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Key Clinical Message We describe the prenatal and postnatal course of an infant with a large 19p deletion. Cases such as ours will improve the knowledge of specific gene functions for every medical specialist. The goal is to allow for a more rapid diagnosis, accurate prognosis and to decrease the likelihood of complications.

Objective: To evaluate the relationship between weight gain and primary cesarean delivery. Methods: This was a retrospective cohort study of women 5442 who delivered a singleton from 2009-2013. Women were classified as normal weight [pre-pregnancy body mass index (BMI) 18.5 - 24.9 kg/m2], overweight (pre-pregnancy BMI 25.0 - 29.9 kg/m2), obese (pre-pregnancy BMI 30.0 - 39.9 kg/m2), and extremely obese (pre-pregnancy BMI ≥ 40.0 kg/m2). Each BMI group was subdivided by weight gain—low, recommended, or excessive, as defined by the 2009 Institute of Medicine guidelines—and rates of primary cesarean delivery were compared. Results: The overall primary cesarean delivery rate was 27.3%, but this varied based on pre-pregnancy BMI. The primary cesarean delivery rate among women of normal weight was 22.3%, overweight women 27.5%, obese women 35.3%, and extremely obese women 45.7%. Among normal-weight, obese, and extremely obese women, the risk of primary cesarean delivery increased with excessive weight gain [normal weight odds ratio (OR) 1.63, (95% confidence interval 1.32 - 2.01); obese OR 1.55 (1.12 - 2.15); extremely obese OR 2.19 (1.18 - 4.08)] compared to recommended weight gain. More than half of women (53.2%) had excessive weight gain. Conclusion: Adherence to guidelines may decrease a woman’s risk of primary cesarean delivery.

Background Pulmonary arterial hypertension carries a high risk of mortality in pregnancy. Recent advances in treatment may improve disease course and allow for successful management of the pregnancy. Case Report We present the case of a 20-year-old gravida 1, para 0 with diagnosis of severe primary pulmonary hypertension. The patient was managed with epoprostenol (prostacyclin) infusion via an indwelling catheter, which was initiated at 23 weeks' gestation. The dose was adjusted to the patient's symptoms and a successful vaginal delivery was achieved at 36 weeks' gestation. Although maternal postpartum course was uncomplicated, unexplained neonatal demise occurred at 11 days of life. Conclusion Successful management of pulmonary hypertension in pregnancy can be accomplished with a multidisciplinary approach and intensive therapy. Long-term effects of epoprostenol on fetal or neonatal well-being are unknown.

OBJECTIVE To determine if the rates of recurrent spontaneous preterm birth in women receiving 17α-hydroxyprogesterone caproate (17P) differ according to maternal race. STUDY DESIGN Retrospective analysis of a cohort of women enrolled in outpatient 17P administration at

To examine the influence of maternal pre-pregnancy body mass index (BMI) on the rates of recurrent spontaneous preterm birth (SPTB) in women receiving 17α-hydroxyprogesterone caproate (17P).Retrospective analysis of a cohort of 6253 women with a singleton gestation and prior SPTB enrolled in 17P home administration program between 16.0 and 26.9 weeks. Data were grouped by pre-pregnancy BMI (lean18.5 kg/m(2), normal 18.5-24.9 kg/m(2), overweight 25-29.9 kg/m(2) and obese ≥30.0 kg/m(2)). Delivery outcomes were compared using χ(2) and Kruskal-Wallis tests with statistical significance set at p 0.05.SPTB28 weeks was significantly lower in normal weight women. Rates of recurrent SPTB37 weeks were highest in the group with BMI18.5 kg/m(2). Lean gravidas were younger, more likely to smoke, and less likely to be African-American than those with normal or increased BMI. In logistic regression, after controlling for race and prior preterm birth28 weeks, the risk of SPTB37 weeks decreased 2% for every additional 1 kg/m(2) increase in BMI.Recurrent spontaneous preterm delivery37 weeks in patients on 17P is more common in lean women (BMI18.5 kg/m(2)), and less common in obese women (BMI ≥30 kg/m(2)) suggesting that the current recommended dosing of 17 P is adequate for women with higher BMI.

