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Background The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. Methods A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1–3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. Results Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0–3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708). Conclusions Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2–related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates., There was a significant positive correlation between SARS-CoV-2 positivity rates in obstetric inpatient units and their surrounding county and state. Healthcare resource utilization related to SARS-CoV-2 testing in obstetric inpatient units may be best informed by surrounding community infection rates.

Evaluate the association between current recommendations for active labor duration in nulliparous women undergoing labor induction and adverse perinatal outcomes.Retrospective cohort study from 2012 to 2015. Subjects were nulliparous, 18-44 years, cephalic, singleton ≥37 weeks undergoing labor induction who reached active labor. We created three subgroups, defined by active labor duration from 6 to 10cm as the median, median-95th percentile, and95th percentile based on contemporary labor curves. We evaluated the association between subgroups and cesarean delivery, chorioamnionitis, blood loss (EBL), 5-minute Apgar score7, and neonatal intensive care unit (NICU) admission using logistic regression.Among 356 women, 34.8% had an active labor duration median, 43.3% were between the median-95th percentile, and 21.9% were95th percentile. The risk of cesarean delivery increased with longer active labor duration; 1.8-fold (95%CI = 1.1-3.1) and 4.0-fold (95%CI = 2.5-6.5) for women whose active labors were between the median-95th percentile and95th percentile, respectively. Chorioamnionitis increased by 3.9-fold (95%CI = 1.2-13.2) in the95th percentile subgroup. Active labor length was not associated with EBL, Apgar scores, or NICU admission.Cesarean delivery and chorioamnionitis increased significantly as induced active labor duration exceeded the median. This study provides a better understanding regarding the risks of longer active labor as defined by contemporary labor curves.

The patient with obesity represents unique challenges to the medical community and, in the setting of pregnancy, additional risks to both mother and fetus. This document will focus on the risks and considerations needed to care for the women with obesity and her fetus during the antepartum, intrapartum, and immediate postpartum stages of pregnancy. Specific attention will be given to pregnancy in the setting of class III and super morbid obesity.

Objective We sought to assess the safety of transcervical Foley catheter (TCF) placement for cervical ripening in women undergoing induction of labor (IOL) after prior cesarean by evaluating the risk of uterine rupture. Study Design We performed a secondary analysis of the Maternal-Fetal Medicine Unit's Cesarean Section Registry, a prospective observational cohort study. We included women with a history of ≤2 low-transverse cesarean deliveries who underwent IOL at ≥24 weeks of gestational age with a live singleton fetus without major anomalies. We excluded those who received prostaglandins or laminaria. We performed multinomial logistic regression to calculate adjusted odds ratios (aORs) for uterine rupture and dehiscence. Relevant confounders included prior vaginal delivery, pregnancy-induced hypertension, chorioamnionitis, and cervical effacement and dilation on admission. Results A total of 2,564 women were eligible. Unadjusted analysis demonstrated no increased risk of uterine rupture with TCF (1.9 vs. 0.9%; p = 0.10) but an increased risk of uterine dehiscence (1.9 vs. 0.6%; p = 0.02). After adjustment, TCF was not associated with an increased risk of uterine rupture (aOR: 2.02; 95% confidence interval [CI]: 0.71–5.78) or uterine scar dehiscence (aOR: 1.32; 95% CI: 0.37–4.72). Conclusion Foley catheter is a safe tool for mechanical dilation in women undergoing IOL after prior cesarean.

Background: The purpose of this study was to estimate prevalence of asymptomatic SARS-CoV-2 infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. Methods: This was a cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1-3 month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. Findings: Data were collected from nine health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient unit. A total of 10,147 SARS-CoV-2 tests were administered, of which 124 were positive (1·2%). Positivity rates varied by site, ranging from 0-3·2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (p=·003, r=·782) and state (p=·007, r=·708). Interpretation: Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2 related healthcare resource utilization in obstetric inpatient units may be best-informed by surrounding community infection rates. Funding Information: Internal funding was used. Declaration of Interests: None to declare. Ethics Approval Statement: The study was IRB approved or determined exempt at each center.

