Change in cervical length and spontaneous preterm birth in nulliparous women with a history of loop electrosurgical excision procedure.

BACKGROUND: Prior studies have shown an association between history of loop electrode procedures (LEEP) and spontaneous preterm delivery (SPTD) independent of mid-trimester cervical length. These studies suggest that there may be other factors beyond an individual cervical length, which contribute to identifying at-risk pregnancies. OBJECTIVE: The objective of this study is to determine the association between change in cervical length and SPTD in women with a history of LEEP. STUDY DESIGN: This is a retrospective cohort study of singleton nulliparous women with a history of LEEP who received serial cervical length measurements at a single institution between 2012 and 2016. Women with serial cervical lengths and available outcome data were included. The cervical length at different gestational ages and the rate of change in length were compared with the risk for SPTD <37 weeks using Student's t-test. RESULTS: One-hundred-thirty subjects met the inclusion criteria for the study. The mean cervical length (35.3 versus 39.8 mm, p = .042 at 16 weeks; 32.2 versus 37.8 mm, p < .01 at 20 weeks; 29.9 versus 35.6 mm, p = .027 at 24 weeks; 21.6 versus 33.4 mm, p < .01 at 28 weeks) was significantly different between women who had an SPTD <37 weeks compared to women who did not. The average rate of change in transvaginal cervical length between 16 to 28 weeks was significantly different between women who had an SPTD <37 weeks compared to women who did not (-1.4 versus 0.4 mm/week, p < .01). CONCLUSION: Women with a history of LEEP who had an SPTD <37 weeks had a shorter cervical length at 16, 20, 24, and 28 weeks' gestation and a higher rate of change in cervical length between 16 and 28 weeks than women without a history of SPTD. Our findings support the concept of the preterm birth syndrome as an evolving biophysical process rather than a distinct event, suggesting improved prediction in the setting of prior history of a LEEP with serial imaging.

Antenatal Testing for Women With Preexisting Medical Conditions Using Only the Ultrasonographic Portion of the Biophysical Profile.

OBJECTIVE: To report the utility of the ultrasonographic biophysical profile, which includes all the components of a biophysical profile minus the nonstress test, in women with maternal indications for antepartum surveillance. METHODS: We conducted a case series reviewing the records of all women at 32 weeks of gestation or greater with at least one indication for antenatal testing (per the American College of Obstetricians and Gynecologists) delivered by a single maternal-fetal medicine practice between 2006 and 2018. Indications included diabetes, hypertension, lupus, antiphospholipid syndrome, sickle cell disease, renal disease, heart disease, hyperthyroidism, isoimmunization, inherited thrombophilia, and prior intrauterine fetal demise. Weekly ultrasonographic biophysical profiles were initiated at 32 weeks of gestation. We calculated the test-positive rate, the percentage of women delivered for an abnormal ultrasonography biophysical profile, and the intrauterine fetal demise rate (false-negative rate). RESULTS: Nine hundred eighty-five women underwent 3,981 ultrasonographic biophysical profiles (four per woman; range 1-11). Sixteen women had an abnormal ultrasonographic biophysical profile, for a test positive rate of 1.6% (95% CI 1.0-2.6%) per woman, or 0.4% (95% CI 0.3-0.7%) per ultrasonographic biophysical profile. Of the 16 women with abnormal ultrasonographic biophysical profiles, 13 were delivered with good outcomes and three women had normal follow-up testing and uncomplicated deliveries at a later date. There were three women with intrauterine fetal demise (false-negative rate of 0.3%, 95% CI 0.1-0.9%). One woman with intrauterine fetal demise had a factor V Leiden mutation, fetal ventriculomegaly, and fetal growth restriction. The second woman with intrauterine fetal demise had advanced maternal age, a factor V Leiden mutation, and fetal growth restriction. The third woman with intrauterine fetal demise had class B diabetes. All three intrauterine fetal demises were diagnosed antepartum with an interval from normal ultrasonographic biophysical profile to intrauterine fetal demise of 7, 7, and 6 days, respectively. CONCLUSION: The use of ultrasonographic biophysical profile in a high-risk cohort is associated with a very low test-positive rate and a very low incidence of intrauterine fetal demise. In women with preexisting medical conditions that place them at higher risk for intrauterine fetal demise, ultrasonographic biophysical profile can be used for antenatal testing.