Prevention of spontaneous preterm birth is an important public health priority. Pessary may be a potential therapy in cases of cervical insufficiency, in singleton and multiple gestations. Availability of transvaginal sonography for accurate assessment of cervical length is allowing for the tailoring of therapy to a more specific subset of patients who may benefit from this treatment. Pessary therapy is attractive given the favorable side effect profile, low cost, and ease of placement and removal. Large randomized trials are ongoing to validate initial favorable findings.

To evaluate the effect of pre-pregnancy body mass index (BMI) on the risk of developing gestational diabetes mellitus (GDM) in a large unselected population.We performed a case control study using data collected in The Consortium on Safe Labor database. The association between BMI and GDM was evaluated both using BMI weight categories adopted by the National Institute of Health, and separately using BMI as a continuous variable. Multiple logistic regression analyses were used to evaluate the effects of BMI, age, ethnicity, parity, chronic hypertension and antenatal steroid use on the risk of GDM. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to approximate relative risks of GDM. A p value of0.05 was considered significant.After controlling for other factors, the risk of GDM increased with an increasing BMI across all weight categories. For each 1 kg/m(2) increase of BMI the OR of developing GDM was 1.08 (95% CI 1.08-1.09) and for each 5 kg/m(2) increase, the OR was 1.48 (95% CI 1.45-1.51).GDM is a multifactorial disorder and pre-pregnancy BMI plays an important role in that risk. Modest changes in pre-pregnancy BMI may decrease the risk of GDM substantially.

To test the hypothesis that the first stage of labor will be longer in nulliparous and multiparous women with diabetes compared to non-diabetic counterparts.A retrospective analysis was performed from 228,668 deliveries between 2002-2008 from the Consortium of Safe Labor (National Institute of Child Health and Human Development, National Institutes of Health). Patients with spontaneous onset of labor from 37 0/7-41 6/7 weeks gestation were included (71,282) and classified as nulliparous or multiparous. Pregnancies were further subdivided regarding presence of preexisting diabetes (preDM) or gestational diabetes (GDM) and normal controls. Labor curves were created matching for body mass index (BMI) and neonatal birth weight. Statistical analysis was performed on descriptive variables using χ(2) with significance designated as p 0.05.Among nulliparous patients, there were 118 women with preDM and 475 women with GDM; 25,771 patients served as normal controls. Among multiparous women, there were 311 with preDM, 1,079 with GDM and 43,528 in the control group. Although differences in dilatation rates were observed in nulliparous and multiparous women with and without diabetes, labor progression was similar between the subgroups when matched for maternal BMI and birth weight.Labor curves of women with preDM and GDM approximate those of non-diabetics, regardless of BMI, birth weight, or parity.

The purpose of this study was to evaluate the labor curves of patients who undergo preterm induction of labor (IOL) and to assess possible predictors of vaginal delivery (VD).Data from the National Institute of Child Health and Human Development Consortium on Safe Labor were analyzed. A total of 6555 women who underwent medically indicated IOL at37 weeks of gestation were included in this analysis. Patients were divided into 4 groups based on gestational age (GA): group A, 24-27+6 weeks; B, 28-30+6 weeks; C, 31-33+6 weeks; and D, 34-36+6 weeks. Pregnant women with a contraindication to VD, IOL ≥37 weeks of gestation, and without data from cervical examination on admission were excluded. Analysis of variance was used to assess differences between GA groups. Multiple logistic regression was used to assess predictors of VD. A repeated measures analysis was used to determine average labor curves.Rates of vaginal live births increased with GA, from 35% (group A) to 76% (group D). Parous women (odds ratio, 6.78; 95% confidence interval, 6.38-7.21) and those with a favorable cervix at the start of IOL (odds ratio, 2.35; 95% confidence interval, 2.23-2.48) were more likely to deliver vaginally. Analysis of labor curves in nulliparous women showed shorter duration of labor with increasing GA; the active phase of labor was, however, similar across all GAs.Most women who undergo medically indicated preterm IOL between 24 and 36+6 weeks of gestation deliver vaginally. The strongest predictor of VD was parity. Preterm IOL had a limited influence on estimated labor curves across GAs.

Despite early literature suggesting an increased risk of infertility and significant pregnancy complications, favorable obstetric and neonatal outcomes can be achieved in patients with scleroderma. Commonly reported complications include prematurity and intrauterine growth restriction, and most of the adverse pregnancy outcomes occur in women with early, diffuse systemic sclerosis. Ideally, patients should undergo preconception counseling to determine if multi-organ involvement precludes pregnancy.