BACKGROUND: Evidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown. OBJECTIVE: This study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality. STUDY DESIGN: Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery. RESULTS: The principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019-associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3-5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257-3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7-43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, -0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P

OBJECTIVE Detection of fetal airway compromise through imaging raises the possible need for ex utero intrapartum treatment (EXIT) procedures. Despite EXIT procedures involving massive resource utilization and posing increased risk to the mother, decisions for EXIT are usually based on anecdotal experience. Our objectives were to analyze prenatal consultations with potential fetal airway obstruction for imaging and obstetric findings used to determine management strategy. METHODS Retrospective chart review was performed for prenatal abnormal fetal airway consults between 2004-2019 at a quaternary pediatric facility. Data collected included demographics, imaging characteristics, delivery information, and airway management. Our primary outcome was EXIT performance and the secondary outcome was postnatal airway management. Fisher's exact test was used to compare management decisions, outcomes, and imaging findings. RESULTS Thirty-seven patients met inclusion criteria. The most common diagnoses observed were lymphatic malformation, teratoma, and micrognathia. Of the imaging findings collected, only midline neck mass location was associated with EXIT procedure performance. Factors associated with invasive airway support at birth were mass-induced in-utero neck extension and neck vessel compression, polyhydramnios, and micrognathia. CONCLUSIONS Multidisciplinary input and interpretation of prenatal imaging can guide management of fetal airway-related pathology. EXIT is an overall safe procedure and can decrease risk due to airway obstruction at birth. We identified in-utero neck extension, neck vessel compression, micrognathia, and polyhydramnios as better indicators of a need for invasive airways measures at birth and suggest use of these criteria in combination with clinical judgement when recommending EXIT. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1357-E1362, 2021.

We found low prevalence of SARS-CoV-2 (2.7% [5/188]) among pregnant and postpartum patients with universal testing. Prevalence among symptomatic patients was similar under initial targeted screening (22.2% [4/18]) and universal approaches (19.1% [8/42]). Among 170 asymptomatic patients, 2 were positive or inconclusive, respectively; repeat testing at 24 hours was negative.

Introduction Induction of labor is a common intervention. The objective was to investigate whether larger Foley catheter volumes for labor induction decrease the total time from induction to delivery. Material and methods Randomized controlled trials comparing larger single-balloon volumes (60-80 mL) during Foley catheter cervical ripening with usual volume (30 mL) in women undergoing labor induction were identified by searching electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) from inception through 2017. The primary outcome was mean time from induction to delivery in hours. Secondary outcomes included time from induction to vaginal delivery, delivery within 24 h, time to Foley expulsion, cesarean section, chorioamnionitis, epidural use, hemorrhage, meconium staining, and neonatal intensive care unit admission. Meta-analysis was performed using the random effects model of DerSimonian and Laird (PROSPERO CRD42017058885). Results Seven randomized controlled trials including 1432 singleton gestations were included in the systematic review. Women randomized to larger volumes of balloon had a significantly shorter time from induction to delivery (mean difference 1.97 h, 95% CI -3.88 to -0.06). There was no difference in cesarean section between groups (16 vs. 18%, relative risk 0.84, 95% CI 0.6-1.17). A larger balloon volume was associated with a nonsignificant decrease in time from induction to delivery in multiparous (mean difference 2.67 h, 95% CI -6.1 to 0.76) and nulliparous women (mean difference 1.82 h, 95% CI -4.16 to 0.53). Conclusion Balloon volumes larger than 30 mL during Foley catheter induction reduce total time to delivery by approximately 2 h.

The objective of this study is to determine placental transfusion blood volumes with intact and cut umbilical cord milking in term newborns. Sixty women at ≥37 weeks’ gestation were enrolled. Following delivery, the umbilical cord was immediately clamped and cut to separate the newborn. Either intact umbilical cord milking (I-UCM) of the placental–umbilical cord unit or cut umbilical cord milking (C-UCM) of the cut umbilical cord segment was performed. For I-UCM, the cord underwent milking three or four times while being attached to placental circulation. For C-UCM, a 10, 20, or 30 cm cord segment was cut separately and milked four times. Blood volumes were compared between I-UCM and C-UCM methods. Mean blood volume with I-UCM (×4) was increased compared to the 30 cm C-UCM technique (48.5 ± 19.0 vs. 24.8 ± 4.0 mL, P

