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This case report demonstrates a complex fetal ovarian cyst. A fetal ovarian cyst is a fluid-filled ovarian tumor. Ovarian cysts are rarely detected in infants but are slightly more common on fetal sonography. The majority of cysts are benign corpus luteal cysts. The size and appearance of the cysts may vary. The largest cyst could possibly occupy the entire abdomen. The cyst will most likely be anechoic, but it can be complicated due to hemorrhage or torsion. Difficulties may arise when trying to differentiate a large ovarian cyst from other cystic lesions, such as enteric or mesenteric cysts. Both placental and maternal hormones can cause excess stimulation of the fetal ovary. A decrease in hormone stimulation after birth causes most neonatal ovarian cysts to spontaneously regress. [ABSTRACT FROM AUTHOR]

Background: Wernicke's encephalopathy is usually associated with alcohol abuse, but can also occur with hyperemesis gravidarum. The effect of delay in thiamine replacement on fetal outcomes is unknown. We present a case of this complication.Case: A primipara with hyperemesis was admitted for mental status changes in her 14th week of pregnancy. Physical examination revealed a lethargic patient with ophthalmoplegia, ataxia, and hyporeflexia. Parenteral thiamine therapy was started. The patient improved rapidly although the ataxia persisted. A spontaneous abortion occurred 2 weeks later.Conclusion: Wernicke's encephalopathy can complicate hyperemesis gravidarum. Early thiamine replacement may decrease the chances of spontaneous abortion. [ABSTRACT FROM AUTHOR]

Importance: Fetal macrosomia (FM) is common in clinical practice and carries increased risk of adverse maternal and neonatal health outcomes. Maternal diabetes mellitus (DM) is a well-known cause of macrosomia with significant research and guidelines focusing on macrosomia in this population. Less is known about causes, prevention, and clinical management for suspected FM in individuals without diabetes., Objective: The objective of this review is to describe the risk factors associated with nondiabetic FM, review risks associated with macrosomia in pregnancy, and potential treatment considerations for this condition., Evidence Acquisition: Original research articles, review articles, and guidelines on macrosomia were reviewed., Results: Risk factors for macrosomia in patients without DM include previous delivery of an infant with macrosomia, excessive pregnancy weight gain, and obesity. Maternal complications of FM include higher rates of cesarean delivery, postpartum hemorrhage, and vaginal laceration. Fetal complications include shoulder dystocia, decreased Apgar scores, and increased risk of childhood obesity. Exercise during pregnancy has been shown to reduce the risk of FM. Induction of labor prior to 39 weeks is not recommended in the setting of suspected macrosomia as there is a lack of adequate evidence to support that this decreases adverse neonatal or maternal outcomes. In addition, elective cesarean delivery for suspected macrosomia is not recommended to be considered unless estimated fetal weight is greater than 5000 g in the absence of DM., Conclusions and Relevance: Delivery of an infant with macrosomia in patients without DM has increased maternal and fetal risks. Predicting infants who will meet criteria for macrosomia is challenging. More research is needed to identify ways to accurately estimate fetal weight, interventions to prevent macrosomia, and additional ways to mitigate risk in patients without DM who have suspected FM.

Importance: Cannabis is commonly used by pregnant patients for alleviation of pregnancy-associated symptoms. Multiple national medical associations have recommended against prenatal cannabis use, yet misinformation regarding its safety and efficacy remains prevalent in public discourse. Effective and evidence-based patient counseling on prenatal cannabis use requires a thorough understanding of the existing data on fetal neurodevelopment., Objective: The aim of this study was to summarize the existing clinical literature on the impacts of intrauterine cannabis exposure on offspring neurodevelopment., Evidence Acquisition: Articles were identified via literature search in PubMed and OVID; relevant articles were reviewed., Results: Limited data have shown associations between intrauterine cannabis exposure and (1) increased startles and difficulty with consolation in the neonatal period, (2) memory challenges, verbal reasoning challenges, and diminished academic performance during early childhood, and (3) inattention, hyperactivity, and aggression during early childhood. Further research with large and diverse samples that use objective measures of cannabis use across multiple time points in pregnancy is required to assess causation, the true extent of impacts, and dose-dependent effects., Conclusions and Relevance: The existing clinical data regarding the impacts of prenatal cannabis use on fetal neurodevelopment are limited by important confounders like genetic predisposition, concomitant tobacco and other substance use during pregnancy, and low socioeconomic status. However, the theoretical and demonstrated associations between prenatal cannabis use and adverse neurodevelopmental outcomes are compelling enough to warrant complete abstinence during pregnancy, pending further research. Providers can utilize this summary to offer data-driven guidance on prenatal cannabis use for pregnant patients.

Importance: Though the incidence of familial Mediterranean fever (FMF) in pregnancy is rare, understanding the etiology and symptomatology of FMF is essential for obstetric treatment of patients with FMF., Objective: Familial Mediterranean fever is a hereditary periodic fever syndrome that has unique obstetric considerations. Familial Mediterranean fever is typically characterized by recurrent episodes of high-grade fevers, pleuritis/pericarditis, and arthritis lasting 1-3 days with complete recovery seen in between episodes. Familial Mediterranean fever is seen worldwide, but particularly in patients of Mediterranean descent. Its incidence varies across ethnicities., Evidence Acquisition: This article provides a comprehensive review of existing literature., Results: It is well established that colchicine is safe and effective to use during pregnancy in patients with FMF to control and prevent flares. Although most pregnancies progress without negative outcomes, FMF has been shown in the literature to be associated with preterm birth and premature rupture of membranes. Its impact on increasing the rate of fetal growth restriction and hypertensive disorders is less understood. Additionally, FMF flares may be suppressed in pregnancy, whereas other sources report that flares are similar to those outside of pregnancy in terms of frequency, type of symptoms, and severity. Breastfeeding is safe in patients with FMF who are taking colchicine. Genetic counseling can be offered to patients with FMF, but in utero diagnostic testing is generally not pursued solely for the indication of FMF diagnosis in the fetus., Conclusions and Relevance: Further investigation of the impact of FMF on pregnancy is needed for advancing our understanding of the condition and optimizing care for pregnant individuals with FMF.