Objective The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. Study Design This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop 2 or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks. Outcomes were analyzed using χ 2 , Student t , or Wilcoxon rank sum tests as appropriate with a significance set at P Results Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. Conclusion Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.

To delineate adverse obstetric and neonatal outcomes as well as indications for cesarean delivery by maternal age in a contemporaneous large national cohort.This was a retrospective analysis of electronic medical records from 12 centers and 203,517 (30,673 women aged 35 years or older) women with singleton gestations stratified by maternal age. Logistic regression was performed to investigate maternal and neonatal outcomes for each maternal age strata (referent group, age 25.0-29.9 years), adjusting for race, parity, body mass index, insurance, pre-existing medical conditions, substance and tobacco use, and site. Documented indications for cesarean delivery were analyzed.Neonates born to women aged 25.0-29.9 years had the lowest risk of birth weight less than 2,500 g (7.2%; P.001), admission to neonatal intensive care unit (11.5%; P.001), and perinatal mortality (0.7%; P.001). Hypertensive disorders of pregnancy were higher in women aged 35 years or older (cumulative rate 8.5% compared with 7.8%; 25.0-29.9 years; P.001). Previous uterine scar was the leading indication for cesarean delivery in women aged 25.0 years or older (36.9%; P.001). For younger women, failure to progress or cephalopelvic disproportion (37.0% for those younger than age 20.0 years and 31.1% for those aged 20.0-24.9-years; P.001) and nonreassuring fetal heart tracing (28.7% for those younger than 20.0 years and 21.2% for those aged 20.0-24.9-years; P.001) predominated as indications. Truly elective cesarean delivery rate was 20.2% for women aged 45.0 years or older (adjusted odds ratio 1.85 [99% confidence interval 1.03-3.32] compared with the referent age group of 25.0-29.9 years).Maternal and obstetric complications differed by maternal age, as did rates of elective cesarean delivery. Women aged 25.0-29.9 years had the lowest rate of serious neonatal morbidity.: II.

To examine the timing of elective delivery and neonatal intensive care unit (NICU) utilization of electively delivered infants from 2008 to 2011.Analysis included 42,290 women with singleton gestation enrolled in a pregnancy education program, reporting uncomplicated pregnancies with elective labor induction (ELI) (n = 27,677) or scheduled cesarean delivery (SCD) (n = 14,613) at 37.0-41.9 weeks' gestation. Data were grouped by type and week of delivery (37.0-37.9, 38.0-38.9, and 39.0-41.9 weeks). ELI and SCD for each week of delivery from 2008 to 2011 and nursery utilization by delivery week were compared.During the 2008-2011 timeframe, a shift in timing of ELI and SCD toward ≥39.0 weeks was observed. In 2008, 80.9% of ELI occurred at ≥39.0 weeks versus 92.6% in 2011 (p 0.001). In 2008, 60.5% of SCD occurred at ≥39.0 weeks versus 78.1% in 2011 (p 0.001). NICU admission and prolonged nursery stays were highest at 37.0-37.9 weeks for both groups.We observed a shift toward later gestational age at elective delivery from 2008 to 2011 and increased NICU utilization for neonates born at39 weeks' gestation.

Objective The objective of the study was to determine the relationships between maternal race and obstetric outcomes in twin gestations by planned mode of delivery. Study Design We performed a secondary analysis of the Consortium on Safe Labor data. Patients with twin gestations in vertex-vertex presentation greater than 32 weeks' gestational age were grouped according to race. Demographic information and neonatal and maternal outcomes were analyzed according to planned mode of delivery: elective cesarean or trial of labor (with subsequent vaginal delivery, unplanned cesarean, or combined delivery). The primary outcome was unplanned cesarean. Secondary outcomes included maternal and neonatal outcomes. Results One thousand nine vertex-vertex twin pregnancies were identified. There were no significant differences across ethnicities in the rate of unplanned cesarean delivery, which occurred in 233 of patients undergoing trial of labor (27%). Elective cesarean occurred in 151 patients (15%). African American women were less likely to have an elective cesarean compared with whites (odds ratio, 0.5; 95% confidence interval, 0.3–0.8), and Asian women were more likely to have an elective cesarean compared with whites (odds ratio, 2.0; 95% confidence interval, 1.2–3.4. Combined delivery occurred in 67 patients (8%) and did not differ among the groups. Subgroup analysis did not reveal any significant differences in neonatal outcomes. Adverse maternal outcomes were rare across ethnicities. Conclusion Unplanned cesarean delivery rates are similar in twin pregnancies, regardless of race. Maternal and neonatal outcomes in twin gestations are similar across ethnicities, regardless of mode of delivery.