Suture Compared With Staple Closure of Skin Incision for High-Order Cesarean Deliveries.

OBJECTIVE: To compare wound complication rates in tertiary or higher-order cesarean delivery based on wound closure technique. METHODS: We performed a retrospective cohort study of all tertiary or higher-order cesarean deliveries performed by one group practice in a large academic medical center from 2005 to 2017. We excluded patients with a vertical skin incision. Although the study was not randomized, wound closure type was relatively uniform in this practice and based on time period: before 2011, the preferred closure was staple closure; after 2011, subcuticular suture closure was preferred. All patients received preoperative antibiotics and closure of subcutaneous tissue 2 cm deep or greater. The primary outcome was a wound complication, defined as a wound infection requiring antibiotics or a wound separation requiring wound packing or reclosure any time up to 6 weeks after delivery. Regression analysis was used to control for any significant differences at baseline between the groups. RESULTS: There were 551 patients with tertiary or higher-order cesarean delivery, 192 (34.8%) of whom had staple closure and 359 (65.2%) of whom had suture closure. Suture closure was associated with a significantly lower rate of wound complication (4.7% [17/359, 95% CI 3.0%-7.5%] vs 11.5% [22/192, 95% CI 7.7%-16.7%], P=.003). On regression analysis controlling for the number of prior cesarean deliveries and the participation of a resident in the closure, suture closure remained independently associated with a lower risk of a wound complication (adjusted odds ratio 0.44, 95% CI 0.23-0.86). CONCLUSION: For women undergoing their third or higher-order cesarean delivery, suture closure is associated with a lower rate of wound complications.

Long-term outcomes of twins based on the intended mode of delivery.

OBJECTIVE: Recent studies have shown that for twin pregnancies with a cephalic presenting first twin, planned vaginal delivery is not associated with adverse short-term neonatal outcomes, as compared to planned cesarean delivery. Our objective was to compare long-term outcomes in twins, based on planned mode of delivery. STUDY DESIGN: This was a prospective, observational cohort of twin pregnancies delivered by a single MFM practice. All the patients with a twin pregnancy >34 weeks delivered from 2005-2014 were surveyed regarding pediatric outcomes at or after 2 years of life. The survey was mail-based, with phone follow-up for nonresponses or for clarification of answers. Using chi-square, Student's t-tests, and regression analysis we compared outcomes between women who planned a vaginal (with active management of the second stage) versus cesarean delivery. The main outcome measures were: (1) a composite of major adverse outcomes (death, cerebral palsy, necrotizing enterocolitis, chronic renal, heart, or lung disease); (2) a composite of minor adverse outcomes (learning disability, speech therapy, occupational therapy, physical therapy). RESULTS: Five hundred and thirty-two women met inclusion criteria and 354 (66.5%) responded. 178 (50.3%) women planned to have a cesarean delivery (100% of whom had a cesarean delivery) and 176 (49.7%) women planned to have a vaginal delivery (83% of whom had a vaginal delivery). The average age of the children at the time of the survey was 5.9 years. There were no differences in any pediatric outcomes between the two groups. After controlling for maternal age, IVF, obesity, and preeclampsia, the planned mode of delivery was not associated with a composite of major adverse outcomes (aOR 0.673, 95% CI 0.228, 1.985), nor a composite of minor adverse outcomes (aOR 0.767, 95% CI 0.496, 1.188). CONCLUSIONS: Planned vaginal delivery with active management of the second stage of labor in twin pregnancies >34 weeks is not associated with adverse childhood outcomes.

The Association between Fetal Fibronectin, Cervical Length, and Amniotic Fluid Sludge with Histological Indicators of Placental Inflammation in Twin Gestations.

