusion criteria were applied, records of 23 patients with vaginal deliveries and 14 patients with cesarean sections were included in the study. Patients who were prescribed opioids after a vaginal delivery were prescribed significantly more pills than were used (PP Conclusion The data in this study show a clear example of overprescribing opioids after vaginal and cesarean deliveries leading to increased opioid pill availability within the community.

Kevin P Yeagle,1 James Michael O’Brien,2 William M Curtin,2 Serdar H Ural2 1Penn State Hershey, Department of the College of Medicine, Hershey, PA, USA; 2Penn State Hershey Obstetrics and Gynecology, Department of Maternal Fetal Medicine, Hershey, PA, USA Objective: To compare Apgar scores of full-term newborns of mothers with gestational (GDM) or type II diabetes mellitus (T2DM) with scores of newborns of mothers without impaired glucose tolerance. Study design: This was a retrospective data collection study (n=297). We reviewed 1-minute and 5-minute neonatal Apgar scores of newborns of mothers with GDM (n=100) or T2DM (n=97). Our control group consisted of newborns of mothers without a prior history of impaired glucose tolerance (n=100). ANOVA and linear model with corrected errors were used and adjusted for newborn sex and weight, and maternal age. Chi-squared analysis was performed for newborn sex. Results: The mean 1-minute and 5-minute Apgar scores were 7.8 and 8.9 for the GDM group and 7.7 and 8.9 for the T2DM group, respectively. There was no statistical difference in the 1-minute and 5-minute Apgar scores between the GDM group and controls (P=0.89 and P=0.13, respectively) nor in the scores between the T2DM group and controls (P=0.67 and P=0.40, respectively). Conclusion: Maternal history of GDM and T2DM does not appear to be associated with the 1-minute and 5-minute Apgar scores of full-term newborns of mothers with GDM and T2DM as compared to newborns of mothers without a history of impaired glucose tolerance. Keywords: Apgar score, diabetes mellitus, gestational diabetes, term birth

Objective: To compare healthcare utilization and outcomes using the Carpenter-Coustan (CC) criteria vs. the National Diabetes Data Group (NDDG) criteria for gestational diabetes mellitus (GDM). Methods: This is a retrospective cohort study. Prior to 8/21/2013, patients were classified as “GDM by CC” if they met criteria. After 8/21/2013, patients were classified as “GDM by NDDG” if they met criteria and “Meeting CC non-GDM” if they met CC, but failed to reach NDDG criteria. “Non-GDM” women did not meet any criteria for GDM. Records were reviewed after delivery. Results: There was a 41% reduction in GDM diagnosed using NDDG compared to CC (P=0.01). There was no significant difference in triage visits, ultrasounds for growth or hospital admissions. Women classified as “Meeting CC non-GDM” were more likely to have preeclampsia than “GDM by CC” women [OR 11.11 (2.7, 50.0), P=0.0006]. Newborns of mothers “Meeting CC non-GDM” were more likely to be admitted to neonatal intensive care units than “GDM by CC” [OR 6.25 (1.7, 33.3), P=0.006], “GDM by NDDG” [OR 5.56 (1.3, 33.3), P=0.018] and “Non-GDM” newborns [OR 6.47 (2.6, 14.8), P=0.0003]. Conclusion: Using the NDDG criteria may increase healthcare costs because while it decreases the number of patients being diagnosed with GDM, it may also increase maternal and neonatal complications without changing maternal healthcare utilization.

