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The purpose of this review article is to evaluate the peripartum outcomes of yoga during pregnancy, including the postpartum period and lactation. The PubMed database was analyzed from January 1970 to January 2011. We identified five prospective observational studies (n = 575) and three randomized clinical trials (RCTs; n = 298), which were analyzed separately. The nonrandomized trials indicated a significant reduction in rates of preterm labor (p < 0.0006), intrauterine growth retardation (p <0.003), low birth weight (p < 0.01), pregnancy discomforts (p = 0.01), and perceived sleep disturbances (p = 0.03) in those who practiced yoga during pregnancy. Results of the RCTs indicated that doing yoga during pregnancy can significantly lower pain and discomfort (p < 0.05) and perceived stress (p = 0.001) and improve quality of life in physical domains (p = 0.001). All three RCTs were poorly compliant with the Consolidated Standard of Reporting Trials statement. While awaiting an appropriately designed RCT to determine the benefits of yoga during pregnancy, it remains a viable exercise option., (Copyright © 2012 Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.)

Sepsis is a life-threatening syndrome caused by the body's response to infection. The Global Maternal Sepsis Study (GLOSS) suggests sepsis plays a larger role in maternal morbidity and mortality than previously thought. We therefore sought to compare national and international guidelines for maternal sepsis to determine their consistency with each other and the Third International Consensus for Sepsis and Septic Shock (SEPSIS-3). Using Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and organization Web sites, we identified seven guidelines on maternal sepsis in the English language—The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Society of Obstetric Medicine of Australia and New Zealand, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland Institute of Obstetricians and Gynaecologists, and World Health Organization. Guidelines were reviewed to ascertain the commonality and variation, if any, in definitions of maternal sepsis, tools and criteria utilized for diagnosis, obstetric warning systems used, as well as evaluation and management of maternal sepsis. These variables were also compared with SEPSIS-3. All guidelines provided definitions consistent with a version of the SEPSIS, although the specific version utilized were varied. Clinical variables and tools employed for diagnosis of maternal sepsis were also varied. Evaluation and management of maternal sepsis and septic shock were similar. In conclusion, national and international maternal sepsis guidelines were incongruent with each other and SEPSIS-3 in diagnostic criteria and tools but similar in evaluation and management recommendations. Key Points Definitions for maternal sepsis and septic shock are varied. Maternal sepsis guidelines differ in proposed criteria and tools. Maternal sepsis guidelines have similar management recommendations. [ABSTRACT FROM AUTHOR]

Objective This study aimed to develop and evaluate a scoring system—called the Sepsis-Associated Adverse Outcomes in Pregnancy (SAAP) Score—to identify individuals with maternal infection that have composite maternal adverse outcomes (CMAO). Study Design Using the International Classification of Disease codes, we identified pregnant and postpartum (up to 6 weeks after birth) individuals admitted at our center with a primary diagnosis of infection. The primary outcome was CMAO which included any of the following: maternal intensive care unit admission, surgical intervention, vasopressor use, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, dialysis, organ failure, venous thromboembolism, or maternal death. Regularized logistic regression was used to identify variables that best discriminate CMAO status. Variables were chosen for inclusion following evaluation of statistical and clinical significance. Model performance was evaluated using area under the curve (AUC) with 95% confidence intervals (CIs), sensitivity, specificity, and predictive values. Results Of the 23,235 deliveries during the study period, 227 (0.9%) individuals met inclusion criteria and among them CMAO occurred in 39.2% (95% CI: 33.1–45.7%). The SAAP score consisted of six variables (white blood cell count, systolic blood pressure, respiratory rate, heart rate, lactic acid, and abnormal diagnostic imaging) with scores ranging from 0 to 11 and a score of ≥7 being abnormal. An abnormal SAAP score had an AUC of 0.80 (95% CI: 0.74–0.86) for CMAO. The sensitivity and specificity of the SAAP score for CMAO was 0.71 (95% CI: 0.60–0.80) and 0.73 (95% CI: 0.64–0.80), respectively. The positive predictive value was 0.62 (95% CI: 0.52–0.72) and negative predictive value was 0.79 (95% CI: 0.71–0.86). Conclusion Pending external validation, the sixth variable SAAP score may permit early recognition of pregnant and postpartum individuals with infection who are likely to develop adverse maternal outcomes. Key Points Sepsis is a leading cause of maternal morbidity and mortality. Early recognition improves maternal sepsis outcomes. The SAAP score may permit early recognition of maternal adverse outcomes due to infection. [ABSTRACT FROM AUTHOR]

Objective: To ascertain the composite maternal and neonatal outcomes in pregnant individuals with moderate, severe, or critical coronavirus disease 2019 (COVID-19) treated with remdesivir. Materials and methods This is a secondary analysis of the COVID in Pregnancy Registry in Houston, Texas. Women were included if they met the criteria of moderate, severe or critical COVID-19 illness. Composite adverse maternal outcome was defined as any of the following outcomes: placental abruption, pregnancy-related hypertension, chorioamnionitis, stroke, delivery with estimated blood loss >1000 mL, diagnosis of pulmonary embolism or deep venous thromboembolism, or maternal death. Composite adverse neonatal outcome was defined as any of the following: Apgar score ≤3 at 5 min, arterial cord pH <7.0, positive SAR-CoV-2 test, intraventricular hemorrhage, periventricular leukomalacia, stillbirth, or neonatal death. Comparative analyses between participants receiving remdesivir versus those not exposed were performed. Results A total of 994 patients were diagnosed with COVID-19 infection. Of these, 95 (9.6%) met criteria for moderate, severe, or critical disease. Forty-one percent of these patients (n = 39) received remdesivir. Baseline demographic characteristics were not different between groups. No patients reported an allergic reaction with the administration of remdesivir; however, 16.7% of the patients had the medication discontinued due to transaminitis. Patients receiving the drug were more likely to have a longer illness duration on admission, more likely to require oxygen support on arrival and have a longer hospital stay. Conclusions Remdesivir appears to be safe, well tolerated within our cohort with no cases of recorded adverse reaction. [ABSTRACT FROM AUTHOR]