OBJECTIVE: The objective of this study was to evaluate the association of screening tests for preterm birth (short cervical length [CL], positive fetal fibronectin (FFN), and amniotic fluid [AF] sludge) in twin gestations with histologic evidence of placental inflammation. STUDY DESIGN: Historical cohort study of 596 twin gestations delivered in a single maternal-fetal medicine practice with CL and FFN testing from 22 to 256/7 weeks. A short CL was defined as ≤25 mm. Placental lesions evaluated were chronic and acute membrane inflammation and funisitis. Fischer's exact test and logistic regression were used. RESULTS: None of the screening tests was associated with chronic inflammation. All were associated with acute inflammation. On regression analysis, a short CL and positive FFN remained independently associated with acute inflammation (adjusted odds ratio [aOR]: 5.66 and 2.51, respectively) and funisitis (aOR: 5.66 and 7.17, respectively). AF sludge was not independently associated with acute inflammation nor funisitis. CONCLUSION: In twin gestations, a short CL and a positive FFN at 22 to 26 weeks are associated with acute but not chronic inflammation on placental histology. These findings imply that mechanisms underlying preterm birth in twins that result in positive screening tests weeks prior to delivery are not reflected as chronic placental inflammation. Therefore, pathologic interpretation of etiologic mechanisms for preterm birth may be limited using solely histologic reports.

Long-term outcomes of twins based on gestational age at delivery.

OBJECTIVE: Prematurity is associated with adverse outcomes. However, there are less data regarding long-term outcomes of twins based on gestational age at delivery. Our objective was to identify the association between gestational age at delivery and long-term outcomes in twins. STUDY DESIGN: All patients with a twin pregnancy ≥24 weeks delivered by a single Maternal Fetal Medicine practice from 2005 to 2014 were surveyed regarding pediatric outcomes at or after 2 years of life. We excluded twins with aneuploidy or major fetal anomalies. The survey was mail-based, with phone follow-up for nonresponses or for clarification. Using logistic regression analysis, we compared long-term outcomes between twins born in four gestational age groups: 24 to 27-6/7 weeks, 28 to 31-6/7 weeks, 32 to 35-6/7 weeks, and 36 weeks or later. RESULTS: Six hundred fifty-three twin deliveries met inclusion criteria and 425 (65.1%) mothers responded. Mean age at the time of survey completion was 6.0 ± 2.4 years. Earlier gestational age was significantly associated with neonatal death (14, 2, 0, and 0% in the four groups, respectively, p < .001). Prematurity was associated with a composite of major adverse outcomes (death; cerebral palsy; necrotizing enterocolitis; chronic renal, heart, or lung disease) (14, 7, 4, and 2% in the four groups, p = .036), as well as minor adverse outcomes (learning disability; need for speech, occupational, or physical therapy) (83, 69, 54, and 38%, p < .001). CONCLUSIONS: Long-term morbidity in twin pregnancies is inversely related to gestational age at delivery. However, for twins born after 28 weeks, neonatal death and severe long-term morbidity are rare.

The association between fetal fibronectin and spontaneous preterm birth in twin pregnancies with a shortened cervical length.

OBJECTIVE: To estimate the association between a positive fetal fibronectin (fFN) and spontaneous preterm birth (SPTB) in twin pregnancies with a shortened cervical length (CL). STUDY DESIGN: Retrospective cohort study of asymptomatic twin pregnancies managed by a single MFM practice from 2005 to 2016. We included all women with a shortened CL ≤25 mm at 22-28 weeks, and compared outcomes between women with a positive and negative fFN result. RESULTS: One hundred fifty-five patients were included, 129 (83.2%) of whom had a negative fFN and 26 (16.8%) of whom had a positive fFN. Baseline characteristics were similar between groups, except for the CL at the time of diagnosis of short cervix (15 mm in the positive fFN group versus 20 mm in the negative fFN group, p = .002). The risk of SPTB <32 weeks was significantly higher in the positive fFN group (46.2 versus 12.6%, aOR 3.54, 95% CI 1.26, 9.92) and the mean gestational age at delivery was significantly earlier (31.1 versus 35.2 weeks, p < .001). CONCLUSIONS: In asymptomatic women with twin pregnancies and a shortened CL, a positive fFN is significantly associated with SPTB and can modify the risk substantially. If performing a screening CL assessment in a twin pregnancy, fFN testing should be done concurrently.

Risk factors for blood transfusion in patients undergoing high-order Cesarean delivery.

