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The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL)., Study Design: Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing >275 lb at the time of delivery who attempted a TOL with a singleton gestation >34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD., Results: During the study period, there were 357 pregnant women who weighed >275 lb (all with body mass index [BMI] >40 kg/m(2)), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m(2), P = .038), were less likely to be parous (32.2% vs 65.8%, P < .0001), and were more likely to be induced (80.5% vs 57.8%) compared to those having a vaginal delivery. Using a multivariable logistic regression model, among nulliparous women, maternal age, parity, and cervical dilation at time of admission were independent predictors for CD. Furthermore, an increase in BMI of 10 kg/m(2) was associated with a 3.5 increased odds (P = .002) for CD., Conclusion: Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to examine the association between restraint use, race, and perinatal outcome after motor vehicle accidents (MVAs) during pregnancy., Study Design: The Duke Trauma Registry and medical records were searched for information on pregnant women at >14 weeks' gestation who were involved in an MVA and who received care through the Emergency Department and the Obstetric Units. Between January 1994 and December 31, 2010, 126 women were identified. Variables that were collected included type of trauma, gestational age at presentation, and delivery outcomes. A prognostic study was performed that evaluated the associations between maternal demographics, details of the accident that included restraint use, and maternal treatment that was related to the accident in relationship to perinatal outcome., Results: There was no difference in the mean age or median gravidity or parity by race among pregnant women who were cared for after an MVA. There was no difference in mean age or racial distribution between women who were restrained compared with women who were unrestrained; unrestrained women were more likely to be nulliparous. Unrestrained women were more likely to require nonobstetric surgery that was related to the trauma. The overall rate of placental abruption was 6%. There were 6 intrauterine fetal deaths, 3 each in the unrestrained (25%) and restrained groups (3.5%; P = .018). Airbags deployed in 17 accidents. Among the 7 women with placenta abruption, 4 women (57%) experienced air bag deployment., Conclusion: Lack of restraint use during pregnancy is associated with an increased risk of fetal death., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to examine racial disparities and the "Hispanic paradox" in pregnancy outcomes at a tertiary-care medical center., Study Design: A cross-sectional study of pregnancy events was performed with information from the Duke University birth database. The latter includes data on birth outcomes, cost, and health services factors. The final sample included 10,755 women with Medicaid insurance, who gave birth during calendar years 1994-2004. Pregnancy comorbidities and outcome measures were identified by International Classification of Diseases, 9th revision, and Current Procedural Terminology (CPT) codes. Univariate and multivariate analyses were performed to compare racial/ethnic groups., Results: African-American women were younger and more likely to be employed, to have a medical comorbidity, to remain in the hospital for >4 days, and to have hospital charges of >$7500. African-American women had higher rates of preterm birth, small-for-gestational-age infants, preeclampsia, and stillbirths. There were no differences by race for gestational diabetes mellitus. With the use of white women as the reference group, Hispanic women had lower odds for preterm birth (odds ratio, 0.66; 95% CI, 0.54-0.80), and African-American women had greater odds for preeclampsia (odds ratio, 1.30; 95% CI, 1.07-1.58) and small-for-gestational-age infants (odds ratio, 1.74; 95% CI, 1.29-2.36). With the use of African-American women as the reference, Hispanic women were less likely than African-American women to experience any adverse pregnancy event, with the exception of gestational diabetes mellitus., Conclusion: Poverty and insurance status does not explain differences in adverse pregnancy outcomes between African-American women and Hispanic women with Medicaid insurance.

Objective: This study was undertaken to determine why residents choose obstetrics and gynecology., Study Design: Applicants to obstetrics and gynecology residency programs were surveyed; a 5-point scale (5 = most important) was used to rate various aspects of the specialty. Univariate statistics were performed. Bivariate analysis comparing results that were based on gender and timing of decisions was completed with Student t test, chi2, and Kruskal-Wallis tests., Results: A total of 153 applicants (42% response rate) from 10 programs participated; 85.3% of respondents were female. Surgical opportunities, variety of clinical experience, and fast-paced/high-acuity experiences attract applicants to obstetrics and gynecology. When considering programs, resident camaraderie, gynecologic experience, and commitment to education were most important. Over 70% of residents decided to pursue obstetrics and gynecology during or after their third-year clerkship., Conclusion: Surgical opportunities and clinical variety appeal to applicants. The majority choose obstetrics and gynecology during or after their core clerkship. In addition, program dynamics are important when choosing a residency.