Maternal biologic factors can affect the fetal fraction in cell-free DNA-based prenatal screening assays, thereby limiting the effectiveness. Higher rates of indeterminate results because of a low fetal fraction have been described in cases of maternal autoimmune disease in pregnancy. Existing studies are confounded by the concomitant maternal use of anticoagulants, which may independently influence the test characteristics.This study aimed to evaluate the differences in fetal fraction, indeterminate results, and total cell-free DNA concentration among women with an autoimmune disease in comparison with controls, using our in-house developed, noninvasive prenatal screening platform in the absence of maternal anticoagulation use.This was a retrospective, single institution cohort study of a previously validated, cell-free DNA-based, noninvasive prenatal screening assay using a low-pass whole-genome sequencing platform between 2017 and 2019. A diagnosis of an autoimmune disease included systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, and others. Immunomodulator therapies included biologics, corticosteroids, hydroxychloroquine, azathioprine, and intravenous immunoglobulin. Women who were using anticoagulants were excluded. We evaluated the association between autoimmune disease and fetal cell-free DNA fraction, indeterminate results, and total cell-free DNA concentration using univariate and multivariate analyses, stratified according to immunomodulator therapy and adjusted for body mass index, fetal sex, and gestational age at sample collection.A total of 1445 patients met inclusion criteria. Of those, 43 women had a confirmed autoimmune disease, with 25 of those not on immunomodulator therapy and 18 on immunomodulator therapy. The mean fetal fraction for women with an autoimmune disease was significantly lower than for controls (9.7% vs 11.9%; P=.004). The rate of indeterminate results was significantly higher among women with an autoimmune disease than among controls (16.3% vs 3.5%; P.001). The total cell-free DNA concentration was not statistically different between the groups (94.8 pg/µL for women with an autoimmune disease vs 83.9 pg/µL for controls; P=.06). In a logistic regression, women with an autoimmune disease had significantly higher odds of receiving an indeterminate result than controls, (adjusted odds ratio, 5.3; 95% confidence interval, 2.0-14.2). Linear regression analysis showed a significant negative association between having an autoimmune disease and the fetal cell-free DNA fraction (aβ, -2.1; 95% confidence interval, -3.4 to -0.6). When stratifying by treatment status, the mean fetal fraction was 9.8%, 9.6%, and 11.9% for women with an autoimmune disease not on immunomodulator therapy, women with an autoimmune disease on immunomodulator therapy, and the controls, respectively (P=.02). The rate of indeterminate results increased in a stepwise fashion from 3.5% to 11.1% to 20.0% for controls, women with an autoimmune disease on immunomodulator therapy, and women with an autoimmune disease not on immunomodulator therapy, respectively (P.001). Logistic regression analysis demonstrated higher odds of an indeterminate result for women with an autoimmune disease not on immunomodulator therapy than for controls, (adjusted odds ratio, 7.3; 95% confidence interval, 2.3-22.5). There was a negative association between women with an autoimmune disease not on immunomodulator therapy and the fetal fraction when compared with controls (aβ, -2.2; 95% confidence interval, -4.2 to -0.3).Women with an autoimmune disease have lower fetal cell-free DNA fractions and higher rates of indeterminate results than women without an autoimmune disease. There was no difference in total cell-free DNA concentration. Treatment of maternal autoimmune diseases with immunomodulator therapy may decrease the indeterminate result rate.