Importance: With advances in prenatal cell-free DNA (cfDNA) technology, the information available with cfDNA continues to expand beyond the common fetal aneuploidies such as trisomies 21, 18, and 13. Due to the admixture of maternal and fetal/placental DNA, prenatal cfDNA remains a screening test with the possibility of false-positive and false-negative results., Objective: This review aims to summarize unusual incidental maternal and fetal genomic abnormalities detectable by cfDNA and to provide anticipatory guidance regarding management., Evidence Acquisition: Of 140 articles identified with keywords such as "incidental" and "discordant" cfDNA, 55 original research articles, review articles, case series, and societal guidelines were reviewed., Results: Prenatal cfDNA may incidentally identify a spectrum of maternal genomic abnormalities such as malignancy, mosaicism, and copy number variants. When discordant with fetal diagnosis, these cases require additional investigation with maternal genetic testing and follow-up evaluation. Such incidental fetal/placental abnormalities may include rare autosomal trisomies, uniparental disomy, and triploidy. Further evaluation of fetal/placental abnormalities can be pursued with a combination of ultrasound and prenatal diagnosis with chorionic villous sampling and/or amniocentesis. Societal guidelines do not currently recommend cfDNA screening for rare autosomal trisomies, microdeletions, or copy number variants, and some experts suggest that sex chromosome screening should be opted in after counseling., Conclusions: Knowledge about possible incidental findings with prenatal cfDNA is needed to inform pretest and posttest counseling with appropriate follow-up evaluation., Relevance: As cfDNA technology has advanced to include genome-wide findings, it is important for clinicians, genetic counselors, and societal guidelines to acknowledge the spectrum of possible results outside of the traditional and sex chromosome aneuploidies.

Importance: The latent phase of labor poses a challenge for pregnant patients due to the limited options available for pain relief and management. Therapeutic rest, an intervention involving medication administration during this phase, has shown promise in addressing prelabor discomfort and anxiety., Objective: To emphasize the significance of therapeutic rest during early labor, describe methods of administering this intervention, review data on efficacy and maternal/fetal outcomes, and determine appropriate criteria and timing of utilization., Evidence Acquisition: Articles were obtained from a thorough PubMed literature search; relevant articles were reviewed., Results: Studies have shown that delaying admission to active labor benefits maternal and fetal outcomes. Pregnant patients admitted in the latent phase are at greater risk for obstetric interventions and have heightened emotional challenges. However, administering therapeutic rest during this phase has shown promising outcomes without significantly increasing the risks of adverse events. Randomized controlled trials are needed to evaluate the efficacy of therapeutic rest on subsequent admission rates for patients in active labor., Conclusions: Therapeutic rest offers a favorable approach to managing pain and discomfort in early labor. Although there are criteria and contraindications, the interventions have shown effectiveness without substantial adverse effects, providing a potential outpatient management strategy for the latent phase of labor., Relevance: This review offers insight into potential interventions and outcomes for managing the latent stage of labor in pregnant patients.

Importance: Diabetes mellitus is one of the most common complications in pregnancy with adverse maternal and neonatal risks proportional to the degree of suboptimal glycemic control, which is not well defined. Literature guiding providers in identifying and managing patients at highest risk of complications from diabetes is lacking., Objective: This article reviews the definition, epidemiology, and pathophysiology of suboptimal control of diabetes in pregnancy, including "diabetic fetopathy"; explores proposed methods of risk stratification for patients with diabetes; outlines existing antepartum management and delivery timing guidelines; and guides direction for future research., Evidence Acquisition: Original research articles, review articles, and professional society guidelines on diabetes management in pregnancy were reviewed., Results: The reviewed available studies demonstrate worsening maternal and neonatal outcomes associated with suboptimal control; however, the definition of suboptimal based on parameters followed in pregnancy such as blood glucose, hemoglobin A 1c , and fetal growth varied from study to study. Studies demonstrating specific associations of adverse outcomes with defined suboptimal control were reviewed and synthesized. Professional society recommendations were also reviewed to summarize current guidelines on antepartum management and delivery planning with respect to diabetes in pregnancy., Conclusions: The literature heterogeneously characterizes suboptimal glucose control and complications related to this during pregnancy in individuals with diabetes. Further research into antepartum management and delivery timing for patients with varying levels of glycemic control and at highest risk for diabetic complications is still needed.

Importance: Although the risk of parvovirus B19 infection during pregnancy and subsequent risk of adverse fetal outcome are low, understanding management practices is essential for proper treatment of fetuses with nonimmune hydrops fetalis. In addition, continued investigation into delivery management, breastfeeding recommendations, and congenital abnormalities associated with pregnancies complicated by parvovirus B19 infection is needed., Objective: This review describes the risks associated with parvovirus B19 infection during pregnancy and the management strategies for fetuses with vertically transmitted infections., Evidence Acquisition: Original articles were obtained from literature search in PubMed, Medline, and OVID; pertinent articles were reviewed., Results: Parvovirus B19 is a viral infection associated with negative pregnancy outcomes. Up to 50% of people of reproductive age are susceptible to the virus. The incidence of B19 in pregnancy is between 0.61% and 1.24%, and, overall, there is 30% risk of vertical transmission when infection is acquired during pregnancy. Although most pregnancies progress without negative outcomes, viral infection of the fetus may result in severe anemia, congestive heart failure, and hydrops fetalis. In addition, vertical transmission carries a 5% to 10% chance of fetal loss. In pregnancies affected by fetal B19 infection, Doppler examination of the middle cerebral artery peak systolic velocity should be initiated to surveil for fetal anemia. In the case of severe fetal anemia, standard fetal therapy involves an intrauterine transfusion of red blood cells with the goal of raising hematocrit levels to approximately 40% to 50% of total blood volume. One transfusion is usually sufficient, although continued surveillance may indicate the need for subsequent transfusions. There are fewer epidemiologic data concerning neonatal risks of congenital parvovirus, although case reports have shown that fetuses with severe anemia in utero may have persistent anemia, thrombocytopenia, and edema in the neonatal period., Conclusions and Relevance: Parvovirus B19 is a common virus; seropositivity in the geriatric population reportedly reaches 85%. Within the pregnant population, up to 50% of patients have not previously been exposed to the virus and consequently lack protective immunity. Concern for parvovirus B19 infection in pregnancy largely surrounds the consequences of vertical transmission of the virus to the fetus. Should vertical transmission occur, the overall risk of fetal loss is between 5% and 10%. Thus, understanding the incidence, risks, and management strategies of pregnancies complicated by parvovirus B19 is essential to optimizing care and outcomes. Further, there is currently a gap in evidence regarding delivery management, breastfeeding recommendations, and the risks of congenital abnormalities in pregnancies complicated by parvovirus B19. Additional investigations into optimal delivery management, feeding plans, and recommended neonatal surveillance are needed in this cohort of patients.

