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We present two consecutive pregnancies with shared ultrasound findings-sloping forehead, micrognathia, ambiguous genitalia, brachycephaly, short extremities, single umbilical artery, choroid plexus cysts, and clenched hands. Subsequent whole exome sequencing identified TRAIP gene variants implicating diagnosis of Seckel syndrome 9 (SCKL9). Prenatal testing in subsequent pregnancy identified one variant. Our case highlights the utility of whole exome sequencing when prenatal ultrasound findings lend suspicion. Molecular confirmation allows for testing strategies in, or prior to, subsequent pregnancies. The finding of a rare, novel missense variant in TRAIP gene further implicates this mutation as having deleterious clinical manifestations.

Objective: To evaluate demographics and outcomes of maternal-fetal pairs in early onset fetal growth restriction (FGR) requiring delivery prior to 34 weeks’ gestation based on ultrasound indication leading to diagnosis. Study Design: This is a descriptive study of maternal-fetal pairs with early FGR diagnosed prior to 30 weeks’ gestation and delivering between 22w0d and 34w0d under the care of Wake Forest University Perinatology 01/2012–12/2016. Serial ultrasounds to assess fetal growth and umbilical artery flow Doppler velocimetry were evaluated. Pairs were dichotomized into those with maternal comorbidities leading to ultrasound diagnosis, and those with ultrasound indicated only by appreciation of uterine size less than dates on exam. Patient characteristics and outcomes were tracked. Univariate and multivariate analyses were performed as appropriate. Results: 56 pregnancies were identified with FGR prior to 30 weeks and subsequent delivery prior to 34 weeks. Common comorbidities present in the group with maternal comorbidities included chronic hypertension (30.5%), hypertensive disorders of pregnancy (36.1%), preexisting diabetes (13.9%), gestational diabetes (5.6%). None of the women in the S

Objectives To assess deviations in longitudinally measured cytokines with preterm birth (PTB). Methods Prospective longitudinal study targeting 80 subjects. Phlebotomy specimens for broad panel of cytokine analysis were obtained at three time (T) intervals: first trimester (T1: 8–14 weeks’ gestation), second trimester (T2: 18–22 weeks’ gestation), and third trimester (T3: 28–32 weeks’ gestation). Important demographics and outcomes were tracked. Data were stratified and the target groups were analyzed as follows: “Uncomplicated” (delivered ≥37 weeks) or “Preterm Birth” ( Results Complete data replete with phlebotomy at all three visits were obtained on 80 women. Birth outcomes were as follows: 11 Uncomplicated Term Birth (UTB), 28 PTB, 4 low birth weight (LBW), 16 OB complications (OBC), 11 current infections (IFN), and 10 mixed complications (MC=2 or more of the above). 28 PTB were compared to 11 uncomplicated term deliveries. In both groups, T helper type 1 (TH1) cytokine (IL-1β), pleiotrophic pro-inflammatory cytokine (IL-6), and counter-regulatory cytokine (IL-10) responses decreased over gestation, but rates of change in IL-1β, IL-6, and IL-10 were significantly different. Stratification of women by smoking status additionally demonstrated significant variance in immune status over the course of pregnancy Conclusions Women delivering PTB demonstrated significant differences in cytokine trajectory over pregnancy; these data further validate key role played by immune regulation in directing pregnancy outcome. Likewise, smoking impacts longitudinal trajectory of cytokines over pregnancy.

Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycemia with onset during pregnancy. The article aims to provide clinicians with a working framework to minimize maternal and neonatal morbidity. Landmark historical and recent data are reviewed and presented to provide clinicians with a quick, easy reference for recognition and management of GDM. Data presented tie in insights with underlying pathophysiologic processes leading to GDM. Screening and diagnostic thresholds are discussed along with management upon diagnosis. Good clinical practice regarding screening, diagnosis, and management of GDM effectively reduces risk and improves outcomes of women and fetuses in affected pregnancies.