Background During the early months of the coronavirus disease of 2019 (COVID-19) pandemic, risks to pregnant women of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were uncertain. Pregnant patients can serve as a model for the success of the clinical and public health response during public health emergencies as they are typically in frequent contact with the medical system. Population-based estimates of SARS-CoV-2 infections in pregnancy are unknown due to incomplete ascertainment of pregnancy status or inclusion of only single centers or hospitalized cases. Whether pregnant women were protected by the public health response or through their interactions with obstetrical providers in the early pandemic is poorly understood. Objective(s) To estimate the SARS-CoV-2 infection rate in pregnancy and examine disparities by race/ethnicity and English-language proficiency in Washington State. Study design Pregnant patients with a polymerase chain reaction (PCR)-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 1-June 30, 2020 were identified within 35 hospitals/clinic systems capturing 61% of annual deliveries in Washington State. Infection rates in pregnancy were estimated overall and by Washington State Accountable Community of Health (ACH) region and cross-sectionally compared to SARS-CoV-2 infection rates in similarly aged adults in Washington State. Race/ethnicity and language used for medical care among the pregnant patients were compared to recent data from Washington State. Results A total of 240 pregnant patients with SARS-CoV-2 infections were identified during the study period with 70.7% from minority racial and ethnic groups. The principal findings in our study are: 1) The SARS-CoV-2 infection rate in pregnancy was 13.9/1,000 deliveries (95% confidence interval [CI], 8.3-23.2) compared to 7.3/1,000 (95%CI 7.2-7.4) in 20-39 year old adults in Washington State (Rate Ratio [RR] 1.7, 95%CI 1.3-2.3), 2) the SARS-CoV-2 infection rate reduced to 11.3/1000 (95%CI 6.3-20.3) when excluding 45 cases of SARS-CoV-2 detected through asymptomatic screening (RR 1.3, 95%CI 0.96-1.9), 3) the proportion of SARS-CoV-2 cases in pregnancy among most non-white racial/ethnic groups was 2-4 fold higher than the race and ethnicity distribution of women in Washington State who delivered live births in 2018, and 5) the proportion of SARS-CoV-2 infected pregnant patients receiving medical care in a non-English language was higher than estimates of limited English proficiency in Washington State (30.4% versus 7.6%). Conclusions The SARS-CoV-2 infection rate in pregnant people was 70% higher than similarly aged adults in Washington State, which could not be completely explained by universal screening at delivery. Pregnant patients from nearly all racial/ethnic minority groups and patients receiving medical care in a non-English language were overrepresented. Pregnant women were not protected from COVID-19 in the early months of the pandemic with the greatest burden of infections occurring in nearly all racial/ethnic minority groups. This data coupled with a broader recognition that pregnancy is a risk factor for severe illness and maternal mortality strongly suggests that pregnant people should be broadly prioritized for COVID-19 vaccine allocation in the U.S. similar to some states.

Background Arthrogryposis multiplex congenita is the presence of multiple congenital contractures of two or more body parts. Congenital cytomegalovirus (CMV) infection is a rare etiology of arthrogryposis. Case presentation We report a case of intrauterine fetal akinesia and arthrogryposis multiplex congenita delivered at term with subsequent neonatal demise. Placental pathology and autopsy revealed congenital CMV infection. Conclusions Evaluation for potential CMV infection is an important part of the arthrogryposis evaluation which is often missed due to lack of maternal infectious symptoms during pregnancy.

Background The impact of the coronavirus disease 2019 (Covid-19) on pregnant women is incompletely understood, but early data from case series suggest a variable course of illness from asymptomatic or mild disease to maternal death. It is unclear whether pregnant women manifest enhanced disease similar to influenza viral infection or whether specific risk factors might predispose to severe disease. Objective To describe maternal disease and obstetrical outcomes associated with Covid-19 disease in pregnancy to rapidly inform clinical care. Study Design Retrospective study of pregnant patients with a laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection from six hospital systems in Washington State between January 21, 2020 and April 17, 2020. Demographics, medical and obstetric history, and Covid-19 encounter data were abstracted from medical records. Results A total of 46 pregnant patients with a SARS-CoV-2 infection were identified from hospital systems capturing 40% of births in Washington State. Nearly all pregnant individuals with a SARS-CoV-2 infection were symptomatic (93.5%, n=43) and the majority were in their second or third trimester (43.5%, n=20 and 50.0%, n=23, respectively). Symptoms resolved in a median of 24 days (interquartile range 13-37). Seven women were hospitalized (16%) including one admitted to the intensive care unit. Six cases (15%) were categorized as severe Covid-19 disease with nearly all patients being either overweight or obese prior to pregnancy, asthma or other co-morbidities. Eight deliveries occurred during the study period, including a preterm birth at 33 weeks to improve pulmonary status in a woman with Class III obesity. One stillbirth occurred of unknown etiology. Conclusions Nearly 15% of pregnant patients developed severe Covid-19, which occurred primarily in overweight or obese women with underlying conditions. Obesity and Covid-19 may synergistically increase risk for a medically-indicated preterm birth to improve maternal pulmonary status in late pregnancy. Collectively, these findings support categorizing pregnant patients as a higher risk group, particularly for those with chronic co-morbidities.

