An interactive childbirth education platform to improve pregnancy-related anxiety: a randomized trial.

BACKGROUND: Perinatal anxiety is one of the most common conditions during pregnancy and is associated with adverse maternal and neonatal outcomes. Interventions that are focused on childbirth education and health literacy have been shown to help decrease pregnancy-related anxiety. These programs, however, have limitations. Transportation, childcare, and work conflicts pose barriers to patients. In addition, many of these programs have not been studied in high-risk patients, who are most at risk for pregnancy-related anxiety. Thus, it is uncertain whether an online childbirth education course can help to improve outcomes in a high-risk patient population. OBJECTIVE: This study aimed to compare an interactive online platform for childbirth education (Birthly) with usual prenatal education on anxiety, emergency healthcare utilization, and delivery outcomes for high-risk pregnancies. STUDY DESIGN: We performed a randomized trial comparing an interactive online childbirth education platform combined with usual prenatal education (intervention) with usual prenatal education alone (usual care). Nulliparous, English-speaking patients with internet access and a high-risk pregnancy (medical or mental health disorders) were included. Patients in 2 urban clinics that serve underresourced patients were enrolled at <20 weeks of gestation. The intervention included 3 interactive courses (prenatal bootcamp, breastfeeding, newborn care) and access to a clinician-moderated online community. Pregnancy-related Anxiety Scale questionnaires were administered at randomization and at 34 to 40 weeks. The primary outcome was third-trimester Pregnancy-related Anxiety Scale score. Secondary outcomes included change in Pregnancy-related Anxiety Scale score, unscheduled emergency visits, delivery, and postpartum outcomes. To demonstrate a 15% decrease in Pregnancy-related Anxiety Scale score, 37 patients would be needed per group. Accounting for a 20% loss to follow-up rate, we planned to recruit 90 total patients or 45 per group. RESULTS: A total of 90 patients were randomized with no differences in demographics or baseline Pregnancy-related Anxiety Scale scores. Most patients self-identified as Black and were publicly insured. More than 60% of patients (62.2%) in the intervention arm completed at least 1 Birthly course. Patients in the intervention arm had significantly lower third-trimester Pregnancy-related Anxiety Scale scores (indicating lower anxiety) compared with those receiving usual care (44.6±7.3 vs 53.9±13.8; P<.01), with a decrease in score of 8.3 points vs 0.7 for usual care (P<.01). Patients in the intervention arm also had fewer emergency visits (1 [0-2] vs 2 [1-3]; P=.003). There were no differences in delivery outcomes. Patients in the intervention arm were more likely to breastfeed at delivery, although this was not different by the postpartum visit. Finally, patients who received the intervention were more likely to be satisfied with their childbirth education (94.6% vs 64.9%; P<.01). CONCLUSION: An interactive online childbirth education platform can reduce pregnancy-related anxiety and emergency healthcare utilization while improving satisfaction in a high-risk patient population.

Undetected Fetal Growth Restriction During the Coronavirus Disease 2019 (COVID-19) Pandemic.

This was a retrospective cohort study of patients who delivered singleton, small-for-gestational-age (SGA) neonates between April and June 2019, before the coronavirus disease 2019 (COVID-19) pandemic (pre-COVID-19), and between April and July 2020, during the pandemic (COVID-19 epoch). The primary outcome was the rate of undetected antenatal fetal growth restriction (FGR) in the two periods. A total of 268 patients met inclusion criteria. Patients who delivered small-for-gestational-age neonates during the COVID-19 epoch were significantly more likely to have undetected FGR compared with those who delivered pre-COVID-19 (70.1% vs 58.1%, P =.04). Patients who delivered SGA neonates during the COVID-19 epoch had more telehealth visits but fewer in-person prenatal visits, recorded fundal height measurements, and growth ultrasonograms. As telemedicine continues to be incorporated into prenatal care, these data may lend further support toward self-assessment of fundal height or routine third-trimester growth ultrasonograms to identify fetal growth abnormalities.

Elevated HbA1c on universal prenatal screening is associated with decreased postpartum weight retention.

OBJECTIVE: To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes. METHODS: This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016-2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7-6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c. RESULTS: 2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant (B = -0.86, p < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines. CONCLUSION: Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Arcuate Uterus as an Independent Risk Factor for Adverse Pregnancy Outcomes.

