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To determine whether vaginal progesterone treatment for women with a short cervix, diagnosed after 24 weeks of pregnancy, reduces preterm birth rates.A retrospective cohort study that included women with a singleton pregnancy, threatened preterm labor, and a short cervix measured between 24Patients who received vaginal progesterone had a lower rate of preterm delivery at less than 37 weeks of pregnancy (18.2% [22/121] versus 28.9% [73/253]; adjusted hazard ratio 0.50; 95% confidence interval 0.28-0.73, P = 0.001). The diagnosis-to-delivery interval was significantly greater in patients who received progesterone than in those who did not-median time to delivery in weeks: 8.2 (interquartile range [IQR] 6.2-9.8) versus 6.6 (4.8-8.8), (P 0.001). The frequency of neonatal intensive care unit admission was significantly lower in patients who received progesterone than in those who did not (8.3% [10/121] versus 16.2% [41/253], P = 0.04).The administration of vaginal progesterone to patients with an episode of threatened premature labor and a short cervix presenting after 24 weeks of pregnancy was associated with lower rates of premature births.

Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for the trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture.A retrospective cohort study was conducted, including women who underwent TOLACs from 2003 to 2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥ 24 weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was a uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders.A total of 11,235 women were included, 6795 of which had a PVD. Women with PVD had significantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p 0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p 0.0001), were more likely to undergo labor induction (OR 1.56, p 0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p 0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22.PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients.

To investigate trial of labor after cesarean (TOLAC) success rates in twin gestations with no prior vaginal delivery.A retrospective study of women with twin gestations who underwent a TOLAC and had no prior vaginal delivery during 2011-2020. TOLAC success and failure groups were compared.Of 675 twin gestations with a history of cesarean delivery and no prior vaginal delivery, 83 (12.3%) elected to undergo a TOLAC and 26 (31.3%) succeeded. Two (7.7%) women delivered by cesarean for the second twin after vaginal delivery of the first twin. Epidural analgesia was positively associated with TOLAC success (odds ratio [OR] 4.31, 95% confidence interval [CI] 1.56-11.94, P = 0.004). Uterine rupture occurred in two patients (3.5%) of the TOLAC failure group. The proportion of cases with low Apgar score (7) at 5 min was higher in the TOLAC success group (4 [15.4%] versus 1 [1.8%]; OR 10.1, 95% CI 1.07-96.22, P = 0.032) and the neonatal composite adverse outcome rate was lower in this group (OR 0.22, 95% CI 0.07-0.69, P = 0.009).TOLAC in women with twins with no prior vaginal delivery is associated with a low success rate. No independent predictors of successful TOLAC were identified.

Background Preeclampsia is associated with increased risk of future heart failure (HF), but the relationship between preeclampsia and HF subtypes are not well-established. Objectives The objective of this analysis was to identify the risk of HF with preserved ejection fraction (HFpEF) following a delivery complicated by preeclampsia/eclampsia. Methods A retrospective cohort study using the New York and Florida state Healthcare Cost and Utilization Project State Inpatient Databases identified delivery hospitalizations between 2006 and 2014 for women with and without preeclampsia/eclampsia. The authors identified women admitted for HF after discharge from index delivery hospitalization until September 30, 2015, using International Classification of Diseases-9th Revision-Clinical Modification diagnosis codes. Patients were followed from discharge to the first instance of primary outcome (HFpEF hospitalization), death, or end of study period. Secondary outcomes included hospitalization for any HF and HF with reduced ejection fraction, separately. The association between preeclampsia/eclampsia and HFpEF was analyzed using Cox proportional hazards models. Results There were 2,532,515 women included in the study: 2,404,486 without and 128,029 with preeclampsia/eclampsia. HFpEF hospitalization was significantly more likely among women with preeclampsia/eclampsia, after adjusting for baseline hypertension and other covariates (aHR: 2.09; 95% CI: 1.80-2.44). Median time to onset of HFpEF was 32.2 months (interquartile range: 0.3-65.0 months), and median age at HFpEF onset was 34.0 years (interquartile range: 29.0-39.0 years). Both traditional (hypertension, diabetes mellitus) and sociodemographic (Black race, rurality, low income) risk factors were also associated with HFpEF and secondary outcomes. Conclusions Preeclampsia/eclampsia is an independent risk factor for future hospitalizations for HFpEF.

Objective To test the hypothesis that elevated umbilical artery (UA) partial pressure of carbon dioxide (pCO2) is associated with neonatal morbidity and to compare the risk of neonatal morbidity with different patterns of UA acidosis. Study Design This was a secondary analysis of a prospective cohort of term, singleton, nonanomalous deliveries with universal cord gas collection. The primary outcome was composite neonatal morbidity. Multivariable logistic regression was used to determine the relative risk (RR) for neonatal morbidity in patients with and without UA hypercarbia. A receiver operating characteristic curve determined the predictive value of pCO2 for neonatal morbidity. An additional multivariable logistic regression was used to evaluate the risk of neonatal morbidity in different patterns of UA acidosis. Results UA hypercarbia was associated with an increased risk of neonatal morbidity (RR: 2.56, 95% confidence interval [CI]: [2.07, 3.17]). After adjusting for UA acidemia, this association remained significant (adjusted RR: 1.39, 95% CI: [1.05, 1.83]). UA pCO2 was less predictive of neonatal morbidity than UA pH (area under the curve [AUC]: 0.65, 95% CI: [0.62, 0.68] vs. AUC: 0.72, 95% CI: [0.69, 0.75], p Conclusion UA hypercarbia is an independent predictor of neonatal morbidity, even in the setting of concomitant UA acidemia. UA mixed and metabolic acidosis carry significantly greater risk of neonatal morbidity compared with respiratory acidosis. Key Points

We aimed to determine the factors associated with a successful trial of labor after cesarean (TOLAC) in the setting of preterm delivery of women with no prior vaginal delivery. A retrospective cohort study conducted at two tertiary medical centers during 2010–2020, including all TOLACs with a single cesarean delivery and no prior vaginal delivery, delivering a singleton preterm newborn. Factors associated with successful vaginal delivery were examined by multivariable analysis. Of the 232 women with TOLAC who constituted the study cohort, 178 (76.7%) successfully delivered vaginally. Previous cesarean delivery characteristics did not differ between study groups. Maternal characteristics did not differ between TOLAC success and failure groups. The median gestational age at delivery was 35 3/7 weeks (IQR 34 0/7–36 0/7). The rate of epidural analgesia administration was higher in the TOLAC success group (54.5% vs. 35%, p = 0.013). Preterm premature rupture of membranes (PPROM) rate was lower in the TOLAC success group (53.9% vs. 83%, p