Background Despite a lack of high-quality evidence, the use of ‘non-indicated’ term labour induction is increasingly restricted throughout the world. Objectives To assess published associations between the regular use of modelled risk-based ‘non-indicated’ term labour induction (hereinafter ‘preventive induction’) and rates of common adverse birth outcomes. Search strategy MEDLINE and PUBMED databases were searched electronically. Selection criteria Studies were identified that compared term birth outcomes following either the current standard approach with its emphasis on the expectant management of intermediate-level risk or the regular use of preventive induction. Data collection and analysis Four studies from four unique databases were identified. A meta-analysis was performed using STATA IC12. Main results Pregnancies exposed to the regular use of preventive induction (n = 1153), as compared with pregnancies receiving the current standard approach (n = 1865), experienced a lower caesarean delivery rate (5.7% versus 14.4%; relative risk 0.39, 95% CI 0.31–0.50; I2 P = 0.21), a lower neonatal intensive care unit admission rate (2.9% versus 6.5%; relative risk 0.45, 95% CI 0.31–0.65; I2 P = 0.57), and a lower weighted adverse outcome index score (2.8 versus 6.1). Conclusions The regular use of preventive induction, as compared with the current standard approach, was associated with a more favourable pattern of birth outcomes. Other recently published meta-analyses have also determined that certain types of ‘non-indicated’ labour induction are beneficial. Accordingly, the current broad restrictions on ‘non-indicated’ labour induction should be reconsidered. Adequately powered multi-site randomised clinical trials are needed to definitively study the risks and benefits of modelled risk-based ‘non-indicated’ (i.e. ‘preventive’) term labour induction.

Objective Our objective was to determine whether epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. Study design This secondary analysis, retrospective cohort study included term parturients with placental examination during 2005. Logistic regression used fever (⩾38 °C) as the dependent variable. Significance was defined as P⩽0.05. Result There were 488 (76%) of 641 term parturients with placental examination and epidural. Independent predictors of intrapartum fever were epidural odds ratio (OR)=3.4, confidence interval (CI): 1.70, 6.81, histologic chorioamnionitis OR=3.18, 95% CI: 2.04, 4.95, birthweight OR=2.07, 95%CI: 1.38, 3.12, vaginal exams OR=1.15, 95% CI:1.06, 1.24, duration ruptured membranes OR=1.03, 95% CI: 1.01,1.05, parity⩾1 OR=0.44: 0.29, 0.66 and thick meconium OR=0.35: 95%CI: 0.24, 0.85. Conclusion Epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. Modification of labor management may reduce the incidence of intrapartum fever.

Objective.Our objective was determining if abnormal Doppler evaluation had a higher prevalence of placental pathology compared to normal Doppler in suspected fetal growth restriction (FGR) of cases delivered at 37 weeks.Study Design.This retrospective cohort study of suspected FGR singletons with antenatal Doppler evaluation delivered at 37 weeks had a primary outcome of the prevalence of placental pathology related to FGR. Significance was defined asp≤0.05.Results.Of 100 pregnancies 46 and 54 were in the abnormal and normal Doppler cohorts, respectively. Placental pathology was more prevalent with any abnormal Doppler, 84.8% versus 55.6%, odds ratio (OR) 4.46, 95% confidence interval (CI): 1.55, 13.22, andp=0.002. Abnormal middle cerebral artery (MCA) Doppler had a higher prevalence: 96.2% versus 54.8%, OR 20.7, 95% CI: 2.54, 447.1, andp<0.001.Conclusion.Abnormal Doppler was associated with more placental pathology in comparison to normal Doppler in fetuses with suspected FGR. Abnormal MCA Doppler had the strongest association.

Quantitative assessment of fetal heart function has been difficult. Increasingly, tissue Doppler imaging (TDI) is used to measure fetal cardiac function noninvasively. There are two principal techniques, spectral pulsed wave (PW) TDI and color TDI (CTDI). Published reference values for fetal myocardial velocities are based on spectral PW TDI only. However, previous phantom, adult, and animal studies have shown that PW TDI velocities are systematically higher than CTDI velocities. There are no fetal studies so far. We hypothesized that myocardial velocities derived by PW TDI and CTDI are significantly different in the fetus. This prospective observational study included 91 fetuses (gestational age 28.6 ± 6.6 weeks; range 19-40 weeks) seen for routine prenatal ultrasound. From apical 4-chamber views, tricuspid ring (right ventricle), lateral and septal mitral ring were sampled by PW TDI and CTDI. Bland-Altman analysis was used for comparisons. PW and CTDI S' velocities correlated strongly in all three cardiac segments (r = 0.6 to 0.9; P < 0.01). There was a systematic bias toward higher velocities with PW TDI versus CTDI (bias 0.96 cm/s; 95% CI 1.08-0.85 cm/s). However, the strength of the correlation and bias varied depending on the region of the fetal heart sampled. PW TDI and CTDI velocity measurements are feasible in the fetus and correlate well. However, PW TDI velocities are higher than CTDI velocities with significant regional variation. This precludes a mathematical conversion of PW to CTDI in vivo. As PW TDI and color TDI vary, different reference values for fetal CTDI velocities were generated.