BACKGROUND: The objective was to identify risk factors associated with blood transfusion in patients undergoing high-order Cesarean delivery (CD). STUDY DESIGN AND METHODS: This was a retrospective cohort study of patients undergoing third or more CD by a single maternal-fetal medicine practice between 2005 and 2016. We compared risk factors between women who did and did not receive a red blood cell transfusion during the operation or before discharge. Repeat analysis was performed after excluding women with placenta previa. RESULTS: A total of 514 patients were included, 18 of whom (3.5%; 95% confidence interval [CI], 2.2%-5.5%) received a blood transfusion. Placenta previa was the most significant risk factor for transfusion (61.1% of patients who received a transfusion vs. 1% of patients who did not; p < 0.001). Patients with a placenta previa had a 68.8% likelihood of requiring a blood transfusion. After women who had placenta previa were excluded, the incidence of blood transfusion was seven of 498 (1.4%; 95% CI, 0.7%-2.9%). Risk factors significantly associated with blood transfusion in the absence of previa were prophylactic anticoagulation during pregnancy and having labored. The incidence of transfusion in patients with no placenta previa, no anticoagulation, and no labor was 0.7% (95% CI, 0.3%-2.1%). Placenta previa was the most predictive risk factor for transfusion with a positive predictive value of 68.8% and a negative predictive value of 98.4%. CONCLUSION: In patients undergoing a third or more CD, only placenta previa, prophylactic anticoagulation during pregnancy, and having labored are independently associated with requiring a blood transfusion. These data can be used to guide physician ordering of prepared blood products preoperatively.

A comparison of cervical length measurement techniques for the prediction of spontaneous preterm birth.

OBJECTIVE: To evaluate the clinical utility of a novel means of assessing the cervix by measuring the angle of the curvature and to evaluate the performance of this technique as well as two other commonly used techniques of cervical length assessment in predicting spontaneous preterm birth (SPTB). METHODS: This was a retrospective cohort analysis of singleton gestations with a history of SPTB. Transvaginal ultrasound images of cervical length obtained between 20 and 23 6/7 weeks were re-measured using three techniques: (1) straight linear distance between the internal and external os, (2) sum of two contiguous linear segments tracing the internal to the external os, and (3) measurement of the angle of the curve within the cervix using an electronic protractor. A short cervical length was defined as ≤25 mm. RESULTS: A total of 181 women were included. The relative risk (RR) for SPTB by cervical angle ≤160° was 1.2 (95% CI 0.7-2.0) and the ROC curve revealed an area under the curve of 0.54 (95% CI 0.44-0.63). The RR for SPTB by short cervical length measured by the straight technique was 2.3 (95% CI 1.3-4.0) and by the segmental technique 2.1 (95% CI 1.2-3.8). There was a 99.4% agreement between the two techniques with an intraclass Kappa coefficient of 0.96. CONCLUSIONS: In women with a history of SPTB, cervical angle measurement does not correlate with the risk of SPTB. Cervical length measured via straight and segmental techniques had excellent agreement in identifying short cervix, and both identified a short cervix predictive of SPTB.

The effect of a sonographic estimated fetal weight on the risk of cesarean delivery in macrosomic and small for gestational-age infants.

OBJECTIVE: To assess the association of a sonographic estimated fetal weight (sonoEFW) with the risk of cesarean delivery in women with macrosomic or small for gestational age (SGA) infants. METHODS: Retrospective cohort of singleton deliveries >24 weeks by one MFM practice from 2005 to 2014. We included all patients who delivered an infant with macrosomia (birth weight ≥4000 g) or SGA (birth weight <10th percentile). We compared the risk of cesarean delivery between patients who did and did not have a sonoEFW within four weeks of delivery. Regression analysis was performed to control for any differences in baseline characteristics. RESULTS: In patients with macrosomic infants (n = 352), the risk of cesarean delivery was significantly higher in the sonoEFW group (45.3% versus 17.6%, aOR 2.144, 95% CI: 1.06-4.34). When we restricted the analysis to the subgroup of 265 patients who attempted vaginal delivery, our results were similar (22.3% versus 9.1%, aOR 2.73, 95% CI: 1.15-6.48). In patients with an SGA infant (n = 614), the risk of cesarean delivery was not higher in the sonoEFW group (37.4% versus 24.1%, aOR 1.23, 95% CI: 0.80-2.07), nor in those who attempted vaginal delivery (19.8% versus 13.7%, aOR 1.17, 95% CI: 0.62-2.21). CONCLUSIONS: A sonoEFW prior to delivery is independently associated with cesarean delivery in women with macrosomic infants, but not those with SGA infants. This should be considered when deciding to obtain a sonoEFW at the end of pregnancy, particularly if not for an accepted indication.