Objectives Serum bile acid (BA) levels testing is used for the diagnosis of intrahepatic cholestasis of pregnancy (ICP). We aimed to determine the performance of routine liver tests in the evaluation of ICP. Methods A retrospective cohort study conducted at a university hospital, including all pregnant women who underwent serum BA levels testing due to suspected ICP during 2007–2019. Liver tests were performed in all women including: aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALK), gamma-glutamyl transferase (GGT), and total bilirubin (TB). The optimal combination of laboratory values was determined by an algorithm developed in the Python programming language. Results Of 640 women who met the inclusion criteria, 22% (n = 142) were diagnosed with ICP (serum BA>10 μmol/L). A combined laboratory score of: (TB>11 μmol/L) or (ALK>255 U/L) or (GGT>32 U/L) or (AST>31 U/L), had a sensitivity of 94%, negative predictive value (NPV) of 97%, specificity of 50%, positive predictive value of 35%, and a negative likelihood ratio of 0.11 for the diagnosis of ICP. The AUC of the laboratory model alone was 0.72 (95% CI: 0.69–0.75). The addition of history of ICP to the suggested laboratory score resulted in a sensitivity of 97%, NPV of 98% and a negative likelihood ratio of 0.06. The AUC of the final model was 0.76 (95% CI: 0.72–0.79). Conclusions A combined laboratory score incorporating AST, GGT, ALK and TB was shown to reliably exclude the diagnosis of ICP. This may be particularly useful in settings with limited access to BA levels testing.

Although repeated antenatal corticosteroids (ACS) courses are not recommended, a single rescue ACS course has been shown to decrease neonatal morbidity among preterm singletons. However, little is known regarding the effects of rescue ACS course in twin pregnancies.A retrospective cohort study conducted during 2015-2017 at a tertiary-care center including all twins delivered between 24-34 weeks of gestation who received at least one course of ACS.Overall, 162 (70.4%) twins were exposed to a single ACS course and 68 (29.6%) to an additional rescue ACS course. Rescue ACS course was associated with lower rates of respiratory distress syndrome (7.4% vs. 19.1%,Rescue ACS course was associated with improved respiratory and neonatal outcomes in twin gestations. Further studies are warranted to confirm our findings and better delineate the optimal regimen of rescue ACS in this setting.

Objective To investigate whether fetal head station at the index cesarean delivery is associated with a subsequent trial of labor success rate among primiparous women. Methods A retrospective cohort study conducted at two tertiary medical centers included all primiparous women with subsequent delivery after cesarean delivery for second-stage dystocia during 2009-2019, identified from the electronic medical record databases. Univariate and multivariate analyses were performed to assess the factors associated with successful trial of labor after cesarean (TOLAC) (primary outcome). Additionally, all women with failed TOLAC were matched one-to-one to women with successful TOLAC, according to factors identified in the univariate analysis. Results Of 481 primiparous women with prior cesarean delivery for second-stage dystocia, 64.4% (n=310) attempted TOLAC, and 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index cesarean delivery, as compared with those with higher head station (79.0% vs 60.5%, odds ratio [OR] 2.46, 95% CI 1.49-4.08). The proportion of neonates weighing more than 3,500 g in the subsequent delivery was lower in those with successful TOLAC compared with failed TOLAC (29.7% vs 43.2%, OR 0.56, 95% CI 0.33-0.93). In a multivariable analysis, lower fetal head station at the index cesarean delivery was the only independent factor associated with TOLAC success (adjusted OR 2.38, 95% CI 1.43-3.96). Matching all women with failed TOLAC one-to-one to women with successful TOLAC, according to birth weight and second-stage duration at the subsequent delivery, lower fetal head station at the index cesarean delivery remained the only factor associated with successful TOLAC. Conclusion Lower fetal head station at the index cesarean delivery for second-stage dystocia was independently associated with a higher vaginal birth after cesarean rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to deliver vaginally after prior second-stage arrest.

Among deliveries34 weeks, there is inconclusive evidence regarding the preferred route of delivery when there is a need to expedite delivery during the second stage of labor. As it is unreasonable that future randomized controlled trials will be conducted to settle this query, every clinical data concerning this topic, may be helpful. We aim to compare neonatal outcomes among women undergoing emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) during the second stage of labor among singleton gestations34 weeks.A retrospective cohort study including all women who underwent either ECD or VAD at the second stage of labor between 30°Of the 153,672 live singleton deliveries during the study period, 2871 (1.9%) delivered before 34°Cesarean delivery during the second stage of labor of gestations34 weeks was associated with a higher rate of lower Apgar scores and longer length of stay.Delivery by second stage CD of premature neonates34 weeks is associated with a higher rate of lower Apgar score.

Objective The clinical significance of nuchal cord (NC) at the time of delivery is unclear. Studies have found that NC is associated with lower umbilical artery (UA) pH. Since fetal hypercarbia precedes respiratory acidosis, we hypothesize UA pCO2 is elevated in neonates with NC at the time of delivery. Study design This is a secondary analysis of a prospective cohort study of women with full-term singleton pregnancies admitted in labor or for induction of labor at an institution with a universal umbilical cord gas policy. We compared patients with NC at the time of delivery to those without NC. Women were excluded if they did not have validated UA gases, had a major fetal anomaly, or had an intrauterine fetal demise. The primary outcome of the study was UA pCO2. Secondary outcomes were other components of UA gas and neonatal morbidity composite. Baseline characteristics were compared utilizing chi-square or Fisher's exact test or the Student's t-test. UA gas parameters were compared using the Kruskal–Wallis test. Multivariable logistic regression was utilized to adjust for confounders. Results Of the 8,580 study participants, 7,608 had validated umbilical cord gases. The incidence of NC in the population was 24.15% (n = 1,837). UA pCO2 was higher in those with NC than without (58 mm Hg [53–64] vs. 55 mm Hg [50–60], p 65 mmHg; adjusted odds ratio [aOR]: 1.97, 95% confidence interval [CI]: 1.72–2.25, p Conclusion NC is associated with an increased risk of hypercarbia and acidemia. However, this is not associated with increased risk of neonatal morbidity. Key Points

