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Objective This study aimed to compare cesarean delivery (CD) rates and maternal/neonatal outcomes before and after the 2014 ACOG/SMFM Obstetric Care Consensus for Safe Prevention of Primary CD. Study Design This retrospective study compared unscheduled CD rates and outcomes of singleton, cephalic, term pregnancies at a tertiary-care teaching maternity hospital. Births 5 years before (March 2009–February 2014) and after (June 2014–May 2019) release of the consensus were included. Chi-square and t-test were used to compare outcomes and logistic regression to adjust for confounders. Results In this study, 44,001 pregnancies were included, 20,887 before and 23,114 after the consensus. Unscheduled CD rates increased after the consensus (12.9 vs. 14.3%, p Conclusion At our tertiary-care maternity hospital, the Safe Prevention of Primary CD Care Consensus was not associated with a change in unscheduled CD, though VBAC deliveries increased. We did not demonstrate improved neonatal outcomes and showed increased maternal morbidity that warrants further study. Key Points

Objectives Early diagnosis of gestational diabetes can lead to greater optimization of glucose control. We evaluated associations between maternal serum analytes (alpha-fetoprotein [AFP], free beta-human chorionic gonadotropin [beta-hCG], inhibin, and estriol) and the development of gestational diabetes mellitus (GDM). Methods This retrospective cohort study identified single-ton pregnancies with available second trimester serum analytes between 2009 and 2017. GDM was identified by ICD-9 and -10 codes. We examined the associations between analyte levels and GDM and to adjust for potential confounders routinely collected during genetic serum screening (maternal age, BMI, and race) using logistic regression. Optimal logistic regression predictive modeling for GDM was then performed using the analyte levels and the above mentioned potential confounders. The performance of the model was assessed by receiver operator curves. Results Out of 5,709 patients, 660 (11.6%) were diagnosed with GDM. Increasing AFP and estriol were associated with decreasing risk of GDM, aOR 0.76 [95% CI 0.60–0.95] and aOR 0.67 [95% CI 0.50–0.89] respectively. Increasing beta-hCG was associated with a decreasing risk for GDM(aOR 0.84 [95% CI 0.73–0.97]). There was no association with inhibin. The most predictive GDM predictive model included beta-hCG and estriol in addition to the clinical variables of age, BMI, and race (area under the curve (AUC 0.75), buy this was not statistically different than using clinical variables alone (AUC 0.74) (p=0.26). Conclusions Increasing second trimester AFP, beta-hCG, and estriol are associated with decreasing risks of GDM, though do not improve the predictive ability for GDM when added to clinical risk factors of age, BMI, and race.

To describe racial/ethnic representation in United States (US) and Australian obstetric research, represented by the Maternal-Fetal Medicine Units Network (MFMU) and Australian Research Centre for Health of Women and Babies (ARCH) trials. MFMU studies were identified through PubMed and ARCH studies through their online publication listing from 2011 to 2016. Observational and randomized cohorts and primary and secondary data analyses were included. Studies with race-based enrollment were excluded. Racial/ethnic representation was expressed as the mean racial/ethnic percentages of the studies (i.e.,: studies weighted equally regardless of sample size). Racial/ethnic percentages in MFMU studies were compared to US registered births and ARCH compared to Australian census ancestry data. 38 MFMU studies included 580,282 women. Racial/ethnic representation (% [SD]) included White 41.7 [12.3], Hispanic 28.1 [15.4], Black 26.2 [12.3], Asian 3.6 [2.3], and American Indian/Alaskan Native (AI/AN) 0.2 [0.02]. No studies reported Native Hawaiian/other Pacific Islanders (NHOPI) separately. Comparatively, registered US births (%) were White 75.7, Hispanic 28.1, Black 16.1, Asian/Pacific Islander 7.1, and AI/AN 1.1, which differed from the MFMU (P = 0.02). 20 ARCH studies included 51,873 women. The most reported groups were White 76.5 [17.4], Asian 15.2 [14.8], and Aboriginal/Torres Strait Islander 13.9 [30.5], compared to census numbers of White 88.7, Asian 9.4, and Aboriginal/Torres Strait Islander 2.8 (P < 0.01). Two ARCH studies reported African ethnicity. There is racial diversity in studies by MFMU and ARCH, with opportunities to increase enrollment and enhanced reporting of Asian, AI/AN, and NHOPI races in MFMU studies and Black race in ARCH studies.