Guidelines for the management of first-trimester spontaneous and induced abortion vary in terms of rhesus factor D (RhD) testing and RhD immune globulin (RhIg) administration. These existing guidelines are based on limited data that do not convincingly demonstrate the safety of withholding RhIg for first-trimester abortions or pregnancy losses. Given the adverse fetal and neonatal outcomes associated with RhD alloimmunization, prevention of maternal sensitization is essential in RhD-negative patients who may experience subsequent pregnancies. In care settings in which RhD testing and RhIg administration are logistically and financially feasible and do not hinder access to abortion care, we recommend offering both RhD testing and RhIg administration for spontaneous and induced abortion at <12 weeks of gestation in unsensitized, RhD-negative individuals. Guidelines for RhD testing and RhIg administration in the first trimester must balance the prevention of alloimmunization with the individual- and population-level harms of restricted access to abortion., (Copyright © 2024. Published by Elsevier Inc.)

Importance: In pregnancy, cell-free DNA (cfDNA) represents short fragments of placental DNA released into the maternal blood stream through natural cell death. Noninvasive prenatal screening with cfDNA is commonly used in pregnancy to screen for common aneuploidies. This technology continues to evolve, and laboratories now offer cfDNA screening for single-gene disorders., Objective: This article aims to review cfDNA screening for single-gene disorders including the technology, current syndromes for which screening may be offered, limitations, and current recommendations., Evidence Acquisition: Original research articles, review articles, laboratory white papers, and society guidelines were reviewed., Results: Cell-free DNA screening for single-gene disorders is not currently recommended by medical societies. There may be a role in specific circumstances and only after comprehensive pretest counseling. It can be considered in the setting of some fetal ultrasound anomalies, and usually only after diagnostic testing is offered and declined., Conclusions: Given the limitations of using cfDNA screening for single-gene disorders, caution is recommended when considering these tests. It should only be offered with involvement of a reproductive genetic counselor, medical geneticist, or maternal fetal medicine specialist to ensure comprehensive counseling and appropriate utilization.

Importance: Luteal phase defects (LPDs), or an insufficiency of progesterone production during the luteal phase of the menstrual cycle, have been identified as a potential cause of recurrent pregnancy loss (RPL), but its exact contribution to RPL is not well-defined. In addition, the role of exogenous progesterone supplementation during pregnancy remains controversial., Objective: The goal of this review is to provide an updated, evidence-based summary of LPD, including prevalence and potential pathophysiologic mechanisms, and to explore the current controversies regarding progesterone supplementation for management and treatment of RPL., Evidence Acquisition: A literature review identified relevant research using a PubMed search, Cochrane summaries, review articles, textbook chapters, databases, and society guidelines., Results: Endogenous progesterone plays a crucial role in the first trimester of pregnancy, and therefore, insufficiency may contribute to RPL. However, the precise relationship between LPD and RPL remains unclear. Luteal phase defect is primarily a clinical diagnosis based on a luteal phase less than 10 days. Although there may be a possibility of incorporating a combined clinical and biochemical approach in defining LPD, the current lack of validated diagnostic criteria creates a challenge for its routine incorporation in the workup of infertility. Moreover, no treatment modality has demonstrated efficacy in improving fertility outcomes for LPD patients, including progesterone supplementation, whose inconsistent data do not sufficiently support its routine use, despite its minimal risk. It is imperative that women diagnosed with LPD should be worked up for other potential conditions that may contribute to a shortened luteal phase. Future work needs to focus on identifying a reproducible diagnostic test for LPD to guide treatment., Conclusions and Relevance: Currently, the perceived relationship between LPD and RPL is challenged by conflicting data. Therefore, patients with an abnormal luteal phase should undergo a thorough workup to address any other potential etiologies. Although supplemental progesterone is commonly utilized for treatment of LPD and RPL, inconsistent supporting data call for exogenous hormone therapy to be only used in a research setting or after a thorough discussion of its shortcomings.

Respiratory syncytial virus is a leading cause of lower respiratory tract illness globally in children aged <5 years. Each year, approximately 58,000 hospitalizations in the United States are attributed to respiratory syncytial virus. Infants aged ≤6 months experience the most severe morbidity and mortality. Until recently, prevention with the monoclonal antibody, palivizumab, was only offered to infants with high-risk conditions, and treatment primarily consisted of supportive care. Currently, 2 products are approved for the prevention of respiratory syncytial virus in infants. These include the Pfizer bivalent recombinant respiratory syncytial virus prefusion F protein subunit vaccine, administered seasonally to the pregnant person between 32 0/7 and 36 6/7 weeks of gestation, and the monoclonal antibody, nirsevimab, administered to infants aged up to 8 months entering their first respiratory syncytial virus season. With few exceptions, administering both the vaccine to the pregnant person and the monoclonal antibody to the infant is not recommended. All infants should be protected against respiratory syncytial virus using one of these strategies. Key considerations for pregnant individuals include examining available safety and efficacy data, weighing accessibility and availability, and patient preferences for maternal vaccination vs infant monoclonal antibody treatment. It will be critical for maternal-fetal medicine physicians to provide effective and balanced counseling to aid patients in deciding on a personalized approach to the prevention of respiratory syncytial virus in their infants., (Copyright © 2023. Published by Elsevier Inc.)

