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Objective: To determine the prevalence of positive antiphospholipid (aPL) antibodies among pregnant women with placenta-mediated complications delivered at >340/7 weeks of gestation. Methods: This was a single-center retrospective observational study conducted between 2017 and 2022. Inclusion criteria included pregnant or post-partum women, >18 years, diagnosed with any of the following placenta-mediated complications and delivered at >340/7 weeks of gestation: small-for-gestational-age neonate (SGA ≤ 5th percentile according to local birthweight charts), preeclampsia with severe features, and placental abruption. The primary outcome was the prevalence of positive aPL antibodies: Lupus anticoagulant, Anticardiolipin, or Anti-ß2glycoprotein1. Results: Overall, 431 women met the inclusion criteria. Of them, 378(87.7%) had an SGA neonate, 30 had preeclampsia with severe features (7%), 23 had placental abruption (5.3%), and 21 patients had multiple diagnoses(4.9%). The prevalence of aPL antibodies in the cohort was 4.9% and was comparable between the three subgroups (SGA—3.9%; PET with severe features—3.3%; and placental abruption—13% (p = 0.17)). Conclusion: aPL antibodies prevalence in women with placenta-mediated complications > 34 weeks of gestation was 4.9%, with comparable prevalence rates among the three subgroups. Future prospective studies are needed to delineate the need for treatment in those who tested positive for aPL antibodies and do not meet Anti-Phospholipid Antibody Syndrome clinical criteria.

One of the hallmarks of twin pregnancies is the slower rate of fetal growth when compared with singleton pregnancies during the third trimester. The mechanisms underlying this phenomenon and whether it represents pathology or benign physiological adaptation are currently unclear. One important implication of these questions relates to the type growth charts that should be used by care providers to monitor growth of twin fetuses. If the slower growth represents pathology (ie, intrauterine growth restriction caused uteroplacental insufficiency), it would be preferable to use a singleton growth chart to identify a small twin fetus that is at risk for perinatal mortality and morbidity. If, however, the relative smallness of twins is the result of benign adaptive mechanisms, it is likely preferable to use a twin-based charts to avoid overdiagnosis of intrauterine growth restriction in twin pregnancies. In the current review, we addressed this question by describing the differences in fetal growth between twin and singleton pregnancies, reviewing the current knowledge regarding the mechanisms responsible for slower fetal growth in twins, summarizing available empirical evidence on the diagnostic accuracy of the 2 types of charts for intrauterine growth restriction in twin pregnancies, and addressing the question of whether uncomplicated dichorionic twins are at an increased risk for fetal death when compared with singleton fetuses. We identified a growing body of evidence that shows that the use of twin charts can reduce the proportion of twin fetuses identified with suspected intrauterine growth restriction by up to 8-fold and can lead to a diagnosis of intrauterine growth restriction that is more strongly associated with adverse perinatal outcomes and hypertensive disorders than a diagnosis of intrauterine growth restriction based on a singleton-based chart without compromising the detection of twin fetuses at risk for adverse outcomes caused by uteroplacental insufficiency. We further found that small for gestational age twins are less likely to experience adverse perinatal outcomes or to have evidence of uteroplacental insufficiency than small for gestational age singletons and that recent data question the longstanding view that uncomplicated dichorionic twins are at an increased risk for fetal death caused by placental insufficiency. Overall, it seems that, based on existing evidence, the of use twin charts is reasonable and may be preferred over the use of singleton charts when monitoring the growth of twin fetuses. Still, it is important to note that the available data have considerable limitations and are primarily derived from observational studies. Therefore, adequately-powered trials are likely needed to confirm the benefit of twin charts before their use is adopted by professional societies.

Oxytocin uterotonic agents are routinely administered during the third stage of labor, however, the administration route is varying, intravenously or intramuscularly. We aimed to compare the effect of different regimens of postpartum oxytocin administration on hemoglobin (Hb) and hematocrit (Hct) decline.A randomized, 3-arm study of women who delivered vaginally at term in a single tertiary medical center was conducted. Immediately following the delivery of the fetus women randomly received one of 3 oxytocin regimens: 1) intramuscular 10units (IM group); 2) intravenous 10units in 100 ml 0.9%NaCl solution over 10-15 min (IV group); or 3) combined IV + IM regimens (IV + IM group). Primary outcome was defined as the level of Hb decline between prepartum and postpartum measurements.Overall, 210 women (70 in each group) were randomized, with 171 included in the final analysis (IM group-61, IV group-57, IV + IM group-53). There was no significant difference between the groups regarding maternal age, pre-pregnancy body-mass-index (BMI), parity, operative vaginal deliveries rate, the rate of episiotomy or perineal tears or neonatal birthweight. Mean prepartum Hb and Hct level were 12.3 ± 1.1 g/dl and 36.9 ± 2.7%, respectively, with no significant difference between the groups. Mean postpartum HB and Hct decline was 1.3 ± 0.8 g/dl and 3.7 ± 2.3%, respectively, with no difference between the groups. In multivariable analysis after adjusting for parity, pre-pregnancy BMI, labor induction, episiotomy or perineal tears and neonatal birthweight, oxytocin regimen was not associated with any difference in hematological measurements.Postpartum Hb and Hct decline was usually minor following vaginal deliveries, and was not affected by postpartum oxytocin regimen.

Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.

Intrahepatic cholestasis of pregnancy (ICP) is characterized by elevated total bile acids (TBA). Although elevated maternal TBA is a major risk factors for fetal morbidity and mortality, it is unclear why some fetuses are more prone to the hazardous effect of bile acids (BA) over the others. It is unclear whether fetuses are protected by placental BA uptake, or it is the fetal BA metabolism that reduces fetal BA as compared to maternal levels. Therefore, we aimed to compared TBA levels in the umbilical vein and artery to maternal TBA in women with ICP. The study included 18 women who had TBA > 40 μmol/L and their 23 fetuses. We found that the TBA level in umbilical vein was significantly lower compared to maternal TBA level. The TBA levels in umbilical vein and umbilical artery were similar. No fetus had a serious neonatal complication. Importantly, since TBA level remains low even though maternal TBA level is high the fetuses are protected from the hazardous effects of maternal BA. Our findings suggest that there is no effective metabolism of BA in the fetus and the main decrease in TBA in the fetus is related to placental BA uptake.

To investigate the current practices of maternal-fetal medicine (MFM) specialists regarding the prevention and management of preterm birth (PTB) in twin pregnancies.This was a cross-sectional study of Canadian MFM specialists. Participants responded to an anonymous survey regarding the prevention and management of PTB in twins, including lifestyle and gestational weight gain recommendations, cervical length screening, PTB prevention, and labour and delivery practices.Of 137 MFM specialists surveyed, 95 (69%) responded. Most MFM specialists recommend against activity restriction (77.9%), avoidance of sexual activity (96.7%), routine progesterone (97.8%), routine prophylactic cerclage (98.9%), and routine administration of antenatal corticosteroids (95.6%). There were considerable inconsistencies with respect to gestational weight gain management. Despite lack of support by guidelines, most MFM specialists reported using routine cervical length screening (97.8%) and progesterone for short cervix (92.3%). Over half (52.7%) of MFM specialists recommend cervical cerclage when the cervix is15mm. In cases of PTB, most MFM specialists recommend vaginal delivery when twins are in vertex presentation (63%-75%). MFM specialists are less likely to recommend vaginal delivery when twin B is non-vertex (35%-41%).There is a considerable variation among MFM specialists regarding the prevention and management of PTB in twins, and the practice of many MFM specialists differs from that recommended by professional societies' guidelines. These findings underscore the necessity for high-quality studies and up-to-date recommendations.

OBJECTIVE To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes. DESIGN A population-based retrospective cohort study (2007-2017). SETTING Ontario, Canada. METHODS Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies. RESULTS For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively. CONCLUSIONS We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds. TWEETABLE ABSTRACT Potential twin-specific OGTT thresholds for GDM were identified.

OBJECTIVE We aimed to quantify the risk of future maternal type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) based on the type and number of abnormal 75-g oral glucose tolerance test (OGTT) values and the diagnostic criteria used for the diagnosis of GDM. RESEARCH DESIGN AND METHODS We conducted a population-based retrospective cohort study of all nulliparous women with a live singleton birth who underwent testing for GDM using a 75-g OGTT in Ontario, Canada (2007–2017). We estimated the incidence rate (per 1,000 person-years), overall risk (expressed as adjusted hazard ratio [aHR]), and risk at 5 years after the index pregnancy of future maternal T2DM. Estimates were stratified by the type and number of abnormal OGTT values, as well as by the diagnostic criteria for GDM (Diabetes Canada [DC] vs. International Association of the Diabetes and Pregnancy Study Groups [IADPSG] criteria). RESULTS A total of 55,361 women met the study criteria. The median duration of follow-up was 4.4 (interquartile range 2.8–6.3; maximum 10.3) years. Using women without GDM as reference (incidence rate 2.18 per 1,000 person-years), women with GDM were at an increased risk of future T2DM; this risk was greater when using the DC compared with the IADPSG criteria (incidence rate 18.74 [95% CI 17.58–19.90] vs. 14.07 [95% CI 13.24–14.91] per 1,000 person-years, respectively). The risk of future maternal T2DM increased with the number of abnormal OGTT values and was highest for women with three abnormal values (incidence rate 49.93 per 1,000 person-years; aHR 24.57 [95% CI 21.26–28.39]). The risk of future T2DM was also affected by the type of OGTT abnormality: women with an abnormal fasting value had the greatest risk, whereas women with an abnormal 2-h value had the lowest risk (aHR 14.09 [95% CI 12.46–15.93] vs. 9.22 [95% CI 8.19–10.37], respectively). Similar findings to those described above were observed when the risk of T2DM at a fixed time point of 5 years after the index pregnancy was considered as the outcome of interest. CONCLUSIONS In women with GDM, individualized information regarding the future risk of T2DM can be provided based on the type and number of abnormal OGTT values, as well as the diagnostic criteria used for the diagnosis of GDM.