Objective This study was aimed to describe sequential compression device (SCD) adherence and its associations with SCD education in hospitalized antepartum women. Study Design This study included antepartum, nonlaboring women admitted from 2016 to 2018, 1 year before and after an SCD education intervention. SCD use was assessed through the Kendall SCD 700 series compliance meter, which tracks the time the SCD machine takes within the monitoring interval. Recruitment occurred after 60 to 80 hours of monitoring, at which time a patient survey was completed. SCD use was the percentage of time the machine was on during monitoring. Mann–Whitney U and Chi-square tests were used to compare associations between SCD use, education, and pharmacologic prophylaxis. Results Among 125 recruited women, 123 provided adherence data, 69 before and 54 after the education. Median SCD use was 17.3% before and 20.7% after (p = 0.71). Pharmacologic prophylaxis use was similar between the two periods and was not associated with SCD use. Among 121 surveys, the most common reason as to why SCDs were not worn was prevention of walking (52/121 [43.0%]). Conclusion Using a novel monitoring technique, we found low-SCD use among antepartum inpatients, which was neither affected by education nor concurrent pharmacologic prophylaxis. Improving mobility with SCDs may improve use in this population. Key Points

We conducted this study to compare outcomes for pregnancies conceived ≤6 months after dilation and evacuation (DE) with those conceived6 months after DE. This retrospective cohort study included women who underwent DE (14-26 weeks) and were readmitted with a subsequent pregnancy. The primary outcome was the rate of preterm birth (37 weeks). We identified 737 DEs with 214 subsequent pregnancies. Outcomes were available for 85.5% of these pregnancies. Preterm birth37 weeks occurred in 9.4% (3/32) of patients with an interpregnancy interval ≤6 months and 20.7% (12/58) of patients with an interpregnancy interval6 months (p = .17). No differences in preterm birth34 weeks, postpartum haemorrhage, placentation abnormalities, intrauterine growth restriction, cervical insufficiency or mode of delivery were noted. Adverse pregnancy outcomes were not higher in the group of women who conceived ≤6 months after DE compared to those who waited longer than 6 months. IMPACT STATEMENT What is already known on this subject: A small number of studies have noted an increased risk of adverse pregnancy outcomes with an interpregnancy interval of 6 months or fewer after a spontaneous or an induced abortion. What the results of this study add: We present the first study exploring pregnancy outcomes after dilation and evacuation for termination of pregnancy at 14 weeks or greater. Our results do not support an increased rate of adverse events with an interpregnancy interval of 6 months or fewer following dilation and evacuation. What the implications are of these findings for clinical practice and/or further research: Because of limitations in sample size, our results should be interpreted in the context of other studies.