Inherited Factor V deficiency is a rare bleeding disorder. We describe the genetic analysis and anesthetic management of a parturient with severe Factor V deficiency who presented in spontaneous labor. Good hemostatic conditions were obtained with prophylactic fresh frozen plasma administration of 10 mL/kg. Detailed genetic analysis by next-generation sequencing identified several relevant mutations in the coding part of the Factor V (F5) gene in our patient, her parents, and the newborn.

The objective of this study was to compare the perinatal outcomes in growth-restricted (IUGR) twins with a matched group of IUGR singletons. We performed a retrospective cohort study evaluating the perinatal outcomes in IUGR twins matched for gestational age at delivery to the next four IUGR singletons (1:4) in our perinatal database. The perinatal outcomes evaluated included rates of uncorrected perinatal mortality (PMR), admission to the neonatal intensive care unit (NICU), respiratory distress syndrome, grades 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia, and length of NICU stay. A cohort of twins with IUGR were matched with a cohort of IUGR singletons and compared for perinatal outcomes. A p value < 0.05 was considered significant. During the study period, we identified 99 IUGR twins meeting our inclusion criteria. These were matched with 396 singletons with IUGR. The mean gestational age at delivery for the twins was 34 +/- 3.8 weeks and 35 +/- 3.5 weeks for the singletons ( p = 0.11). The PMR in twins was significantly higher than in singletons (OR, 2.2; 95% confidence interval, 1.1 to 5.7). Perinatal morbidity was similarly significantly higher in IUGR twins. Compared with age-matched singletons, twins with IUGR have higher perinatal mortality and morbidity rates.

The purpose of this study was to determine if abnormal multiple marker screens (MMS) are associated with adverse perinatal outcomes in intrauterine growth restriction (IUGR) pregnancies.This was a case control study of IUGR pregnancies (birth weight10th percentile for gestational age [GA]) delivered in our unit over 6 years. Cases were compared with controls for the association between abnormal MMS and adverse perinatal outcomes (APO).Of the 261 IUGR pregnancies, 39 (16%) had at least 1 APO. An elevated HCG was significantly associated with an APO (OR 2.6, 95% CI 1.1-6.4). A low uE3 was also associated with an APO (OR 5.5, 95% CI 2.2-14). The association between an elevated AFP and APO was not statistically significant (OR 1.6, 95% CI, 0.6-4.6).An elevated HCG and low uE3 were associated with APO in cases of IUGR. This information could be useful in identifying a subset of IUGR cases deserving closer surveillance.

Objective The rarer of 2 alleles of a polymorphism in the promoter of the tumor necrosis factor alpha gene ( TNF ) has been associated with spontaneous preterm birth following preterm premature rupture of the fetal membranes in some populations. The aim of this study was to assess if the presence of symptomatic bacterial vaginosis amplifies the risk of spontaneous preterm birth in those with a "susceptible" TNF genotype. Study design A case-control study was performed at our institution. Cases (n=125) were defined as women who delivered before 37 weeks as a result of ruptured membranes or preterm labor, while control subjects (n=250) were defined as women who delivered after 37 weeks. DNA was collected from maternal blood and analyzed for the TNF genotype. Information on symptomatic bacterial vaginosis and other risk factors for preterm birth was obtained by review of the antenatal record. Multiple logistic regression was also used to test the interaction between bacterial vaginosis, the TNF genotype, and preterm birth. Results Maternal carriers of the rarer allele ( TNF-2 ) were at a significantly increased risk of spontaneous preterm birth [odds ratio (OR) 2.7, 95% CI 1.7-4.5]. The association between TNF-2 and preterm birth was modified by the presence of bacterial vaginosis, such that those with a "susceptible" genotype and bacterial vaginosis had increased odds of preterm birth compared with those who did not (OR 6.1, 95% CI 1.9-21.0). Conclusion This study provides preliminary evidence that an interaction between genetic susceptibilities (ie, TNF-2 carriers) and environmental factors (ie, bacterial vaginosis) is associated with an increased risk of spontaneous preterm birth.

