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Fetal growth restriction (FGR) is associated with an increased risk of adverse perinatal outcomes. The cerebroplacental ratio (CPR) represents the interaction of alterations in blood flow to the fetal brain and placenta. CPR has been utilized as a superior reflection of fetal hypoxia/acidemia and therefore a better predictor of fetal morbidity. We sought to determine the role of the CPR as an adjunctive tool to identify fetuses at increased risk of adverse perinatal outcomes in a study population of marijuana (MJ) exposed FGR fetuses.This was a retrospective cohort study of high-risk singleton pregnancies over a 4-year period. Self-identified daily MJ users with FGR fetuses in the 3rd trimester were isolated. Fetal biometry, amniotic fluid indices, and CPRs were calculated. A CPR1 was considered abnormal. FGR fetuses with normal and abnormal CPRs were then compared.26/192 (13.5%) of MJ exposed fetuses were diagnosed with FGR in the 3rd trimester. 12/26 (46%) had an abnormal CPR and 14 had a normal CPR (mean CPR 0.60 vs 1.57,Approximately half of the MJ exposed FGR fetuses had an abnormal CPR. In this subset of patients,90% had severe FGR, a higher proportion had absence/reversal of end diastolic flow in the UA, and a higher proportion had oligohydramnios. This demonstrates that an abnormal CPR identifies a group of FGR fetuses at a greater risk of adverse perinatal outcomes.

The recent legalization of marijuana has increased overall use, including in pregnancy. Studies have previously associated marijuana use with adverse fetal neurodevelopmental outcomes. We sought to compare fetal sonographic growth parameters and placental perfusion, as measured by umbilical artery Dopplers, in women using daily marijuana versus nonusers.A retrospective cohort study capturing self - identified pregnant daily marijuana users with gestational aged matched controls was performed. We compared maternal demographics, fetal biometry, nuchal translucency, and umbilical artery Dopplers in marijuana users versus controls. Intrauterine growth restriction was defined as an estimated fetal weight10th %.In 55 first trimester ultrasounds, there were no differences in crown rump lengths or nuchal translucencies between the groups. Likewise, in 195-second trimester ultrasounds, no differences were noted in biometry. Second trimester umbilical artery systolic to diastolic ratios were higher in marijuana users compared to nonusers (4.02 versus 3.92,Our data shows that daily marijuana use is associated with impaired fetal growth and increased placental vascular resistance. Marijuana consumption in pregnancy should be avoided until further studies delineate its exact potential for fetotoxicity.

Thrombophilias have been implicated in complications related to ischemic placental disease including recurrent pregnancy loss, intrauterine fetal demise, preeclampsia, fetal growth restriction, placental abruption, and preterm delivery. Maternal screening and treatment may lower the recurrence of these outcomes. Our objective was to estimate if antenatal screening for thrombophilias with the intention to offer treatment among women with a prior adverse pregnancy outcome (APO) is preferable to no screening. A decision-analytical model was constructed for pregnant women with prior APO, comparing screening for thrombophilia with intention to treat with no screening. Values obtained from previously published studies include probability of positive test: 0.3 (0.1 to 0.6); good outcome with treatment: 0.9 (0.3 to 0.99); no thrombophilia, good outcome: 0.75 (0.5 to 0.9); test negative, thrombophilia positive: 0.05 (0.01 to 0.1); test negative, thrombophilia positive, good outcome: 0.75 (0.5 to 0.9); thrombophilia/test negative, good outcome: 0.98 (0.5 to 0.99). Sensitivity analyses were run over a wide range of assumptions. Thrombophilia screening with intention to treat in women with prior APO associated with ischemic placental disease is the strategy of choice compared with no testing over a wide range of assumptions. Sensitivity analyses support this to be robust. Women with poor pregnancy history related to placental ischemic disease may benefit from thrombophilia screening and treatment in a subsequent pregnancy.