Context The optimal 50 g-glucose challenge test (GCT) cutoff for the diagnosis of gestational diabetes mellitus (GDM) in twin pregnancies is unknown. Objective This work aimed to explore the screening accuracy of the 50 g-GCT and its correlation with the risk of large for gestational age (LGA) newborn in twin compared to singleton pregnancies. A population-based retrospective cohort study (2007-2017) was conducted in Ontario, Canada. Participants included patients with a singleton (n = 546 892 [98.4%]) or twin (n = 8832 [1.6%]) birth who underwent screening for GDM using the 50 g-GCT. Methods We compared the screening accuracy, risk of GDM, and risk of LGA between twin and singleton pregnancies using various 50 g-GCT cutoffs. Results For any given 50 g-GCT result, the probability of GDM was higher (P = .0.007), whereas the probability of LGA was considerably lower in the twin compared with the singleton group, even when a twin-specific growth chart was used to diagnose LGA in the twin group (P Conclusion The screening performance of the 50 g-GCT for GDM and its correlation with LGA differ between twin and singleton pregnancies.

Thrombocytopenia is the second most common hematological disorder in pregnancy and complicates approximately 10% of all pregnancies. The data regarding the association of mild thrombocytopenia in women undergoing cesarean section and risk of bleeding or bleeding-related complications are scarce. Thus, the aim of the current study was to assess the association of mild thrombocytopenia with hemorrhage-related morbidities, among patients undergoing elective cesarean section. We performed a retrospective cohort study, in a single tertiary university-affiliated medical center, between 1 January 2012 and 31 May 2019. Medical charts of women who underwent elective cesarean section at term (37+0/7–41 + 6/7 weeks of gestations) were retrieved and analyzed. We compared women with mild thrombocytopenia (platelet count of 100–149 × 103/μL) to women with normal platelet count (150–450 × 103/μL). The primary outcome was the need for red blood cell transfusion during the index admission. A secondary outcome was severe bleeding not requiring blood transfusion defined as postpartum hemoglobin decline of ≥ 3 g/dL as compared to the prepartum levels. During the study period, 1577 women were included in the final analysis, of them 396 (25.11%) had mild thrombocytopenia prior to delivery. As compared to the control group, women with mild thrombocytopenia had higher rates of blood transfusion (3.79 vs. 1.52%, p = 0.01), and had a significant decline in hemoglobin levels. In a multivariable logistic regression model, mild thrombocytopenia was independently associated with blood transfusion with adjusted OR of 2.34 (95% CI 1.10–4.96, p = 0.03). Preoperative mild thrombocytopenia is associated with an increased risk of blood loss and blood transfusion in women undergoing elective CS. More studies are required to assess those observations in context of urgent cesarean sections and whether any preventive measures can reduce the risk for bleeding.

To identify risk factors for postpartum hemorrhage (PPH) following cesarean delivery (CD).A retrospective study of all women who underwent CD in a university-affiliated tertiary hospital (2014-15). PPH was defined as any of the following: clinical PPH (≥1000 ml estimated blood loss), hemoglobin (Hb) drop ≥3 g/dl (the difference between pre-CD Hb level within a 24 h prior to the delivery) and post-CD (nadir level during the first 72 h after CD)) or the need for blood products transfusion. The characteristics of women with PPH following CD were compared to a control group of those with CD without PPH.Of the 15,564 deliveries during the study period, 3208 (20.6%) women met inclusion criteria, of them, 307 (9.6%) had PPH and 2901 (90.4%) served as controls. Women in the PPH group were younger (32.6 ± 5.3In women undergoing cesarean section, urgent CD, the duration of the surgery, and the number of the previous CD are associated with the risk of PPH and should be taken into consideration during the postpartum assessment.

To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD. This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries. Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73–8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39–0.97, and aOR 0.49; 95% CI 0.25–0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC. Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.

Objective: The aim of the current study was to identify the optimal cutoff that should define discordance in dichorionic twin gestations through correlation with abnormal placental pathology as a specific measure of fetal growth restriction of the smaller twin. Methods: We performed a retrospective cohort study of all women with dichorionic twin pregnancies who gave birth in a single center between 2002 and 2015. We investigated the association between the level of growth discordance and maternal vascular malperfusion (MVM) pathology in the placenta of the smaller twin, with and without adjustment for whether the smaller twin is small for gestational age (SGA). Results: A total of 1,198 women with dichorionic twin gestation met the study criteria. The rate of MVM pathology in the placenta of the smaller twin increased with the level of discordance and was most obvious for discordance ≥25% (rate of MVM 12.0% compared with 2.8% in cases with discordance Conclusion: Our findings suggest that discordant growth in dichorionic twins should raise the concern of fetal growth restriction of the smaller twin, irrespective of whether the smaller twin is SGA, only when the discordance s ≥25%. The association of lower levels of discordance with abnormal placental pathology is mainly driven by the confounding effect of SGA of the smaller twin.

