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The association between prenatal phthalate exposure and late preterm birth (LPTB) is unclear. We examined singleton pregnancies (2006-2011) from a racially and socioeconomically diverse sample of women in the CANDLE cohort of the ECHO-PATHWAYS Consortium. Urine collected in the second and third trimester was analyzed for 14 phthalate metabolites. Multivariate logistic and linear regressions were performed for LPTB, defined as delivery 34-37 weeks, and gestational week, respectively. Models were controlled for socio-demographics, behavioral factors, clinical measurements, medical history, and phthalates in the other trimester. Effect modification by race and pregnancy stress, indicated by intimate partner violence (IPV), was investigated. We conducted a secondary analysis in women with spontaneous preterm labor. The rate of LPTB among 1408 women (61% Black, 32% White) was 6.7%. There was no evidence of decreased gestational age (GA) in association with any phthalate metabolite. Each two-fold increase in third trimester mono-benzyl phthalate (MBzP) was associated with 0.08 weeks longer gestational age (95% CI: 0.03, 0.12). When restricting to women with spontaneous labor, second trimester mono-n-butyl phthalate (MBP) was associated with 54% higher odds (95% CI: 2%, 132%) of LPTB. Associations were not modified by maternal race or IPV exposure. In conclusion, we observed mixed evidence concerning our hypothesis that prenatal phthalate exposure increases risk of LPTB, though secondary analyses suggest increased risk of spontaneous LPTB associated with MBP, which is consistent with a recent pooled analysis of 16 cohorts.

Hyperreactio luteinalis (HL) is a rare benign complication of pregnancy that is characterized by progressive ovarian enlargement and hyperandrogenism. We present a case of a 30-year-old woman with a spontaneous monochorionic diamniotic twin pregnancy who presented with early-onset preeclampsia, concern about possible twin-twin transfusion syndrome, and bilateral enlarged ovarian masses. Both ovaries had multiple thin-walled unilocular cysts; one ovary measured 17.9 × 17.5 × 9.1 cm and the other 12.5 × 11 × 12.3 cm. After extensive counseling, the patient underwent an uncomplicated dilation and evacuation. Postoperative assessment indicated elevated androgen levels, which spontaneously resolved, supporting the clinical diagnosis of HL. It is important to consider HL in the differential diagnosis of adnexal masses in pregnancy. HL spontaneously regresses after delivery and is managed expectantly. HL has been associated with gestational trophoblastic disease, multiple gestations, preeclampsia, and twin-twin transfusion syndrome.

INTRODUCTION:: Hypertensive disorders of pregnancy are a leading cause of maternal and neonatal morbidity and mortality. Timeliness of treatment improves maternal and neonatal outcomes. This study assesses the impact of implementing a program for severe range blood pressure (SRBP) management during inpatient obstetrical care. METHODS:: We prospectively collected data from a single academic center during 2015-2016 comparing outcomes before and after a system change. The changes included 1) an algorithm to improve blood pressure (BP) recheck times (for validating SRBP) and time to intravenous medication when indicated; 2) improved medication access making all medications equally available; and 3) multidisciplinary training including simulation sessions. All patients with ICD-10 codes of pregnancy-related hypertensive disorders who had SRBP were evaluated over a three-month period before and after program implementation. SRBP treatment included intravenous labetalol or hydralazine or oral nifedipine. Primary endpoints compared time to BP recheck, time to medication when indicated and type of medication. RESULTS:: More women had a BP recheck within one hour post-implementation (330/344, 95.9%) vs. pre-implementation (390/425, 91.7%) (P=.0025). A similar improvement occurred when evaluating BP recheck within 10 minutes (60.5% vs. 40.0%, respectively, P=.0001). For the 113 post-implementation and 89 pre-implementation SRBP events requiring treatment, time to medication did not improve (median 13 and 14 minutes, respectively, P=.40). Use of labetalol vs. hydralazine post-implementation increased from 13.3% to 38.1% (P=.0001); nifedipine was rarely used (1 and 3 patients, respectively). CONCLUSION:: Implementation of an algorithm to treat SRBP can improve BP recheck rates and impact choice of intravenous medications.

ObjectiveTo evaluate whether a standardized approach to identify pregnant women at risk for shoulder dystocia (SD) is associated with reduced incidence of SD and brachial plexus injury (BPI).MethodsBetween 2011 and 2015, prospective data were collected from 29 community-based hospitals in the USA during implementation of an evidence-based practice bundle, including an admission risk assessment, required "timeout" before operative vaginal delivery (OVD), and low-fidelity SD drills. All women with singleton vertex pregnancies admitted for vaginal delivery were included. Rates of SD, BPI, OVD, and cesarean delivery were compared between a baseline period (January 2011-September 2013) and an intervention period (October 2013-June 2015), during which there was a system-wide average bundle compliance of 90%.ResultsThere was a significant reduction in the incidence of SD (17.6%; P=0.028), BPI (28.6%; P=0.018), and OVD (18.0%; P