Preterm birth remains a major complication of fetal laser surgery (FLS) due to twin-to-twin transfusion syndrome (TTTS).Objectives: We tested the hypothesis that neonatal outcomes in fetuses born at >24 weeks are worse in TTTS survivors compared to uncomplicated monochorionic diamniotic (MCDA) twins.Methods: 196 patients with TTTS treated with laser therapy and 91 uncomplicated MCDA gestations were compared. Neonatal outcomes included respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal death. Risk factors assessed were TTTS, maternal age, maternal body mass index, race, premature prolonged rupture of membranes, stage of TTTS, parity, and gestational age (GA) at delivery.Results: GA at delivery was lower in the TTTS group (31.0 ± 4.6 vs. 33.5 ± 2.4 weeks, p < 0.001). RDS and TTN occurred at higher rates in the TTTS than in the uncomplicated MCDA group. After multivariate logistic regression, the only factor significantly associated with the composite adverse outcome was GA at delivery (OR 0.61; 95% CI: 0.58-0.7).Conclusion: TTTS twins treated with FLS are deliver 2.5 weeks earlier than uncomplicated MCDA twins. Respiratory complications were significantly higher in TTTS twins and were mainly the consequence of the early GA at delivery. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to compare the perinatal outcomes among U.S.-born and foreign-born Hispanics and Caucasians and ascertain if length of time in the US was associated with the rate of adverse outcomes. Study Design  Retrospective cohort analysis of gravidae enrolled in our institutional perinatal database. Women delivering a non-anomalous, singleton, at 24 weeks or more and self-identified as Caucasian or Hispanic were included. Women were stratified by country of birth and ethnicity into U.S.-born Caucasian, U.S.-born Hispanic, and U.S. foreign-born Hispanic. Composite maternal (CMM) and neonatal (CNM) morbidity was assessed. Results  Of 20,422 women, 21% were Caucasian, 15% were U.S.-born Hispanics, and 64% were U.S. foreign-born Hispanics. Compared to Caucasians, U.S.-born and foreign-born Hispanic were older, more likely to be a grand multiparous, obese and less likely to be married. Compared to Caucasians, foreign-born Hispanics had a 1.42-fold increased risk of CMM (95% CI 1.26–1.30). Paradoxically, the rate of CNM was 40% lower among neonates born to foreign-born Hispanics (95% CI 0.51–0.74). A significant direct relationship was noted between time in the USA and CMM but not CNM among foreign-born Hispanics. Conclusion  Despite less favorable baseline characteristics, U.S. foreign-born Hispanics have 40% less CNM compared to both Caucasians and U.S.-born Hispanics. [ABSTRACT FROM AUTHOR]

Objective: To estimate whether the frequency of adverse maternal and neonatal outcomes differs between low-risk nulliparous and multiparous women at 39-41 weeks of gestation.Methods: This is a secondary analysis of an observational obstetrics cohort of maternal-neonatal dyads at 25 hospitals. Low-risk women with nonanomalous singletons who delivered between 39 0/7 and 41 6/7 weeks of gestation were included. The composite neonatal adverse outcome included 5-minute Apgar score less than five, ventilator support or cardiopulmonary resuscitation, seizure, hypoxic ischemic encephalopathy, sepsis, bronchopulmonary dysplasia, persistent pulmonary hypertension, necrotizing enterocolitis, birth injury or perinatal death. The composite maternal adverse outcome included infection, third- or fourth-degree perineal laceration, thromboembolism, transfusion of blood products, or maternal death. Small for gestational age (SGA), large for gestational age (LGA), and shoulder dystocia requiring maneuvers were also evaluated. Multivariable regression was used to estimate adjusted relative risks (aRRs) and adjusted odds ratios (aORs) with 95% CIs.Results: Of the 115,502 women in the overall cohort, 39,870 (34.5%) met eligibility criteria for this analysis; 18,245 (45.8%) were nulliparous. The risk of the composite neonatal adverse outcome (1.5% vs 1.0%, aRR 1.80, 95% CI 1.48-2.19), composite maternal adverse outcome (15.1% vs 3.3%, aRR 5.04, 95% CI 4.62-5.49), and SGA (8.9% vs 5.8%, aOR 1.45, 95% CI 1.33-1.57) was significantly higher in nulliparous than multiparous patients. The risk of LGA (aOR 0.65, 95% CI 0.60-0.71) and shoulder dystocia with maneuvers (aRR 0.68, 95% CI 0.60-0.77) was significantly lower in nulliparous rather than multiparous patients.Conclusion: The risk of composite adverse outcomes and SGA among low-risk nulliparous women at 39-41 weeks of gestation is significantly higher than among multiparous counterparts. However, nulliparous women had a lower risk of shoulder dystocia with maneuvers and LGA. [ABSTRACT FROM AUTHOR]