Importance: Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery., Objective: To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques., Evidence Acquisition: Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022)., Results: Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma., Conclusion and Relevance: Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.

All patients with twin pregnancy should have first trimester ultrasound and be offered screening for chromosomal aneuploidy as well as diagnostic testing. Screening for aneuploidy in twins presents unique challenges compared with singletons. Cell-free DNA screening should be considered first-line; however, this option may not be available or may have limitations in certain clinical scenarios, such as vanishing twins. If cell-free DNA screening is not available, maternal serum marker screening in conjunction with nuchal translucency assessment should be offered. Patients with positive aneuploidy screening tests or fetal structural abnormalities should be offered diagnostic testing., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: The use of tobacco and nicotine products during pregnancy is known to increase the risk of adverse effects on the fetus. Increased education and research have resulted in greater rates of smoking cessation during pregnancy, with a decline from 13.2% of pregnant individuals smoking in 2006 to 7.2% in 2016. However, smoking while pregnant still proves to be a prevalent issue that is associated with numerous adverse outcomes, including low birth weight, preterm birth, and developmental delays. Smoking cessation before or during pregnancy can help mitigate these effects, but the appropriate treatment can be challenging to ascertain. Accordingly, clinicians should look to provide individualized care composed of behavioral counseling in conjunction with pharmacotherapies when indicated, combined with ongoing support and education.

Importance: Obstetrics and gynecology (OB/GYN) accounts for at least half of all open abdominal surgeries performed. Rates of surgical wound complications after open procedures in OB/GYN range from 5% to 35%. Therefore, optimizing management of surgical wound complications has the potential to significantly reduce cost and morbidity. However, guidelines addressing best practices for wound care in OB/GYN are limited., Objective: The objectives of this review are to describe the fundamentals of wound healing and to evaluate available evidence addressing surgical wound care. Based on these data, we provide recommendations for management of extrafascial surgical wound dehiscence after OB/GYN procedures., Evidence Acquisition: Literature search was performed in PubMed, Medline, OVID, and the Cochrane database. Relevant guidelines, systematic reviews, and original research articles investigating mechanisms of wound healing, types of wound closure, and management of surgical wound complications were reviewed., Results: Surgical wound complications in OB/GYN are associated with significant cost and morbidity. One of the most common complications is extrafascial dehiscence, which may occur in the setting of hematomas, seromas, or infection. Management includes early debridement and treatment of any underlying infection until healthy granulation tissue is present. For wounds healing by secondary intention, advanced moisture retentive dressings reduce time to healing and are cost-effective when compared with conventional wet-to-dry gauze dressings. Negative pressure wound therapy can be applied to deeper wounds healing by secondary intention. Review of published evidence also supports the use of delayed reclosure to expedite wound healing for select patients., Conclusions: Optimizing surgical wound care has the potential to reduce the cost and morbidity associated with surgical wound complications in OB/GYN. Advanced moisture retentive dressings should be considered for wounds healing by secondary intention. Data support delayed reclosure for select patients, although further studies are needed.

Twin pregnancy presents unique considerations for aneuploidy screening. Pre-test counseling regarding benefits, alternatives, and options for aneuploidy screening should be provided to all patients carrying twin pregnancy. This article aims to review the options for aneuploidy screening in twin pregnancy including the potential benefits and limitations., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Genetic carrier screening is performed to identify carriers of rare genetic diseases. Identification of carriers allows patients to make informed reproductive health choices and can decrease the incidence of genetic disorders with serious medical implications., Objective: This review aims to provide an overview of the history of prenatal genetic screening and the various forms of carrier screening, a synopsis of recent changes in society recommendations and current practice guidelines, and discussion of clinical challenges associated with carrier screening., Evidence Acquisition: Published practice guidelines from relevant professional societies were reviewed and synthesized. PubMed search was performed for relevant history and clinical considerations of carrier screening., Results: Information and evidence summarized in this review include professional society practice guidelines, review articles, and peer-reviewed research articles., Conclusions and Relevance: Current practice guidelines differ between stakeholder professional organizations. Expanded carrier screening offers increased identification of rare disease carriers allowing for more informed reproductive choices. However, there are several barriers to the implementation of expanded carrier screening for all patients.

Importance: CenteringPregnancy (CP) is a model for group prenatal care associated with improved perinatal outcomes for preterm birth and low birthweight, increased rates of breastfeeding, and higher rates of patient and clinician satisfaction., Objective: The study aims to review the literature related to perinatal outcomes associated with CP, benefits and barriers to implementation, and utility of the model., Evidence: An electronic-based search was performed in PubMed using the search terms "CenteringPregnancy" OR "Centering Pregnancy," revealing 221 articles., Results: The CP model improves patient centeredness, efficiency, and equality in prenatal care. Challenges include administrative buy-in, limited resources, and financial support. Multisite retrospective studies of CP demonstrate improved maternal, neonatal, postpartum, and well-being outcomes, especially for participants from minority backgrounds; however, prospective studies had mixed results. CenteringPregnancy is feasibly implemented with high tenet fidelity in several low- and middle-income settings with improved perinatal outcomes compared with traditional care., Conclusions: CenteringPregnancy is feasible to implement, largely accepted by communities, and shows positive qualitative and quantitative health outcomes. This body of literature supports CP as a potential tool for decreasing racial inequalities in prenatal access, quality of care, and maternal mortality. Further investigation is necessary to inform obstetric clinicians about the potential outcome differences that exist between group and traditional prenatal care.

Importance: Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care., Objective: To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario., Evidence Acquisition: Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed., Results: These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B Streptococcus prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens., Conclusions: Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B Streptococcus , we recommend 1-time dose of metronidazole 500 mg IV., Relevance: Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.