Relaxin, a systemic and placental hormone, has potential roles in fetoplacental growth. Human placenta expresses two RLN genes, RLNH1 and RLNH2. Maternal obesity is common and is associated with abnormal fetal growth. Our aims were to relate systemic and cord blood RLNH2, placental RLNs and their receptor (RXFP1) with fetoplacental growth in context of maternal body mass index, and associations with insulin-like growth factor 2 (IGF2) and vascular endothelial growth factor A (VEGFA) in the same placentas. Systemic, cord blood and placental samples were collected prior to term labor, divided by prepregnancy body mass index: underweight/normal (N = 25) and overweight/obese (N = 44). Blood RLNH2 was measured by ELISA; placental RLNH2, RLNH1, RXFP1, IGF2 and VEGFA were measured by quantitative immunohistochemistry and mRNAs were measured by quantitative reverse transcription PCR. Birthweight increased with systemic RLNH2 only in underweight/normal women (P = 0.036). Syncytiotrophoblast RLNH2 was increased in overweight/obese patients (P = 0.017) and was associated with placental weight in all subjects (P = 0.038). RLNH1 had no associations with birthweight or placental weight, but was associated with increased trophoblast and endothelial IGF2 and VEGFA, due to female fetal sex. Thus, while systemic RLNH2 may be involved in birthweight regulation in underweight/normal women, placental RLNH2 in all subjects may be involved in placental weight. A strong association of trophoblast IGF2 with birthweight and placental weight in overweight/obese women suggests its importance. However, an association of only RLNH1 with placental IGF2 and VEGFA was dependent upon female fetal sex. These results suggest that both systemic and placental RLNs may be associated with fetoplacental growth.

To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency). We included all operative vaginal deliveries between 2008 and 2014 at a tertiary care teaching hospital, stratified into forceps-assisted and vacuum-assisted deliveries. Complications included severe perineal lacerations (3rd and 4th degree) and neonatal injuries (subgaleal/subdural/cerebral hemorrhage, facial nerve injury, and scalp injury), which were identified by International Classification Diagnosis-9 codes. Providers were categorized by operative vaginal delivery volume (mean annual forceps- or vacuum-assisted deliveries over the study interval) and time since residency. Regression analyses were used to compare complication rates by provider volume and time since residency, adjusting for potential confounders, using 0–1 deliveries per year and 10 forceps per year (aOR 0.50 [95%CI 0.30–0.81]) and at 15–19 years (aOR 0.45 [95% CI 0.22–0.94], and ≥25 years (aOR 0.45 [0.27–0.73]) since residency. There were no associations with neonatal injuries. Among vacuum-assisted deliveries, severe perineal injury decreased at ≥25 years since residency (aOR 0.35 [95%CI 0.17–0.74], with no association with provider volume. Neonatal injury decreased at 5–9 years (aOR 0.53 [95%CI 0.30–0.93]), and 15–19 years since residency (aOR 0.53 [95%CI 0.29–0.97]), due to differences in scalp injuries. Neonatal injuries other than scalp injury were rare. Severe perineal lacerations decreased with increasing operative vaginal delivery experience, primarily among forceps-assisted vaginal delivery. Providers >5 years since residency may have lower scalp injury with vacuums, but this cohort was largely underpowered for neonatal injury.

IntroductionPreeclampsia is a medical condition complicated with hypertension and proteinuria during pregnancy. While preeclampsia affects approximately 5% of pregnancies, it remains without a cure. In addition, women who had preeclampsia during pregnancy have been reported to have an increased risk for cardiovascular disease later in life. However, the disease etiology and molecular mechanisms remain poorly understood. The paucity in the literature on preeclampsia associated maternal cardiovascular risk in different ethnic populations also present a need for more research. Therefore, the objective of this study was to identify cardiovascular/metabolic single nucleotide polymorphisms (SNPs), genes, and regulatory pathways associated with early-onset preeclampsia.Materials and methodsWe compared maternal DNAs from 31 women with early-onset preeclampsia with those from a control group of 29 women without preeclampsia who delivered full-term normal birthweight infants. Women with multiple gestations and/or known medical disorders associated with preeclampsia (pregestational diabetes, chronic hypertension, renal disease, hyperthyroidism, and lupus) were excluded. The MetaboChip genotyping array with approximately 197,000 SNPs associated with metabolic and cardiovascular traits was used. Single nucleotide polymorphism analysis was performed using the SNPAssoc program in R. The Truncated Product Method was used to identify significantly associated genes. Ingenuity Pathway Analysis and Ingenuity Causal Network Analysis were used to identify significantly associated disease processes and regulatory gene networks respectively.ResultsThe early-onset preeclampsia group included 45% Filipino, 26% White, 16% other Asian, and 13% Native Hawaiian and other Pacific Islanders, which did not differ from the control group. There were no SNPs associated with early-onset preeclampsia after correction for multiple comparisons. However, through gene-based tests, 68 genes and 23 cardiovascular disease-related processes were found to be significantly associated. Associated gene regulatory networks involved cellular movement, cardiovascular disease, and inflammatory disease.ConclusionsMultiple cardiovascular genes and diseases demonstrate associations with early-onset preeclampsia. This unfolds new areas of research regarding the genetic determinants of early-onset preeclampsia and their relation to future cardiovascular disease.