Beginning in October 1995, and for several years thereafter, our institution used indomethacin as a first-line tocolytic drug. Our purpose is to compare the outcomes of very low birth weight infants who were exposed to antenatal indomethacin with those who were not exposed to this therapy. We used our center's component of the NICHD Neonatal Research Network's Generic Data Base which recorded the outcomes of all live born infants weighing less than 1500 g over a 5-year period. We abstracted data concerning neonatal morbidity (death, Grades III to IV intraventricular hemorrhage (IVH), necrotizing enterocolitis and patent ductus arteriosus), as well as other factors including gestational age, birth weight, antenatal corticosteroid treatment and maternal hypertension or pre-eclampsia. Univariate analysis was performed using Fisher's exact test. Multivariate analysis using logistic regression was performed to control for confounding factors. A total of 85 infants who were exposed to antenatal indomethacin were compared to 464 infants who were not exposed to the drug. In the univariate analysis, antenatal indomethacin exposure was not associated with a significant increase in the incidence of necrotizing enterocolitis or patent ductus arteriosus. The incidence of Grades III to IV IVH was 17.9% in those infants exposed to antenatal indomethacin compared to 7.1% in the nonexposed infants (p=0.008). The incidence of neonatal death in the exposed infants was 27.7 versus 16.4 in the nonexposed infants (p=0.02). After controlling for antenatal corticosteroids, maternal pre-eclampsia, gestational age and birth weight, antenatal indomethacin was significantly associated with an increased incidence of IVH, but not neonatal death. Antenatal indomethacin was associated with significantly higher rates of IVH. Additional studies assessing the potential risks of indomethacin tocolysis are needed before it is used as a first-line tocolytic therapy.

Objective Pulmonary embolism is a major cause of maternal death. The work up for suspected pulmonary embolism is complex, with many potential diagnostic options. We performed a cost analysis to evaluate which of several diagnostic strategies was the most cost-effective with the least number of deaths from pulmonary embolism. Study design We created a decision tree to evaluate the following strategies: (1) Compression ultrasonography followed by anticoagulation (if there is a positive result) or secondary tests, ventilation perfusion scans or spiral computed tomography (if there is a negative result); high probability ventilation perfusion scans (a positive test result) resulted in anticoagulation; low probability ventilation perfusion scans (a negative test) resulted in no treatment; intermediate tests that resulted in a second test (computed tomography or pulmonary angiography). (2) Ventilation perfusion scans as a primary test followed by anticoagulation (as outlined in [1]). (3) Computed tomography followed by anticoagulation (if there is a positive result). The following assumptions were made: The incidence of pulmonary embolism in pregnant women with suspected pulmonary embolism is 5%; 40% of documented pulmonary embolisms have a positive compression ultrasound result; 10% of ventilation perfusion scans for suspected pulmonary embolism are high probability, 60% are indeterminate, and 30% are low probability for pulmonary embolism; the sensitivity of computed tomography is 95%; the sensitivity of angiography is 98%. The assumed mortality rate of treated pulmonary embolism is 0.7% and of untreated pulmonary embolism in pregnancy is 15% (range, 10%-50%). The angiography-associated mortality rate is 0.5%, and the anticoagulation associated mortality rate is 0.2%. The following costs were used for the model: compression ultrasonography, $200.00; ventilation perfusion scans, $400.00; angiography, $1000.00; computed tomography, $500.00; and anticoagulation, $5982.00. Results With baseline assumptions, spiral computed tomography as the initial diagnostic regimen was found to be the most cost-effective at $17,208 per life saved. Sensitivity analyses were performed over a wide range of assumptions that included alteration of the probability of pulmonary embolism, the sensitivity of computed tomography, ventilation perfusion scans, and compression ultrasonography, the cost of computed tomography, and the mortality rate of untreated pulmonary embolism. Our findings remained robust over a wide range of assumptions. Conclusion Suspected pulmonary embolism remains a diagnostic quandary. Our analysis indicated that spiral computed tomography offers the most cost-effective method for diagnosing this potentially fatal condition.

Venous thromboembolic disease is a major cause of maternal morbidity and mortality. Virchow's triad of hypercoagulability, venous stasis, and vascular damage all occur during pregnancy. The risk of venous thromboembolism is five to six times higher during pregnancy and the puerperium. Risk factors include age greater than 35, antiphospholipid antibodies, inherited thrombophilias, operative delivery, increased parity, obesity, mechanical heart valves,and family history. Prophylactic and therapeutic anticoagulation is recommended for women at risk. Low molecular weight heparins are safe and effective in most cases.