Background  Women with a history of spontaneous preterm birth (SPTB) are at a significantly increased risk for recurrent preterm birth (PTB). To date, only one large U.S. clinical trial comparing 17-OHPC (17-α-hydroxyprogesterone caproate or "17P") to placebo has been published, and this trial was stopped early due to a large treatment benefit. Objective  This study aimed to assess whether 17-OHPC decreases recurrent PTB and neonatal morbidity in women with a prior SPTB in a singleton gestation. Study Design  This was a double-blind, placebo-controlled international trial involving women with a previous singleton SPTB (clinicaltrials.gov : NCT 01004029). Women were enrolled at 93 clinical centers (41 in the United States and 52 outside the United States) between 16 0/7 to 20 6/7 weeks in a 2:1 ratio, to receive either weekly intramuscular (IM) injections of 250 mg of 17-OHPC or an inert oil placebo; treatment was continued until delivery or 36 weeks. Co-primary outcomes were PTB < 35 weeks and a neonatal morbidity composite index. The composite included any of the following: neonatal death, grade 3 or 4 intraventricular hemorrhage, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, or proven sepsis. A planned sample size of 1,707 patients was estimated to provide 98% power to detect a 30% reduction in PTB < 35 weeks (30% to 21%) and 90% power to detect a 35% reduction in neonatal composite index (17%–11%) using a two-sided type-I error of 5%. Finally, this sample size would also provide 82.8% power to rule out a doubling in the risk of fetal/early infant death assuming a 4% fetal/early infant death rate. Analysis was performed according to the intention-to-treat principle. Results  Baseline characteristics between the 1,130 women who received 17-OHPC and 578 women who received placebo were similar. Overall, 87% of enrolled women were Caucasian, 12% had >1 prior SPTB, 7% smoked cigarettes, and 89% were married/lived with partner. Prior to receiving study drug, 73% women had a transvaginal cervical length measurement performed and <2% had cervical shortening <25 mm. There were no significant differences in the frequency of PTB < 35 weeks (17-OHPC 11.0% vs. placebo 11.5%; relative risk = 0.95 [95% confidence interval (CI): 0.71–1.26]) or neonatal morbidity index (17-OHPC 5.6% vs. placebo 5.0%; relative risk = 1.12 [95% CI: 0.68–1.61]). There were also no differences in frequency of fetal/early infant death (17-OHPC 1.7% vs. placebo 1.9%; relative risk = 0.87 [95% CI: 0.4–1.81]. Maternal outcomes were also similar. In the subgroup of women enrolled in the United States (n  = 391; 23% of all patients), although the rate of PTB < 35 weeks was higher than the overall study population, there were no statistically significant differences between groups (15.6% vs. 17.6%; relative risk = 0.88 [95% CI: 0.55, 1.40]. Conclusion  In this study population, 17-OHPC did not decrease recurrent PTB and was not associated with increased fetal/early infant death. [ABSTRACT FROM AUTHOR]

Objective  To determine whether basal insulin analogs reduce the rate of composite neonatal morbidity compared with neutral protamine Hagedorn (NPH) in women with type 2 diabetes mellitus (T2DM). Study Design  This was a retrospective cohort study of women with T2DM and singleton pregnancy at a single tertiary center. Primary outcome was a composite neonatal morbidity of any of the following: shoulder dystocia, large for gestational age, neonatal intensive care unit admission, neonatal hypoglycemia, or respiratory distress syndrome. Secondary outcomes were rates of maternal hypoglycemic events, hypertensive disorders, preterm birth, and primary cesarean delivery. Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated. Results  Of 233 women with T2DM that met the inclusion criteria, 114 (49%) were treated with basal insulin analogs and 119 (51%) with NPH. The rate of composite neonatal morbidity was similar between groups (73 vs. 60%; aRR: 1.18; 95% CI: 0.92–1.51). There were no differences in the rates of maternal adverse outcomes between the groups. Basal insulin analog was associated with a lower rate of primary cesarean delivery as compared with NPH (21 vs. 36%; aRR: 0.44; 95% CI: 0.25–0.78). Conclusion  Among pregnant women with T2DM managed with either basal or NPH insulin regimen, the rates of composite neonatal morbidity and maternal complications were similar. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to determine if transvaginal cervical length at 16-20 weeks is predictive of preterm birth <34 weeks in a large cohort of twin pregnancies. Study design: This is a secondary analysis from a randomized trial of 17 alpha-hydroxyprogesterone caproate in twins to prevent preterm birth. Transvaginal cervical length was performed at 16-20-week gestation. The inclusion criteria were non-anomalous twins with transvaginal cervical length at 16-20 weeks. Receiver-operating characteristic (ROC) curves were generated to determine the transvaginal cervical length associated with preterm birth. Results: Of 655 pregnancies, 27% (N = 178) women met our inclusion criteria. The rate of spontaneous preterm birth before 34 weeks was 16% (N = 29). A receiver operator characteristic curve was generated for all preterm birth <34 weeks (spontaneous and indicated) which demonstrated an area under the curve of 0.51, 95% CI (0.41-0.61). When indicated preterm birth (n = 15) were excluded, the area under the curve was 0.59 (95% CI 0.47-0.70), indicating that transvaginal cervical length values were not a clinically useful test for the prediction of spontaneous preterm birth. A transvaginal cervical length of 30 mm from this model would produce a sensitivity of detecting spontaneous preterm birth of 95% and a specificity of 14%. Conclusion: In an asymptomatic twin population, a single transvaginal cervical length between 16 and 20 weeks was not predictive of spontaneous preterm birth before 34 weeks. Thus, our findings suggest that routine transvaginal cervical length screening of twins should not be performed between 16-20 weeks. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to compare adverse pregnancy outcomes between fetuses with estimated fetal weight (EFW) < 10 to > 10% in women with preterm preeclampsia (PE) with severe features. Materials and Methods All women with preterm PE with severe features and nonanomalous singletons with EFW were identified at a tertiary center. Women with oligohydramnios or absent/reversed umbilical Doppler velocimetry were excluded. Using multivariable analysis, we compared the composite maternal and neonatal morbidities (CMM and CNM) between those with appropriate for gestational age (AGA) fetal growth, defined as EFW at 10 to 90th versus those with fetal growth restriction (FGR), defined as EFW < 10th percentile for gestational age (GA). Results In this study, 165 patients were included; 112 had EFW at 10th to 90th percentile, and 53 had FGR. Of the 53 with FGR, 33 (62%) had EFWat 5 to 9% for GA and 20 (38%) had EFW < fifth percentile for GA. The CMM was significantly higher among women with FGR versus AGA (29 vs. 7%; p < 0.001). The CNM was significantly higher with FGR versus AGA (20 vs. 6%; p = 0.01). Conclusion Women with preterm PE with severe features and FGR, when compared with those with AGA, have significantly higher risk of CMM and CNM. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to compare characteristics between neonatal brachial plexus palsy (NBPP) cases that were litigated versus those that were not.Study Design: From May to December 2012, the University of Michigan Interdisciplinary Brachial Plexus Program surveyed 51 consecutive families whose children were treated for NBPP. Obstetric data was self-reported. Unless NBPP resolved, children were followed for at least two years. Student's t-test and Chi-square test with odds ratio and 95% confidence intervals were calculated.Results: Among 51 families surveyed, obstetric data were available for 98% (n = 50). Litigation was pursued by 48% (n = 24). Comparing families that litigated versus those that did not, there were no differences in demographics, peripartum characteristics, operative versus spontaneous vaginal birth, shoulder dystocia in current pregnancy (65% versus 54%; p = 0.56) or birth weight above 9 lbs. The number of children having brachial nerve surgery was significantly higher among families that litigated (46%) versus those that did not (8%; p = 0.002).Conclusion: Though there were no differences in peripartum events, almost 1 out of 2 children managed by interdisciplinary team had concomitant litigation. The only factor associated with litigation was having brachial nerve surgery. Efforts are warranted to avert NBPP and mitigate litigations. [ABSTRACT FROM AUTHOR]