Objective The objectives of this study were to characterize the length of the second stage of labor in a large contemporary cohort of women with varying obstetrical histories and to investigate the factors associated with the length of the second stage. Study Design This was a retrospective cohort study conducted at a tertiary medical center. Women with singleton spontaneous vaginal deliveries between the years 2005–2017 were included. The length of the second stage was compared between groups based on obstetrical history and maternal and obstetrical characteristics were evaluated to identify factors associated with the length of the second stage. Results There were 100,759 deliveries included in the study. The second stage of labor was longest in nulliparous women with an epidural (median 96 min, interquartile range 53−142 min), which was 57 min longer than in nulliparous women without an epidural. In parous, grand-multiparous, grand-grand multiparous, and women with a prior cesarean delivery, all without an epidural, there was no clinically significant difference in the length of the second stage (median 6−7 min). The length of the second stage was significantly shorter in women delivering preterm compared to women delivering at term. Birthweight, previous cesarean delivery, gestational age, use of epidural analgesia, and induction of labor were all independently positively associated with the length of the second stage, while parity was negatively associated with the length of the second stage. Conclusion The median length of the second stage of labor was considerably longer than historically described in nulliparous women and relatively shorter in parous women.

Objectives To test the hypothesis that increasing latency from diagnosis to delivery in patients with preterm hypertensive disorders of pregnancy is associated with an increased maternal risk of cardiovascular admission after delivery. Study design Retrospective cohort from the IBM MarketScan® Commercial Database from 2006 to 2016. Patients age 15–45 years with a preterm delivery complicated by a hypertensive disorder of pregnancy, at least 6 months of continuous insurance coverage prior to delivery and at least 365 days of coverage post-delivery were included. Main outcome measures Hospital readmission after delivery for a composite of acute cardiovascular events (cardiomyopathy, heart failure, cardiac arrest, myocardial infarction) or cerebrovascular events. Cox proportional hazards were used to estimate the risk of the primary outcome for each week of latency from diagnosis to delivery. Results There were 34,989 women in the study with a median follow-up of 2.57 years (IQR 1.66 to 1.54 years) with a median time from diagnosis to delivery of three days (IQR 0 to 14 days). An increasing time from diagnosis to delivery was associated with an increased risk of an acute cardiovascular event (adjusted HR 1.06, 95% CI 1.01, 1.11 per week), in models adjusted for maternal comorbidities and demographic factors. Later gestational age at diagnosis was associated with a decreased risk of maternal cardiovascular admission after delivery (aHR 0.94, 95% CI 0.91, 0.98 for each week increase in gestational age). Conclusions Prolonging expectant management of preterm hypertensive disorders of pregnancy is associated with an increased risk of maternal cardiovascular disease after delivery.

OBJECTIVE:To test the hypothesis that a longer length of time between diagnosis of hypertensive disorders of pregnancy and delivery is associated with increased risk of cardiovascular morbidity in the years after delivery.METHODS:This is a retrospective cohort study based in the New York State Inpat

Background COVID-19 during pregnancy is associated with adverse outcomes for mother and fetus. SARS-CoV-2 vaccination has significantly reduced the risk of symptomatic disease. Several small studies have reported the safety of SARS-CoV-2 vaccination during pregnancy, with no adverse effect on obstetric outcomes. Objective To examine the association between SARS-CoV-2 vaccination during pregnancy and maternal and neonatal outcomes in a large cohort study. Furthermore, to evaluate if timing of vaccination during pregnancy is related to adverse outcomes. Methods A retrospective cohort study of women who delivered between December 2020 and July 2021 at a large tertiary medical center. Excluded were women with multiple pregnancy, vaccination prior to pregnancy, COVID-19 infection during or before pregnancy, or unknown timing of vaccination. Primary outcomes were the incidence of preterm labor and of small for gestational age. Secondary outcomes were other maternal and neonatal complications. A secondary analysis investigating the association between time of vaccination and outcomes was also performed. Multivariable logistic regression models were used to adjust for potential confounders. Results There were 5618 women who met the inclusion criteria: 2,305 (41%) women were vaccinated and 3,313 (59%) were unvaccinated. There were no differences between vaccinated and non-vaccinated patients with respect to primary outcomes. The rate of preterm birth was 5.5% in the vaccinated group compared to 6.2% in the unvaccinated group (p = 0.31). Likewise, the rates of small for gestational age were comparable between the two groups (6.2% vs. 7.0% respectively, p = 0.2). In a secondary analysis focusing on time of vaccination and its relationship with outcomes, patients vaccinated in the second trimester (n = 964) and in the third trimester (n = 1329) were independently compared to their unvaccinated counterparts. Women who were vaccinated in the second trimester were more likely to have a preterm birth (8.1% vs. 6.2%, p Conclusions SARS-CoV-2 vaccine appears to be safe during pregnancy with no increase in incidence of preterm labor and small for gestational age compared to unvaccinated women. However, in women vaccinated during the second trimester there may be an increase in the rate of preterm birth.

We conducted a systematic review and meta-analysis of published nomograms for fetal corpus callosum and cavum septi pellucid biometry. A structured literature search was conducted to identify studies that reported normal measurements of the fetal corpus callosum and cavum septi pellucidi. Random effects metaanalysis was used to calculate normal ranges, and reference curves are provided. The quality assessment demonstrated that there was generally poor reporting regarding maternal characteristics and neonatal outcomes. Our findings emphasize that standardization of research protocols and publishing criteria for normal biometric ranges is needed.

Purpose: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. Methods : A retrospective cohort study was conducted, including women who underwent TOLACs from 2003-2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥24 weeks’ gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders.Results: A total of 11,235 women undergoing TOLAC were included, 6,795 of whom had a PVD. Women with PVD had significantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, pConclusion: PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients.