Objective Evaluate the association between spontaneous active labor duration utilizing contemporary labor curves and risk of adverse outcomes. Materials and Methods This is a retrospective cohort study from January 2012 to January 2015. Subjects were nulliparous, 18 to 44 years, with a cephalic, singleton ≥37 weeks in spontaneous labor. Subjects were placed into three subgroups, defined by active labor duration from 6 to 10 cm as less than the median, the median-95th, and >95th percentile based on contemporary labor curves published by Zhang et al. We evaluated the association between subgroups and cesarean delivery, chorioamnionitis, estimated blood loss, Apgar score Results Six-hundred forty two women met the inclusion criteria. Compared with women whose active labor was less than the median, the risk of cesarean was higher in the median-95th percentile ([adjusted OR, aOR] 3.1, 95% CI 1.8–5.5) and the >95th percentile ([aOR] 6.8, 95% CI 3.9–11.7) subgroups. There was an increased odds of chorioamnionitis in the median-95th percentile subgroup ([aOR] 2.5, 95% CI 1.1–5.9). Conclusion Chorioamnionitis and cesarean delivery increased significantly as labor duration exceeded the median. This study provides a better understanding regarding the potential risk of cesarean and chorioamnionitis using contemporary labor curves.

Abnormal placentation is a significant source of maternal morbidity and mortality with increasing incidence due to rising rates of cesarean delivery. While traditionally managed with cesarean-hysterectomy, other management strategies are available. We report a case of a G4P2 woman with two prior cesarean deliveries, who presented at 21 weeks and was diagnosed with an extensive placenta percreta. She expressed a desire for pregnancy termination. Given extensive intra-abdominal placental invasion, intrauterine fetal demise was induced with fetal intracardiac potassium chloride, systemic methotrexate was administered, and the pregnancy was managed conservatively with the demised fetus in situ. Resolution of placental tissue occurred over 4 months. Chorioamnionitis developed at the equivalent of 41 weeks’ gestational age, and she underwent a successful gravid hysterectomy. Antepartum management with induced fetal demise and delayed hysterectomy can be considered in extreme cases of previable invasive placenta percreta.

To determine whether 1,5-anhydroglucitol is predictive of neonatal birth weight.A retrospective cohort study including 85 pregnancies complicated by diabetes (Type 1=37, Type 2=24, gestational=24). Women had simultaneous hemoglobin A1c and 1,5-anhydroglucitol measurements every 4-8 weeks throughout pregnancy until delivery. Neonatal birth weight was evaluated by standardized z-scores. Linear regression analysis was performed to determine an association of 1,5-anhydroglucitol with neonatal birth weight z-score.Type 1 diabetic patients had the lowest mean 1,5-anhydroglucitol of 3.5mcg/mL (SD=1.6mcg/mL) and highest mean hemoglobin A1c of 6.5% (SD=0.74%) compared to gestational diabetic patients who had the highest mean 1,5-anhydroglucitol of 6.7mcg/mL (SD=3.8mcg/mL) and lowest mean hemoglobin A1c of 6.0% (SD=0.94%). Mean 1,5-anhydroglucitol values were significantly different between diabetes types (p0.01). Mean neonatal birth weight was above population averages for all diabetes classifications, although mean birth weight z-scores did not differ significantly between diabetic types (p=0.38). Multivariate linear regression showed a negative association between log-transformed 1,5-anhydroglucitol and birth weight (coefficient -0.82, 95% CI -1.19, -0.46).In pregnancies complicated by diabetes, low 1,5-anhydroglucitol was associated with increased neonatal birth weight. 1,5-Anhydroglucitol may be useful in the assessment of glycemic control in pregnancy in addition to A1c.