Objective: Preterm delivery of growth restricted (IUGR) fetuses prior to 32 wks is rarely indicated, occurring in

Objective To assess post-partum inflammation for patients delivering prior to 34 6/7 weeks by birth etiology. Methods This was an observational study of early preterm birth (PTB) occurring between 20 0/7 and 34 6/7 weeks of gestation. Serum C-reactive protein (CRP) levels were measured 1 month post-partum. CRP measurements were compared by birth etiology. Results A total of 399 women were analyzed. Distribution of birth etiology was 35% (n = 138) preterm labor (PTL), 28% (n = 115) preterm premature rupture of membranes (pPROM), and 37% (n = 141) indicated preterm birth (IPTB). Serum CRP varied by birth etiology (P = 0.036). Women with pPROM had elevated median CRP levels compared to women with PTL (P = 0.037). IPTB demonstrated elevated CRP levels when compared to PTL (P = 0.019). Pre-eclamptic/eclamptic subjects exhibited increased median CRP levels compared to PTL (P = 0.04). Conclusion Post-partum inflammation varies by birth etiology. Such variation may serve as identification of subjects whose future pregnancies and, ultimately, overall health status may benefit from inter-pregnancy interventions aimed at reducing inflammatory-associated risk factors.

Background Uterine synechia are bands of fibrous tissue that when seen on prenatal ultrasound are not felt to pose significant risk to a fetus outside of early pregnancy loss. On the contrary, amniotic bands are diagnosed when bands of amniotic tissue are found to entrap and possible amputate involved fetal parts. Case presentation Ultrasound imaging demonstrated a twin pregnancy affected by entrapment of twin B’s head in a uterine synechium versus an amniotic band at 11 weeks + 0 days. The entrapment persisted until the second trimester. After a review of still images and video clips with a fetal surgeon, the patient was scheduled for possible fetal surgery. Upon arrival at 16 weeks + 0 days, the entrapment was observed to have spontaneously resolved. The patient experienced preterm premature rupture of membranes at 17 weeks + 6 days, and developed chorioamnionitis at 18 weeks + 5 days. Shortly after diagnosis with chorioamnionitis, she delivered spontaneously at 18 weeks + 5 days. Postnatal hysteroscopy demonstrated uterine synechium at the uterine fundus, which was resected. Conclusions This is the first case of fetal head entrapment by a uterine synechium.

Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycemia with onset during pregnancy. The article aims to provide clinicians with a working framework to minimize maternal and neonatal morbidity. Landmark historical and recent data are reviewed and presented to provide clinicians with a quick, easy reference for recognition and management of GDM. Data presented tie in insights with underlying pathophysiologic processes leading to GDM. Screening and diagnostic thresholds are discussed along with management upon diagnosis. Good clinical practice regarding screening, diagnosis, and management of GDM effectively reduces risk and improves outcomes of women and fetuses in affected pregnancies.

Simulation training has been demonstrated to increase medical student confidence with vaginal deliveries; however, effect on skill performance is still lacking. To determine if integration of simulation training into the OB/GYN clerkship improves performance of vaginal deliveries, we assessed the effectiveness of simulation in third-year medical students.During the OB/GYN clerkship, third-year students were assigned to receive vaginal delivery simulation (n=54) or cervical exam simulation (n=56), with each group serving as a simulation naïve control for the other skill. As a final assessment of their skill, students performed a simulated vaginal delivery scored by a blinded observer using a procedural checklist (score 0-30). A satisfactory score was considered 26 or greater. The individual scores and percentage of satisfactory scores were compared between both groups using a Mann-Whitney U test and chi-square test, respectively.Vaginal delivery students had a significantly higher mean score (27 +/- 3.2) and percentage of students achieving a passing score (85%) than the cervical exam students (22 +/- 3.5 and 15%). There were no differences in vaginal delivery performance based on gender, nor was there any difference in the number of real-life deliveries performed between vaginal delivery and cervical exam students.Even though medical students had an equivalent clinical rotation experience, a short period of simulation training had a marked effect on their end-of-rotation performance. During initial resident or midwife training more than 5 hours of simulation will likely be required to properly prepare 100% of trainees.

Objective: To assess effect of perioperative music intervention on maternal anxiety levels, physiologic metrics, and medication use for anxiety, nausea and pain during and after scheduled cesarean section. Methods: Women assigned to music intervention group were compared against controls. Physiologic metrics, medication requirements, and STAI scores were assessed for all participants. Results: 50 women were enrolled, assigned to either music intervention (n=25) or control (n=25) and analyzed. Physiologic metrics were similar between groups. Antiemetic, anxiolytic, and analgesic medication use intraoperatively and postoperatively were not significantly different. State and Trait scores by the STAI did not vary significantly by intervention (p=0.09). STAI scores before and after procedure demonstrated the least change for the intervention group (r=0.6) when compared to controls (r=0.2; p