Objective This study aims to evaluate the usefulness of prognostic scoring systems to differentiate women admitted for pyelonephritis who develop maternal morbidity and require prolonged hospitalization. Study Design Multicenter retrospective cohort study to compare the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Modified Obstetric Early Warning System (MOEWS) to predict prolonged hospitalization (> 4 days) and composite maternal morbidity for all pregnant women admitted with pyelonephritis between 2012 to 2013. One-way analysis of variance for continuous variables, Fisher's exact test for categorical variables, and receiver operating characteristic curves were used. Results Among 123 pyelonephritis cases analyzed, 25 (20%) required prolonged hospitalization. Women with prolonged hospitalization had higher rates of composite maternal morbidity, required diagnostic imaging, and had delayed administration of intravenous antibiotics (292 ± 381 vs. 218 ± 233 min, p = 0.002). APACHE II and MOEWS scores calculated from data collected within the first 24 hours of admission had a modest ability to discriminate maternal morbidity (APACHE II: area under the curve [AUC], 0.72; 95% confidence interval [CI], 0.58-0.86 and MOEWS: AUC, 0.71; 95% CI, 0.56-0.85). Conclusion We observed that one in five pregnancies admitted for treatment of pyelonephritis requires hospitalization for over 4 days with significant maternal morbidities. Prognostic scoring systems may be useful clinical tools to assess these patients systematically and improve morbidity. [ABSTRACT FROM AUTHOR]

Background While traumatic delivery with large for gestational age (LGA; birth weight above 90%) is acknowledged, there is paucity of data regarding other morbidity and mortality associated with LGA. Our hypothesis was that compared with appropriate for gestational age (AGA), LGA have a significantly higher rate of composite neonatal morbidity (CNM). Objective Our objective was to compare the CNM among uncomplicated LGA versus AGA at term (37 weeks or more) among all available Maternal-Fetal Medicine Units (MFMU) databases. We excluded women who delivered before 37 weeks, those with hypertension or diabetes, multiple gestations, and known anomalies, and those with birth weight less than 10% for GA. Using multivariable analysis, we compared the CNM between LGA and AGA. Random-effect logistic regressions were used to account for study heterogeneity, with adjustment for potential confounders. We calculated adjusted odds ratio (aOR) and 95% confidence intervals (CI). Results Approximately 60% (n = 50,734) of all participants met inclusion criteria. Among uncomplicated pregnancies, the rate of LGA was 12.1%. The rate of CNM was 15% in LGA and 10% in AGA (aOR: 1.58; 95% CI: 1.46-1.70). The likelihood of stillbirth and neonatal mortality was similar among both groups. Subgroup analysis revealed that CNM was increased among both birth weight > 95% and birth weight 90 to 95% and at different GA at delivery. Conclusion Among uncomplicated pregnancies at term, LGA newborns, compared with AGA, have a significantly higher likelihood of CNM but similar stillbirth and neonatal death risk. Trials are warranted to determine appropriate management of LGA to decrease these risks. [ABSTRACT FROM AUTHOR]

Background Antenatal detection of fetal growth restriction (FGR) prompts antepartum surveillance to reduce perinatal mortality, yet most cases of FGR are undetected. Objective This study aims to compare rates of adverse neonatal outcomes when FGR is detected versus undetected. Study Design Small-for-gestational-age (SGA) newborns (birth weight < 10% for gestational age) delivered at the Magee-Women's Hospital in Pittsburgh, PA from 2003 to 2010 were divided into three groups: those whom did not undergo third-trimester fetal growth ultrasound (SGA-no US), were appropriate for gestational age (AGA) by ultrasound (SGA-undetected), or were FGR by ultrasound (SGA-detected). We then compared rates of 5-minute Apgar < 4 and neonatal death (ND), with AGA newborns as the referent. Results Out of 29,885 neonates, 2,475 (8.3%) were SGA. Out of the 826 (33%) SGA neonates who underwent growth ultrasound, 185 (22%) were considered FGR. In the SGA-no US group, the adjusted odds ratio (aOR) for Apgar < 4 was 2.84 (95% confidence interval (CI): 1.28-6.29) and 3.87 (95% CI: 2.09-7.18) for ND. The risk of Apgar < 4 (aOR: 3.10, 95% CI: 0.93-10.28) and ND (aOR: 2.16, 95% CI: 0.66-7.14) were not significantly elevated for SGA-undetected neonates, while SGA-detected neonates were most at risk, with an aOR of 18.20 (95% CI: 6.82-48.60) for Apgar < 4 and 18.24 (95% CI: 7.90-42.13) for ND. Conclusion Fetal growth ultrasound effectively stratifies risk amongst SGA neonates. [ABSTRACT FROM AUTHOR]