Background. We investigated whether serotesting sexual partners of pregnant women for herpes simplex virus (HSV) improves adherence to safer-sex practices. Methods. A total of 287 HSV-2–seronegative pregnant women were recruited, and their partners were invited for HSV serologic testing. On the basis of test results, women were placed into 4 groups: those at risk for HSV-2 infection, those at risk for HSV-1 infection, those whose partner was not tested, and those not at risk for HSV infection. Women received safer-sex counseling and completed diaries of sexual activity. Results. Women in HSV-2–serodiscordant couples (ie, those in relationships in which they were at risk for HSV-2 acquisition) reported a smaller percentage of days with unprotected genital sex acts as compared to women who were not at risk (2% vs 8%; relative risk [RR], 0.3 [95% confidence interval {CI}, .1–.8]; P = .002) and to women whose partners' HSV status was unknown (2% vs 11%; RR, 0.2 [95% CI, .1–.8]; P = .02). Women in HSV-1–serodiscordant couples showed no difference in the frequency of genital sex acts, unprotected genital sex acts, or oral sex acts as compared to those not at risk and to those whose partners' status was unknown. Conclusions. Pregnant women at known risk of HSV-2 acquisition by partner serotesting were less likely to engage in unprotected genital sex acts than HSV-2–seronegative women with partners who were negative or not tested.

To compare the risk of gestational hypertension and preeclampsia in pregnancies conceived through standard in vitro fertilization (IVF) using autologous oocytes with pregnancies conceived using donated oocytes.We conducted a retrospective, matched cohort study of women undergoing IVF using autologous compared with donor oocytes between 1998 and 2005. Women with live births resulting from oocyte donor pregnancies were matched for age and plurality (singleton or twin) with women undergoing autologous IVF. Primary outcomes were the incidence of preeclampsia or gestational hypertension (with and without proteinuria) in the third trimester. Data on preterm delivery, low birth weight, and embryo cryopreservation were also recorded.Outcome data were available for 158 pregnancies, including 77 ovum-donor recipient pregnancies and 81 pregnancies using autologous oocytes. There were no differences in age, parity, and gestational type between the two cohorts. The incidence of gestational hypertension and preeclampsia was significantly higher in ovum-donor recipients compared with women undergoing autologous IVF (24.7% compared with 7.4%, P.01, and 16.9% compared with 4.9%, P=.02, respectively). Ovum-donor recipients were more likely than women undergoing autologous IVF to deliver prematurely (34% compared with 19%). This association remained after controlling for multiple gestation (odds ratio 2.6, 95% confidence interval 1.04-6.3). Sixteen pregnancies from cryopreserved embryos were more likely to have hypertensive disorders of pregnancy (odds ratio 5.0, 95% confidence interval 1.2-20.5).Pregnancies derived from donor oocytes and cryopreserved-thawed embryos may be at a higher risk for hypertensive disorders of pregnancy. These findings inform future research and help counsel women using assisted reproductive technology.

To compare 30-mL and 60-mL Foley balloon inflation for labor induction and the effect on length of labor and mode of delivery.Women with term, vertex, singleton pregnancies (n=192) and a Bishop score less than 5 were assigned randomly to receive a transcervical Foley balloon inflated to either 30 mL or 60 mL. Exclusion criteria were painful, regular contractions on admission, ruptured membranes, low-lying placenta, or prior hysterotomy. Randomization was stratified by parity, and health care providers were blinded to Foley balloon size. Primary outcome was delivery within 24 hours of Foley balloon placement. Secondary outcomes included delivery within 12 hours, time from Foley balloon placement to expulsion, cervical dilation after Foley balloon expulsion, maximum oxytocin dose, method of delivery, chorioamnionitis, meconium, cervical laceration, abruption, 5-minute Apgar score, and umbilical cord gases.A higher proportion of women randomly assigned to the 60-mL Foley balloon achieved delivery within 12 hours of placement compared with the 30-mL Foley balloon group (26% compared with 14%, P=.04). This difference was more pronounced among nulliparous women. There was no difference in median time interval to delivery or proportion of women who achieved delivery within 24 hours. Median cervical dilation after Foley balloon expulsion was higher in the 60-mL Foley balloon group (4 cm compared with 3 cm, P.01). There were no differences in the frequencies of cesarean delivery, maternal morbidity, or neonatal outcomes.Labor induction using Foley balloons inflated to 60 mL was more likely to achieve delivery within 12 hours compared with 30-mL inflation. There were no differences in delivery within 24 hours, cesarean delivery, labor complications, or neonatal outcomes.I.