To characterize immune modulation as expressed by cytokine assays at three time-points in human pregnancy.This is a prospective, longitudinal study of a broad panel of cytokine expression during singleton pregnancies resulting in an uncomplicated, full-term, live births. Peripheral blood was obtained at 8-14, 18-22, and 28-32 weeks gestation. Six cytokines - IFN-γ, IL-4, TNF-α, IL-1β, IL-6, and IL-10 - were measured in supernatants obtained from whole blood stimulations with PHA or LPS and were compared to unstimulated controls. Samples were processed by Luminex-100 MAP®. We used Generalized Linear Models (GLM) to evaluate cytokine trajectories.Complete data were obtained for 45 uncomplicated pregnancies. Overall, peripheral blood WBC's demonstrated dampened cytokine responses. However, over the course of pregnancy, we found enhanced counter-regulatory cytokine expression (e.g., shown by increased IL-10).The overall decrease in pro-inflammatory cytokines and increase in counter-regulatory cytokines as uncomplicated pregnancy progresses supports the evolving concepts of immunoregulation for the maintenance of a viable pregnancy.

Bacterial vaginosis (BV) infections are common in women of reproductive age and are easily diagnosed and treatable. Aside from being an annoyance when symptoms of discharge, odor, and pruritus occur in the gravid female, BV infections increase risk of late miscarriage, preterm labor, preterm premature rupture of membranes, and, consequently, preterm delivery. Antepartum and puerperal issues such as chorioamnionitis and endometritis are increased in the context of maternal BV. Moreover, the morbidities and mortality of preterm delivery are consequently increased as a result of BV during pregnancy. Although the pathology associated with BV appears to result from inflammation, more investigation is needed in terms of designing guidelines for appropriate screening and treatment for the prevention of adverse outcomes.

The preterm birth rate in the USA is nearing 13%. The recent rise has been attributed to increased indicated preterm births and multiple births following artificial conceptions. There are few obstetrical interventions that successfully delay or prevent spontaneous preterm birth or reduce the risk factors leading to indicated preterm birth. On the other hand, there are many strategies that have improved outcomes for those infants who are born preterm. These include the use of corticosteroids for fetal maturation and regionalization of perinatal care for high-risk mothers and their infants. Several interventions, including progesterone use and cerclage, demonstrate promise in reducing spontaneous preterm births. The most pressing need is to better define the populations of pregnant women for whom these and other interventions will effectively reduce preterm birth.

We sought to compare two approaches to antenatal testing for their impact on the workforce. This is a prospective observational study of women who presented for antenatal testing. All women were given a survey upon presentation. As per hospital protocol, nonstress testing (NST) was performed semiweekly and biophysical profile (BPP) was performed weekly. The choice of testing was determined by the attending physician. χ2- and Student's t-tests were performed where appropriate. A P-value of

We sought to evaluate neonatal hearing assessment by the otoacoustic emission (OAE) test in very low birth weight (VLBW) infants exposed to antenatal steroids. This is a retrospective cohort study of infants

Late preterm newborns (LPNs), those with gestational ages (GAs) between 34 weeks and 36 weeks 6 days, account for 70% of preterm births. Because they have a mature appearance and are often cared for in a well baby nursery (WBN), parents may anticipate that the nursery course will be similar to that of a term infant and that their newborn will be discharged with his/her mother. How frequently their hospitalizations are prolonged beyond that of their mothers and the morbidities associated with prolonged hospitalization (PH) have not been well described. The objectives of the study were to (1) determine the proportion of LPNs with a PH and (2) describe the most common morbidities in LPNs and identify those associated with PH. The authors conducted retrospective chart reviews of the neonatal courses of LPNs born between December 2002 and April 2007 at the University of Utah Hospital. They compared maternal and newborn discharge dates to determine the proportion of LPNs with a PH and calculated frequencies of conditions and interventions indicating morbidity and identified associations between each of the conditions/interventions and PH. Of 235 LPNs, 94 (40%) had a PH; 75% of 34-week LPNs had a PH compared with 50% of those with GAs of 35 weeks and 25% of those with GAs of 36 weeks. The most common conditions/interventions were an oxygen need, phototherapy for jaundice, and hypothermia requiring an isolette. A need for nasogastric feeding and antibiotic administration for >3 days was consistently associated with a PH. LPNs whose only intervention was phototherapy for jaundice or IV antibiotics for