To evaluate the correlation between urine protein/creatinine ratio (UPCR) and proteinuria in a 24-h urine collection and to calculate the predicative accuracy of different cutoffs of UPCR for the diagnosis of proteinuria. A retrospective cohort study including women who admitted for the evaluation for suspected preeclampsia (PET) beyond 20 weeks of gestation in a single tertiary center. Both UPCR test and quantification of proteinuria using 24-h urine collection were obtained during their index hospitalization no more than 48 h apart. Women with pre-existing diabetes mellitus, known renal disease or proteinuria prior to pregnancy or chronic hypertension were excluded. Predictive accuracy of UPCR for several cutoffs of proteinuria was evaluated. Multivariate logistic regression analysis was used to assess diagnostic accuracy of UPCR in sub-populations according to obstetrical characteristics. Overall 463 patients were included. Of them 316 (68.3%) have 24-h urine protein collection of ≥ 300 mg/day. Mean gestational age at evaluation was 34.0 ± 3.4 weeks. Median (and interquartile range) time interval between UPCR and 24-h urine collection was 1.8 (1.6–1.9) days. Sensitivity and specificity of UPCR of 0.3 for predicting proteinuria ≥ 300 mg/day were 90.1% and 63.3%, respectively. The corresponding values for difference proteinuria cutoffs: ≥ 1000 mg/day and 5000 mg/day were 98.4, 100% and 29.1, 36.0%, respectively. The optimal UPCR thresholds for 24-h urine protein collection of ≥ 300 mg/day, ≥ 1000 mg/day and 5000 mg/day were 0.31, 0.70 and 2.49, respectively. The predictive accuracy of UPCR > 0.30 in predicting proteinuria was unaffected by demographic and obstetrical characteristics as maternal age, pre-pregnancy BMI, gestational age at examination, creatinine levels or by multiple gestation [adjusted OR 18.27 (95% CI 9.97–33.47)]. UPCR was strongly correlated with various cutoffs of proteinuria obtained by 24-h urine collection. UPCR cutoff varied depending on the specific measured outcome. This correlation was not affected by gestational age at examination.

Our objective was to evaluate the effects of time and temperature on umbilical-cord blood analysis.This prospective study included the term spontaneous vaginal deliveries. One venous and seven arterial samples were drawn from each umbilical cord within 5 min from delivery. Three samples were immediately refrigerated (3 °C), while all other samples were stored at room temperature (23-26 °C). Samples were analyzed in pairs (refrigerated and room-temperature samples) at 0, 20, 40, and 60 min after delivery for pH and lactate levels. Repeated-measures analysis using a generalized linear model was used to compare the change in pH and lactate values over time.518 samples from 74 women were analyzed. The mean gestational age was 39.1 ± 1.1 weeks. All neonates had an Apgar score of ≥9 in the 1st and 5th minutes. Mean arterial pH and lactate levels at delivery (time 0) were 7.32 ± 0.07 and 4.00 ± 1.36 mmol/L, respectively. Over time, a statistically significant decrease in pH and a reciprocal increase in lactate levels were observed. The mean change in arterial pH following 60 min was 0.021 ± 0.028 (room-temperature) and 0.016 ± 0.023 (refrigerated);Both time and temperature have significant effects on cord blood analysis. Yet, these changes are minor and may not have any clinical significance unless in extreme cases in which medicolegal aspects emerge.

To evaluate the effect of the choice growth chart and threshold used to define small for gestational age (SGA) on the predictive value of SGA for placenta-related or unexplained antepartum stillbirth.A retrospective cohort study of all women with a singleton pregnancy who gave birth 24 week gestation in a single center (2000-2016). The exposure of interest was SGA, defined as birth weight 10th or 25th centile according to three fetal growth charts (Hadlock et al., Radiology 181:129-133, 1991; intergrowth-21st (IG21), WHO 2017, and a Canadian birthweight-based reference-Kramer et al., Pediatrics 108:E35, 2001). The outcome of interest was antepartum stillbirth due to placental dysfunction or unknown etiology. Cases of stillbirth attributed to other specific etiologies were excluded.A total of 49,458 women were included in the cohort. There were 103 (0.21%) cases of stillbirth due to placental dysfunction or unknown etiology. For cases in the early stillbirth cluster (≤ 30 weeks), the detection rate was high and was similar for the three ultrasound-based fetal growth charts of Hadlock, IG21, and WHO (range 83.3-87.0%). In contrast, the detection rate of SGA for cases in the late stillbirth cluster ( 30 weeks) was low, being highest for WHO and Hadlock (36.7% and 34.7%, respectively), and lowest for IG21 (18.4%). Using a threshold of the 25th centile increased the detection rate for stillbirth by approximately 15-20% compared with that achieved by the 10th centile cutoff.At 30 week gestation, the Hadlock or WHO fetal growth charts provided the best balance between detection rate and false positive rate for stillbirth.