OBJECTIVE: The aim of the study is to estimate the association between arcuate uterus and pregnancy outcomes using controls selected from a similarly high-risk cohort. STUDY DESIGN: This is a retrospective cohort study of women with an arcuate uterus cared for by a single maternal-fetal medicine practice from 2005 to 2020. We included all women with a singleton pregnancy ≥20 weeks and diagnosis of arcuate uterus and randomly selected (3:1) patients with a singleton pregnancy and no uterine anomaly from the same practice as controls. Baseline characteristics and pregnancy outcomes were compared between the two groups. Chi-square, Fisher's exact, and independent samples t-test were used for data analysis, as indicated. RESULTS: A total of 37 women with an arcuate uterus (55 independent singleton pregnancies) and 165 controls were included. There were no differences in baseline characteristics. Women with an arcuate uterus had a significantly higher rate of spontaneous preterm birth less than 37 weeks (10.9 vs. 3.0%, p = 0.031) and were more likely to require vaginal progesterone (5.5 vs. 0.6%, p = 0.049) and administration of antenatal corticosteroids (16.4 vs. 5.5%, p = 0.020). Arcuate uterus was also associated with lower birthweight (3,028.1 ± 528.0 vs. 3257.2 ± 579.9 g, p = 0.010) and higher incidence of intrauterine fetal growth restriction (20.0 vs. 7.3%, p = 0.008), despite similar starting body mass index (BMI) and weight gain throughout pregnancy. There were no differences in preeclampsia, malpresentation, cesarean delivery, blood transfusion, retained placenta, or morbidly adherent placenta. CONCLUSION: Arcuate uterus is associated with a significantly increased risk of spontaneous preterm birth (<37 weeks), need for vaginal progesterone for short cervix and antenatal corticosteroids, fetal growth restriction, and lower mean birthweight. These findings suggest that arcuate uterus is not just a normal variant of uterine anatomy but rather a risk factor for poor fetal growth, short cervix, and a higher risk pregnancy. KEY POINTS: · Arcuate uterus is associated with increased risk of preterm birth and fetal growth restriction.. · Women with arcuate uteri had higher rates of vaginal progesterone use during pregnancy.. · Arcuate uterus should be treated as a true finding rather than a normal anatomical variant..

The Association between Gestational Weight Gain in Each Trimester and Pregnancy Outcomes in Twin Pregnancies.

OBJECTIVE: Adequate maternal weight gain in twin pregnancies is associated with improved outcomes such as increased fetal growth and decreased incidence of preterm birth. However, it remains unclear when gestational weight gain has the greatest influence on pregnancy outcomes. Our objective was to identify at which time in a twin pregnancy does inadequate maternal weight gain have the greatest association with adverse pregnancy outcomes. STUDY DESIGN: This is a retrospective cohort study of women with twin pregnancies and normal prepregnancy body mass index (BMI, 18.5-24.9 kg/m2) who delivered at ≥24 weeks' gestation by a single maternal-fetal medicine practice between 2005 and 2017. Baseline characteristics and pregnancy outcomes were compared between women with and without adequate average gestational weight gain (weight gain per week based on the 2009 Institute of Medicine recommendations). This analysis was performed for weight gain over the entire pregnancy, as well as from 0 to 16, 16 to 24, and 24 weeks to delivery. Multivariable regression analysis was performed to control for potential confounding variables. RESULTS: A total of 609 women with twin pregnancies and normal prepregnancy BMI were included, of whom 386 (63.4%) had adequate average gestational weight gain over the entire pregnancy and 223 (36.6%) did not. Inadequate average gestational weight gain between 0 and 16 weeks' gestation was associated with a higher incidence of birthweight less than the 10th percentile for gestational age (adjusted odds ratio [aOR]: 1.67; 95% confidence interval [CI]: 1.11-2.51) and less than the 5th percentile for gestational age (aOR: 2.10; 95% CI: 1.29-3.40). Inadequate gestational weight gain between 16 and 24 weeks was associated with lower birthweight of the larger twin (ß: -0.09; p = 0.04). Inadequate weight gain from 24 weeks to delivery was associated with spontaneous preterm birth <37 weeks' gestation (aOR: 1.67; 95% CI: 1.13-2.47), <34 weeks' gestation (aOR: 4.32; 95% CI: 2.45-7.63), <32 weeks' gestation (aOR: 9.07; 95% CI: 3.66-22.48), and a lower incidence of preeclampsia (aOR: 0.31; 95% CI: 0.16-0.63). CONCLUSION: In twin pregnancies, gestational weight gain between 0 and 16 weeks as well as between 16 and 24 weeks is most associated with fetal growth, whereas gestational weight gain after 24 weeks is most associated with preterm birth. This may help elucidate the mechanism of action of the impact of gestational weight gain in twin pregnancies.