The Independent Association of a Short Cervix, Positive Fetal Fibronectin, Amniotic Fluid Sludge, and Cervical Funneling with Spontaneous Preterm Birth in Twin Pregnancies.

Objective To estimate the independent association of a short cervical length (CL), positive fetal fibronectin (fFN), amniotic fluid (AF) sludge, and cervical funneling with spontaneous preterm birth in twin pregnancies. Methods Retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from June 2005 to February 2014. All patients underwent transvaginal sonographic CL and fFN testing. We reviewed all images from the first CL at 22(0/7) to 25(6/7) weeks for the presence of (1) a short CL, which is defined as ≤25 mm, (2) AF sludge, and (3) cervical funneling, and also recorded (4) the fFN result from that time. Image reviewers were blinded to pregnancy outcomes. Patients with cerclage were excluded. Using logistic regression, we calculated the independent association between these four biomarkers and spontaneous preterm birth. Results A total of 635 patients with twin pregnancies were included. The markers independently associated with spontaneous preterm birth <35 weeks were short CL (adjusted odds ratio [aOR]: 10.73; 95% confidence interval [CI]: 3.21-35.81), positive fFN (aOR: 3.25; 95% CI: 1.13-9.33), and AF sludge (aOR: 2.11; 95% CI: 1.04-4.27). Similarly, these three markers were independently associated with earlier gestational ages at delivery. Cervical funneling was not independently associated with spontaneous preterm birth <35 weeks nor gestational age at delivery. The risk of spontaneous preterm birth increased significantly with the number of positive biomarkers (short CL, positive fFN, and AF sludge). Conclusion In twin pregnancies, a short CL, positive fFN, and AF sludge are independently associated with spontaneous preterm birth. Cervical funneling is not independently associated with spontaneous preterm birth in twins.

Cervical Pessary and Vaginal Progesterone in Twin Pregnancies With a Short Cervix.

OBJECTIVE: To evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix. METHODS: This was a retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2015. We included patients at 28 weeks of gestation or less who were diagnosed with a cervical length less than 20 mm. At the time of diagnosis, all patients were prescribed vaginal progesterone. Starting in 2013, they were also offered pessary placement in addition to vaginal progesterone. We compared outcomes between patients who received a pessary and matched women in a control group in a one-to-three ratio. Women in the control group were matched to women in the case group according to cervical length and gestational age (within 5 mm and 1 week, respectively, of the case patient at the time of pessary placement). We excluded patients with cerclage, monochorionic-monoamniotic placentation, major fetal congenital anomalies discovered before or after birth, patients with twin-twin transfusion syndrome, and patients for whom there were no appropriate controls. Chi-square, Fisher exact, and Student's t tests were used, as appropriate. Regression analysis was performed to control for significant differences at baseline. RESULTS: Twenty-one patients received a cervical pessary, and they were compared with 63 matched women in the control group. As expected (as a result of matching), baseline gestational age (25.7±2.1 compared with 25.9±2.1 weeks of gestation, P=.671) and cervical length (10.9±3.6 mm compared with 11.9±4.5 mm, P=.327) were similar between the groups. Patients with a pessary had a significantly lower incidence of delivery at less than 32 weeks of gestation (1/21 [4.8%] compared with 18/63 [28.6%], adjusted P=.05), longer interval to delivery (65.2±16.8 compared with 52.1±24.3 days, adjusted P=.025), and a lower incidence of severe neonatal morbidity (2/21 [9.5%] compared with 22/63 [34.9%], adjusted P=.04). CONCLUSION: For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.

The association between maternal height and pregnancy outcomes in twin gestations.