To investigate clinical and sonographic features associated with sonographic accuracy for the prediction of small for gestational age (SGA) and macrosomia at birth.The database of a tertiary medical center was retrospectively searched for women who gave birth at term to a singleton healthy neonate in 2007-2014 and underwent sonographic estimated fetal weight (sEFW) evaluation within 3 d before delivery. Fetal growth restriction (FGR) and SGA were defined as sEFW or birth weight10th percentile for gestational age; macrosomia was defined as birth weight4000 grams. Data on maternal age, parity, gestational age, fetal gender, presentation, placental location, diabetes, hypertension, and oligo/polyhydramnios were compared between pregnancies with a false-negative and false-positive diagnosis of SGA or macrosomia.Of the 5425 fetal weight evaluations, 254 (4.7%) deviated by15% from the actual birth weight. Nulliparity, absence of diabetes, neonatal female gender, anterior placenta, lower birth weight, and oligohydramnios were associated with a high deviation. We identified 482 SGA neonates (8.9%) and 633 macrosomic neonates (11.7%). A false-positive diagnosis of FGR was associated with oligohydramnios, absence of diabetes, and posterior placenta, and a false-negative diagnosis, with older maternal age, nulliparity, and male gender. A false-positive diagnosis of macrosomia was associated with older maternal age, multiparity, polyhydramnios, anterior placenta, and lack of hypertensive complications, and a false-negative diagnosis, with diabetes, hypertension, oligohydramnios, and vertex presentation.The accuracy of sEFW is affected by clinical and sonographic pregnancy characteristics. Further analyses should focus on improving accuracy especially at the fetal weight extremes.

A rise in the rate of cesarean delivery (CD) has been found to be associated with a higher length of hospital stay, making it a public health concern. We aimed to evaluate risk factors for prolonged hospitalization following CD.A retrospective cohort study, in a single tertiary medical center, was conducted (2011-2019). Cesarean deliveries were categorized into three groups according to the postpartum length of stay (a) up to 3 days (the routine post cesarean hospital stay in our center, reference group) (b) 4-9 days, and (c) 10 days or above (prolonged hospitalization). Risk factors were examined using univariate analysis as well as multivariate logistic regression. A specific risk prediction score was developed to predict the need for prolonged hospitalization and ROC curve was assessed utilizing the performance of our model.Overall, 87,424 deliveries occurred during the study period. Of them, 19,732 (22.5%) were cesarean deliveries. Hospitalization period was distributed as follows: 10,971 (55.6%) women were hospitalized for up to 3 days, 7,576 (38.4%) stayed for 4-9 days and 1,185 (6%) had a prolonged hospitalization period (≥10 days). Using multivariate analysis, multiple pregnancy (OR = 1.29, 95%CI 1.05-1.58), preterm delivery 37 weeks (OR = 8.32, 95%CI 6.7-10.2), Apgar score 7 (OR = 1.41, 95%CI 1.11-1.78) and non-elective CD (OR = 1.44, 95%CI 1.15-1.8) were identified as independent risk factors for prolonged hospitalization. Antenatal thrombocytopenia (PLT 100 K) was found to be a protective factor (OR = 0.51, 95%CI 0.28-0.92). Our score model included antenatal risk factors and was found to be predicting the outcome, with an AUC of 0.845 (95%CI 0.83-0.86, p-value 0.001).A prediction score model for prolonged hospitalization after CD may be beneficial for risk assessment and post-partum management.

OBJECTIVE: To evaluate the correlation of maternal and cord blood levels of SARS-CoV-2 antibodies in pregnant women immunized against COVID-19. METHODS: A prospective cohort study was performed of pregnant women who delivered at a single university affiliated tertiary medical center. Women who received the COVID-19 vaccine (BNT162b2 Pfizer©) were approached. The correlation between levels of maternal sera and umbilical cord SARS-CoV-2 specific IgG was assessed. RESULTS: Overall, 58 women were included; of them, 19 had received a single dose and 39 received two doses of the COVID-19 vaccine. Positive levels of umbilical cord IgG were found in 13/19 (68.4%) and 38/39 (97.4%) women after the administration of a single dose and two doses of the vaccine, respectively. The levels of SARS-CoV-2 IgG antibodies in the maternal sera of vaccinated women were positively correlated to their respective concentrations in cord blood sera (ρ = 0.857; R2 linear = 0.719; P

Over the past few decades, we have been experiencing an increase in the incidence of multiple gestations, mostly due to the widespread use of assisted reproduction technologies [...]

We aimed to investigate the association of advanced maternal age with intrapartum cesarean delivery and to assess its risk factors and perinatal outcomes.A retrospective cohort study of all women with singleton pregnancies who attempted a trial of labor (≥24 + 0 weeks of gestation) in a single center (2011-2017). The study population was stratified by parity (nulliparous or multiparous) and further sub-categorized into three cohorts: (1) women35 years at birth (reference group), (2) women aged 35-40 years, and (3) women40 years. Labor and delivery characteristics and neonatal outcomes were compared.Overall, 55,089 women were included: 39, 192 (71.1%) were under 35 years old, 15,90712,892 (28.923.4%) were 35-40 y and 3,015 (5.5%) were40 y. For nulliparas, the rate of intrapartum Cesarean deliveries increased with maternal age and approached 25.3% in those40 y as compared to 8.9% for those35 y. The positive association between Cesarean section rates and maternal age extends beyond nulliparas and is also seen in multiparas, although to a smaller degree. After adjusting for confounders, maternal age was significantly and independently associated with intrapartum cesarean delivery in a dose-dependent manner in nulliparous women, [adjusted Odd Ratio (aOR) 1.56 (95% Confidence Interval (CI) 1.39-1.76) and 2.53 (2.07-3.09)] among women aged 35-40 y and40 y, respectively. Maternal age was not significantly associated with adverse neonatal outcome.Advanced maternal age is an independent risk factor for intrapartum Cesarean delivery. Yet, the majority of older gravidae who attempt a trial of labor, even if nulliparous, deliver vaginally without an increase in adverse neonatal outcome.