The effect of microbiome exposure at birth on pediatric outcomes using a twin cohort discordant for microbiome exposure at birth.

OBJECTIVE: Microbiome exposure at birth has been associated with long-term pediatric outcomes. However, it is difficult to determine if differences in outcomes are truly due to microbiome exposure at birth or other exposures after birth and in early infancy. Using a twin cohort, we sought to determine the association between length of exposure to the maternal vaginal-fecal microbiome and long-term pediatric health outcomes by comparing outcomes between presenting and nonpresenting twins born to women who labored. METHODS: We performed a mail-based survey study of women in a single maternal-fetal medicine practice who delivered twin pregnancies ≥24 weeks. The survey study was sent to women when twins were between 2 and 10 years old to assess the long-term health outcomes, including any medical diagnoses or problems with grown and development. For this study, we included all women who labored, and we compared health outcomes for the presenting versus nonpresenting twin with the primary outcome being the development of asthma/reactive airway disease and allergies. The length of exposure to the maternal vaginal-fecal microbiome was measured using the time from rupture of membranes (ROM) to delivery of each twin. Chi-square and Student's t-test were used. RESULTS: Two hundred fifty-seven sets of twins were eligible for analyses. The presenting twin had a longer time of ROM than the nonpresenting twin (617 ± 2408 min versus 2 ± 5 minutes, p < .001). There were no significant differences between health outcomes for the presenting versus nonpresenting twin in the overall cohort, including the development of asthma/reactive airway disease (9.3 versus 10.1%, p = .77) or allergies (12.5 versus 7.8%, p = .08). There were no differences in any outcomes when comparing the presenting versus nonpresenting twin for those twins delivered vaginally or by cesarean delivery. CONCLUSION: In twins born to women who labored and either delivered vaginally or via cesarean section, delivery order was not associated with any significant increase in defined adverse pediatric outcomes, including the development of asthma or allergies. Using twins as a model for microbiome exposure may help to elucidate the role of the maternal vaginal-fecal microbiome on long-term pediatric health outcomes.

The association between high-normal blood pressure and the development of preeclampsia in twin pregnancies.

Objective: We sought to determine if women with twin pregnancies and blood pressure (BP) above the 95th percentile but within normal ranges (i.e. less than 140 systolic and 90 diastolic) are at increased risk of hypertensive disorders of pregnancy.Methods: Retrospective cohort study of all women with twin pregnancies being cared for by a single Maternal Fetal Medicine practice between 2012 and 2018. We identified all women who had a systolic blood pressure (SBP) or diastolic blood pressure (DBP) above the 95th percentile but less than 140 systolic and 90 diastolic at any point during pregnancy. Based on prior publications, the 95th percentile was defined as: a SBP 121-139 mmHg up to 30 weeks or 131-139 mmHg after 30 weeks, a DBP 81-89 mmHg up to 34 weeks or 85-89 mmHg after 34 weeks. We excluded women diagnosed with chronic hypertension either before or during pregnancy. The primary outcome was the development of preeclampsia. Chi-square and logistic regression were used.Results: A total of 457 patients met the inclusion criteria, of whom 109 (23.9%) had either a systolic or diastolic BP above the 95th percentile (but normal) at any time during pregnancy. These women were significantly more likely to develop preeclampsia (30.3 versus 12.6%, p < .001, aOR 2.32 (1.31, 4.09)) and gestational hypertension without preeclampsia (16.5 versus 4.6%, p < .001, aOR 4.27 (2.01, 9.07)).Conclusions: In women with twin pregnancies, a high-normal systolic or diastolic BP (above 120 systolic or 80 diastolic prior to 30 weeks, or above 130 systolic or 84 diastolic after 30 weeks) is associated with a significantly increased risk of gestational hypertension and preeclampsia.

Weight gain and pregnancy outcomes in overweight or obese women with twin gestations.