Objective: The aim of this study was to compare the distributions of protein kinase C isozymes in human nonpregnant and pregnant myometrial tissues and primary cell cultures., Study Design: Myometrial tissues were obtained at hysterectomy from nonpregnant women and at cesarean delivery from women both before and during early labor at term. Western immunoblot analysis was performed on homogenates of myometrial tissues and primary cell cultures with monoclonal antibodies specific for protein kinase C isozymes. Redistribution and translocation of protein kinase C were examined by means of immunocytochemical methods., Results: Nonpregnant myometrial tissues contained protein kinase C isozymes alpha, gamma, delta, mu, iota, and zeta but not beta(1), beta(2), theta, or epsilon. Pregnant myometrial tissues both before and during early labor contained the same protein kinase C isozymes and also beta(1) and beta(2). The protein kinase C isozyme distribution in primary myometrial cell cultures was identical to that in the myometrial tissues. Protein kinase C redistribution and translocation were demonstrated in these cultured myometrial cells., Conclusion: Both human myometrial tissues and primary cell cultures expressed a broad range of protein kinase C isozymes. Protein kinase C isozymes beta(1) and beta(2) were absent in nonpregnant myometrium but were induced during pregnancy. Labor at term did not alter protein kinase C isozyme expression.

Objective: The aim of the study was to evaluate home uterine activity monitoring as an intervention in reducing the rate of preterm birth among women treated for preterm labor., Study Design: A total of 186 women were treated in the hospital with magnesium sulfate for preterm labor and were prospectively randomly assigned to study groups; among these, 162 were ultimately eligible for comparison. Eighty-two of these women were assigned to the monitored group and 80 were assigned to an unmonitored control group. Other than monitoring, all women received identical prenatal follow-up, including daily perinatal telephone contact and oral terbutaline therapy. Outcome comparisons were primarily directed toward evaluation of preterm birth at <35 weeks' gestation. Readmissions for recurrent preterm labor and observations lasting <24 hours were evaluated in monitored and unmonitored groups. Compliance with monitoring was also evaluated in the monitored group., Results: The monitored and control groups were demographically similar. According to a multivariate logistic regression model, women with cervical dilatation of >/=2 cm were 4 times more likely to be delivered at <35 weeks' gestation (P <.05). Gestational ages at delivery were similar in the monitored and control groups. There was no significant difference in the overall rate of preterm delivery at <35 weeks' gestation between the monitored group (10.9%) and the control group (15.0%). The overall rates of delivery at <37 weeks' gestation were high (48.8% and 60.0% for monitored and control groups, respectively), and the difference was not significant. The numbers of women with >/=1 instance of readmission and treatment for recurrent preterm labor were equal in the monitored and control groups. The numbers of women with >/=1 hospital observation lasting <24 hours were not different between the groups. Compliance with monitoring did not significantly differ for women who were delivered at <35 weeks' gestation, women with >/=2 cm cervical dilatation at enrollment, or for African American women., Conclusion: A reduction in the likelihood of preterm delivery at <35 weeks' gestation was not further enhanced by the addition of home uterine monitoring to the outpatient management regimens of women treated for preterm labor.

Objective: Our purpose was to determine whether the continuation of antibiotics postoperatively after cesarean section in patients whose labors were complicated by chorioamnionitis would reduce the incidence of endometritis., Study Design: Patients with a clinical diagnosis of chorioamnionitis treated with ampicillin during labor and who required cesarean delivery for obstetric indications received preoperative intravenous clindamycin and gentamicin and were randomized into 2 groups. Group 1 received no scheduled postoperative antibiotics and group 2 continued to receive clindamycin 900 mg every 8 hours and gentamicin 1.5 mg/kg every 8 hours until afebrile for a minimum of 24 hours (temperature