Importance: Autoimmune and rheumatologic conditions can lead to multiple adverse maternal, obstetric, and neonatal outcomes, especially if they flare during pregnancy. Although many medications to control these conditions exist, concerns regarding their safety often unnecessarily limit their use., Objective: We aim to review the current evidence available describing the use of monoclonal antibody (mAb) therapeutics in pregnancy and postpartum and understand the impact of their use on the developing fetus and neonate., Evidence Acquisition: Original research articles, review articles, case series and case reports, and pregnancy guidelines were reviewed., Results: Multiple retrospective (including 1924 patients) and prospective studies (including 899 patients) of anti-tumor necrosis factor (TNF) agent use in pregnancy found no significant increase in rates of miscarriage, preterm birth, or congenital anomalies compared with controls. Most societies, including American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, recommend initiation or continuation of TNF-α inhibitors during pregnancy for patients with autoimmune diseases. An increased risk of mild infections in newborns has been reported, although infections requiring hospitalizations are rare. Data suggest that breastfeeding while taking anti-TNF agents is safe for neonates. Less data exist for the use of other mAbs including anticytokine, anti-integrin, and anti-B-cell agents during pregnancy and postpartum., Conclusions and Relevance: Current evidence suggests that the use of mAbs, particularly anti-TNF agents, is safe in pregnancy and postpartum, without significant adverse effects on the pregnant patient or infant. The benefits of ongoing disease control in pregnant patients result in favorable maternal and neonatal outcomes.

Importance: Peripartum separation of the pubic symphysis is a rare but potentially severe complication of childbirth, which may lead to prolonged immobilization. Thus, prompt diagnosis and treatment are paramount., Objective: The purpose of this review is to define peripartum separation of the pubic symphysis and provide a thorough review of its etiology, clinical manifestations, diagnostic imaging techniques, management, and prognosis., Evidence Acquisition: This was a literature review using PubMed and Google Scholar., Results: Peripartum pubic symphysis separation is defined as disruption of the pubic symphysis joint and ligamentous structures with greater than 1 cm of separation during delivery. Risk factors include fetal macrosomia, nulliparity, and precipitous labor. Patients often present with a sensation of something "giving way" in the pubic symphysis area at the time of delivery, or with severe pain in the pubic symphysis region with attempted mobilization postpartum. In severe cases, associated hematomas, pelvic fractures, sacroiliac joint disruption, and urinary tract injury may be seen. Imaging such as x-ray or ultrasound may be used to confirm the diagnosis. Although most patients recover well with conservative management, orthopedic surgical intervention may be indicated in more severe or unresolved cases., Conclusions and Relevance: Pubic symphysis separation is increasingly identified peripartum due enhanced accessibility and utilization of imaging modalities. It can be debilitating and lead to prolonged immobility postpartum. Therefore, early recognition and diagnosis are important, as this can guide decision-making for management. A multidisciplinary team approach, including coordination with obstetrics, orthopedic surgery, physical therapy, and occupational therapy should be used for early detection and treatment to ensure optimal patient outcomes.

Importance: As prenatal care is in transition after the COVID-19 pandemic, reviewing fundamental physical examination approaches is necessary for providers examining obstetrical patients., Objective: The objective of this review is 3-fold: (1) convey why the age of telemedicine necessitates reconsideration of the standardized physical examination in routine prenatal care; (2) identify the screening efficacy of examination maneuvers used within a standard prenatal examination of the neck, heart, lungs, abdomen, breasts, skin, lower extremities, pelvis, and fetal growth; and (3) propose an evidence-based prenatal physical examination., Evidence Acquisition: A comprehensive literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines., Results: We conclude that an evidence-based prenatal examination for asymptomatic patients includes the following maneuvers: inspection and palpation for thyromegaly and cervical lymphadenopathy, cardiac auscultation, fundal height measurement, and a pelvic examination for purposes including testing for gonorrhea and chlamydia, assessing pelvimetry, and assessing cervical dilation later in the pregnancy, intrapartum, or in the setting of ultrasonogram-detected prelabor preterm cervical shortening., Conclusions and Relevance: Although not true of all physical examination maneuvers, this article demonstrates that there are maneuvers that continue to play important screening roles in asymptomatic patients. With the increase in virtual visits and fewer in-person prenatal appointments, the rational basis for maneuvers recommended in this review should inform decision making around the prenatal examination performed.

Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved, and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient's rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for antiphospholipid syndrome (APS) (GRADE 2B); (9) we recommend therapeutic unfractionated or low-molecular-weight heparin for patients with a history of thrombosis and antiphospholipid (aPL) antibodies (GRADE 1B); (10) we suggest treatment with low-dose aspirin alone in patients with systemic lupus erythematosus and antiphospholipid antibodies without clinical events meeting criteria for antiphospholipid syndrome (GRADE 2C); (11) we recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-Sjögren's-syndrome-related antigen A or B (anti-SSA/SSB) antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); (12) we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA/SSB antibodies outside of a clinical trial setting (GRADE 1B); (13) we recommend that patients with systemic lupus erythematosus undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); (14) we recommend that pregnancy be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); (15) we recommend antenatal testing and serial growth scans in pregnant patients with systemic lupus erythematosus because of the increased risk of fetal growth restriction (FGR) and stillbirth (GRADE 1B); and (16) we recommend adherence to the Centers for Disease Control and Prevention medical eligibility criteria for contraceptive use in patients with systemic lupus erythematosus (GRADE 1B)., (Copyright © 2022. Published by Elsevier Inc.)

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above., (Copyright © 2022 American College of Obstetricians and Gynecologists. Published by Elsevier Inc. All rights reserved.)