Pregnant patients receiving hemodialysis (HD) have long hospital stays for the purpose of electronic fetal monitoring (EFM) during HD, which allows for monitoring of fetal well-being. However, more frequent dialysis allows for smaller fluid shifts, preventing maternal hypotension. Our aim was to determine differences in rates of EFM abnormalities during HD versus non-stress testing (NST) off dialysis for gravid women with renal failure.Retrospective cohort study over a 13-year period (2000-2013) identified five patients with renal failure in pregnancy. EFM tracings were reviewed during HD (cases) and routine inpatient NST off HD (controls). Standardized nomenclature was used to identify EFM abnormalities. The rate of abnormalities per hour of EFM was calculated. Kruskal-Wallis test was used and statistical significance was set at p 0.05.There were no significant differences in late decelerations (p = 0.2) between cases and controls. Significantly fewer variable decelerations (p = 0.01) and contractions (p ≤0.001) were noted during dialysis compared to controls. Significantly more prolonged decelerations (p = 0.02) were noted during HD compared to controls.There may be no fetal benefit of EFM during HD for gravid women with renal disease attributed to hypertensive and diabetic nephropathy. There may be cost savings by shifting HD to the outpatient setting.

To compare cesarean complication rates between women with body mass index (BMI) 40-49.9 kg/m(2) and BMI ≥ 50 kg/m(2) and associations with surgical techniques.This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI ≥ 50 and an equal number with BMI 40-49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use.Among 498 patients (249 with BMI ≥ 50 and 249 with BMI 40-49.9) there were no differences in estimated blood loss1000 mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI ≥ 50 and 162 with BMI 40-49.9), those with BMI ≥ 50 had a significantly higher rate of wound separations (p = 0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons.Wound complications, particularly separations, increase with BMI ≥ 50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.

Healthcare providers commonly use obstetric ultrasound to assess fetal well-being. However, the potential for fetal findings to manifest maternal disease is often underappreciated. This article will review the relationships between obstetric ultrasound findings and underlying maternal medical conditions in three settings: (1) fetal growth abnormalities related to underlying maternal disease, (2) congenital malformations secondary to diabetes and maternal exposure to chemical and infectious teratogens, and (3) congenital heart block due to maternal autoimmune disease. The obstetric ultrasound should be a tool used for the care and evaluation of the maternal as well as the fetal patient. How to cite this article Yamasato K, Burlingame J. Fetal Ultrasound as a Window into Maternal Health. Donald School J Ultrasound Obstet Gynecol 2016;10(1):37-41.

Background. Fetal intracranial injury is a potentially devastating sequelae of maternal trauma, but there is little guidance regarding fetal evaluation in this setting. Case. A 23-year-old woman at 27-week gestation was admitted after a high-speed motor vehicle accident. The initial obstetrical ultrasound was unremarkable, but persistently minimal fetal heart rate variability was observed. Ultrasound on day 3 after the accident showed an intracranial hyperechogenic lesion and subdural fluid collection. The neonate, following an uneventful birth at 39 weeks, had seizures and abnormal muscle tone. MRI was consistent with in utero intracranial hemorrhage. Conclusion. Serial fetal imaging following maternal trauma, particularly when accompanied by abnormal fetal heart rate tracings, should be considered when fetal injury is a concern, even in the setting of a normal initial ultrasound.