The available data unambiguously support the beneficial, short-term fetal effects of antenatal corticosteroids in women at risk for preterm delivery. There are still several incompletely addressed questions, including the use of corticosteroids in women with preterm premature rupture of membranes, the optimal corticosteroid preparation to be used, and the impact of repeated dosing. These issues are discussed in this review from the perspective of recent scientific evidence on the mechanisms responsible for positive short-term effects on survival and possible harmful long-term effects.

The objective of this study is to develop a simple, brief, self-report perinatal depression inventory that accurately measures severity in a number of populations. Our team developed 159 Likert-scale perinatal depression items using simple sentences with a fifth-grade reading level. Based on iterative cognitive interviewing (CI), an expert panel improved and winnowed the item pool based on pre-determined criteria. The resulting 67 items were administered to a sample of 628 pregnant and 251 postpartum women with different levels of depression at private and public sector obstetrics clinics, together with the Beck Depression Inventory (BDI-II), Edinburg Postpartum Depression Scale (EPDS), and the Patient Health Questionnaire (PHQ-9), as well as Module A of the Structured Clinical Interview for DSM-IV Diagnoses (SCID). Responses were evaluated using Item Response Theory (IRT). The Perinatal Depression Inventory (PDI)-14 items are highly informative regarding depression severity and function similarly and informatively across pregnant/postpartum, white/non-white, and private-clinic/public-clinic populations. PDI-14 scores correlate well with the PHQ-9, EPDS, and BDI-II, but the PDI-14 provides a more precise measure of severity using far fewer words. The PDI-14 is a brief depression assessment that excels at accurately measuring depression severity across a wide range of severity and perinatal populations. Electronic supplementary material The online version of this article (doi:10.1007/s00737-015-0553-9) contains supplementary material, which is available to authorized users.

Background and Objectives: The increasing use and acceptance of robotic platforms calls for the need to train not only established surgeons but also residents and fellow trainees within the context of the traditional residency and fellowship program. Our study aimed to clarify the current status of robotic training in gynecologic fellowship programs in the United States. Methods: This was a Web-based survey of four gynecology fellowship programs in the United States from November 2010 to March 2011. Programs were selected based on their geographic areas. A questionnaire with 43 questions inquiring about robotic surgery performance and training was sent to the programs and either a fellow or the fellowship director was asked to complete. Participation was voluntary. Results: We had 102 responders (18% respond rate) with an almost equal response rate from all four gynecologic fellowships, with a median response rate of 25% (range 21–29%). Minimally Invasive Surgery (MIS) and Gynecologic Oncology (Gyn Onc) fellowships had the highest rate of robotic training in their fellowship curriculum—95% and 83%, respectively. Simulator training was used as a training tool in 74% of Female Pelvic Medicine and Reconstructive Surgery (FPMRS); however, just 22% of Reproductive Endocrinology and Infertility fellowships had simulator training. Eighty-seven percent of Gyn Onc fellows graduate with >50 robotic cases, but this was 0% for Reproductive Endocrinology Infertility fellows. Conclusion: Our study showed that the use of a robotic system was built into fellowship curriculum of >80% of MIS and Gyn Onc fellowship programs that were entered in our study. Simulator training has been used widely in Ob&Gyn fellowship programs as part of their robotic training curriculum.

Objectives The purpose of this study was to determine job satisfaction among program directors in obstetrics and gynecology with the use of a validated tool and to identify specific sources of dissatisfaction that might lead to job change. Study design The program director satisfaction and a global job satisfaction survey were sent to all program directors in the United States. Motivators for seeking a job change were assessed. The χ 2 test, Kruskal-Wallis test, correlation analysis, and multiple linear regression were used. Results Seventy percent of 254 surveys were completed. Global job satisfaction (minimum, 4; maximum, 16) was 11.9±2.9; mean program director satisfaction score was 135±25.8 (minimum, 54; maximum, 200). Job satisfaction was highest in chairs, full professors, those whose age was >50 years, and those with >5 years of experience ( P =.02) and in facets that were related to work with residents, colleagues, and patients. Dissatisfaction was highest with regard to salary, promotion opportunities, and resources. Forty-six percent of those who responded were considering a job change in 3 years; the most common reason for a job change that was cited was administrative hassles. Conclusion Although job satisfaction is high among program directors, administrative hassles may lead to high rate of rapid turnover.