Objective This study aims to compare how national guidelines approach the management of obesity in reproductive age women. Study Design We conducted a search for national guidelines in the English language on the topic of obesity surrounding the time of a pregnancy. We identified six primary source documents and several secondary source documents from five countries. Each document was then reviewed to identify: (1) statements acknowledging increased health risks related to obesity and reproductive outcomes, (2) recommendations for the management of obesity before, during, or after pregnancy. Results All guidelines cited an increased risk for miscarriage, birth defects, gestational diabetes, hypertension, fetal growth abnormalities, cesarean sections, difficulty with anesthesia, postpartum hemorrhage, and obesity in offspring. Counseling on the risks of obesity and weight loss before pregnancy were universal recommendations. There were substantial differences in the recommendations pertaining to gestational weight gain goals, nutrient and vitamin supplements, screening for gestational diabetes, and thromboprophylaxis among the guidelines. Conclusion Stronger evidence from randomized trials is needed to devise consistent recommendations for obese reproductive age women. This research may also assist clinicians in overcoming one of the many obstacles they encounter when providing care to obese women. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of tocolytic treatment with indomethacin (I), magnesium sulfate (M) and nifedipine (N) for acute tocolysis in women with advanced cervical dilation (4-6 cm).Methods: A single center, randomized trial was carried out involving patients in preterm labor (cervix 1-6 cm). Secondary analysis of women with advanced cervical dilation (cervix 4-6 cm) at 24-32 weeks' gestation who received intravenous M, oral N or I suppositories comprised this study population.Results: Over 38 months, 92 women with advanced cervical dilation were randomized to one tocoloytic type. Days gained in utero (11.7) and percent remaining undelivered at 48 h (60.8%), 72 h (53.1%) and >7 days (38.3%) were similar regardless of tocolytic employed (p = 0.923, 0.968, 0.791, 0.802, respectively). Likewise, gestational age at delivery (30.7 ± 3.2) was similar between groups (p = 0.771). Finally, neonatal statistics were not different when stratified by tocolytic treatment.Conclusion: There were no statistical differences between tocolytics in treating women with advanced cervical dilation. All offered significant days gained in utero after therapy, a high percentage remaining undelivered after 48 or 72 h and after 7 days. It would appear from data that there may be advantages to tocolytic treatment even in women with advanced cervical dilation. [ABSTRACT FROM AUTHOR]

Objective The purpose of this review was to determine the likelihood ofmalignancy or complications with ultrasonographic diagnosis of adnexal masses in pregnancy and to evaluate the obstetrical outcomes. Materials andMethods A review of literature was performed using keywords “adnexal mass and pregnancy” or “ovarian mass and pregnancy.” Results Out of the 340 abstracts reviewed, 313 were excluded. The incidence of adnexalmass in pregnancy varied from 0.1 to 2.4%, with an average of 0.02%. Regarding the likelihood of malignancy, in seven publications, there were 557 women with 563 adnexal masses. Of these 563 masses, 48% were classified as simple and 52% as complex. Among the simple masses, 1% were malignant. Among the complex masses, 9% were malignant. When comparing laparoscopy and laparotomy, the rate of preterm contractions was found to be higher in patients undergoing laparotomy and this was statistically significant. Other measures, such as spontaneous abortion, vaginal bleeding, < 37 week delivery, and intrauterine fetal demise, were not found to have a significant difference. Conclusion Adnexal masses in pregnancy occur infrequently and depending on whether the surgery was performed emergently or electively, via laparoscopy or laparotomy, the outcomes will vary. [ABSTRACT FROM AUTHOR]

Objectives Substance abuse in pregnancy remains a major public health problem. Fetal teratogenicity results from the effect of these substances during fetal development, particularly when used in combination. This review will focus on and attempt to clarify the existing literature regarding the association of substance abuse on the development of congenital anomalies and the long-term implications in exposed offspring. Methods Systematic review of available English literature using the PubMed database of all peer-reviewed articles on the subject. Results A total of 128 articles were included in this review. Alcohol was the most common substance associated with fetal anomalies, particularly facial dysmorphisms and alterations in the central nervous system development. Adverse maternal environments associated with risky behaviors and lack of adequate prenatal care precludes the timely detection of fetal anomalies, confounding most studies linking causality. In addition, although methodological differences and limited availability of well-designed trials exist, substance abuse in pregnancy has been associated with adverse long-term outcomes in infant growth, behavior, cognition, language and achievement. Conclusion The literature summarized in this review suggests that drug exposure during pregnancy may increase the risk of congenital anomalies and long-term adverse effects in exposed children and adolescents. These conclusions must be tempered by the many confounders associated with drug use. A multidisciplinary approach is paramount for appropriate counseling regarding the known immediate and longterm risks of substance abuse in pregnancy. [ABSTRACT FROM AUTHOR]

Background/Aims: To examine the relationship of the amniotic fluid index (AFI) and single deepest pocket (SDP) with an AFV as modelled by Brace or Magann. Methods: AFI and SDP were evaluated for their correlation with an actual AFV using the Spearman correlation coefficient. Results: 482 AFI and 468 SDP pregnancies were evaluated. There was a significant association between the AFI and SDP and an actual AFV (p < 0.0001). The AFI range of 5.1-20 was better correlated than 5.1-24 for normal AFVs Brace (κ = 0.175) and Magann (κ = 0.356) versus 5.1-24 (κ = 0.150 and κ = 0.319), respectively. The agreement level t for the AFI (κ = 0.175) and SDP (κ = 0.126) using Brace was slight and for the AFI (κ = 0.356) and SDP (κ = 0.295) using Magann was fair. Conclusions: Both the AFI and SDP were correlated with actual AFV using both models. AFI of 5.1-20 better categorizes normal volumes. Although the Magann model correlates AFI/SDP and AFV better, the superiority is minimal. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background Maternal obesity is becoming more prevalent in obstetrics and has been linked with pregnancy complications and perinatal outcomes. The gradient of association of increasing maternal obesity and pregnancy outcome is less well studied. Aims To determine the influence of an increasing gradient of obesity, categorised by the body mass index ( BMI), on pregnancy outcomes and to determine the BMI thresholds at which pregnancy complications occur. Materials and Methods Secondary analysis of an observational study on pregnancy and obesity. The BMI at the first prenatal visit was grouped into BMI categories (<18.5, 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, 40-44.9, and ≥45) and compared with the normal category ( BMI 18.5-25) for pregnancy outcomes and adjusted for known cofounders. Results A total of 4,490 women were stratified into the pre-pregnancy BMI categories: <18.5 ( n = 276), 18.5-24.9 ( n = 1965), 25-29.9 ( n = 1072), 30-34.9 ( n = 551), 35-39.9 ( n = 317), 40-44.9 ( n = 167), and ≥45 ( n = 142). The maternal demographics were significantly different between BMI groups ( P < 0.001). Compared to women with a normal BMI, different BMI thresholds convey an increased risk for specific pregnancy complications: BMI≥25 for gestational diabetes ( P < 0.001), induction of labour ( P < 0.001), caesarean delivery ( P < 0.001) and large for gestational age neonate ( P < 0.001); BMI≥30 for pre-eclampsia ( P < 0.001), wound infection ( P = 0.001), shoulder dystocia ( P < 0.001) and meconium ( P = 0.006); BMI≥35 for urinary tract infection ( P < 0.001) and postpartum haemorrhage ( P < 0.001); BMI≥40 for endometritis ( P < 0.001). Conclusions Body mass index thresholds exist at which pregnancy complications significantly increase and they vary depending on outcome ranging from BMI ≥25 to a BMI ≥40. [ABSTRACT FROM AUTHOR]