OBJECTIVE: We sought to assess the association between maternal height and the risk of preterm birth, fetal growth restriction and mode of delivery in twin gestations. STUDY DESIGN: Cohort study of patients with twin pregnancies delivered from 2005 to 2014. We compared pregnancy outcomes between patients of short stature ≤159 cm to those of normal stature ≥160 cm. Patients with monoamniotic twins and major fetal anomalies were excluded. Pearson's correlation, Chi-square and Student's t-test were used as appropriate. RESULTS: Six hundred and sixty-six patients were included, 159 (23.9%) of whom had short stature (mean height 155.8 ± 2.5 cm) and 507 (76.1%) of whom had normal stature (mean height 167.2 ± 5.5 cm). There were no differences in outcomes between the groups in regards to preterm birth, gestational age (GA) at delivery, birth weight of either twin, preeclampsia, gestational diabetes or cesarean section rate. Results were similar when the groups were stratified by parity. As a continuous variable, maternal height did not correlate with GA at delivery (p= 0.388), cesarean delivery (p = 0.522) nor the birth weight of the larger (p = 0.206) or smaller (p = 0.307) twin. CONCLUSION: In twin pregnancies, maternal short stature is not associated with preterm birth, fetal growth restriction or cesarean section rate. This suggests that although anthropometric measurements have long been used to counsel patients in regards to outcomes, patients of short stature should be reassured that their height does not appear to lead to adverse twin pregnancy outcomes.

Fetal fibronectin, cervical length, and the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage.

OBJECTIVE: The objective of this study is to estimate the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage based on the results of fetal fibronectin (fFN) and cervical length (CL) screening. METHODS: Retrospective cohort of patients with a singleton pregnancy and an ultrasound or physical exam indicated Shirodkar cerclage placed by one maternal-fetal medicine practice from November 2005 to January 2015. Patients routinely underwent serial CL and fFN testing from 22 to 32 weeks. Based on ROC curve analysis, a short CL was defined as ≤15 mm. All fFN and CL results included are from after the cerclage placement. RESULTS: One hundred and four patients were included. Seventy eight (75%) patients had an ultrasound-indicated cerclage and 26 (25%) patients had a physical exam-indicated cerclage. A positive fFN was associate with preterm birth <32 weeks (15.6% versus 4.2%, p = 0.043), <35 weeks (37.5% versus 11.1%, p = 0.002), <37 weeks (65.6% versus 20.8%, p < 0.001), and earlier gestational ages at delivery (35.2 ± 3.9 versus 37.4 ± 2.9, p = 0.001). A short CL was also associated with preterm birth <35 weeks (50.0% versus 11.9%, p < 0.01), preterm birth <37 weeks (55.0% versus 29.8%, p = 0.033), and earlier gestational ages at delivery (34.8 ± 4.1 versus 37.2 ± 3.0, p = 0.004). The risk of preterm birth <32, <35, and <37 weeks increased significantly with the number of abnormal markers. CONCLUSION: In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short CL are both associated with preterm birth. The risk of preterm birth increases with the number of abnormal biomarkers.

The association between second trimester estimated fetal weight and small for gestational age at birth.

OBJECTIVE: To analyze diagnostic accuracy of second trimester ultrasound fetal growth parameters as predictors of small for gestational age (SGA) birth weight. METHODS: We reviewed the fetal biometry from 714 consecutive patients with second trimester ultrasounds. The estimated fetal weight (EFW) and abdominal circumference (AC) percentiles were tested as predictors of SGA at birth (<10‰). RESULTS: 87 (12.2%) patients had an SGA baby. Patients with a second trimester EFW ≤25‰ were significantly more likely to have SGA at birth (24.2% versus 10.3%, p < 0.001). Similar results were seen for women with second trimester AC ≤25‰ (likelihood of SGA 21.9% versus 11.2%, p = 0.013). A second trimester EFW ≤25‰ was a better predictor of SGA at birth than a second trimester EFW ≤ 10‰ (Positive likelihood ratio 2.30 versus 2.09). In the second trimester, only 9 (1.3%) patients had an EFW 0-10‰, only 43 (6%) patients had an EFW 11-20‰, and only 46 (6.4%) patients had an EFW 91-99‰. Each other EFW centile had more than 10% of the patients. CONCLUSIONS: The incidence of second trimester EFW or AC ≤10‰ is less common than expected from standard tables. An EFW ≤25‰ and an AC ≤25‰ should be considered the second trimester marker for risk of SGA at birth. However, due to the low likelihood ratio of, it is not clear if second trimester ultrasound should be used as a predictor of SGA at birth.

Glycemic control in twin pregnancies with gestational diabetes: are we improving or worsening outcomes?