Importance: Cystic fibrosis (CF) is one of the most common autosomal recessive disorders. Carrier screening for CF should be offered to all women considering becoming pregnant or who are pregnant. Understanding the available screening tests, their limitations, and the benefits of screening is of paramount importance to the obstetrician-gynecologist., Objectives: The objective is to review the current guidelines for CF carrier screening including the options for carrier screening, the potential complexities associated with carrier screening for CF, and indications for referral to certified genetic counselors or maternal-fetal medicine specialists., Evidence Acquisition: A MEDLINE search of "cystic fibrosis," "cystic fibrosis carrier screening pregnancy," and "inheritance of cystic fibrosis" in the review was performed., Results: The evidence cited in this review includes 2 medical society committee opinions and 15 additional peer-reviewed journal articles that were original research or expert opinion summaries., Conclusions and Relevance: The American College of Obstetricians and Gynecologists recommends that obstetricians offer CF carrier screening to all pregnant women or women considering becoming pregnant. Based on recent guidelines from ACMG, additional expanded carrier screening can be recommended to patients in the future, with additional CF variants and other autosomal or X-linked recessive conditions. It is important for the prenatal care provider to understand the guidelines for carrier screening as well as the potential complexities associated with carrier screening due to the multiple pathogenic variants in the CFTR gene that may be associated with varying phenotypes. With the options for CF carrier screening, screening performance in different populations, a basic understanding of the disease and interpretation of carrier screening results is of paramount importance to the prenatal care provider.

Importance: The measurement of human chorionic gonadotropin (hCG) levels in different body fluids is a commonly utilized tool in obstetrics and gynecology, as well as other fields. It is often one of the first steps in the medical workup of female patients, and the results and interpretation of this test can have significant downstream ramifications. It is essential to understand the uses and limitations of hCG as a testing and therapeutic measure to appropriately evaluate, counsel, and treat patients., Objective: The purpose of this article is to review the current literature on hCG, including its origins, structure, pharmacokinetics, metabolism, and utility in testing and medical treatment., Evidence Acquisition: Original research articles, review articles, and guidelines on hCG use were reviewed., Conclusions and Relevance: While the primary function of hCG is to maintain early pregnancy, testing for hCG demonstrates that this molecule is implicated in a multitude of different processes where results of testing may lead to incorrect conclusions regarding pregnancy status. This could affect patients in a myriad of settings and have profound emotional and financial consequences. In addition, hCG testing may be revealing of alternative pathology, such as malignancy. It is imperative to understand the nuances of the physiology of hCG and testing methods to effectively use and interpret this test for appropriate patient management.

Importance: Leiomyomata, or fibroids, are a common gynecological problem affecting many women of reproductive age. Historically, myomectomy is offered to women with symptomatic fibroids who desire to preserve fertility. More recently, uterine artery embolization (UAE) has been explored as another fertility-sparing option., Objective: This review aims to provide an in-depth summary of the effects on fertility and reproductive outcomes following myomectomy and UAE for the treatment of symptomatic fibroids., Evidence Acquisition: Articles were obtained from PubMed using search terms myomectomy , uterine artery embolization , and fertility , as well as American Society of Reproductive Medicine practice committee reports. References from identified sources were searched to allow for thorough review., Results: While myomectomy and UAE are both fertility-sparing options for women with fibroids, reproductive outcomes following myomectomy are superior to UAE with higher rates of clinical pregnancy and live births and lower rates of spontaneous abortion, abnormal placentation, preterm labor, and malpresentation., Conclusions: Myomectomy should be offered to women with symptomatic submucosal or cavity-distorting fibroids who have a strong desire for a future pregnancy. For women who are not appropriate surgical candidates, UAE can be offered, although detrimental effects on future fertility should be disclosed., Relevance: A thorough understanding of the efficacy of both myomectomy and UAE, as well as their impact on future fertility, allows for improved counseling when deciding the optimal intervention for women with fibroids who desire future fertility.

Importance: The scientific benefits of breastfeeding for the parent and baby are clear, but the goal is often simplified to "breast is best." Patients' decisions to breastfeed are more nuanced than this approach implies, and it is essential for providers to understand other factors that contribute to this complex decision., Objective: We reviewed the current literature of the health benefits of breastfeeding, local and global breastfeeding trends and current disparities, and the historical, political, and social factors that influence a patient's decision to breastfeed., Evidence Acquisition: Original research articles, review articles, and guidelines on breastfeeding were reviewed., Results: Rates of breastfeeding have increased in the United States and globally after public health interventions, but significant disparities persist. Numerous factors influence a patient's decision to breastfeed including the medical benefits, formula marketing campaigns, historical connections to slavery and oppression, limited societal support for working parents, mental or physical health concerns, previous sexual abuse or trauma, gender identity, and others., Conclusions and Relevance: Understanding both the medical importance of breastfeeding and the various other factors that influence a patient's decision or ability to breastfeed is essential for counseling patients before delivery. Providers have a responsibility to navigate this complex conversation with patients to empower them to make an informed decision that works for them.

Importance: For patients who present with prelabor rupture of membrane (PROM) in the late preterm period (34 to 36 6/7 weeks), management remains unclear due to lack of consensus. However, recent guidelines have suggested that shared decision-making may be used and expectant management can be considered up to 37 0/7 weeks., Objective: In this article, we review the contemporary studies comparing the risks and benefits of immediate delivery versus expectant management for patients with late preterm prelabor rupture of membranes (PPROM)., Evidence Acquisition: Original research articles, review articles, and guidelines on management of late PPROM., Results: Three randomized clinical trials and 2 meta-analyses comparing expectant management and immediate delivery outcomes in late PPROM showed no significant difference in neonatal sepsis rates between groups. Expectant management increased the likelihood that pregnancies reached term while decreasing the rate of cesarean delivery. However, data suggest an increased risk of antepartum hemorrhage among patients in the expectant management groups, as well as higher rates of histologic chorioamnionitis., Conclusions and Relevance: We recommend that clinicians offer expectant management as an alternative to immediate delivery in the setting of late PPROM through a shared decision-making process that clearly outlines the risks and benefits.

Importance: Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003., Objective: The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy., Evidence Acquisition: Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed., Results: Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention., Conclusions and Relevance: Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.