We present the sonographic features of a second-trimester fetus diagnosed with a bradyarrhythmia at 19 weeks' gestation. The mother carried a diagnosis of Sjogren syndrome, including the presence of SSA and SSB antibodies. Ultrasound M-mode and fetal echocardiogram revealed the etiology of the bradycardia to be a complete fetal congenital heart block, likely due to transplacental passage of autoimmune anti-Ro/SSA and anti-La/SSB antibodies. Consequential to the congenital heart block, the fetus developed hydrops fetalis at 21 weeks' gestational age. We discuss the 2 major etiologies of congenital heart block and the implications in subsequent pregnancies.

To examine predictive characteristics for cesarean delivery (CD) in women undergoing labor induction with a Foley balloon (FB).A secondary analysis of a randomized, double-blind, control trial examining labor induction with a transcervical 30 mL or 60 mL FB. One-hundred ninety-nine women with term, vertex, singleton pregnancies and Bishop score 5 were randomized to receive a transcervical 30 mL or 60 mL FB. Mode of delivery, labor complications and neonatal outcomes were recorded. A multivariable model was performed to determine predictive characteristics for CD.Increasing maternal age (p = 0.04), nulliparity (p =0.002) and chorioamnionitis (p 0.001) were significantly associated with an elevated risk for CD. Nulliparity was associated in an almost 4-fold increased CD risk (relative risk [RR]: 3.88; 95% confidence interval [CI]: 1.22-12.3). Women aged ≥ 40 years, had an almost 3-fold increased risk of CD as compared to women aged 20-29 (RR: 2.91; 95% CI: 1.36-6.19) years. Chorioamnionitis was associated with nearly a 2-fold increased risk for CD (RR: 1.87; 95% CI: 1.06-3.32). A gestational age of ≥ 41 weeks, prostaglandin use during induction and induction indication did not affect mode of delivery.In patients undergoing labor induction with a FB, increasing maternal age, nulliparity and chorioamnionitis are associated with an elevated risk for CD.

To demonstrate that vaginal delivery is a safe alternative to hysterotomy when planning pregnancy termination of late-second-trimester conjoined twins. We present two cases of conjoined twins in the late second trimester desiring pregnancy termination.The first case involved a multiparous 29-year-old woman at 23 6/7 weeks of gestation with thoraco-omphalopagus conjoined twins. The second case involved an 18-year-old primigravid woman at 25 1/7 weeks of gestation with pyopagus conjoined twins. Both desired pregnancy termination and to avoid hysterotomy. Inductions were initiated with Laminaria and augmented with vaginal misoprostol or oxytocin. Both patients had uncomplicated vaginal deliveries of intact conjoined twins without significant maternity morbidity.Induction of labor and vaginal delivery can be a safe method for late-second-trimester termination of pregnancies with conjoined twins.

To determine whether preeclampsia is associated with an increased risk of cesarean delivery if labor is induced.This retrospective cohort study of 3505 womenor=24 weeks gestation with singleton pregnancies undergoing labor induction compares cesarean delivery rates between preeclamptics and non-preeclamptics. Multivariable logistic regression analysis was used to control for potential confounders including unfavorable cervix (Bishop scoreor=5), method of labor induction, maternal age, parity, gestational age, race/ethnicity, epidural use, medical insurance, and marital status.Among term nulliparous women undergoing labor induction, preeclamptics had a higher cesarean delivery rate then non-preeclamptics (81/267, 30% vs. 363/1568, 23%; p = 0.011), as did preeclamptic compared with non-preeclamptic women who were term and multiparous (10/64, 16% vs. 55/900, 6%, p = 0.003). Preterm preeclamptics also had more cesarean deliveries compared with non-preeclamptics among nulliparous (48/164, 29% vs. 16/245, 7%; p0.001) and multiparous (13/72, 18% vs. 18/225, 8%; p = 0.015) women. In multivariable analysis, preeclampsia still conferred an increased risk of cesarean delivery if labor was induced (adjusted odd ratio = 1.90, 95% CI 1.45-2.48).Women with preeclampsia undergoing labor induction had higher cesarean delivery rates compared with non-preeclamptics regardless of parity or gestational age. However, the majority of women with preeclampsia still had successful vaginal deliveries.