Objective To compare obstetric and neonatal outcomes between human immunodeficiency virus (HIV) positive (HIV+) and HIV negative (HIV−) women and to determine if racial disparities exist among pregnancies complicated by HIV infection. Study Design This was a retrospective analysis of data from the Consortium of Safe Labor between 2002 and 2008. Comparisons of obstetric morbidity, neonatal morbidity, and indications for cesarean delivery were examined. Included were singletons with documented HIV status, race, and antepartum admission. Chi-square, Fisher exact tests, and logistic regression were used for statistical analysis. Results Included were 178,972 patients (178,210 HIV−, 762 HIV+, 464 HIV+ black, 298 HIV+ nonblack). HIV+ women were more likely to have a cesarean delivery, preterm premature rupture of membranes, another sexually transmitted infection, and delivery at an earlier gestational age. Obstetric outcomes were similar between HIV+ black and HIV+ nonblack women. Neonates of HIV+ mothers had lower birth weights and higher rates of neonatal intensive care admissions. HIV+ black women had lower birth weight neonates than HIV+ nonblack women. Conclusion HIV+ women have higher rates of obstetric complications and deliver at an earlier gestational age than HIV− mothers. Lower birth weight was the only notable complication among HIV+ black women compared with HIV+ nonblack women.

To determine the accuracy of clinically estimated fetal weight (CEFW) in patients with gestational diabetes (GDM), pregestational diabetes (DM), and obesity.This is a retrospective analysis of Consortium of Safe Labor data. Subjects were classified into six groups: DM, DM and obese, GDM, GDM and obese, nondiabetic obese, and controls. The mean difference between birth weight (BW) and CEFW, the percent of accurate CEFW (defined as 10% difference), and the sensitivity for identifying BW 4,000 g and 4,500 g were calculated for each group.The accuracy of CEFW in our population was 54.3 to 64.4% and was significantly lower in patients with DM and obesity and patients with obesity but not diabetes. When CEFW was analyzed in the4,000-g and 4,500-g groups, its accuracy was 20 to 51% and 14 to 40%, respectively. CEFW overestimated BW more commonly in GDM, obese GDM, and obese groups. The sensitivity of CEFW for diagnosing BW 4,000 g or 4,500 g was 19.6% and 9.6%, respectively, and it improved in pregnancies complicated by diabetes.CEFW is a poor predictor of macrosomia in pregnancies complicated by obesity and diabetes.

Evaluate the association between body mass index (BMI) and the delivery of an asymmetrically large for gestational age (A-LGA) newborn in women with diabetes.Retrospective analysis of 306 pregnancies complicated by Type 1 and 55 by Type 2 diabetes.The prevalence of Type 1 and Type 2 diabetics delivering large for gestational age (LGA) infants was 42% and 49%, respectively. Of these 49% and 55% were A-LGA, respectively. Pre-pregnancy BMI was not associated with increased odds of delivering an A-LGA newborn in women with Type 1 or 2 diabetes. However, in Type 1 diabetics, each one-pound increase in maternal weight during pregnancy resulted in 4% increased odds of delivering an A-LGA newborn. For Type 2 diabetics, the odds of delivering an A-LGA infant was decreased by 10% for each 0.1 unit/kg increase in insulin dose.Although there is a known association between obesity and LGA in women with diabetes, we found that overweight and obese women with Type 1 or Type 2 diabetes do not have increased odds of delivering an A-LGA newborn. However, insulin dose in Type 2 diabetes and maternal weight gain in Type 1 diabetes were significantly associated with the odds of delivering an A-LGA neonate.