The use of assisted reproductive technology has increased in the United States in the past several decades. Although most of these pregnancies are uncomplicated, in vitro fertilization is associated with an increased risk for adverse perinatal outcomes primarily caused by the increased risks of prematurity and low birthweight associated with in vitro fertilization pregnancies. This Consult discusses the management of pregnancies achieved with in vitro fertilization and provides recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that genetic counseling be offered to all patients undergoing or who have undergone in vitro fertilization with or without intracytoplasmic sperm injection (GRADE 2C); (2) regardless of whether preimplantation genetic testing has been performed, we recommend that all patients who have achieved pregnancy with in vitro fertilization be offered the options of prenatal genetic screening and diagnostic testing via chorionic villus sampling or amniocentesis (GRADE 1C); (3) we recommend that the accuracy of first-trimester screening tests, including cell-free DNA for aneuploidy, be discussed with patients undergoing or who have undergone in vitro fertilization (GRADE 1A); (4) when multifetal pregnancies do occur, we recommend that counseling be offered regarding the option of multifetal pregnancy reduction (GRADE 1C); (5) we recommend that a detailed obstetrical ultrasound examination (CPT 76811) be performed for pregnancies achieved with in vitro fertilization and intracytoplasmic sperm injection (GRADE 1B); (6) we suggest that fetal echocardiography be offered to patients with pregnancies achieved with in vitro fertilization and intracytoplasmic sperm injection (GRADE 2C); (7) we recommend that a careful examination of the placental location, placental shape, and cord insertion site be performed at the time of the detailed fetal anatomy ultrasound, including evaluation for vasa previa (GRADE 1B); (8) although visualization of the cervix at the 18 0/7 to 22 6/7 weeks of gestation anatomy assessment with either a transabdominal or endovaginal approach is recommended, we do not recommend serial cervical length assessment as a routine practice for pregnancies achieved with in vitro fertilization (GRADE 1C); (9) we suggest that an assessment of fetal growth be performed in the third trimester for pregnancies achieved with in vitro fertilization; however, serial growth ultrasounds are not recommended for the sole indication of in vitro fertilization (GRADE 2B); (10) we do not recommend low-dose aspirin for patients with pregnancies achieved with IVF as the sole indication for preeclampsia prophylaxis; however, if 1 or more additional risk factors are present, low-dose aspirin is recommended (GRADE 1B); (11) given the increased risk for stillbirth, we suggest weekly antenatal fetal surveillance beginning by 36 0/7 weeks of gestation for pregnancies achieved with in vitro fertilization (GRADE 2C); (12) in the absence of studies focused specifically on timing of delivery for pregnancies achieved with IVF, we recommend shared decision-making between patients and healthcare providers when considering induction of labor at 39 weeks of gestation (GRADE 1C)., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Venomous snake and spider bites are relatively rare in the Unites States and even more so in the pregnant population. However, the impact of a venomous bite, also known as an envenomation, can be serious in a pregnant patient. Thus, providers in endemic and high-risk areas must be familiar with the management of envenomation in the pregnant population., Objective: The purpose of this article is to review the current literature on the most common snake and spider envenomations in the United States, the effects of envenomation on maternal and fetal health, and the management of envenomation in pregnancy., Evidence Acquisition: Original research articles, review articles, and guidelines on snake and spider envenomation were reviewed., Results: Snake envenomation carries higher risks of maternal morbidity and fetal morbidity and mortality than spider envenomation. Although the data are limited, current literature suggests that both snake and spider antivenom can be used in the pregnant population without significant adverse outcomes. However, the risks of an adverse hypersensitivity reaction with antivenom administration should be weighed carefully with the benefits., Conclusions and Relevance: The use of antivenom therapy in the symptomatic envenomated pregnant population is likely safe with the appropriate monitoring and follow-up. Knowledge of the indications for antivenom therapy and proper escalation of care are vital to optimizing maternal and fetal outcomes. More research is needed to determine the effects of both envenomation and antivenom therapy on the pregnant patient and their fetus.

Importance: Women undergoing cerclage placement remain at high risk for preterm labor and preterm prelabor rupture of membranes (PPROMs). The management of cervical cerclage after PPROM is controversial given the potential for prolonged latency when the cerclage is kept in place balanced with a potential increased risk of maternal infectious morbidity., Objective: In this review, we compared studies that examined maternal, fetal, and neonatal outcomes in women with cerclage at the time of PPROM. We evaluated latency after PPROM and maternal and neonatal complications in the setting of PPROM with cervical cerclage., Evidence Acquisition: Original research articles, review articles, and guidelines on cerclage removal were reviewed., Results: Nine studies comparing cerclage retention versus removal were examined with mixed results, in particular between studies before the routine use of latency antibiotics and corticosteroid administration. There was an associated increase in latency to delivery with retention of cerclage, with a potential increase in maternal infectious morbidity. No significant differences were noted for neonatal mortality, neonatal sepsis, or other neonatal morbidity outcomes. The majority of studies were limited by their retrospective nature and small sample sizes., Conclusions and Relevance: Cerclage removal at the time of diagnosis of PPROM can be considered due to the concern for increased risk of maternal morbidity without definitive benefit in latency to delivery or neonatal outcomes. However, data are limited, and clinicians should engage in shared decision-making with patients in this setting.