To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery.Retrospective cohort study.University hospital.Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded.Charts from 2007 to 2019 were reviewed.Rate of sPTB (37 weeks of gestation) in the second delivery.Of 13 958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180 min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96-1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71-4.12; p 0.001), with a more pronounced risk in those with second-stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94-5.94; p 0.001).Second-stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage caesarean section, particularly if performed after a prolonged second stage.Second-stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth.

BACKGROUND To study the factors associated with successful labor after cesarean (LAC) among women with no prior vaginal delivery, delivering a large for gestational age (LGA) baby. METHODS A retrospective case-control study at two tertiary medical centers in Israel, including all women undergoing LAC with no prior vaginal delivery during 2010-2020, delivering a singleton LGA newborn. Factors associated with successful vaginal delivery were examined by a multivariable analysis. RESULTS Overall, 323/505 (64.0%) had a successful LAC. Arrest of labor as the indication for previous CD was less common in the LAC success group [39 (12.1%) vs. 58 (31.9%), P

To assess the predictive value of middle cerebral artery Doppler peak systolic velocity (MCA-PSV) for moderate-severe fetal anemia following one intrauterine transfusion (IUT) and test the performance of alternate cutoffs to the recommended threshold ≥1.69 multiples of the median (MoM).This was a retrospective cohort study of patients with pregnancies affected by alloimmunization who underwent percutaneous umbilical blood sampling (PUBS) procedures from 2000 to 2020. An MCA-PSV ≥1.69 MoM was the indication for the second IUT. The primary outcome was recurrent moderate-severe fetal anemia. Receiver-operating characteristic (ROC) curves assessed the predictive ability of MCA-PSV for the primary outcome and the Youden index identified the "optimal" cutoff value. Predictive characteristics of MCA-PSV ≥1.69 MoM and the "optimal" cutoff were compared.Of the 58 patients who underwent IUT during the study period, 36 (62%) did not meet inclusion criteria. Of the remaining 22 patients who underwent a second PUBS, 12 (54.6%) fetuses had moderate or severe anemia. Following one IUT, the AUC for MCA-PSV was 0.86 (95% CI 0.70-1.00) for the primary outcome. The "optimal" cutoff MCA-PSV value was 1.74 MoM, which had a greater specificity than ≥1.69 MoM (90Raising the recommended MCA-PSV cutoff to ≥1.74 MoM for recurrent moderate-severe fetal anemia after one IUT would decrease the number of unnecessary procedures without significantly changing the sensitivity of this screening test.

Objective To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge. Methods This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome. Results A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]). Conclusion Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

OBJECTIVES To evaluate the effect of parity on performance characteristics of midtrimester cervical length (CL) in predicting spontaneous preterm birth (sPTB) before 37 weeks. METHODS This was a retrospective cohort study of 13,508 women with no history of sPTB undergoing universal transvaginal CL screening at 17 to 23 weeks' gestation from 2011 to 2016. Patients who declined screening or with unknown delivery outcomes were excluded. Areas under the receiver operator characteristic curves were used to assess and compare the predictive ability of CL screening for sPTB. The sensitivity, specificity, and positive and negative predictive values were estimated for specific CL cutoffs for prediction of sPTB. RESULTS There were 20,100 patients, of whom 2087 (10%) declined screening and 4505 (22%) did not meet inclusion criteria. Of the remaining 13,508 patients, 43% were nulliparous. The incidence rates of sPTB were 6.5% in nulliparas and 4.9% in multiparas (P

Objective: To estimate the prevalence and characteristics of fetal thrombocytopenia at the time of percutaneous umbilical cord sampling (PUBS) in pregnancies complicated by alloimmunization and to conduct a systematic review on fetal thrombocytopenia in these pregnancies. Study Design: Retrospective cohort study of all patients undergoing PUBS at our institution from 2000–2017. Clinical data including fetal platelet counts were abstracted from the medical record and analyzed with routine statistical procedures. A systematic review and metaanalysis were also conducted according to standard procedures. Result: At first procedure, prior to any transfusion, 13/36 fetuses (36%) had thrombocytopenia: 11/36 (31%) had moderate thrombocytopenia, and 2/36 (6%) had severe thrombocytopenia (14 patients had no platelet count at first procedure). The systematic review identified six studies, and the prevalence of fetal thrombocytopenia at the time of PUBS for alloimmunization was 18% (95% confidence interval 11%, 26%). Conclusion: Thrombocytopenia is common and underappreciated in fetuses undergoing PUBS for alloimmunization.

OBJECTIVE To investigate the association between elevated umbilical arterial lactate at birth and electronic fetal monitoring (EFM) characteristics at admission and in the beginning of the active phase of labor. STUDY DESIGN Nested case-control study within a prospective cohort of laboring patients at term who achieved active labor. Neonates with umbilical arterial lactate ≥ 4 mmol/L (cases, n = 119), were matched 1:1 to controls with lactate

COVID-19 during pregnancy is associated with adverse outcomes for both the mother and fetus. SARS-CoV-2 vaccination has significantly reduced the risk for symptomatic disease. Several studies have reported on the safety of SARS-CoV-2 vaccination during pregnancy, with no adverse effects on the obstetrical outcomes. However, data regarding the obstetrical outcomes following a booster dose of the SARS CoV-2 vaccination during pregnancy have not yet to be published.This study aimed to examine the association between the booster dose of the SARS CoV-2 vaccination during pregnancy and obstetrical outcomes.This was a retrospective cohort study of women who delivered between July and October 2021 at a large tertiary medical center. We compared women who received the booster vaccination dose during pregnancy with women who were not vaccinated and with those who only received 2 vaccination doses. Primary outcomes were the incidence of preterm labor and of small for gestational age neonates. Secondary outcomes were other maternal and neonatal complications. A secondary analysis investigating the association between the time from vaccination to delivery and the outcomes was also performed. Multivariable logistic regression models were used to adjust for potential confounders.There were 6507 women who met the inclusion criteria: 294 women received 3 doses of the vaccination, 2845 women received only 2 doses, and 3368 were unvaccinated. Patients receiving 3 doses of the vaccine were older and more likely to smoke than unvaccinated patients. No differences were noted among the triple-vaccinated, twice-vaccinated, and unvaccinated groups with regards to preterm birth and the incidence of small for gestational age neonates. Regarding the secondary outcomes, women in the triple-vaccinated group had higher rates of postpartum hemorrhage (9.5% vs 3.21%; P.001) and gestational diabetes mellitus (12.2% vs 8.3%; P=.02) and were less likely to have hypertensive disorders of pregnancy (0% vs 1.4%; P=.041) than the unvaccinated group. Compared with the twice-vaccinated patients, patients with 3 doses of the vaccine were more likely to experience postpartum hemorrhage (9.5% vs 3.5%; P.001) and were less likely to have a low umbilical artery pH (0.7% vs 6.1%; P.001). In the sensitivity analysis comparing patients who delivered within 2 weeks of the third vaccination dose (n=53) with those who delivered at least 6 weeks after vaccination (n=96), there were no differences in the rates of small for gestational age neonates, preterm birth, postpartum hemorrhage, or cesarean delivery.Receiving the booster dose of the SARS-CoV-2 vaccination during pregnancy was not associated with adverse obstetrical outcomes when compared with unvaccinated or twice-vaccinated women. However, higher rates of postpartum hemorrhage were observed. Further studies on a larger scale are needed to confirm these findings.