Objective: To determine if hemodynamic compromise can be reduced with manual placental removal at 10 compared with 15 minutes. Study Design: Singleton pregnancies admitted for delivery with no contraindication to a vaginal delivery were randomized to a 10-minute group (placentas manually removed if not spontaneously delivered by 10 minutes) versus a 15-minute group. The primary outcome, hemodynamic compromise, was defined as: blood loss exceeding 1000 mL and/or circulatory instability (inability to maintain blood pressure/pulse secondary to acute blood loss) and/or drop in hematocrit of ≥10 percentage points. Results: From July 2006 to July 2010, 156 women were randomized into the 10-minute group and 156 in the 15-minute group. Women in the 15-minute group had a greater likelihood of hemodynamic compromise univariately (19.2% versus 6.4%, p = 0.001) and after adjustments for ethnicity, induction rate, duration of second stage of labor, and nulliparity (relative risk 3.03, 95% confidence interval 1.52 to 5.47, p = 0.002). Conclusion: Hemodynamic compromise is decreased with manual placental removal within 10 minutes of delivery compared with 15 minutes. [ABSTRACT FROM AUTHOR]

Objective: To compare the intrapartum fetal heart rate (FHR) characteristics and selected birth outcomes of nonanomalous trisomy 21 (T21) fetuses to matched controls. Study Design: Nonanomalous, non-growth-restricted T21 infants were identified and matched by gestational age to presumed euploid controls. We excluded women with scheduled cesarean deliveries and multiple gestations. The incidence of abnormal FHR patterns within 3 hours of delivery and birth outcomes were compared between T21 fetuses and controls. The presence of any abnormal FHR pattern was the primary outcome. Birth outcomes included 5-minute Apgar <7, neonatal intensive care unit admission, and cesarean delivery for fetal indications. Results: Forty-four T21 infants and 44 controls were compared. Of the T21 infants, 83% were postnatally diagnosed. No significant differences were noted in the primary outcome (68% versus 59%, p = 0.37) or birth outcomes. Conclusion: T21 is not associated with an increased incidence of abnormal FHR patterns or adverse birth outcomes compared with presumed euploid fetuses. [ABSTRACT FROM AUTHOR]

Aim: The aim of the present study was to compare the two normative datasets of amniotic fluid volume (AFV). Material and Methods: The similarity of the two datasets to classify AFV as oligohydramnios, normal, and polyhydramnios based on fixed cut-offs, stratified by gestational ages (<24 weeks, 24-336/7, 34-366/7, and >37 weeks, and to identify oligohydramnios/small for gestational age (SGA) and polyhydramnios/large for gestational age (LGA) was evaluated. Results: Of the 209 pregnancies assessed, the AFV was 94 ≤ 500 mL, 101 between 501 and 1999 mL, and 14 ≥ 2000 mL. The datasets were in agreement classifying the AFV as oligohydramnios, normal, and polyhydramnios in 76% of the pregnancies. Brace classified more overall patients with oligohydramnios (19%) versus Magann (3%) ( P < 0.001). In term pregnancies (>37 weeks), Brace was more likely to classify pregnancies with oligohydramnios (15%) than Magann (3%) ( P = 0.004). The likelihood ratio (LR) to detect oligohydramnios/SGA was greater with Magann (LR 12.9) versus Brace (LR 2.75). Conclusion: The two datasets classify AFV differently in 24% of cases. Brace's dataset is more likely to categorize patients as having oligohydramnios and Magann's dataset is a more useful test for oligohydramnios/SGA identification. [ABSTRACT FROM AUTHOR]