BACKGROUND: While adequate weight gain in twin pregnancies with normal prepregnancy BMI has been associated with improved pregnancy outcomes, it remains unclear whether adequate weight gain in patients with overweight or obese prepregnancy BMI is associated with similarly improved pregnancy outcomes, and whether this comes at the expense of maternal health risks such as increased risk for gestational diabetes or hypertension. OBJECTIVE: To estimate the association between adherence to weight gain recommendations and pregnancy outcomes in overweight and obese women with twin pregnancies. METHODS: This is a retrospective cohort study of women with overweight (BMI 25.0-29.9 kg/m2) and obese prepregnancy BMI (≥30.0 kg/m2) and twin pregnancies delivered >24 weeks by a single MFM practice between 2005 and 2017. Baseline characteristics, weight gain patterns, and pregnancy outcomes were compared between women who met or exceeded, and who did not meet gestational weight gain requirements, as recommended by the Institute of Medicine (IOM) in 2009. Since total weight gain is also dependent on gestational age at delivery, we used weight gain per week to define adequate weight gain for overweight (0.85 lb/week) and obese (0.68 lb/week) women. RESULTS: A total of 252 overweight and obese women with twin pregnancies met inclusion criteria, 171 (67.9%) of whom met or exceeded weight gain requirements and 81 (32.1%) of whom did not. There were no differences in baseline clinical and demographic characteristics between the two groups. Women with inadequate weight gain had significantly less weight gain in each trimester, as well as less total weight gain for the whole pregnancy. Women with inadequate average gestational weight gain had significantly lower birthweights of the larger twin (2440 versus 2675 g, p = .001) and the smaller twin (2212 versus 2398 g, p = .005), higher incidence of spontaneous preterm birth <37 weeks (33.3 versus 21.1%, p = .03), higher incidence of premature rupture of membranes (24.7 versus 11.7%, p = .008), and greater likelihood of any twin birthweight < 10th percentile for gestational age (51.9 versus 35.5%, p = .01). There were no differences in the likelihood of cesarean delivery, preeclampsia, or gestational diabetes between the two groups. These results did not differ after excluding the 24 women in the cohort with excessive weight gain. CONCLUSIONS: For overweight and obese women with twin gestations, meeting the IOM recommendations for weight gain in pregnancy is associated with improved pregnancy outcomes. CondensationWomen with overweight or obese prepregnancy BMI in twin gestations who gain the recommended amount of weight in pregnancy have improved pregnancy outcomes.

Early treatment-related neutropenia predicts response to palbociclib.

BACKGROUND: Palbociclib is highly active in oestrogen-receptor positive (ER+) metastatic breast cancer, but neutropenia is dose limiting. The goal of this study was to determine whether early neutropenia is associated with disease response to single-agent palbociclib. METHODS: Blood count and disease-response data were analysed from two Phase 2 clinical trials at different institutions using single-agent palbociclib: advanced solid tumours positive for retinoblastoma protein and advanced liposarcoma. The primary endpoint was PFS. The primary exposure variable was the nadir absolute neutrophil count (ANC) during the first two cycles of treatment. RESULTS: One hundred and ninety-six patients (61 breast, 135 non-breast) were evaluated between the two trials. Development of any grade neutropenia was significantly associated with longer median PFS in both the breast cancer (HR 0.29, 95% CI 0.11-0.74, p = 0.010) and non-breast cancer (HR 0.57, 95% CI 0.38-0.85, p = 0.006) cohorts. Grade 3-4 neutropenia was significantly associated with prolonged PFS in the non-breast cohort (HR 0.57, 95% CI 0.38-0.85, p = 0.006) but not in the breast cohort (HR 0.87, 95% CI 0.51-1.47, p = 0.596). Multivariate analysis yielded similar results. CONCLUSIONS: Treatment-related neutropenia in the first two cycles was significantly and independently associated with prolonged PFS, suggesting that neutropenia may be a useful pharmacodynamic marker to guide individualised palbociclib dosing. CLINICAL TRIALS REGISTRATION INFORMATION: Basket Trial: NCT01037790; Sarcoma Trial: NCT01209598.

Weight gain and pregnancy outcomes in underweight women with twin gestations.