Background Preoperative transfusions are frequently given to prevent morbidity in nonpregnant patients with sickle cell disease. We describe a case of a life-threatening delayed hemolytic transfusion reaction with hyperhemolysis syndrome in pregnancy. Case A multigravida with sickle cell disease underwent prophylactic blood transfusion before repeat cesarean delivery. Her immediate postpartum course was uneventful, but on postoperative day number 6 she presented in grave condition with what was thought initially to be an infection versus crisis. Delayed hemolytic transfusion reaction with hyperhemolysis was ultimately diagnosed. Conclusion In the gravida with sickle cell disease and known multiple red cell antibodies, blood transfusion may incur a higher risk for delayed transfusion reaction, hyperhemolysis syndrome, and possible death. Blood transfusion should be used cautiously in these patients.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disorder that predominantly affects the right side of the heart and causes ventricular arrhythmias. In many patients the disease is familial. ARVC may account for as many as 5% of unexpected sudden deaths. We report a case of ARVC diagnosed at 21 weeks gestation treated with an implantable cardiac defibrillator. The remainder of her pregnancy was uneventful and the patient underwent induction of labor at 39 weeks gestation with a passive second stage forceps-assisted delivery resulting in delivery of a normal infant. In the gravida with cardiac arrhythmias, defibrillator placement may offer a safe, life-preserving treatment and should be considered.

In December 2001, the American College of Obstetricians and Gynecologists revised their recommendations for breech delivery. These recommendations acknowledge that although a planned vaginal delivery may no longer be appropriate, there are instances in which vaginal breech delivery is inevitable. Moreover, there continues to be patients who for any number of reasons will choose vaginal over cesarean delivery when faced with a fetus in the breech presentation. We sought to review maternal and fetal outcomes in such circumstances when vaginal breech delivery occurs, and compare these outcomes to elective cesarean deliveries for breech presentation. We performed a retrospective review of all singleton breech deliveries at our county hospital from January 2002 through June 2003. We reviewed maternal age, ethnicity, gestational age, gravity, parity, birthweight, mode of delivery, Apgar scores, umbilical arterial blood gases, and maternal and infant complications of both cesarean deliveries and vaginal breech deliveries. Univariate and logistic regression statistical analyses were performed with NCSS software. We had a total of 150 term breech deliveries with gestational ages between 37 and 42 weeks. Of these, 41 were vaginal breech and 109 were cesarean deliveries. Greater than 95% of patients are of Hispanic origin. There were no statistically significant differences in maternal age, ethnicity, gravity, or gestational age. Mean birthweight was significantly lower and parity was significantly higher in the vaginal delivery group. There was also a higher proportion of patients who underwent labor induction/augmentation in the vaginal group. We found no differences in the outcomes of 5-minute Apgar scores, umbilical arterial blood gas values, neonatal intensive care unit admissions, deaths or maternal/fetal complications reported between the two groups. Mean umbilical arterial blood gas values were greater than 7.18 in both groups. Vaginal breech delivery cannot always be avoided. Moreover, at our county hospital several patients continue to choose vaginal breech delivery. Our data would suggest that vaginal breech delivery remains a viable option in selected patients.

Mother-to-child transmission of human immunodeficiency virus is the most common cause of pediatric human immunodeficiency virus in the United States; the Centers for Disease Control and Prevention recommendations endorse rapid human immunodeficiency virus testing for women with unknown viral status to quicken antiretroviral therapy. We compared the cost-effectiveness of Oraquick (Orasure Technologies, Bethlehem, Pa) rapid testing versus enzyme-linked immunosorbent assay testing for a low-risk population of Mexican American women who are in labor.Using decision analysis techniques, we tested 2 strategies: (1) testing with enzyme-linked immunosorbent assay that was confirmed by Western blot and (2) testing with Oraquick rapid testing that was confirmed by Western blot. All seropositive parturients received zidovudine treatment in labor. The baseline assumptions were the incidence of human immunodeficiency virus in Mexican American mothers (0.05%), mother-to-child transmission with no treatment (25%), with treatment in labor (10%), sensitivity of enzyme-linked immunosorbent assay (98%), positive predictive value of enzyme-linked immunosorbent assay (10%), sensitivity/specificity of Oraquick rapid testing (99%/100%), positive predictive value of Oraquick rapid testing (83%-100%), sensitivity/specificity of Western blot (97%/99%), costs (enzyme-linked immunosorbent assay [dollar 5], Oraquick rapid testing [dollar 15], Western blot [dollar 25], zidovudine treatment [dollar 76] for 12 hours labor, neonatal treatment [dollar 2.50], lifetime treatment of human immunodeficiency virus-affected child [dollar 194,250]). Sensitivity analyses were done over a wide range of assumptions that included the costs of tests, the sensitivity of Oraquick rapid testing, the positive predictive value of enzyme-linked immunosorbent assay and Oraquick rapid testing, and the costs of treatments.Oraquick rapid testing was the preferred strategy at dollar 98 spent per human immunodeficiency virus-negative child versus dollar 491 for enzyme-linked immunosorbent assay testing. Much of the cost of the enzyme-linked immunosorbent assay strategy was due to the treatment of women and infants with false-positive tests. Sensitivity analysis over test costs, test sensitivity, and other variables found the analysis results to be robust. Threshold analysis revealed that, if the cost remaineddollar 409.90, Oraquick rapid testing was the dominant test.In a low prevalence population, the universal use of Oraquick rapid testing is cost-effective because of the low rate of false-positive results, thus preventing the emotional and economic costs of unnecessary treatment for human immunodeficiency virus to the new mother and her family.