Background: People whose singleton pregnancy is affected by hypertensive disorders of pregnancy (HDP) are at risk of future cardiovascular disease. It is unclear, however, whether this association can be extrapolated to twin pregnancies. We aimed to compare the association between HDP and future cardiovascular disease after twin and singleton pregnancies. Methods: We conducted a population-based retrospective cohort study that included nulliparous people in Ontario, Canada, 1992–2017. We compared the future risk of cardiovascular disease among pregnant people from the following 4 groups: those who delivered a singleton without HDP (referent) and with HDP, and those who delivered twins either with or without HDP. Results: The populations of the 4 groups were as follows: 1 431 651 pregnant people in the singleton birth without HDP group; 98 631 singleton birth with HDP; 21 046 twin birth without HDP; and 4283 twin birth with HDP. The median duration of follow-up was 13 (interquartile range 7–20) years. The incidence rate of cardiovascular disease was lowest among those with a singleton or twin birth without HDP (0.72 and 0.74 per 1000 person-years, respectively). Compared with people with a singleton birth without HDP, the risk of cardiovascular disease was highest among those with a singleton birth and HDP (1.47 per 1000 person-years; adjusted hazard ratio [HR] 1.81 [95% confidence interval (CI) 1.72–1.90]), followed by people with a twin pregnancy and HDP (1.07 per 1000 person-years; adjusted HR 1.36 [95% CI 1.04–1.77]). The risk of the primary outcome after a twin pregnancy with HDP was lower than that after a singleton pregnancy with HDP (adjusted HR 0.74 [95% CI 0.57–0.97]), when compared directly. Interpretation: In a twin pregnancy, HDP are weaker risk factors for postpartum cardiovascular disease than in a singleton pregnancy.

OBJECTIVE To determine maternal and neonatal complications associated with an intrapartum cesarean delivery (CD) with and without a history of a previous CD. METHODS A retrospective cohort study of all women who underwent an unplanned intrapartum CD following a trial of labor in a university-affiliated tertiary hospital, between 2009 and 2016. Perinatal outcomes of women with and without a history of a previous CD were compared. Composite adverse maternal outcome included one or more of the following: postpartum hemorrhage, need for blood transfusion, or cesarean hysterectomy. Composite adverse neonatal outcome included one or more of the following: 5-min Apgar score

We aimed to investigate the association of mild thrombocytopenia with postpartum hemorrhage (PPH) and blood transfusion among women with twin gestations.A retrospective cohort study (Jan 2015 to May 2019) was performed. Women with twin pregnancies and pre-delivery mild thrombocytopenia were compared to those with normal platelet count. The primary outcome was the rate of PPH, defined as a composite of one or more of the following: (1) need for packed red blood cell transfusion; (2) postpartum hemoglobin decline of ≥3 g/dL; and (3) the use of postpartum uterotonics agents in addition to oxytocin.Of 1085 women who were included in final analysis, 315 (30.9%) had mild thrombocytopenia (and 770 (69.1%) served as controls. The rate of PPH was increased in the study group (14% vs. 9.4%, P = 0.03), as was the use of uterotonic agents (3.8% vs. 1.3%, respectively, P = 0.02). The rate of blood product transfusion and hemoglobin decline3 g/dL was not significantly different between the groups. In multivariate logistic regression analysis, mild thrombocytopenia was associated with a higher risk for PPH (OR 1.55 [95% CI 1.02-2.35], P = 0.02).Mild thrombocytopenia in twin pregnancies is associated with an increased risk of interventions such as the use of uterotonic agents.

To evaluate whether induction of labor (IOL), as compared with expectant management, in gestational diabetes mellitus (GDM) mothers at term (between 370/7 and 406/7), decreases caesarean section (CS) rate and the rate of adverse composite neonatal outcomes. A retrospective cohort study, of all women with GDM and a singleton gestation who delivered at term in a single, tertiary, university-affiliated medical center (2007–2014). We compared outcomes of women who underwent IOL at each week of gestation between 370/7 and 406/7 weeks with women who were managed expectantly. The primary outcome was CS rate. Overall, 2472 GDM patients included in the study, of which 880 women had IOL. CS rate was not found to be significantly different between the groups at any gestational age. IOL at 37 weeks was associated with adverse composite neonatal outcome (aOR 2.2, 95% CI 1.4–3.6) and NICU admission (aOR 2.5, 95% CI 1.4–4.4). At 38 weeks, with NICU admission (aOR 2.0, 95% CI 1.4–2.9), and at 39 weeks with fracture of the clavicle. In a sub-analysis of nulliparous women, IOL at 37 weeks had higher odds of NICU admission and adverse composite neonatal outcomes, at 38 weeks with CS and at 39 weeks with fracture of the clavicle. IOL in GDM mothers at term does not reduce CS rate and may be associated with increased CS rate among nulliparous women at 38 weeks. It is also associated with increased risk for adverse composite neonatal outcome or NICU admission when done prior to 390/7 weeks.