OBJECTIVE: To estimate the association between glycemic control and adverse outcomes in twin pregnancies with gestational diabetes (GDM). STUDY DESIGN: A cohort of patients with twin pregnancies and GDM were identified from one maternal-fetal medicine practice from 2005 to 2014. Patients with prepregnancy diabetes were excluded. First, outcomes were compared between patients with GDMA1 and GDMA2 (gestational age at delivery, birthweight, small for gestational age (SGA, birthweight <10th percentile), preeclampsia, and cesarean delivery). Then, finger stick glucose logs were reviewed and correlated with the risk of SGA and preeclampsia. Abnormal finger stick values were defined as: fasting ≥ 90 mg/dL, 1-h postprandial ≥ 140 mg/dL, 2-h postprandial ≥ 120 mg/dL. RESULTS: Sixty-six patients with twin pregnancies and GDM were identified (incidence 9.1%). Comparing the 43 patients with GDMA1 to the 23 patients with GDMA2, outcomes were similar, aside from patients with GDMA1 having lower birthweight of the smaller twin (2184 ± 519 g versus 2438 ± 428 g, p = 0.040). The risk of preeclampsia was not associated with glycemic control. Patients with SGA had lower mean fasting values (83.3 ± 5.5 versus 87.2 ± 7.7 mg/dL, p = 0.033), and a lower percentage of abnormal fasting values (24.0% versus 36.9%, p = 0.040), abnormal post-breakfast values (9.9% versus 27.1%, p = 0.003), and total abnormal values (20.1% versus 27.7%, p = 0.055). CONCLUSION: In twin pregnancies with GDM, improved glycemic control is not associated with improved outcomes, and is associated with a higher risk of SGA. Prospective trials in twin pregnancies should be performed to establish goals for glycemic control in twin pregnancies.

Antenatal Surveillance in Twin Pregnancies Using the Biophysical Profile.

Objectives-The nonstress test is currently the most widely used modality for antenatal surveillance in twin pregnancies, with a quoted false-positive rate of 11%-12%. Our objective was to report our experience with the sonographic portion of the biophysical profile in twin pregnancies as the primary screening modality.Methods-Women with twin pregnancies delivered by a single maternal-fetal medicine practice from 2005 to 2013 were included. We excluded monoamniotic twins. Twin pregnancies began weekly sonography for the biophysical profile starting at 32 to 33 weeks, or earlier if indicated. The nonstress test was performed if the sonographic biophysical profile score was less than 8 of 8. We reviewed biophysical profile scores and outcomes for all patients who delivered at 33 weeks or later to assess the false-positive rate for the biophysical profile, as well as the incidence of intrauterine fetal death (IUFD) after initiation of antenatal surveillance.Results-A total of 539 twin pregnancies were included. The incidence of IUFD per patient was 2 per 539 (0.4%; 95% confidence interval [CI], 0.1%-1.3%), and the incidence of IUFD per fetus was 2 per 1078 (0.19%; 95% CI, 0.05%-0.7%). The overall positive screen rate was 24 per 539 (4.45%; 95% CI, 3.0%-6.5%). The false-positive screen rate, defined as an abnormal biophysical profile that did not diagnose an IUFD or lead to delivery, was 10 per 539 (1.9%; 95% CI, 1.0%-3.4%).Conclusions-In twin pregnancies the use of the sonographic biophysical profile for routine antenatal surveillance has a low false-positive rate, with a very low incidence of IUFD. The sonographic biophysical profile should be considered as a primary mode for antenatal surveillance in twin pregnancies, with a reflex nonstress test for an abnormal score.

Effect of Resident Participation on Outcomes in High-Order Cesarean Deliveries.