Aim Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates. Methods A decision–analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness. Results Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted. Conclusions Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

Objective:To evaluate B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac structure and function in normal women through pregnancy and the postpartum.Methods:In this prospective observational study, we obtained serial transthoracic echocardiograms, BNP, and NT-proBNP at seven intervals from 6 weeks’ gestation through 12 months postpartum. Women with hypertension or cardiac disease were excluded. Using 6–12 months postpartum as reference for non-pregnant levels, echocardiogram measurements and BNP/NT-proBNP were compared over time using linear mixed models with Tukey-Kramer adjustment for multiple comparisons.Results:Of 116 patients, data was available for 78–114 healthy pregnant or postpartum women within each time interval, and 102 patients provided data for ≥4 intervals. Compared to 6–12 months postpartum, BNP and NT-proBNP remained stable through pregnancy and delivery, increased within 48 h postpartum (PConclusion:In normal women, BNP/NT-proBNP, left atrial, and left ventricular volumes increase within 48 h postpartum without indications of altered diastolic function.

Aim To describe the effects of nifedipine tocolysis on blood pressure and heart rate in non-hypertensive women. Methods This was a retrospective study from 2001 to 2011 to compare blood pressures and heart rates among non-hypertensive women on nifedipine tocolysis up to 8 h after nifedipine initiation. Measurements at 20–60 and 61–120 min were compared to assess the differential effects of dosing on hemodynamics and reflected the effects of the initial and complete loading doses, respectively. Charts were reviewed for hypotension-related emergent delivery. Results One hundred and thirty-eight patients were included. Over the 8-h study interval, mean systolic blood pressure (P

To compare the surgical approach used for hysterectomy at 2 teaching hospitals before and after introduction of the robotic surgical system.Retrospective cohort study (Canadian Task Force classification II-3).Two gynecologic training sites at the University of Hawaii.Women who underwent hysterectomy between January 1, 2005, and December 31, 2011.ICD-9 procedural codes were used to identify hysterectomies performed between January 1, 2005, and December 31, 2011. Hysterectomies were categorized according to surgical approach: abdominal, vaginal, laparoscopic-assisted vaginal/total laparoscopic, and robotic. Each hysterectomy was also categorized according to primary preoperative diagnosis as general gynecology, gynecologic oncology, and urogynecology. The rates and numbers of hysterectomies performed during 2005-2006 (2 years before acquisition of the robot), 2007-2008 (first 2 years with the robot), and 2009-2011 (3-5 years after acquiring the robot) were compared using χ(2) tests and analysis of variance. The numbers of hysterectomies reported in resident case logs were also collected and compared. A total of 5894 hysterectomies were performed between 2005 and 2011. The total number of hysterectomies performed at Hospital A, which acquired the robotic surgical system, increased over time (p = .04) but remained stable at Hospital B, which did not acquire the robotic surgical system. At Hospital A, the number of robotic hysterectomies increased as the number of abdominal hysterectomies decreased (p.001), a trend consistent across all diagnostic categories. The number of vaginal and laparoscopic hysterectomies remained stable. Resident case logs also reflected a decrease in the number of abdominal hysterectomies (p = .002) and an increase in the number of combined laparoscopic/robotic hysterectomies (p.001) performed. The total number of hysterectomies performed by residents was unchanged.Introduction of the robotic surgical system was associated with significant changes in the numbers and types of hysterectomies performed in both general and subspecialty gynecology. Although abdominal hysterectomies decreased as robotic hysterectomies increased, other hysterectomies did not. These trends mirror reported resident surgical experience and have implications for resident education.