© 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited., Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

Background We assessed the association of early term at first birth (ETB) with the risk of preterm birth (PTB) and ETB in women with 3 consecutive deliveries. Methods We conducted a retrospective cohort study of all women with 3 consecutive singleton births at a single institute from 1994 to 2013. The risk of PTB ( Results Of 49,259 women delivered in our center during the study period, 4038 met inclusion criteria. The rate for subsequent PTB, spontaneous PTB and recurrent ETB in the 3rd delivery significantly increased as the number of prior ETBs increased. The order of a single prior ETB in one of the first two deliveries was differently associated with the risk of complications in the 3rd delivery, which was higher when the prior ETB was more recent to the third delivery. Conclusion A history of ETB is associated with the risk of future PTB and recurrent ETB. The risk is related to the number and order of prior ETBs.

Background: We aimed to explore the association of the number, order, gestational age and type of prior PTB and the risk of preterm birth (PTB) in the third delivery in women who had three consecutive singleton deliveries. Methods: A retrospective cohort study of all women who had three consecutive singleton births at a single medical center over a 20-year period (1994&ndash, 2013). The primary outcome was PTB (&lt, 37 weeks) in the third delivery. Results: 4472 women met inclusion criteria. The rate of PTB in the third delivery was 4.9%. In the adjusted analysis, the risk of PTB was 3.5% in women with no prior PTBs, 10.9% in women with prior one PTB only in the first pregnancy, 16.2% in women with prior one PTB only in the second pregnancy, and 56.5% in women with prior two PTBs. A similar trend was observed when the outcome of interest was spontaneous PTB and when the exposure was limited to prior spontaneous or indicated PTB. Conclusions: In women with a history of PTB, the risk of recurrent PTB in subsequent pregnancies is related to the number and order of prior PTBs. These factors should be taken into account when stratifying the risk of PTB.

Twin pregnancies account for about 3.3% of all deliveries in the United States, with most of them being dichorionic diamniotic. Maternal physiological adaptation in twin pregnancies is exaggerated, and the rate of almost every maternal and fetal complication in twin pregnancies is higher than that in singleton pregnancies. Therefore, twin pregnancies necessitate closer antenatal surveillance by care providers, who are familiar with the specific challenges unique to these pregnancies. In addition, there is evidence that following women with twins in a specialized twin clinic can result in improved obstetrical outcomes. The importance of the first antenatal visit in twin pregnancies cannot be over emphasized and should preferably take place early in gestation, as that is the optimal period to correctly identify the number of fetuses and the type of placentation (chorionicity and amnionicity). This will allow the patients, families, and caregivers to make the appropriate modifications and tailor an optimal antenatal follow-up plan. This plan should focus on general recommendations such as weight gain and level of activity, education regarding the complications specific to twin pregnancies along with the relevant symptoms and indications to seek care, and close maternal and fetal monitoring. In this review, we summarize the available evidence and current guidelines regarding antenatal care in dichorionic diamniotic twin pregnancies.

The choice of fetal growth chart to be used in antenatal screening for fetal growth restriction (FGR) has an important impact on the proportion of fetuses diagnosed as small for gestational age (SGA), and on the detection rate for FGR. We aimed to compare diagnostic accuracy of SGA diagnosed using four different common fetal growth charts [Hadlock, Intergrowth-21st (IG21), World Health Organization (WHO), and National Institute of Child Health and Human Development (NICHD)], for abnormal placental pathology.A secondary analysis of data from a prospective cohort study in low-risk nulliparous women. The exposure was SGA (birthweight10th centile for gestational age) using each of the four charts. The outcomes were one of three types of abnormal placental pathology associated with fetal growth restriction: maternal vascular malperfusion (MVM), chronic villitis, and fetal vascular malperfusion.A total of 742 nulliparous women met the study criteria. The proportion of SGA was closest to the expected rate of 10% using the Hadlock chart (12.7%). The detection rates (DR) and false positive rates (FPR) for MVM pathology were similar for the Hadlock (DR = 53.1%, FPR = 10.8%), WHO (DR = 59.4%, FPR = 14.2%), and NICHD (DR = 53.1%, FPR = 12.3%) charts, and each was superior when compared to the IG21 chart (DR = 34.4%, FPR = 3.8%, p 0.001). The diagnosis of SGA was associated with increased risks of preeclampsia and preterm birth for all four charts.The selection of fetal growth chart to be used in screening programs for FGR has important implications with regard to the false positive and detection rate for FGR.