Background: Adherence to minimum weight gain recommendations in twin pregnancies as defined by the Institute of Medicine (IOM) guidelines is associated with improved pregnancy outcomes; however, these recommendations have yet to be made for underweight women (BMI < 18.5 kg/m2).Objective: To determine if existing pregnancy weight gain recommendations in twin gestations apply to women with underweight prepregnancy body mass index (BMI), and if these women have similar pregnancy outcomes to women with normal prepregnancy BMI.Methods: This is a retrospective cohort study of women with underweight (BMI < 18.5 kg/m2) and normal prepregnancy BMI (18.5-24.9 kg/m2) and twin pregnancies delivered > 24 weeks by a single Maternal Fetal Medicine (MFM) practice between 2005-2017. Weight gain patterns and pregnancy outcomes were compared between women with underweight prepregnancy BMI and normal prepregnancy BMI. The primary outcomes of the study were gestational age at delivery and intrauterine growth restriction.Results: A total of 664 women met inclusion criteria during the study period, 55 (8.3%) of whom had an underweight prepregnancy BMI, and 609 (91.7%) of whom had a normal prepregnancy BMI. There were no differences in baseline clinical and demographic characteristics between the groups, nor any differences in overall weight gain or weight gain patterns between the two groups. There were no significant differences between the groups in birthweight of the larger twin (2415 versus 2489 g, p = .26) or the smaller twin (2150 versus 2190 g, p = .55), gestational age at delivery (35.8 versus 35.8 weeks, p = .96), incidence of preterm birth < 34 weeks (16.4 versus 16.3%, p = .98), spontaneous preterm birth < 34 weeks (9.1 versus 11.7%, p = .57), or the incidence of either twin with a birthweight < 10% for gestational age (60.0 versus 56.0%, p = .57) or < 5% for gestational age (36.4 versus 30.9%, p = .40).Conclusions: Women with underweight prepregnancy BMI who gain equal weight to women with normal prepregnancy BMI have similar pregnancy outcomes. The recommendations for adequate weight gain in women with underweight prepregnancy BMI should therefore not exceed those for women with normal prepregnancy BMI.

Serial Cervical Length Evaluation in Low-Risk Women with Shortened Cervical Lengths in the Midtrimester: How Many Will Dilate Prior to 24 Weeks?

OBJECTIVE: To determine what proportion of women with a short cervical length (CL) without a history of spontaneous preterm birth (SPTB) will ultimately be dilated at <24 weeks. STUDY DESIGN: This is a retrospective cohort study of women with singleton pregnancies with a short CL (≤25 mm) between 16 and 22 weeks' gestational age (GA). We excluded women with a history of SPTB. We examined the progression of women with short CL based on the CL measurement and GA at diagnosis. The primary outcome was cervical dilation or spontaneous delivery <24 weeks. RESULTS: A total of 163 women were included, of whom 27 (16.6%) were ultimately dilated and 4 (2.5%) had pregnancy loss by 24 weeks. The median GA at diagnosis of short CL was 195/7 (range: 15-22) weeks. Women with a CL <15 mm were more likely to have cervical dilation or loss prior to 24 weeks than women whose CL was 15 to 25 mm (42.5 vs. 11.9%, <0.001, adjusted odds ratio: 3.72, 95% confidence interval: 1.52-9.09). GA at diagnosis was not associated with risk of progression. CONCLUSION: In women with a short CL without a history of SPTB, the risk of dilation or pregnancy loss <24 weeks is significant, approaching 50% for women with a CL <15 mm.

Accuracy of sonographic estimated fetal weight in suspected macrosomia: the likelihood of overestimating and underestimating the true birthweight.