OBJECTIVE: To investigate the prevalence of appendiceal pathology in women undergoing surgery for a suspected ovarian neoplasm and the predictive value of intraoperative findings to determine the need for appendectomy at the time of surgery. METHODS: Retrospective analysis of patients who underwent oophorectomy and appendectomy during the same surgical procedures at the University of Virginia Health System from 1992 to 2007. Observations were stratified based on the nature (benign, borderline, or malignant) and histology (serous compared with mucinous) of the ovarian neoplasm, frozen compared with final pathological diagnosis, and the gross appearance of the appendix. RESULTS: Among the 191 patients identified, frozen section was consistent with seven mucinous and 35 serous carcinomas, 16 serous and 33 mucinous borderline tumors, 71 mucinous and serous cystadenomas, and 29 cases of suspected metastatic tumor from a gastrointestinal primary. The highest rates of coexisting appendiceal pathology were associated with serous ovarian cancers (94.4% of grossly abnormal and 35.3% of normal appendices) and ovarian tumors suspected to be of primary gastrointestinal origin (83.3% grossly abnormal and 60.0% normal appendices harbored coexisting mucinous neoplasms). Linear regression analysis revealed that appearance of the appendix and frozen section diagnosis of the ovarian pathology were statistically significant predictors of coexisting appendiceal pathology, but the latter was more important. CONCLUSION: The prevalence of coexisting, clinically significant appendiceal pathology is low with a frozen section diagnosis of serous or mucinous cystadenoma. Appendectomy is recommended when frozen section diagnosis is mucinous or serous ovarian carcinoma, borderline tumor or metastatic carcinoma of suspected gastrointestinal origin.

Objective: To investigate feasibility of identifying the number of vessels in umbilical cord during nuchal translucency screening. Methods: We performed a prospective study in patients undergoing nuchal translucency screening at 11.0-13.9 weeks’ from 2011-2012. An oblique transverse view of fetal abdomen utilizing Doppler flow and a cross section view of free loop of umbilical cord were obtained. Maternal characteristics, technical aspects of first trimester ultrasound, and number of umbilical cord vessels identified in the second trimester were collected. McNemar’s test and kappa analysis were used to compare quantification of umbilical cord vessels in the first vs. second trimesters. Results: Total of 123 women were included. The number of umbilical cord vessels was successfully visualized in 95.9% of patients utilizing the bladder view, and 65.0% of patients on cross sectional cord views. Three-vessel cord was correctly identified in 99.2% of patients; one case was incorrectly diagnosed with a two two-vessel cord. McNemar’s test indicated that overall, first and second trimester ultrasounds have the same propensity to detect umbilical cord vessels (p=0.414), with moderate agreement (kappa=0.226). Conclusions: Identification of umbilical cord vasculature is possible in the first trimester and can be used as an adjunct to early fetal anatomy evaluation.

140 Effects of low pre-pregnancy body mass index and gestational weight gain on neonatal outcomes Milana Berguig, Julia Timofeev, Helain Landy MedStar Georgetown University Hospital, Obstetrics and Gynecology, Washington, DC, MedStar Washington Hospital Center, Obstetrics and Gynecology, Washington, DC OBJECTIVE: To evaluate the effect of low pre-pregnancy body mass index (BMI) and low gestational weight gain on neonatal outcomes as compared to parturients with normal BMI and normal or excessive weight gain. STUDY DESIGN: A retrospective review of a multicenter cohort of deidentified data in the Consortium on Safe Labor (NICHD). This database includes information on 233,844 births from 228,668 deliveries from 2002-2008. Maternal factors and neonatal outcomes were analyzed by BMI (low BMI 18.5 kg/m, normal 18.5-24.9 kg/m) and weight gain during gestation as recommended by the Institute of Medicine 2009 guidelines (normal weight gain of 28-40lbs for women with low BMI, and 25-35lbs for women with normal BMI). Chi square and Fisher’s exact tests were used for statistical analysis, with significance determined at two-tailed 0.05. RESULTS: Low pre-pregnancy BMI showed statistically significant increases in the risk of small for gestational age (SGA) infants (OR 1.96, CI 1.93 2.00), NICU admission (OR 1.24, CI 1.21 1.26), and neonatal death (OR 1.62, CI 1.47 1.79). No statistically significant differences were seen in gestational age at delivery or need for newborn resuscitation. When considering recommended weight gain, women who gained less weight ( 28 lbs for low BMI, and 25 lbs for normal BMI) had higher risks of poor pregnancy outcomes (SGA, 5-minute Apgar score 7, NICU admission, antepartum and intrapartum stillbirth (Table). CONCLUSION: Pregnancy outcomes are influenced by both pre-pregnancy BMI and weight gain during pregnancy. These findings suggest that women can minimize their risk of neonatal morbidity and mortality by optimizing their weight prior to conception and gaining the recommended weight amount throughout the pregnancy.