To evaluate the correlation between urine protein/creatinine ratio (UPCR) and proteinuria in a 24-h urine collection and to calculate the predicative accuracy of different cutoffs of UPCR for the diagnosis of proteinuria.A retrospective cohort study including women who admitted for the evaluation for suspected preeclampsia (PET) beyond 20 weeks of gestation in a single tertiary center. Both UPCR test and quantification of proteinuria using 24-h urine collection were obtained during their index hospitalization no more than 48 h apart. Women with pre-existing diabetes mellitus, known renal disease or proteinuria prior to pregnancy or chronic hypertension were excluded. Predictive accuracy of UPCR for several cutoffs of proteinuria was evaluated. Multivariate logistic regression analysis was used to assess diagnostic accuracy of UPCR in sub-populations according to obstetrical characteristics.Overall 463 patients were included. Of them 316 (68.3%) have 24-h urine protein collection of ≥ 300 mg/day. Mean gestational age at evaluation was 34.0 ± 3.4 weeks. Median (and interquartile range) time interval between UPCR and 24-h urine collection was 1.8 (1.6-1.9) days. Sensitivity and specificity of UPCR of 0.3 for predicting proteinuria ≥ 300 mg/day were 90.1% and 63.3%, respectively. The corresponding values for difference proteinuria cutoffs: ≥ 1000 mg/day and 5000 mg/day were 98.4, 100% and 29.1, 36.0%, respectively. The optimal UPCR thresholds for 24-h urine protein collection of ≥ 300 mg/day, ≥ 1000 mg/day and 5000 mg/day were 0.31, 0.70 and 2.49, respectively. The predictive accuracy of UPCR 0.30 in predicting proteinuria was unaffected by demographic and obstetrical characteristics as maternal age, pre-pregnancy BMI, gestational age at examination, creatinine levels or by multiple gestation [adjusted OR 18.27 (95% CI 9.97-33.47)].UPCR was strongly correlated with various cutoffs of proteinuria obtained by 24-h urine collection. UPCR cutoff varied depending on the specific measured outcome. This correlation was not affected by gestational age at examination.

We aimed to explore the association of vegetarian–vegan diets and pregnancy outcomes. A retrospective, web-based study conducted in 2017. Women who delivered

OBJECTIVE The value of using customized birth-weight centiles to improve the diagnostic accuracy for fetal growth restriction (FGR), in comparison with using population-based charts, remains a matter of debate. One potential explanation for the conflicting data is that most studies used measures of perinatal mortality and morbidity as proxies for placenta-mediated FGR, many of which are not specific and may be confounded by other factors such as prematurity. The aim of this study was to compare the diagnostic accuracy of small-for-gestational age (SGA) at birth, defined according to customized vs population-based charts, for associated abnormal placental pathology. METHODS This was a secondary analysis of data from a prospective cohort study on risk factors for placenta-mediated complications and abnormal placental pathology in low-risk nulliparous women. All placentae were sent for detailed histopathological examination by two perinatal pathologists. The primary exposure was SGA, defined as birth weight

To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD.This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries.Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73-8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39-0.97, and aOR 0.49; 95% CI 0.25-0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC.Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.

ObjectiveThe aim of this study was to investigate the effect of short or long interpregnancy interval (IPI) with placental mediated pregnancy complications after already complicated first delivery.MethodsWe performed a retrospective cohort analysis of all women with singleton pregnancies who delivered their first three consecutive deliveries in one university-affiliated medical center (1994–2013). Placental mediated complications included placental abruption, small for gestational age, preeclampsia, gestational hypertension, or preterm delivery. Following first complicated delivery, IPI was compared stratified by second delivery outcome. Following two complicated deliveries, IPI was compared stratified by third delivery outcome. IPI was evaluated as continuous or categorical variable (>18, 18–60, >60 months). Related samples Cochrans’ Q test and Mann-Whitney analysis were used as appropriate.ResultsOverall, 4310 women entered analysis. Of them, 18.3%, 10.5%, and 9.3% had complicated first, second, and third delivery, consecutively. Evaluated continuously, longer IPI, but not short IPI, was associated with higher rates of complicated second delivery. Stratified to categories, IPI had no effect on recurrent complications evaluated separately or as composite.ConclusionOur results suggest that long IPI may increase risk for placental mediated pregnancy complications. Further studies are needed to evaluate this effect.

To compare the incidence and risk factors for gestational diabetes mellitus (GDM) between women with twin and singleton pregnancies. Retrospective study of all women who had a twin or singleton birth in Ontario (2012–2016). Risk ratios (RR) and 95% CIs for GDM (stratified by type of treatment) were adjusted for relevant confounding variables. Multivariable Poisson regression analysis was used to identify risk factors for GDM in twin and singleton gestations. Of 270,843 women who met inclusion criteria, 266,942 (98.6%) and 3901 (1.4%) had a singleton and a twin pregnancy, respectively. Women with twins had a significantly higher risk for overall GDM (aRR = 1.13, 95% CI 1.01–1.28) and diet-treated GDM (aRR = 1.20, 95% CI 1.01–1.42) while the association with insulin-treated GDM was not significant (aRR = 1.07, 95% CI 0.89–1.28). Maternal age ≥ 35 years, non-Caucasian ethnicity and BMI > 30 kg/m2 were independent risk factors for GDM among women with twins and singletons, and the magnitude of the association of these factors with GDM was similar. Women with twins are at increased risk of GDM, mainly due to a higher rate of diet-treated GDM. Despite higher baseline risk of GDM in women with twins, the effect of known risk factors for GDM is similar to that observed in singletons.

Objective: To evaluate the outcomes of vacuum-assisted vaginal deliveries (VAD) among neonates of mothers with gestational diabetes mellitus (GDM).Study design: Retrospective cohort study of women ...