Soft markers were originally introduced to prenatal ultrasonography to improve the detection of trisomy 21 over that achievable with age-based and serum screening strategies. As prenatal genetic screening strategies have greatly evolved in the last 2 decades, the relative importance of soft markers has shifted. The purpose of this document is to discuss the recommended evaluation and management of isolated soft markers in the context of current maternal serum screening and cell-free DNA screening options. In this document, "isolated" is used to describe a soft marker that has been identified in the absence of any fetal structural anomaly, growth restriction, or additional soft marker following a detailed obstetrical ultrasound examination. In this document, "serum screening methods" refers to all maternal screening strategies, including first-trimester screen, integrated screen, sequential screen, contingent screen, or quad screen. The Society for Maternal-Fetal Medicine recommends the following approach to the evaluation and management of isolated soft markers: (1) we do not recommend diagnostic testing for aneuploidy solely for the evaluation of an isolated soft marker following a negative serum or cell-free DNA screening result (GRADE 1B); (2) for pregnant people with no previous aneuploidy screening and isolated echogenic intracardiac focus, echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive (GRADE 1B); (3) for pregnant people with no previous aneuploidy screening and isolated thickened nuchal fold or isolated absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening through cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference (GRADE 1B); (4) for pregnant people with no previous aneuploidy screening and isolated choroid plexus cysts, we recommend counseling to estimate the probability of trisomy 18 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive (GRADE 1C); (5) for pregnant people with negative serum or cell-free DNA screening results and an isolated echogenic intracardiac focus, we recommend no further evaluation as this finding is a normal variant of no clinical importance with no indication for fetal echocardiography, follow-up ultrasound imaging, or postnatal evaluation (GRADE 1B); (6) for pregnant people with negative serum or cell-free DNA screening results and isolated fetal echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend no further aneuploidy evaluation (GRADE 1B); (7) for pregnant people with negative serum screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and discussion of options for no further aneuploidy evaluation, noninvasive aneuploidy screening through cell-free DNA, or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference (GRADE 1B); (8) for pregnant people with negative cell-free DNA screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend no further aneuploidy evaluation (GRADE 1B); (9) for pregnant people with negative serum or cell-free DNA screening results and isolated choroid plexus cysts, we recommend no further aneuploidy evaluation, as this finding is a normal variant of no clinical importance with no indication for follow-up ultrasound imaging or postnatal evaluation (GRADE 1C); (10) for fetuses with isolated echogenic bowel, we recommend an evaluation for cystic fibrosis and fetal cytomegalovirus infection and a third-trimester ultrasound examination for reassessment and evaluation of growth (GRADE 1C); (11) for fetuses with an isolated single umbilical artery, we recommend no additional evaluation for aneuploidy, regardless of whether results of previous aneuploidy screening were low risk or testing was declined. We recommend a third-trimester ultrasound examination to evaluate growth and consideration of weekly antenatal fetal surveillance beginning at 36 0/7 weeks of gestation (GRADE 1C); (12) for fetuses with isolated urinary tract dilation A1, we recommend an ultrasound examination at ≥32 weeks of gestation to determine if postnatal pediatric urology or nephrology follow-up is needed. For fetuses with urinary tract dilation A2-3, we recommend an individualized follow-up ultrasound assessment with planned postnatal follow-up (GRADE 1C); (13) for fetuses with isolated shortened humerus, femur, or both, we recommend a third-trimester ultrasound examination for reassessment and evaluation of growth (GRADE 1C)., (Copyright © 2021. Published by Elsevier Inc.)

In the United States, it is estimated that 1% to 4% of pregnant women are infected with hepatitis C virus, which carries approximately a 5% risk of transmission from mother to infant. Hepatitis C virus can be transmitted to the infant in utero or during the peripartum period, and infection during pregnancy is associated with an increased risk of adverse fetal outcomes, including fetal growth restriction and low birthweight. The purpose of this document is to discuss the current evidence, provide updated recommendations regarding screening, review treatment, and address management of hepatitis C virus during pregnancy. The following are the Society for Maternal-Fetal Medicine's recommendations: (1) We suggest that third trimester assessment of fetal growth may be performed, but antenatal testing is not indicated in the setting of hepatitis C virus diagnosis alone (GRADE 2C); (2) we suggest screening for viral hepatitis in patients with a diagnosis of intrahepatic cholestasis of pregnancy at an early gestational age or with high levels of bile acids (GRADE 2C); (3) we recommend that obstetrical providers screen all pregnant patients for hepatitis C virus by testing for anti-hepatitis C virus antibodies in every pregnancy (GRADE 1B); (4) we suggest that obstetrical care providers screen hepatitis C virus-positive pregnant patients for other sexually transmitted infections (if not done previously), including human immunodeficiency virus, syphilis, gonorrhea, chlamydia, and hepatitis B virus (GRADE 2C); (5) we recommend vaccination against hepatitis A and B viruses (if not immune) for patients with hepatitis C virus (GRADE 1B); (6) we recommend that direct-acting antiviral regimens only be initiated in the setting of a clinical trial during pregnancy and that people who become pregnant while taking a direct-acting antiviral should be counseled in a shared decision-making framework about the risks and benefits of continuation (GRADE 1C); (7) we suggest that if prenatal diagnostic testing is requested, patients are counseled that data regarding the risk of vertical transmission are reassuring but limited (GRADE 2C); (8) we recommend against cesarean delivery solely for the indication of hepatitis C virus (GRADE 1B); (9) we suggest that obstetrical care providers avoid internal fetal monitors and early artificial rupture of membranes when managing labor in patients with hepatitis C virus unless necessary in the course of management (ie, when unable to trace the fetal heart rate with external monitors and the alternative is proceeding with cesarean delivery) (GRADE 2B); (10) we recommend that hepatitis C virus status not alter standard breastfeeding counseling and recommendations unless nipples are cracked or bleeding (GRADE 1A)., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Peripartum cardiomyopathy is a rare form of heart failure due to left ventricular systolic dysfunction that affects women late in pregnancy and the postpartum period. A diagnosis of exclusion, peripartum cardiomyopathy can be difficult to diagnose in the context of the normal physiologic changes of pregnancy and requires a high index of suspicion., Evidence Acquisition: Original research articles, review articles, and guidelines on peripartum cardiomyopathy were reviewed., Results: The etiology of peripartum cardiomyopathy remains poorly defined, but theories include genetic predisposition, as well as myocardial inflammation and angiogenic dysregulation. Risk factors for this condition include hypertensive disorders of pregnancy, Black race, and maternal age older than 30 years. Patients with peripartum cardiomyopathy are at increased risk of acute clinical decompensation, cardiac arrhythmias, thromboembolic complications, and death. Primary treatment modalities include initiation of a medication regimen aimed at the optimization of preload and reduction of afterload. Maternal clinical status is the primary determinant for timing of delivery., Conclusions: Prompt diagnosis and medical management by an interdisciplinary care team are vital for improving outcomes in patients with peripartum cardiomyopathy.

Importance: Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians., Objective: The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy., Evidence Acquisition: This was a literature review using primarily PubMed and Google Scholar., Results: Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy., Conclusions and Relevance: Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.