Background and objectives To evaluate the feasibility of a minimally invasive approach for hysterectomy for benign disease at a university teaching hospital. Methods Five hundred thirty-seven consecutive patients underwent hysterectomy for benign disease at Penn State Milton S. Hershey Medical Center in 2010. No cases were excluded. Minimally invasive approaches included total vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy. All surgeries were completed with the resident as the primary surgeon or first assistant. Results The median age was 45 years, the median body mass index was 30 kg/m2, the median estimated uterine size was 11 cm, and 22% of patients had a prior cesarean section. Of the 537 hysterectomies, 526 (98%) were started with a minimally invasive approach and 517 (96%) were completed in that fashion; thus only 9 conversions (2%) were required. Of the cases in which a minimally invasive approach was used, 16% were vaginal and 84% were laparoscopic. The median operative time was 86 minutes, the median blood loss was 95 mL, the median hospital stay was 1 day, and the median uterine weight was 199 g. For the minimally invasive hysterectomies, there was a 5% major complication rate. Conclusion Our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time, amount of blood loss, hospital stay, and complication rate. Thus our study supports that a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility is feasible.

Recurrent miscarriage is defined as the loss of three consecutive pregnancies before 20 weeks' gestational age. Patients are referred to subspecialists such as reproductive endocrinology or maternal fetal medicine to exclude the most common causes of recurrent miscarriage including autoimmune disorders, structural uterine pathology, metabolic derangements, hematologic conditions, and chromosomal abnormalities. Unfortunately, this extensive list of conditions accounts for less than 50% of patients affected by recurrent miscarriage, leaving the remaining 50% without answers. Multiple treatment modalities, including supplementation with progesterone, human chorionic gonadotropin, aspirin with and without heparin, and immune modulators have been tested for this large percentage of patients with very few answers. In fact, the only successful intervention addressed in the literature consists of supportive care at a dedicated recurrent miscarriage clinic. Without large randomized clinical trials, there is no evidence to support the use of supplemental medications in this patient population.

OBJECTIVE: Accurate prenatal diagnosis of congenital diaphragmatic hernia is important for perinatal planning and potential fetal surgery. We describe the application and usefulness of helical CT amniography in the evaluation of suspected congenital diaphragmatic hernia in three fetuses. CONCLUSION: Helical CT amniography is an efficient means for evaluation of congenital diaphragmatic hernia. Accurate diagnosis was made in all three patients.

To establish the frequency of the atypical glandular cells of uncertain significance (AGCUS) category, and its subcategories, as defined by the Bethesda System (TBS).Our computerized records of cervical/vaginal cytology specimens submitted from January 1, 1993, through December 31, 1995, were retrospectively reviewed for specimens diagnosed as AGCUS. When appropriate, our subcategory of "AGCUS favor premalignant/malignant lesion" was further qualified as "favor endocervical adenocarcinoma in situ" or "suspicious for endometrial carcinoma." The number of specimens and patients diagnosed for each subcategory were grouped by calendar year. Differences in frequency between time periods were tested for statistical significance using chi 2 analysis.AGCUS was diagnosed in 1181 of 177,715 submitted specimens (0.66%). The frequency of subcategories was as follows: "favor reactive" (65%), "unable to further classify" (30%), "favor premalignant/malignant" (2.9%), "suspicious for endometrial carcinoma" (1.9%), and "favor endocervical adenocarcinoma in situ" (0.4%). From 1993 to 1995 there was an increase in the rate of diagnosis of AGCUS (0.55 to 0.73%; P0.001) and a decrease in the percentage of specimens with AGCUS subclassified as "favor premalignant/malignant" (6.2 to 0.5%; P0.001). Other subcategories showed no significant change in frequency over this time period. The rate of biopsy-proven preinvasive or invasive lesions in AGCUS patients also showed no significant change from year to year over this time period.The AGCUS diagnosis can be anticipated at a low but consistent rate from a cytology laboratory using TBS. Any comparison of laboratories should take into consideration the change in reporting frequencies that occurs as part of the "learning curve" following introduction of TBS reporting. Uniform diagnostic criteria and additional reports with large numbers of cytologic specimens will be needed to establish the expected frequency of AGCUS and its subcategories.