To conduct a systematic review and meta-analysis of published nomograms for fetal vermis biometry. A structured literature search was conducted to identify studies that reported normal measurements of the fetal vermis. A customized quality assessment tool was used to review the selected articles. Random effects meta-analysis was used to calculate normal ranges for vermian craniocaudal diameter, anteroposterior diameter, and surface area. A total of 21 studies were included for qualitative review and 3 studies were included for quantitative synthesis. The 3 included articles comprised a total of 10 910 measurements from gestational ages 17-35 weeks. The quality assessment demonstrated that there was generally poor reporting regarding maternal characteristics and neonatal outcomes. Except for one article with a large sample size, the mean number of fetuses per week of gestational age was 15.9, with the lowest number being 5. There was significant statistical heterogeneity. Non-visualization rates ranged from 0-35.4 %. The craniocaudal diameter (reported in 3 articles) increased from a mean of 7.90 mm (95 % confidence interval [CI] 7.42, 8.38) at 17 weeks to 21.90 mm (95 % CI 20.63, 23.16) at 35 weeks gestation. The anteroposterior diameter (reported in 2 articles) increased from 6.30 mm (95 % CI 5.42, 7.18) at 17 weeks to 15.85 (95 %CI 15.49, 16.21) at 32 weeks. Reference ranges for vermis biometry across gestation based on meta-analysis of existing references are provided. However, because many of the underlying studies suffered from significant methodological issues, the ranges should be used with caution.ZIEL: Durchführung eines systematischen Reviews und Metaanalyse veröffentlichter Nomogramme für die Biometrie des fetalen Vermis cerebelli. Eine strukturierte Literaturrecherche wurde durchgeführt, um Studien zu identifizieren, die über normale Messungen des fetalen Vermis berichteten. Ein angepasstes Qualitätsbewertungs-Tool wurde verwendet, um die ausgewählten Artikel zu überprüfen. Eine Metaanalyse mit Random Effects wurde angewandt, um Normalbereiche für den kraniokaudalen Durchmesser des Vermis, den anteroposterioren Durchmesser und die Oberfläche zu berechnen. Insgesamt wurden 21 Studien zur qualitativen Überprüfung und 3 Studien zur quantitativen Synthese eingeschlossen. Die 3 eingeschlossenen Artikel umfassten insgesamt 10 910 Messungen von der 17.–35. SSW. Die Qualitätsbewertung zeigte, dass es im Allgemeinen eine schlechte Berichterstattung bezüglich mütterlicher Charakteristiken und des neonatalen Outcomes gab. Mit Ausnahme eines Artikels mit großer Stichprobengröße betrug die durchschnittliche Anzahl der Föten pro SSW 15,9, wobei die niedrigste Anzahl 5 betrug. Es gab eine signifikante statistische Heterogenität. Die Raten für Nichtdarstellbarkeit lagen zwischen 0 und 35,4 %. Der kraniokaudale Durchmesser (in 3 Artikeln angegeben) stieg von durchschnittlich 7,90 mm (95 %-Konfidenzintervall (KI) 7,42–8,38) in der 17. SSW auf 21,90 mm (95 %-KI 20,63–23,16) in der 35. SSW. Der anteroposteriore Durchmesser (in 2 Artikeln angegeben) stieg von 6,30 mm (95 %-KI 5,42–7,18) in der 17. SSW auf 15,85 mm (95 %-KI 15,49–16,21) in der 32. SSW. Basierend auf einer Metaanalyse bestehender Literatur werden Referenzbereiche für die Biometrie des Vermis nach Schwangerschaftsalter angegeben. Da jedoch viele der zugrunde liegenden Studien unter erheblichen methodischen Problemen litten, sollten diese Bereiche mit Vorsicht angewandt werden.

To evaluate the characteristics and outcomes of women who had never delivered vaginally and underwent a trial of labor after cesarean (TOLAC) of small for gestational age (SGA) neonates, and to identify risk factors for unplanned repeat cesarean delivery. A retrospective cohort study from two tertiary medical centers. All women undergoing a TOLAC with no prior vaginal delivery, delivering a singleton SGA neonate at term between 2005 and 2020 were included. Factors associated with successful vaginal delivery were examined by a multivariable analysis. Of the 255 women who met the inclusion criteria and underwent TOLAC, 72.2% delivered vaginally. In a multivariable analysis, maternal height [adjusted odds ratio (aOR) (95% CI): 1.10 (1.02–1.19), p = 0.012] and epidural administration [aOR (95% CI): 2.78 (1.0–7.73), p = 0.050] were positively independently associated with TOLAC success, and hypertensive disorders were negatively independently associated with TOLAC success [aOR (95% CI): 0.52 (0.004–0.74), p = 0.029]. The success rate of TOLAC among women with no prior vaginal delivery, delivering a SGA neonate is relatively high. Maternal height, hypertensive disorders, and epidural administration are independent factors associated with TOLAC success. Epidural administration is a modifiable factor and should be taken in consideration during TOLAC management.