Summary Introduction With advances in genitourinary reconstructive surgery, women with exstrophy–epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including mullerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy. Objectives We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC. Study design/Results This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects. Discussion Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed. Table . Pregnancy resulting in live birth versus spontaneous abortion or termination. Outcomes of 22 pregnancies in 12 EEC patients Outcome Total pregnancies (n = 22) Bladder exstrophy pregnancies (n = 20) Cloacal exstrophy pregnancies (n = 2) Total pregnancies 22 (100%) 20 2 Spontaneous abortion 4 (18%) 3 (15%) 1 (50%) Terminations 4 (18%) 3 (15%) 1 (50%) Live births 14 (64%) 14 (70%) 0

Sex differences in neurochemical markers that correlate with behavior in aging mice NEUROBIOL AGING. We examined whether the enzymatic activities of choline acetyltransferase (ChAT) and glutamic acid decarboxylase (GAD) were altered similarly with age in male and female mice, and whether these changes were correlated with age-related alterations in memory and anxiety. ChAT and GAD activities were measured in neocortex, hippocampus, and striatum of behaviorally characterized male and female C57BL/6 mice (5, 17, and 25 months). Generally, ChAT activity was increased, and GAD activity decreased, with age. However, disparate changes were revealed between the sexes; activities of both enzymes were decreased in 17-month males, whereas alterations in females were not observed until 25-months. Furthermore, enzyme-behavior correlations differed between the sexes; in males, ChAT activity was related to one behavioral task, whereas in females, activities of both enzymes were correlated with multiple tasks. Significant enzyme-behavior correlations were most evident at 17 months of age, likely the result of behavioral and enzymatic sex differences at this age. These data represent the first comprehensive report illustrating differential alterations of ChAT and GAD activities in aging male and female mice.

Genital herpes in pregnancy frequently complicates management, although neonatal herpes, a potentially catastrophic complication, is rare1,2. Maternal acquisition of genital herpes simplex virus (HSV) type 1 or 2 near the time of delivery accounts for most neonatal herpes. Neonatal HSV incidence has been stable in recent decades, although a shift toward more HSV-1 infections has been reported1,3. Concurrently, a decline in HSV-1 seroprevalence, but not HSV-2, has been noted among reproductive-aged women in nationwide surveys4,5. We determined trends in the seroprevalence of HSV-1 and HSV-2 among pregnant women delivering in a single urban academic center during two decades in Seattle, Washington.

Objective To estimate the association between the lengths of the first stage of labor, mode of delivery, and perinatal outcomes in women undergoing labor induction. Study Design Retrospective cohort study of singleton, term pregnancies with labor induction and delivered during the second stage. The length of the first stage was examined by 6-hour intervals as predictors of mode of delivery and perinatal morbidity using χ 2 test and multivariable logistic regression analysis. Results There were 3620 women who met study criteria. Compared with women with a first stage between 0-12 hours, women with longer first stages had a higher risk of cesarean delivery during the second stage, up to an adjusted odds ratio of 7.44 in those with a first stage ≥24 hours (95% confidence interval [CI], 3.43–16.1). Women with a first stage ≥24 hours also had higher odds of postpartum hemorrhage (adjusted odds ratio [aOR], 3.16; 95% CI, 1.73–5.79), chorioamnionitis (aOR, 2.83; 95% CI, 1.19–6.69), and neonatal admission to the intensive care nursery (aOR, 2.03; 95% CI, 1.10–3.74). Conclusion In women who underwent induction of labor, even when a second stage of labor was reached, the risk for cesarean delivery and maternal morbidity remained increased when the length of the first stage was longer than 24 hours. However, in this clinical scenario, the frequency of cesarean delivery remains less than 50%. The decision for surgical intervention thus should not be based on the elapse of time alone.