Objective Vein of Galen aneurysmal malformations (VGAMs) are rare congenital malformations thought to develop during weeks 6 to 11 of fetal life. Although they represent less than 1% of all cerebral vascular malformations, they constitute up to 30% of all pediatric vascular malformations. Vein of Galen aneurysmal malformations cause high-output heart failure in the fetus and neonate secondary to the decreased resistance and high blood flow in the lesion. We describe 2 cases, 1 prenatal and 1 postnatal, in which unusual aortic Doppler flow patterns and substantial brachiocephalic vessel dilation contributed to the discovery of a VGAM. Methods Echocardiographic findings associated with VGAM malformations in 2 cases are described. Results Unusual Doppler flow patterns and substantial brachiocephalic vessel dilation were seen in both cases. Pseudocoarctation of the aorta was also noted in both cases. Conclusions The echocardiographic findings in fetal and neonatal VGAM may include pseudocoarctation of the aorta. Abnormal fetal cardiac findings should raise the practitioner's suspicion for cerebral malformations and vice versa.

Objective The purpose of this study was to determine whether sensory or affective dimensions of pain with genetic amniocentesis are associated with identifiable clinical correlates. Study design Women completed the short-form McGill Pain Questionnaire after second-trimester genetic amniocentesis. The effect of maternal weight, parity, previous amniocentesis, previous surgery, history of menstrual cramps, maternal anxiety, presence of fibroid tumors, and depth and location of needle insertion on pain intensity was determined. The T-test, correlation matrix, Kruskal-Wallis test, and multiple logistic regression were used for analysis; a probability value of Results One hundred twenty-one women were enrolled: 19.3% reported no pain, 42.9% described the pain as mild, 31.1% described the pain as discomforting, and 6.7% described the pain as distressing or horrible. Mean intensity of pain was 1.6±1.3 (on a scale of 0-7). Pain was most often described as sharp, cramping, fearful, and stabbing. Anxiety and pain were increased in women with an indication of abnormal serum screen as compared with women with advanced maternal age. Anxiety and a history of menstrual cramps were associated with increased affective dimensions of pain and had moderate correlation with quantified pain intensity. A history of previous amniocentesis and needle insertion in the lower one third of the uterus were associated with increased pain. Maternal weight, parity, previous surgery, fibroid tumors, and depth of needle insertion were not correlated with perceived pain. Presence or absence of an accompanying person was not associated with pain intensity. Conclusion Women report mild pain or discomfort with genetic amniocentesis. Increased pain is associated with increased maternal anxiety, a history of menstrual cramps, a previous amniocentesis, and insertion of the needle in the lower uterus.

Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2,000 to 4,000 births and accounts for 8% of all major congenital anomalies. Recurrence risk for a subsequent pregnancy is estimated at 2%. The mortality rate for CDH when diagnosed antenatally, varies with fetal age and with the presence or absence of hydramnios and degree of pulmonary hypoplasia. The prognosis has improved dramatically in recent years, primarily due to advances in neonatal and surgical interventions. Neonatal survival rates with an antenatal diagnosis now exceed 80% in some centers. Treatment for infants with CDH reflects other pediatric surgical problems in that a majority of the clinical research that shapes treatment is retrospective in nature. Because CDH is a relatively rare disease, using a compilation of cases, such as the CDH database provides, greatly aids our understanding of this disease process. Moreover, the application of a quality assessment scale provides the practitioner with a knowledge base to critically evaluate the published retrospective data.