Objective The possible connection between COVID-19 and hypertensive disorders of pregnancy (HDP) remains unclear (1). Elucidating these outcomes is important both to better understand COVID-19 pathophysiology and to improve patient care in pregnant patients with COVID-19. Our objectives were to test the hypothesis that COVID-19 infection is associated with an increased risk of HDP and to examine the association between the gestational age at COVID-19 infection and delivery and HDP risk. Study Design This was a retrospective cohort study at Barnes-Jewish Hospital in St. Louis, which has a universal COVID-19 testing policy on admission to labor and delivery. All women admitted for delivery from June 1, 2020-November 30, 2020, with a positive Sars-CoV-2 test at any time during pregnancy were compared 1:2 with randomly selected controls who had a negative SARS-CoV-2 test and were matched for race and parity. COVID-19 was diagnosed with nasopharyngeal RT-PCR or rapid antigen testing. HDP was diagnosed using standard criteria. Cox proportional hazards models with left truncation to account for the varying gestational age at COVID-19 diagnosis, and random effects (frailty) to account for the matching design and small cluster sizes, were used to examine the association between COVID-19 and HDP (2). As a sensitivity analysis we also examined early (before 32 weeks gestation) vs. late COVID-19 infection and HDP development. The study was deemed exempt from review by the Institutional Review Board. Results Of 1856 births, there were 83 women (4.5%) with COVID-19 infection. There was no significant difference in baseline characteristics between COVID-19 infected women and controls. Patients with COVID-19 infection had almost a two-fold risk of HDP (HR 1.93 (95%CI 1.13, 3.31). However, COVID-19 infection was not associated with severity of HDP, and severity of COVID-19 (3) was not associated with HDP development. Among patients with COVID-19 and HDP at delivery, the median interval from COVID-19 diagnosis to delivery was 3.8 weeks (IQR 0.29, 11.5). In additional analysis, early, but not late, COVID-19 infection was associated with HDP development (HR for early COVID-19 2.17 (95%CI 1.11, 4.24), HR for late COVID-19 1.68, (95%CI 0.79, 3.57). Conclusions Early COVID-19 infections are associated with HDP, even when accounting for differential exposure and delivery times, suggesting that COVID-19 infection may alter pregnancy physiology and increase the risk of HDP development over time. Infection closer to term is not associated with HDP, which likely reflects our high proportion of asymptomatic infections found at the time of delivery from a universal testing policy (4) and insufficient time to develop HDP in these cases. Furthermore, emerging evidence suggests that COVID-19 modulates placental ACE2 expression, which may be related to HDP development (5). Our study is limited by sampling in a single institution with a high HDP incidence. However, our results suggest that monitoring of patients with antepartum COVID-19 infection should encompass precautions for HDP development.

Subgaleal hemorrhage (SGH) is a severe neonatal morbidity that is associated with vacuum-assisted delivery (VAD). Large sonographic head circumference (sHC) was previously associated with complicated VAD. Nevertheless, the association of large sHC with SGH formation following VAD is underreported. We aim to evaluate the role of sonographic head circumference (sHC) with SGH formation following attempted VAD.A retrospective case-control study. Cases comprised singleton pregnancies for whom attempted VAD resulted in SGH with an sHC measured within 2 weeks from delivery. Controls were VAD deliveries which not resulted in SGH, with an sHC measured within 2 weeks from delivery. We matched controls in a 1:1 ratio by gestational age, parity and year of delivery.Overall, 118 women were included in the SGH study group and were matched to 118 controls. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birth weight in the SGH group (median 3422 vs. 3195 grams,sHC is not associated with SGH formation following VAD.

Chronic hypertension complicates up to 5% of pregnancies and is increasing in prevalence. Women with hypertension have increased risks of serious maternal morbidity and mortality in pregnancy, including the development of preeclampsia. In 2017, new guidelines reclassified blood pressure into the following 4 categories: normal (120/80 mm Hg), elevated (120-129/80 mm Hg), stage 1 hypertension (130-139/80-89 mm Hg), and stage 2 hypertension (140/90 mm Hg). This new classification doubles the number of reproductive-aged women with hypertension. Furthermore, studies have demonstrated that women entering pregnancy with stage 1 hypertension have an increased risk of developing hypertensive disorders of pregnancy compared with their normotensive counterparts, but the time course to the development of hypertensive disorders of pregnancy in these women remains uncertain.We sought to evaluate the risk of developing a hypertensive disorder of pregnancy and the time to the development of these disorders in women with stage 1 hypertension vs both normotensive women and those with stage 2 hypertension.This was a retrospective cohort study of all patients from a single tertiary care center with singleton gestations from 2014 to 2016. Patients at prenatal visits before 20 weeks of gestation were classified into 3 blood pressure groups: normotensive (130/80 mm Hg), stage 1 hypertension (130-139/80-89 mm Hg), or stage 2 hypertension (≥140/90 or a history of chronic hypertension). The primary outcome, time to the development of a hypertensive disorder of pregnancy, was compared among groups using Kaplan-Meier curves and the log-rank test. Cox proportional-hazards models were used to adjust for age, race and ethnicity, pregestational diabetes mellitus, and body mass index. In addition, multiple secondary obstetrical, maternal, and neonatal outcomes were assessed.Of the 3000 women in our cohort, 2370 (79.0%) were categorized in the normotensive group, 315 (10.5%) were categorized in the stage 1 hypertension group, and 315 (10.5%) were categorized in the stage 2 hypertension group. The gestational age at diagnosis was significantly earlier in gestation among blood pressure groups (normotensive [38.7 (37.0-39.7)] vs stage 1 hypertension [38.0 (36.4-39.4)] vs stage 2 hypertension [36.4 (33.7-37.8)]; P.001). When the analysis was restricted to only those patients diagnosed with preeclampsia with severe features, the same findings were observed. Women with stage 1 hypertension exhibited a 2-fold increased risk of developing hypertensive disorders of pregnancy compared with normotensive women. Compared with women with stage 2 hypertension, women with stage 1 hypertension exhibited a milder phenotype of hypertensive disorders of pregnancy and exhibited significantly less risk of maternal and neonatal morbidities.Women with stage 1 hypertension are at increased risk of developing hypertensive disorders of pregnancy at earlier gestational ages compared with normotensive women; however, their development of a hypertensive disorder of pregnancy is skewed toward milder diseases compared with women with stage 2 hypertension. These new insights into the graded risk profile of obstetrical hypertensive diseases associated with new blood pressure categories can better inform our antepartum counseling and monitoring and surveillance plans near term and in the postpartum period.