Objective: The purpose of this study is to evaluate women receiving methadone maintenance during pregnancy., Study Design: Thirty-two pregnancies in women receiving methadone maintenance were matched by gestational age to women with a positive urine screen for cocaine at delivery and to drug-free controls. Pregnancy outcome variables were compared, including birth weight and neonatal morbidity. Analysis was by chi2 and t test with significance set at .05., Results: Birth weight of methadone-exposed infants was 2748 g versus 2925 g for cocaine and 3032 g for controls, P = not significant. Birth weight comparison with a 50-mg maternal methadone cutoff dose was not different. A head circumference for methadone infants of 32.4 +/- 4.7 cm was significantly less than controls, 33.5 +/- 4.0 cm, P < .04, but not different from infants of cocaine users, 32.8 +/- 3.1 cm. Women using cocaine had a significantly higher incidence of meconium in labor compared with methadone and controls. Of women taking methadone 27 of 32 (84.3%) were positive for other drugs of abuse in the last screen before or at delivery. Cocaine 12 of 32 (37.5%), other opiates 13 of 32 (40.6%), and marijuana 14 of 32 (43.7%) were the most prevalent. Neonatal withdrawal occurred in 23 of 32 (72%) women taking methadone. The neonates of women using < 50 mg of methadone were as likely to withdraw as those women using > or = 50 mg, 61.5% versus 79.0%, P not significant. Three neonates in the methadone group (9.3%) had major congenital anomalies, with 2 of the 3 (66.6%) resulting in mortality., Conclusions: Birth outcome is not significantly different between methadone and cocaine users. Women receiving methadone maintenance are likely to abuse other illicit drugs.

Objective: Our purpose was to compare the birth outcomes of pregnant women in the Women, Infants and Children Food Supplement Program with women not in the program., Study Design: The vital records of 4713 women, 2895 enrolled in the Women, Infants and Children Food Supplement Program and 1812 not enrolled in the program, whose infants were delivered at Wishard Memorial Hospital over 18 months were reviewed with respect to age, education, race, substance habits, trimester of entry into prenatal care, maternal weight gain, and status in the program. The primary outcome variables evaluated were low birth weight, as defined by the delivery of an infant < 2500 gm, and infant mortality. The primary predictor was program participation versus nonparticipation. Analysis was by t test, chi2, and logistic regression models., Results: Black women, women with no prenatal care, and women who smoke were more likely to deliver a low-birth-weight infant. The incidence of low birth weight was 13.1% for nonparticipants versus 10.2% for program participants (p < 0.05). Univariate analysis confirmed program participants to be at significantly less risk for a low-birth-weight delivery (odds ratio = 0.75, p < 0.05). This relation, however, was not significant in the multivariate model (odds ratio = 0.88), indicating that the effect of participating in the program is being confounded by race, entry into prenatal care, and smoking. The overall infant mortality rate was 12.4 per 1000 for participants and 16 per 1000 for nonparticipants (p = not significant)., Conclusion: Nutritional and nonnutritional benefits to participation in the Women, Infants and Children Food Supplement Program were confirmed. Women enrolled in the program were less likely to deliver a low-birth-weight infant. Multiple variables likely contribute to the poorer outcome for nonparticipants.

In a cross-sectional study of 210 pregnancies resulting in above-average-sized term infants, biparietal diameter, femur length, and abdominal circumference were found to differ among three birth weight percentile groups (greater than 90, 76 to 90, and 51 to 75). Growth rates, however, were similar. Estimated fetal weights, derived from four formulas, showed the same pattern. Differences between large for gestational age infants and other above average sized infants exist; changes in growth are likely to have occurred before the thirty-third week of gestation.

Ultrasonographically determined biparietal diameter, femur length, abdominal circumference, and estimated fetal weight were analyzed with regard to their ability to predict the macrosomic newborn. Receiver operating characteristic curves were plotted for each of these variables. Estimated fetal weight was superior to biparietal diameter or femur length measurements in the identification of the overgrown fetus. Because of limitations of positive predictive values and sensitivities, application of these observations varies with the clinical setting in which they are used.

Fetal weight estimation was performed in 58 women with preterm premature rupture of the membranes within 4 days of delivery. Of twelve formulas evaluated, only two met the requirements for clinical use (i.e., they had a small mean percent error and a high correlation). However, both had high random error, which may be attributable to the very low birth weights studied.