The aim of this review is to discuss three dimensional (3D) power Doppler of the placenta and its clinical applications. There is a strong clinical need to develop noninvasive, simple and widely available methods of evaluating in vivo placental function to assess fetal wellbeing. While conventional ultrasound is a proven tool in the evaluation of fetal structural anomalies and health, its ability to assess placental function, especially prior to the onset of fetal compromise, is the subject of ongoing investigation. Three dimensional power Doppler has the ability to detect vascularity and blood flow with greater detail than conventional ultrasound, which has led to its investigation in preeclampsia, fetal growth restriction, and other placental vascular abnormalities. While more data are needed on the optimal imaging protocol and its predictive ability for clinical outcomes, 3D power Doppler is emerging as a promising new technology that will improve the evaluation of placental function.

There is relatively little information on episiotomies in the context of restricted episiotomy use. This study sought to examine maternal and neonatal injuries with restricted episiotomy use. We performed a retrospective database analysis of vaginal deliveries at a tertiary care maternity hospital from June 2010 to June 2015. Maternal injuries (third- or fourth-degree lacerations) and neonatal injuries (birth trauma) were identified through the International Classification of Diseases, Ninth Revision, codes. Vaginal deliveries were classified as spontaneous, vacuum-assisted, or forceps-assisted. The associations between episiotomy and maternal and neonatal injuries were examined with stratification by parity, type of vaginal delivery, and type of episiotomy (midline or mediolateral). Adjusted-odds’ ratios were calculated for maternal and neonatal injuries using a multiple logistic regression model to adjust for potential confounders. 22,800 deliveries occurred during the study interval involving 23,016 neonates. The episiotomy rate was 6.7 % overall and 22.9 % in operative vaginal deliveries. Episiotomies, both midline and mediolateral, were associated with increased risks of maternal and neonatal injuries regardless of parity (p

Purpose To compare leak point volumes and cost-effectiveness of a variety of adult incontinence products. Methods Adult incontinence products were purchased from local retail stores and categorized into moderate absorbency pads, moderate absorbency briefs, maximum absorbency pads, and maximum absorbent briefs. The leak point for each product was determined by applying fluid to the pad until the first drop of leakage from the pad or brief occurred. Cost-effectiveness was calculated by dividing the cost per product by the amount of fluid absorbed prior to the leak point. The leak points and cost-effectiveness of incontinence products were compared within and between categories. Results Significant differences in leak point volumes were present within all product categories except moderate absorbency pads. When comparing product categories, moderate absorbency pads were the least cost-effective, followed by maximum absorbency pads and absorbent briefs (P Conclusions As a group, absorbent briefs are more cost-effective than incontinence pads, although products of similar absorbency category and design demonstrated varying leak points and cost-effectiveness. These findings may influence physician assessment of urinary incontinence as well as patient selection of incontinence products.

To describe the effects of nifedipine tocolysis on blood pressure and heart rate in non-hypertensive women.This was a retrospective study from 2001 to 2011 to compare blood pressures and heart rates among non-hypertensive women on nifedipine tocolysis up to 8 h after nifedipine initiation. Measurements at 20-60 and 61-120 min were compared to assess the differential effects of dosing on hemodynamics and reflected the effects of the initial and complete loading doses, respectively. Charts were reviewed for hypotension-related emergent delivery.One hundred and thirty-eight patients were included. Over the 8-h study interval, mean systolic blood pressure (P 0.001) and mean diastolic blood pressure (P 0.001) decreased by 5 mmHg and heart rate increased by 4 b.p.m. (P 0.001). Systolic and diastolic blood pressures were unchanged from baseline up to 120 min at all doses. Heart rate increased at both 20-60 and 61-120 min when all doses were considered (P 0.001), but differential dosing effects were not observed. Rates of tachycardia increased (P 0.001), but rates of hypotension were unchanged. No hypotension-related emergent deliveries occurred.Nifedipine tocolysis was associated with hemodynamic changes in non-hypertensive women. Tachycardia was increased but hypotension was unaffected, supporting the general safety of nifedipine in this setting.