Background Having twins is associated with more depressive symptoms than having singletons. However, the association between having twins and psychiatric morbidity requiring emergency department visit or inpatient hospitalization is less well known. Objective This study aimed to determine whether women have higher risk of having a psychiatric diagnosis at an emergency department visit or inpatient admission in the year after having twins vs singletons. Study Design This retrospective cohort study used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes within the Florida State Inpatient Database and State Emergency Department Database, which have an encrypted identifier allowing nearly all inpatient and emergency department encounters statewide to be linked to the medical record. The first delivery of Florida residents at the age of 13 to 55 years from 2005 to 2014 was included, regardless of parity; women with International Classification of Diseases, Ninth Revision, Clinical Modification coding for psychiatric illness or substance misuse during pregnancy or for stillbirth or higher-order gestations were excluded. The exposure was an International Classification of Diseases, Ninth Revision, Clinical Modification code during delivery hospitalization of live-born twins. The primary outcome was an International Classification of Diseases, Ninth Revision, Clinical Modification code during an emergency department encounter or inpatient admission within 1 year of delivery for a psychiatric morbidity composite (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was drug or alcohol use or dependence within 1 year of delivery. We compared outcomes after delivery of live-born twins with singletons using multivariable logistic regression adjusting for sociodemographic and medical factors. We tested for interactions between independent variables in the primary model and conducted sensitivity analyses stratifying women by insurance type and presence of severe intrapartum morbidity or medical comorbidities. Results A total of 17,365 women who had live-born twins and 1,058,880 who had singletons were included. Within 1 year of birth, 1.6% of women delivering twins (n=270) and 1.6% of women delivering singletons (n=17,236) had an emergency department encounter or inpatient admission coded for psychiatric morbidity (adjusted odds ratio, 1.00; 95% confidence interval, 0.88–1.14). Coding for drug or alcohol use or dependence in an emergency department encounter or inpatient admission in the year after twin vs singleton delivery was also similar (n=96 [0.6%] vs n=6222 [0.6%]; adjusted odds ratio, 1.11; 95% confidence interval, 0.91–1.36). However, women with public health insurance were more likely to be coded for drug or alcohol use or dependence after twin than singleton delivery (n=75 [1.2%] vs n=4858 [1.0%]; adjusted odds ratio, 1.27; 95% confidence interval, 1.01–1.60). Women with ≥1 medical comorbidity, severe maternal morbidity, or low income also had an increased risk of psychiatric morbidity after twin delivery (comorbidities, n=7438 [42.8%]; adjusted odds ratio, 1.30; 95% confidence interval, 1.25–1.34; severe maternal morbidity, n=940 [5.4%]; adjusted odds ratio, 1.65; 95% confidence interval, 1.49–1.81; lowest income quartile, n=4409 [26.8%]; adjusted odds ratio, 1.31; 95% confidence interval, 1.23–1.40; second-lowest income quartile, n=4770 [29.0%]; adjusted odds ratio, 1.34; 95% confidence interval, 1.26–1.43). Conclusion Overall, diagnostic codes for psychiatric illness or substance misuse in emergency department visits or hospital admissions in the year after twin vs singleton delivery are similar. However, women with who are low income or have public health insurance, comorbidities, or severe maternal morbidity are at an increased risk of postpartum psychiatric morbidity after twin vs singleton delivery.

Spontaneous labor onset, epidural anesthesia and prior cesarean for non-arrest disorders are strong predictors of successful vaginal birth after cesarean in women delivering a macrosomic fetus. Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women with fetal macrosomia. A retrospective cohort study conducted during 2005–2019 at two university hospitals, including all primiparous women delivering a singleton fetus weighing ≥ 4000 g, after cesarean delivery at their first delivery. A multivariate analysis was performed to evaluate the characteristics associated with TOLAC success (primary outcome). Of 551 primiparous women who met the inclusion criteria, 50.1% (n = 276) attempted a TOLAC and 174 (63.0%) successfully delivered vaginally. In a multivariate analysis, spontaneous onset of labor (aOR [95% CI] 3.68 (2.05, 6.61), P

Background The safest mode of delivery to use for very preterm infants is an ongoing topic of debate. There are many reasons to perform a cesarean delivery in cases of extremely preterm and very preterm infants, including indication for labor, fetal distress, maternal indications, and malpresentation. Objective This study aimed to determine whether cesarean delivery is associated with a considerable improvement in neonatal morbidity. Study Design This study is a retrospective cohort study of all singleton pregnancies, delivered from 22 to 29 weeks’ gestation between 2010 and 2015, admitted for preterm labor or preterm premature rupture of membranes and excluded neonates with a delivery weight ≤500 g, multiple gestations, cases with intrauterine fetal demise, and induced terminations. The primary outcome for the study was a neonatal morbidity composite (Apgar score of 28 days), intraventricular hemorrhage, necrotizing enterocolitis, coagulopathy, discharged on home ventilator support, or discharged with enteric feeding tube). Cesarean deliveries were performed for standard obstetrical indications. Regression models were used and adjusted for nulliparity, delivery year, and presentation at the time of delivery to determine whether cesarean delivery is associated with neonatal morbidity or neonatal death. Results There were 271 eligible deliveries, which included 128 cesarean deliveries and 143 vaginal deliveries. The cesarean delivery group had fewer nulliparous patients and more fetuses presenting in breech position at the time of delivery. The overall composite neonatal morbidity occurred in 202 of the 271 (74.5%) deliveries and mortality occurred in 26 of the 271 (9.59%) deliveries. When adjusting for nulliparity, delivery year, and fetal presentation at the time of delivery, cesarean delivery was associated with a decreased risk for death in the delivery room or within 24 hours after delivery (adjusted risk ratio, 0.18; 95% confidence interval, 0.05–0.63; P=.03). Cesarean delivery was associated with an increased use of exogenous surfactant (adjusted risk ratio, 1.20; 95% confidence interval, 1.05–1.38; P=.01) and bag mask ventilation (adjusted risk ratio, 1.17; 95% confidence interval, 1.01–1.37; P=.03). In a secondary analysis that included only patients who received a complete course of steroids, there were no differences in the composite morbidity or mortality. Conclusion Cesarean delivery performed for standard obstetrical indications in cases of very preterm neonates is associated with a decreased risk for death in the delivery room or within 24 hours of delivery but is not associated with an improvement in the overall morbidity or mortality.