Objective: Macrosomia has increased risk of serious adverse outcomes for both infants and their mothers. As such, many providers recommend induction of labor or cesarean delivery (CD) based on sonographic estimated fetal weight (sonoEFW) cutoffs. It is known that sonoEFW is a poor predictor of birthweight (BW), especially at the extremes of weight. It is not clear, however, whether sonoEFWs tend to underestimate or overestimate the true BW among fetuses with suspected macrosomia. The objective of this study was to compare rates of overestimation of BW among women with suspected macrosomia by sonoEFW.Methods: This was a retrospective cohort study of women who presented to a single maternal-fetal medicine ultrasound unit within 2 weeks prior to delivery from January 2011 to November 2017. We identified women who received a sonoEFW ≥4000 g. The study sample was divided into four sonoEFW categories: 4000-4249, 4250-4499, 4500-4749, and ≥4750 g. Accuracy of sonoEFW was compared across groups, with the primary outcome being overestimation of BW.Results: A total of 502 patients were included, of whom 301 (60.1%) had a sonoEFW 4000-4249 g, 135 (26.9%) had a sonoEFW 4250-4499 g, 45 (9.0%) had a sonoEFW 4500-4749 g, and 21 (4.2%) had a sonoEFW ≥4750 g. In each sonoEFW group, the risk of overestimating BW was greater than 50%, and the likelihood of overestimation of BW increased significantly across sonoEFW groups (69.4, 76.3, 80.0, 95.2%, p < .001). This held true after adjusting for differences in baseline characteristics, including diabetes and amniotic fluid index. BW ≥4500 g was not accurately predicted. Among women with sonoEFW 4500-4749 g, only 28.9% delivered a neonate with a BW >4500 g; for women with a sonoEFW ≥4750 g, only 47.6% had a BW >4500 g. One hundred sixty-one (32.1%) women underwent CD for suspected macrosomia. Of these CDs, 48 (29.8%) of neonates had a BW <4000 g and 134 (83.2%) had a BW <4500 g.Conclusion: In patients undergoing sonoEFW within 2 weeks of delivery, sonoEFWs ≥4000 g are significantly more likely to overestimate than underestimate the true BW. Obstetricians should be cautious about intervening based on sonoEFW alone, given the high risk that this value is an overestimation of the true weight.

Induction of Labor versus Cesarean Delivery in Twin Pregnancies.

OBJECTIVE: This study was aimed to compare maternal and neonatal outcomes between women with twin pregnancies who underwent induction of labor with those women who had planned Cesarean delivery (CD). STUDY DESIGN: This is a retrospective cohort study of women with twin pregnancies ≥ 24 weeks with an indication for delivery but not in labor. Two groups were examined, women who underwent induction and women who underwent planned CD. Maternal and neonatal outcomes were compared between groups both for deliveries at gestational age ≥ 37 weeks and < 37 weeks. RESULTS: A total of 453 patients were included. Overall, 212 (46.8%) women underwent induction and 241 (53.2%) underwent planned CD. Women who underwent induction of labor had a high rate of VD, both in the term and preterm groups (69.8 and 73.6%, respectively). Women who underwent induction of labor had reduced maternal length of stay, neonatal length of stay, and blood loss, without any increase in adverse outcomes. Neonatal ventilation of either twin delivered < 37 weeks was higher in the CD compared with induction group (27.5 vs. 9.4%, p < 0.01), but this was not significant on adjusted odds ratio analysis (aOR = 0.71, 95% CI: 0.19-2.66). CONCLUSION: Labor induction in twin gestations have improved maternal outcomes and similar neonatal outcomes compared with planned CD.

Frequency of spontaneous resolution of vasa previa with advancing gestational age.

BACKGROUND: Vasa previa is a serious obstetric complication that can result in fetal hemorrhage and death on spontaneous labor. Suggested management for vasa previa is elective hospitalization and cesarean delivery before spontaneous labor. There is little reported evidence of the rate of vasa previa resolution over the course of gestation. Identification of the resolution rate and of factors predictive of resolution potentially could improve clinical management and patient counseling. OBJECTIVE: The purpose of this study was to identify the resolution rate of vasa previa across gestation and to determine clinical and sonographic factors that are associated with vasa previa resolution. STUDY DESIGN: We conducted a retrospective cohort study of all women who were diagnosed with vasa previa in a single ultrasound unit between 2005 and 2018. Vasa previa was defined as a fetal vessel within 2 cm of the internal cervical os on transvaginal sonography. The primary outcome was vasa previa resolution, defined as migration of the vasa previa to >2 cm away from the internal os. RESULTS: One hundred women with vasa previa that had been diagnosed at a mean gestational age of 22.8±4.9 weeks were included. Thirty-nine women (39.0%; 95% confidence interval, 30-49%) had resolution of vasa previa at a mean gestational age of 28.6-4.7 weeks. Factors that were associated with vasa previa resolution were an earlier gestational age at diagnosis (adjusted odds ratio, 6.10; 95% confidence interval,1.92-19.40), vasa previa did not cover the internal os at diagnosis (adjusted odds ratio, 8.29; 95% confidence interval, 2.79-24.62), and vasa previa was not the result of a resolved placenta previa (adjusted odds ratio, 2.85; 95% confidence interval, 1.01--8.03). One woman with a dichorionic twin pregnancy and vasa previa resolution (at 31 weeks gestation; fetal vessels located 2.8 cm from the internal os) presented at 33 weeks with massive bleeding and fetal death of twin A. It was unclear whether the death was related to vasa previa or placental abruption. CONCLUSION: Thirty-nine percent of vasa previas in our population resolved over the course of pregnancy. Earlier gestational age at diagnosis, vasa previa not covering the internal os, and not having a resolved placenta previa all are associated independently with an increased likelihood of vasa previa resolution. Women with vasa previa should be observed serially to assess for vasa previa resolution, because many will resolve in the third trimester.