OBJECTIVE: To estimate the effect of resident participation on outcomes in women undergoing high-order cesarean deliveries. METHODS: We performed a retrospective cohort study of patients in one obstetric practice undergoing a third- or greater order cesarean delivery from 2005 to 2014. Patients with placenta previa, accreta, or failed vaginal birth after cesarean delivery were excluded. We compared outcomes between patients whose operations were performed by two attendings with patients whose operations were performed by one attending and one resident. Regression analysis was performed to control for differences at baseline. RESULTS: Three hundred seventy patients were included, 189 (51%) of whom had two attendings and 181 (49%) of whom had one attending and one resident. The mean operative time was slightly but significantly less in the two=attending group (60.9±17.3 compared with 62.5±18.3 minutes, adjusted P=.038). Otherwise, there were no significant differences in measured outcomes between the groups, including wound complications, blood loss (estimated and drop in hemoglobin), blood transfusion, major maternal morbidity (hysterectomy, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, death), postoperative endometritis, and postoperative days in the hospital. Among patients in the resident group, there was no difference in outcomes between cases performed by a junior (first or second year) resident compared with a senior (third or fourth year) resident. CONCLUSION: Resident participation does not negatively affect outcomes in patients undergoing high-order cesarean deliveries. Residents should be included in these complicated cases because they can obtain a significant learning experience without compromising patient safety.

Gestational age at cervical length and fetal fibronectin assessment and the incidence of spontaneous preterm birth in twins.

OBJECTIVES: To estimate the risk of spontaneous preterm birth in twin pregnancies based on transvaginal sonographic cervical length, fetal fibronectin (fFN) testing, and the gestational age at which these tests were performed. METHODS: Women with twin pregnancies, cervical length assessment, and fFN testing between 22 weeks and 31 weeks 6 days in a single maternal-fetal medicine practice from 2005 to 2013 were included. All testing was done on asymptomatic women on an out-patient basis. Women with monochorionic monoamniotic twins and twin-twin transfusion were excluded. Logistic regression analysis was used to estimate the risk of spontaneous preterm birth before 35, 32, and 28 weeks. RESULTS: Six hundred eleven patients were included and underwent a total of 2406 cervical length measurements and 2279 fFN tests over the course of the study period. The likelihood values for spontaneous preterm birth before 35, 32, and 28 weeks were 19.1%, 6.3%, and 2.3%, respectively. The risk of spontaneous preterm birth before 35 weeks increased with a decreasing cervical length (coefficient for the log of the odds ratio [OR coefficient], -0.13; P < .01; 95% confidence interval [CI], -0.22 to -0.037), a positive fFN result (OR coefficient, 1.04; P < .01; 95% CI, 0.45 to 1.64), as well as earlier gestational ages at testing (OR coefficient, -0.214; P < .01; 95% CI, -0.33 to -0.10). Similar results were seen for spontaneous preterm birth before 32 and 28 weeks. CONCLUSIONS: In asymptomatic patients with twin pregnancies, the cervical length, fFN, and gestational age are all significantly associated with spontaneous preterm birth.

Preterm birth or small for gestational age in a singleton pregnancy and risk of recurrence in a subsequent twin pregnancy.

OBJECTIVE: To evaluate whether a history of preterm birth or small for gestational age (SGA) in a singleton pregnancy is associated with an increased risk of recurrence of the same condition in a subsequent twin pregnancy. METHODS: Retrospective cohort study of twin pregnancies delivered in one maternal-fetal medicine practice from 2005 to 2014. Patients with a history of singleton preterm birth at less than 37 weeks of gestation were compared with patients with a history of singleton term birth and nulliparous patients. A similar analysis was performed for a history of SGA (birth weight less than 10%). RESULTS: Six hundred forty-seven twin pregnancies were included. The prior singleton gestational age at delivery was significantly positively correlated with the twin gestational age at delivery (P<.001), and the prior singleton birth weight was significantly positively correlated with the birth weight of the larger twin (P<.001) and the smaller twin (P<.001). The rate of twin preterm birth before 32 weeks of gestation was 3.5% in patients with a prior term birth, 9.2% in nulliparous patients, and 26% in patients with a prior preterm birth (P<.001). The rate of SGA in patients with a prior birth not complicated by SGA was 42.1%, in nulliparous women it was 54.4%, and in patients with a history of SGA it was 65.2% (P=.007). On regression analysis, prior preterm birth and SGA of a singleton pregnancy were independently associated with recurrence of the same condition in a subsequent twin pregnancy. CONCLUSION: Prior preterm birth and SGA in a singleton pregnancy increase the risk of the same condition in a subsequent twin pregnancy. We postulate that the extrinsic mechanism responsible for the pathophysiology of adverse outcomes in twin pregnancies overlaps with that in singleton pregnancies.