OBJECTIVE: To evaluate whether administration of antenatal late-preterm betamethasone is cost-effective in the immediate neonatal period. STUDY DESIGN: Cost-effectiveness analysis of late-preterm betamethasone administration with a time horizon of 7.5 days was conducted using a health-system perspective. Data for neonatal outcomes, including respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), and hypoglycemia, were from the Antenatal Betamethasone for Women at Risk for Late Preterm Delivery trial. Cost data were derived from the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality, and utilities of neonatal outcomes were from the literature. Outcomes were total costs in 2017 United States dollars and quality-adjusted life-years (QALYs) for each individual infant as well as for a theoretical cohort of the 270,000 late-preterm infants born in 2015 in the United States. RESULTS: For an individual patient, compared to withholding betamethasone, administering betamethasone incurred a higher total cost ($6,592 versus $6,265) and marginally lower QALYs (0.02002 QALYS versus 0.02006 QALYs) within the studied time horizon. For the theoretical cohort of 270,000 patients, administration of betamethasone was $88 million more expensive ($1,780 million versus $1,692 million) with lower QALYs (5,402 QALYs versus 5,416 QALYs), compared to withholding betamethasone. For administration of betamethasone to be cost-effective, the rate of hypoglycemia, RDS, or TTN among late-preterm infants receiving betamethasone would need to be less than 20.0%, 4.5%, and 2.4%, respectively. CONCLUSION: Administration of betamethasone in the late-preterm period is likely not cost-effective in the short-term.

Objective To investigate the association between the intraoperative diagnosis of placenta accreta at the time of cesarean hysterectomy and pathological diagnosis. Study Design This is a retrospective cohort study of all patients undergoing cesarean hysterectomy for suspected placenta accreta from 2000 to 2016 at Barnes-Jewish Hospital. The primary outcome was the presence of invasive placentation on the pathology report. We estimated predictive characteristics of clinical diagnosis of placenta accreta using pathological diagnosis as the correct diagnosis. Results There were 50 cesarean hysterectomies performed for suspected abnormal placentation from 2000 to 2016. Of these, 34 (68%) had a diagnosis of accreta preoperatively and 16 (32%) were diagnosed intraoperatively at the time of cesarean delivery. Two patients had no pathological evidence of invasion, corresponding to a false-positive rate of 4% (95% confidence interval [CI]: 0.5%, 13.8%) and a positive predictive value of 96% (95% CI: 86.3%, 99.5%). There were no differences in complications among patients diagnosed intraoperatively compared with those diagnosed preoperatively. Conclusion Most patients undergoing cesarean hysterectomy for placenta accreta do have this diagnosis confirmed on pathology. However, since the diagnosis of placenta accreta was made intraoperatively in nearly a third of cesarean hysterectomies, intraoperative vigilance is required as the need for cesarean hysterectomy may not be anticipated preoperatively.

The role of provider type and level of training have not been examined in regard to impact on postpartum testing for patients with gestational diabetes mellitus (GDM).We sought to determine rates of testing in urban GDM patients and to determine factors associated with diabetes screening compliance, focusing especially on provider type.Class A1 or A2 GDM patients were identified by chart review. Outcomes included ordering and/or performance of postpartum testing for diabetes mellitus. Chi-squared and multivariate logistic regression analyses were performed.Of the 118 patients identified (55% class A1), 58% were African American, 52% had medical assistance insurance, and 83% attended the postpartum visit. Diabetes testing was discussed at 68% of all postpartum visits, but was only ordered at 55% of visits. The 2-hour glucose tolerance test was ordered at 42 of the 98 (43%) of postpartum visits; however, only 16 tests were completed. Patients seeing resident physicians or midwives were more likely to be tested.Rates of postpartum testing for GDM patients are low. Provider and patient compliance with diabetes screening recommendations are inadequate. Increased education and training of providers and patients may improve screening for diabetes among GDM patients.

Obstetric anal sphincter injuries (OASISs) complicate up to 11% of vaginal deliveries; obstetricians must be able to recognize and manage these technically challenging injuries.The aim of this study was to share our approach for management of these challenging complications of childbirth based on a multidisciplinary collaboration between general obstetrician-gynecologists, maternal fetal medicine specialists, and female pelvic medicine and reconstructive surgeons established at our institution.A systematic literature search was performed in 3 search engines: PubMed 1946-, EMBASE 1947-, and the Cochrane Database of Systematic Reviews using keywordsIdentification should begin with an assessment of risk factors, notably nulliparity and operative vaginal delivery, consistently associated with the highest risk of OASISs, and proceed with a thorough examination to grade the degree of laceration. Repair should be performed or supervised by an experienced clinician in an operating room with either regional or general anesthesia. The external anal sphincter may be repaired using either an overlapping or end-to-end anastomosis. Providers should be comfortable with both approaches as the degree of laceration may necessitate one approach over the other. We advocate for use of monofilament suture on all layers to decrease risk of bacterial seeding, as well as preoperative antibiotics and postoperative bowel regimen, which are associated with improved outcomes.Long-term sequelae, including pain, dyspareunia, and fecal incontinence, significantly impact quality of life for many patients who suffer OASISs and may be avoided if evidence-based guidelines for recognition and repair are utilized.

Management of women after mechanical heart valve replacement throughout gestation is one of the most high-risk challenging conditions (Arya 2019). In recent decades, improvements in the field of me...

To compare the utility of maximum vertical pocket versus amniotic fluid index for predicting adverse perinatal outcomes. Systematic review of randomized clinical studies comparing these two ultrasound techniques and random-effects meta-analysis to quantify a range of perinatal outcomes. Six studies with 4278 women were eligible. Use of the maximum vertical pocket reduced the rate of diagnosis of oligohydramnios (pooled relative risk 0.38; 95% confidence interval 0.27, 0.53). Use of the maximum vertical pocket was associated with significantly lower rates of non-reassuring fetal heart tracing, cesarean delivery for fetal distress, and induction of labor for oligohydramnios. There were no differences in the rates of cesarean delivery, presence of meconium, umbilical artery pH