Background/Aim: Marginal or decreased amniotic fluid volume by ultrasound estimate and fetal growth restriction have been shown to be significantly associated with perinatal mortality. The association of fetal growth restriction and precisely measured amniotic fluid volume is unknown. The purpose of this study was to determine if adverse pregnancy outcomes are more likely in pregnancies complicated by small-for-gestational-age (SGA) neonates and dye-determined oligohydramnios. Methods: Admissions to neonatal intensive care unit (NICU) and other pregnancy outcomes were analyzed in parturients with known amniotic fluid volume, calculated by the dye-dilution technique. The pregnancy outcomes of those with oligohydramnios and SGA were compared with pregnancies complicated by just one of these two conditions and pregnancies with normal fluid and birth weight. Results: Of 202 patients, oligohydramnios was present in 26% (53), SGA in 15% (30) and both conditions in (5%) (11). Logistic regression, controlling for gestational age, demonstrated that the combination of oligohydramnios and SGA, compared to normal growth and fluid strongly predicted NICU admission (OR 11.1; 95% CI 2.1-59.2) but not other complications. (OR 4.8; 95% CI 0.3-62.9). Conclu sions: SGA with oligohydramnios significantly increases the likelihood of a NICU admission, but not other morbidity. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Investigators have attempted to derive tools that could provide clinicians with an easily obtainable estimate of the chance of vaginal birth after cesarean delivery for those who undertake trial of labor after cesarean delivery. One tool that has been validated externally was derived from data from the Maternal-Fetal Medicine Units Cesarean Registry. However, concern has been raised that this tool includes the socially constructed variables of race and ethnicity.Objective: This study aimed to develop an accurate tool to predict vaginal birth after cesarean delivery, using data easily obtainable early in pregnancy, without the inclusion of race and ethnicity.Study Design: This was a secondary analysis of the Cesarean Registry of the Maternal-Fetal Medicine Units Network. The approach to the current analysis is similar to that of the analysis in which the previous vaginal birth after cesarean delivery prediction tool was derived. Specifically, individuals were included in this analysis if they were delivered on or after 37 0/7 weeks' gestation with a live singleton cephalic fetus at the time of labor and delivery admission, had a trial of labor after cesarean delivery, and had a history of 1 previous low-transverse cesarean delivery. Information was only considered for inclusion in the model if it was ascertainable at an initial prenatal visit. Model selection and internal validation were performed using a cross-validation procedure, with the dataset randomly and equally divided into a training set and a test set. The training set was used to identify factors associated with vaginal birth after cesarean delivery and build the logistic regression predictive model using stepwise backward elimination. A final model was generated that included all variables found to be significant (P<.05). The accuracy of the model to predict vaginal birth after cesarean delivery was assessed using the concordance index. The independent test set was used to estimate classification errors and validate the model that had been developed from the training set, and calibration was assessed. The final model was then applied to the overall analytical population.Results: Of the 11,687 individuals who met the inclusion criteria for this secondary analysis, 8636 (74%) experienced vaginal birth after cesarean delivery. The backward elimination variable selection yielded a model from the training set that included maternal age, prepregnancy weight, height, indication for previous cesarean delivery, obstetrical history, and chronic hypertension. Vaginal birth after cesarean delivery was significantly more likely for women who were taller and had a previous vaginal birth, particularly if that vaginal birth had occurred after a previous cesarean delivery. Conversely, vaginal birth after cesarean delivery was significantly less likely for women whose age was older, whose weight was heavier, whose indication for previous cesarean delivery was arrest of dilation or descent, and who had a history of medication-treated chronic hypertension. The model had excellent calibration between predicted and empirical probabilities and, when applied to the overall analytical population, an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77), which is similar to the area under the receiver operating characteristic curve of the previous model (0.75) that included race and ethnicity.Conclusion: We successfully derived an accurate model (available at https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator), which did not include race or ethnicity, for the estimation of the probability of vaginal birth after cesarean delivery. [ABSTRACT FROM AUTHOR]

Aim: To determine the factors that influence caesarean operative time and operative time effects on pregnancy outcomes. Methods: Prospective observational study of women undergoing a caesarean delivery (CD). Multiple antepartum, intrapartum and neonatal outcomes were assessed for their influence on the time of the CD and the time effect of CD on pregnancy outcomes. Results: There were 386 (23%) caesarean deliveries performed ≤ 30 min, 1070 (65%) between 31 and 60 min, and 200 deliveries ≥ 60 min. Women younger than 18 years ( P= 0.004) and who had caesarean for fetal labor intolerance were associated with shorter operation time ( P < 0.001). Factors associated with an increased operation time were age > 35 years ( P= 0.049), body mass index (BMI) ≥ 30 ( P < 0.001), pre-existing hypertension ( P= 0.001), prior low segment transverse scar ( P < 0.001), uterus incision other than transverse ( P < 0.001), first-year resident as primary surgeon ( P < 0.001) and accompanying sterilisation procedure ( P < 0.001). Operation time was significantly related to blood loss ( P < 0.001), likelihood of umbilical artery cord gas pH < 7.1 ( P < 0.001) and Apgar scores at five minutes < 7 ( P= 0.009). Conclusions: Operative time is shortened by age < 18 and delivery for fetal labor intolerance, lengthened by age > 35, BMI > 30, prior caesarean, uterine incision, operating surgeon inexperience and accompanying sterilisation. Increased operative time was linked with an increased blood loss, low five-minute Apgar scores and umbilical arterial pH < 7.1. [ABSTRACT FROM AUTHOR]

Objective . The effects of standing, lifting and noise in low-risk, healthy pregnant women are uncertain. In the past, the heterogeneity of the populations studied, the limitations of the designs of the retrospective and case control studies, and a failure of some of the larger investigations to evaluate all the potential confounding variables has hampered many studies. The purpose of this investigation was to evaluate, throughout pregnancy, the effects of standing, repetitive lifting, and noise in the workplace compared with no standing, lifting or noise exposure, on maternal and perinatal outcomes in a large prospective study of a low-risk healthy population of working women cared for by a single group of health providers. Methods . This prospective observational study used an extensive questionnaire to collect antepartum, intrapartum, and postpartum information. Information was collected on the initial visit, each subsequent visit, and immediately after delivery. The participating women were divided into groups based on the amount of time spent standing, the amount and extent of repetitive lifting, and noise exposure in the workplace. Results . Eight hundred and fourteen low-risk active duty women participated in this investigation over a 4-year period. Multivariate analysis with non-exposure compared with exposure reinforced the effect of standing on preterm labor (OR 1.80, 95% CI 1.05, 3.16) and preterm birth (OR 1.69, 95% CI 1.03, 2.80) and showed a trend toward an effect of noise exposure on preterm labor (OR 1.76, 95% CI 0.78, 3.39) after controlling for other exposures. Conclusions . This investigation suggests an association of occupational standing with preterm labor and preterm birth. [ABSTRACT FROM AUTHOR]

The article focuses on the diagnostic and therapeutic advances in premature labor. Preterm delivery, defined as birth before 37 weeks gestation, occurs in about 12% of pregnancies. It is the leading cause of mortality among non-anomalous fetuses. The annual cost of premature birth in the United States exceeds $5 billion, and the rate of preterm delivery has increased in recent years. Specific maternal attributes increase risk of preterm delivery, though these factors need not be present for premature delivery to occur. Standard techniques of physical diagnosis may not accurately detect preterm labor, either missing the diagnosis or prompting unnecessary hospitalization and treatment. Select imaging studies can more reliably indicate a true need for intervention. Almost 75% of preterm births occur after spontaneous preterm labor or preterm premature rupture of the membranes. This article further discusses risk factors for preterm birth, the tests available to accurately diagnose preterm labor and the medications available to prevent or postpone premature delivery.