Objectives We evaluated role of sFlt-1 and VEGF in a preeclampsia model driven by RAS activation. We hypothesized as transgenic crossbreeds develop preeclampsia, features of hypertension, proteinuria, kidney and placenta end-organ damage will occur concurrently with (1) sFlt1 rising higher in preeclamptic mice, (2) VEGF remaining high in preeclamptic mice but equivalent to controls; and, (3) preeclamptic kidneys demonstrating increased VEGF binding. Methods Transgenic hAGT and hREN, or wild type (WT) mice were used. Non-gravid females underwent telemetric transmitter implantation for blood pressure (BP) measurements. Mice were cross-bred: hAGT × hREN for RAS preeclamptic model and pregnant controls (WT × WT). Blood and urine collected on days (GD) 12, 15, and 18. Vascular reactivity in mesenteric arteries investigated by wire myography using KCl, acetylcholine (ACH), phenylephrine (PE). ELISA performed on urine for albumin and on plasma for VEGF and sFlt-1. Necropsies were performed GD 18-19. Kidneys and placenta were sectioned for HE and immunostain. Results 11 RAS pregnancies and 9 WT pregnancies (WTP) compared. 12,414 h of BP data analyzed. RAS mice demonstrated higher BP and proteinuria. RAS mice had glomerular endotheliosis (80% vs. 11%; p = 0.02), and placental necrosis (60% vs. 0%; p Conclusions While RAS model of preeclampsia recapitulates human preeclamptic state with high fidelity, renal injury may actually be mediated by increased VEGF binding. Disclosures J.M. Denney: None. C.E. Shaw: None. A. Gendron-Fitzpatrick: None. I. Bird: None. D. Shah: None.

Objective: We evaluated whether the recorded indications for late preterm delivery were supported by generally accepted medical indications in a cohort of late preterm birth (LPTB). In addition, we compared neonatal outcomes in cases of LPTB with and without generally accepted medical indications. Methods: We conducted a retrospective cohort study of LPTB from 2007-2009 in two tertiary care centers and two community hospitals in Salt Lake City, UT. Subjects delivered a live born infant between 34-36 6/7 weeks’ gestation. Data were abstracted from maternal and neonatal medical records. An instrument created prior to data collection explicitly defined criteria for generally accepted medical indications for iatrogenic LPTB. Major neonatal morbidity was defined as a composite outcome of death in the first 120 days of life, intraventricular hemorrhage, necrotizing enterocolitis, and need for mechanical ventilation. Results: 244 cases of LPTB were analyzed. 18.9% of LPTB cases (46/244) did not meet criteria for a generally accepted medical indication for late preterm delivery. The recorded diagnoses ‘placenta previa’, ‘oligohydramnios’, ‘preeclampsia’, ‘maternal disease’, and ‘placental abruption’ were most likely to fail to meet criteria for generally accepted indication after review of primary medical records. LPTB without generally accepted medical indication was associated with an increased risk of composite major neonatal morbidity (19.1% vs. 7.9%, P = 0.03). Need for neonatal ventilator support was independently associated with LPTB without generally accepted medical indication (19.1% vs. 6.9%, P = 0.02). Conclusion: Almost one fifth of LPTB, and its neonatal sequelae, may be avoidable.

Objective This study was undertaken to characterize the course of bacterial vaginosis in pregnancy and to discern the bacterial morphotypes responsible for infection. Study Design Vaginal secretions were obtained in each trimester of pregnancy and were evaluated for bacterial vaginosis by Gram stain, categorized as normal or any of the following: Lactobacillus deficient, Gardnerella , Bacteroides , or Mobiluncus positive and by Nugent score. Results were evaluated for trends of bacterial vaginosis and Gram stain over pregnancy. Results One hundred forty-eight women were evaluated. Seventy-one women (48%) were bacterial vaginosis negative in all trimesters, compared with 14 (9.4%) who were positive throughout pregnancy. Among the 14 women who remained bacterial vaginosis positive, Gram stain findings were Gardnerella + Bacteroides + Lactobacillus , with approximately 50% harboring Mobiluncus . Few women become bacterial vaginosis positive as pregnancy progressed (6.1%). With each increasing week of pregnancy, the risk of becoming bacterial vaginosis positive decreased (0.93: 0.91-0.95; P Conclusion In this population, the majority of pregnant women trend toward bacterial vaginosis negative status. Few women are bacterial vaginosis positive across their pregnancy.