This study presents three cases of endometriosis in cesarean section scars. The main symptom was lower abdominal pain in the region of the scar. The pain was aggravated menstrually. Computed tomography and needle biopsy were of major value in reaching the correct diagnosis. Surgical excision and fascial repair is the definitive treatment. All patients were pain free in the postoperative follow-up visits, which varied from 6 months to 2 1/2 years. (J GYNECOL SURG 12:141, 1996)

Background More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule—by increasing the gestational age of delivery for a substantial number of pregnancies—might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown. Objective To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States. Study Design Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole. Results A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007−2009 with 2011−2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038−1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002−0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater. Conclusions Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

Background and Aims: Patients undergoing elective cesarean delivery (CD) have a high-risk of spinal-induced hypotension (SIH). We hypothesized that a colloid preload would further reduce SIH when compared with a crystalloid preload. Material and Methods: Eighty-two healthy parturients undergoing elective CD were included in the study. Patients were randomly assigned to two groups (41 patients in each group) to receive either Lactated Ringer's solution (1500 ml) or hydroxyethyl starch (6% in normal saline, 500 ml) 30 min prior to placement of spinal anesthesia. All patients were treated with a phenylephrine infusion (100 mcg/min), titrated during the study. Results: There was no statistical difference between groups with regards to the incidence of hypotension (10.8% in the colloid group vs. 27.0% in the crystalloid group, P = 0.12). There was also no difference between groups with respect to bradycardia, APGAR scores, and nausea and vomiting. Significantly less phenylephrine (1077.5 ± 514 mcg) was used in the colloid group than the crystalloid group (1477 ± 591 mcg, P = 0.003). Conclusion: The preload with 6% of hydroxyethyl starch before CD might be beneficial for the prevention of SIH.

Hyperemesis gravidarum, or pernicious vomiting of pregnancy, is a complication of pregnancy that affects various areas of the woman’s health, including homeostasis, electrolytes, and kidney function, and may have adverse fetal consequences. Recent research now provides additional guidelines for protection against and relief from hyperemesis gravidarum. Alterations to maternal diet and lifestyle can have protective effects. Medicinal methods of prevention and treatment include nutritional supplements and alternative methods, such as hypnosis and acupuncture, as well as pharmacotherapy.

Aims: The objective of this study was to examine the impact of one trial (the HYPITAT trial) on management of gestational hypertension. Study design: This is a retrospective cohort study of 5077 patients delivered at our institution from 7/1/2008 to 6/15/2011. “Pre-HYPITAT” was defined as 7/1/2008–9/30/2009 and “Post-HYPITAT” as 10/1/2009–6/15/2011. The primary outcome is the rate of delivery intervention for gestational hypertension. Secondary maternal and neonatal outcomes were analyzed in patients with gestational hypertension only. Statistical analyses included the χ2-test, Fisher’s exact test, and the two-sample t-test. Results: The rate of delivery intervention Pre-HYPITAT was 1.9%, compared to 4% Post-HYPITAT (P Conclusion: There was a statistically significant increase in delivery intervention for gestational hypertension at our institution after the publication of the HYPITAT trial. There was no significant change in immediate maternal or neonatal outcomes for patients with gestational hypertension.

Combined with the enlarging uterus compressing the venous system of the pelvis and the vessel trauma incurred in delivery, an increase in clotting factor production in pregnancy predisposes the gravid patient to the peril of thromboembolism. When a patient has an inherited thrombophilia and becomes pregnant, this combination of risk factors in the presence of pregnancy may be the tipping point, pushing the coagulation cascade into an activated state. All thrombophilias, deep vein thrombosis, and pulmonary embolism are factors associated with complications in pregnancy that may lead to catastrophic consequences. This review report on the most frequent thromboembolic complications in pregnancy.