OBJECTIVE:: To ascertain if a dye-determined amniotic fluid volume was predictive of intrapartum and perinatal outcome. MATERIALS AND METHODS:: The low and normal amniotic fluid volumes (<5th percentile and =5th percentile for gestational age) and the raw dye-determined amniotic fluid distributions were correlated with 10 clinical outcome measures in 74 pregnancies. RESULTS:: In this observational study, median gestational age at delivery was 36 weeks (range 26 to 41) and 16 deliveries were for fetal distress (14 Cesarean and two forceps). There were no differences between the outcomes of pregnancies with low and normal amniotic fluid volumes for any of the clinical outcomes (variable decelerations influencing delivery, p=0.381; late decelerations, p=0.875; Cesarean births for fetal intolerance of labor, p=0.259; intrauterine growth restriction, p=0.998; or umbilical cord arterial pH<7.2, p=0.259). Analogous results were obtained when the gestational age-adjusted amniotic fluid volumes were compared directly between the pregnancies with normal and abnormal outcomes. There was no difference between the mean amniotic fluid volumes in those pregnancies with variable decelerations influencing delivery (p=0.287), late decelerations (p=0.555), Cesarean births for fetal intolerance of labor (p=0.310), intrauterine growth restriction (p=0.267) or umbilical cord arterial pH<7.2, and the pregnancies without these intrapartum events. Reduced variability was more commonly observed in pregnancies with higher amniotic fluid volumes (p=0.038, 771?ml, 95% CI 468 to 1269, compared to those without normal variability 444?ml, 95% CI 374 to 526). CONCLUSIONS:: Dye-determined amniotic fluid volume does not appear to be predictive of adverse intrapartum and neonatal outcome.Journal of Perinatology (2004) 24, 423-428. doi:10.1038/sj.jp.7211122 Published online 29 April 2004 [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to determine whether there is a correlation between neonatal birth weight and an estimated or dye-determined amniotic fluid volume. Study design: A prospective observational study of women undergoing an amniocentesis and subsequent delivery within 72 hours. Amniotic fluid volume was estimated using the amniotic fluid index (AFI) and single deepest pocket technique and calculated by the dye-dilution technique. Results: One hundred seventy-five women participated in the study. Linear regression modelling showed no significant relationship between birth weight and amniotic fluid volume adjusted for gestational age (P = .062). Similarly, there was no evidence of an association between birth weight and a dye determined amniotic fluid volume (P = .180), fixed cutoffs for the AFI (P = .224), percentiles for the AFI (P = .112), or fixed cutoffs for the single deepest pockets (P = .867). Conclusion: Neonatal birth weight is not correlated with a dye-determined or ultrasound estimated amniotic fluid volume. [ABSTRACT FROM AUTHOR]

Objective: Our purpose was to perform a meta-analysis of studies on the risks of cesarean delivery for fetal distress, 5-minute Apgar score <7, and umbilical arterial pH <7.00 in patients with antepartum or intrapartum amniotic fluid index >5.0 or <5.0 cm.Study Design: Using a MEDLINE search, we reviewed all studies published between 1987 and 1997 that correlated antepartum or intrapartum amniotic fluid index with adverse peripartum outcomes. The inclusion criteria were studies in English that associated at least one of the selected adverse outcomes with an amniotic fluid index of 5.0 cm. Contingency tables were constructed for each study, and relative risks and standard errors of their logs were calculated. Fixed-effects pooled relative risks were calculated for groups of studies that were homogeneous, whereas random-effects pooled relative risks were calculated for significantly heterogeneous groups of studies.Results: Eighteen reports describing 10,551 patients met our inclusion criteria. An antepartum amniotic fluid index of 5.0 cm, is associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 2.2; 95% confidence interval, 1.5-3.4) and an Apgar score of <7 at 5 minutes (pooled relative risk, 5.2; 95% confidence interval, 2.4-11.3). An intrapartum amniotic fluid index of Conclusions: An antepartum or intrapartum amniotic fluid index of

Do extra outpatient visits, in addition to regularly scheduled visits, identify a pregnancy at risk of an adverse outcome? This prospective investigation analysed additional outpatient visits, by low-risk obstetric patients. One hundred and sixty-two women were evaluated with one to two additional visits and 66 had three or more visits. Antepartum and intrapartum pregnancy complications between groups was similar suggesting that frequency of additional visits does not identify a pregnancy at risk for an adverse outcome. [ABSTRACT FROM AUTHOR]

Two ultrasound techniques, the amniotic fluid index (AFI) and the single deepest pocket (SDP), are currently used to detect oligohydramnios, predict variable decelerations, risk of Caesarean delivery for fetal distress, Apgar scores, umbilical cord artery pH, perinatal mortality, and cerebral palsy. Both techniques poorly identify oligohydramnios. Both techniques identify pregnancies at risk for variable decelerations, low Apgar scores, and Caesarean delivery for fetal distress. Only the SDP is predictive of a compromised fetus–umbilical artery pH, as a stand-alone test, has been correlated with perinatal mortality, and as part of the biophysical profile has been linked to cerebral palsy. This brief communication reviews the comparability of these two techniques and which method, if either, is superior in the identification of oligohydramnios, the predictability of these techniques to identify an adverse pregnancy outcome, and the ability to predict cerebral palsy and perinatal mortality. [ABSTRACT FROM AUTHOR]