Asthma is a chronic inflammatory disease of the airway system that is characterized by bronchoconstriction and bronchial hyperresponsiveness that are triggered by a host of stimuli. Asthma is the most common respiratory disease in pregnancy and affects approximately 4% of pregnant women. This article reviews asthma as a public health concern, the normal physiology of pregnancy,the pathophysiology of asthma in pregnancy, the effects of asthma on pregnancy and pregnancy on asthma, objective lung function testing, goals for the pregnant woman who has asthma, and treatment of chronic and acute episodes of asthma.

The ultrasound assessment of the cervix has contributed to the understanding of the pathways to preterm birth. Transvaginal ultrasound measurement of the cervix provides an objective and noninvasive tool for the evaluation of cervical status. Despite widespread use of this procedure, standardization of measurement indications, technique, and interval between examinations has not been achieved. The American College of Radiology has recently recommended that the cervix and lower uterine segment be imaged as part of every obstetric ultra-sound examination in the second trimester. These guidelines specifically suggest a search for a short cervix (less than 30 mm) or funneling. The expert panel on women's imaging further recommended evaluating the cervix sonographically on both the initial examination and all follow-up examinations for twin gestations. The American Institute of Ultrasound in Medicine guidelines indicate that evaluation of the uterus, including cervix, should be performed, but does not indicate specifically that the cervix should be measured. In contrast, the American College of Obstetricians and Gynecologists, although recognizing that cervical length assessment may be helpful in predicting the risk of preterm delivery (particularly from a negative predictive value), does not recommend routine use of cervical length measurement because of the lack of proved treatment or intervention methods. A review of the literature suggests that at the time of this writing the role of routine screening of low-risk women with cervical length assessment by ultrasound is not supported. In contrast, in women at risk for preterm delivery(eg, women with a prior history of preterm birth or women with multiple gestations) cervical length assessment may be useful for its negative predictive value. At present, however, there is no therapeutic intervention that has been proved to decrease the risk of preterm delivery in women with a documented cervix on ultrasound.

Objective We evaluated the cost benefit of cystic fibrosis screening in Mexican American gravid women. Study design With the use of decisions analysis techniques, a cost-benefit analysis was performed. Baseline assumptions were based on published references. Sensitivity analyses were performed. Results Under the baseline assumptions, screening was not cost beneficial. Threshold analysis showed that, if the test was priced under $53.00, screening became cost beneficial. Sensitivity analysis demonstrated that lower acceptance rates of amniocentesis or termination made the screening strategy less attractive. If the test sensitivity was raised to 90%, which required testing of >60 mutations, the cost of screening would need to be Conclusion Cystic fibrosis screening is not cost beneficial in Mexican American women over a wide range of assumptions. This is principally due to the poor sensitivity of the test in this population. Cultural factors, such as lower acceptance of amniocentesis and pregnancy termination of affected fetuses, further lower the cost-benefit ratio of screening.

We sought to evaluate if the placental alpha-microglobulin (PAMG)-1 test vs the combined traditional diagnostic test (CTDT) of pooling, nitrazine, and ferning would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes.A decision analysis model was used to estimate the economic impact of PAMG-1 test vs the CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the annual net cost-benefit per person tested. Baseline probabilities and costs assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2013 US dollars.Annual net benefit from PAMG-1 was $20,014 per person tested, while CTDT had a net benefit of $15,757 per person tested. If the probability of rupture is38%, PAMG-1 will be cost-beneficial with an annual net benefit of $16,000-37,000 per person tested, while CTDT will have an annual net benefit of $16,000-19,500 per person tested. If the probability of rupture is38%, CTDT is more cost-beneficial. Monte Carlo simulations of 1 million trials selected PAMG-1 as the optimal strategy with a frequency of 89%, while CTDT was only selected as the optimal strategy with a frequency of 11%. Sensitivity analyses were robust.Our cost-benefit analysis provides the economic evidence for the adoption of PAMG-1 in diagnosing preterm premature rupture of membranes in uncertain presentations and when CTDT is equivocal at 34 to37 weeks' gestation.