Amniocentesis compared with antenatal corticosteroids prior to early term scheduled cesarean delivery.

Objective: There are a variety of maternal or fetal conditions that require late preterm or early term delivery. In cases where early delivery is indicated, optimal management is not always clear. Historically, obstetricians used amniocentesis to document fetal lung maturity, but recently, many have transitioned to administration of antenatal corticosteroids (ACS). The objective of this study was to compare neonatal outcomes between women undergoing amniocentesis or receiving ACS prior to scheduled cesarean delivery (CD) less than 39 weeks. Methods: This was a retrospective cohort study of women undergoing scheduled CD by one maternal-fetal medicine practice between 36 and 38 6/7 weeks, from 2005 to 2017. We identified women who underwent amniocentesis or received ACS within 2 weeks prior to delivery. Neonatal outcomes were compared between the two groups, with the primary outcome being neonatal intensive care unit (NICU) admission. Results: A total of 502 women were included, of whom 313 (62.4%) underwent amniocentesis and 189 (37.6%) received ACS. Overall, 55 (11.0%) of neonates were admitted to the NICU. NICU admission was not significantly different between groups (11.8 versus 9.5%, p=.46). This held true after adjusting for gestational age and other differences in baseline characteristics. There were no significant differences between groups for all other neonatal outcomes, including NICU admission for respiratory indications, respiratory support, neonatal greater than maternal length of stay, low Apgar scores, and neonatal death. Rates of hypoglycemia were low and not significantly different between groups (2.2% in the amniocentesis group versus 0.5% in the ACS group, p=.27). Diabetes was the only covariate significantly associated with NICU admission (aOR 3.19, 95% CI 1.35, 7.54). Conclusions: In women undergoing scheduled CD between 36 and 38 6/7 weeks, administration of ACS is associated with similar neonatal outcomes compared to amniocentesis. This supports the current notion that outcomes are similar with ACS compared to amniocentesis for late preterm and early term deliveries. Brief rationale: The objective of this study was to compare neonatal outcomes between women undergoing amniocentesis or receiving antenatal corticosteroids (ACS) prior to scheduled cesarean delivery (CD) less than 39 weeks. We found that in women undergoing scheduled cesarean delivery between 36 and 38 6/7 weeks, administration of antenatal corticosteroids is associated with similar neonatal outcomes compared to amniocentesis.

Pregnancy outcomes in viable pregnancies with a septate uterus compared with viable pregnancies after hysteroscopic uterine septum resection.

BACKGROUND: Septate uterus is one of the more common Müllerian anomalies and is the anomaly most amenable to surgical correction. It is currently uncertain if hysteroscopic septum resection reduces the incidence of adverse pregnancy outcomes. OBJECTIVE: The purpose of this study was to compare pregnancy outcomes in women who had reached at least 20 weeks gestation with those women with a uterine septum and those women who had undergone septum resection before pregnancy. STUDY DESIGN: Retrospective cohort study of women with a history of uterine septum who were cared for by a large maternal-fetal medicine practice from 2005-2018. We included women with singleton pregnancies at >20 weeks gestation. Baseline characteristics and pregnancy outcomes were compared between women with a history of a hysteroscopic uterine septum resection and women with an unresected septum. Regression analysis was performed to control for differences in baseline characteristics. The analysis was repeated in nulliparous women only. RESULTS: A total of 109 women (163 pregnancies) were included. In the entire population, pregnancy outcomes did not differ between the groups, aside from a higher rate of cesarean delivery in the resected septum group. In the 63 nulliparous women, septum resection was associated with later gestational ages at delivery (39.1 vs 37 weeks; P=.030), decreased preterm birth <37 weeks gestation (4.5% vs 31.6%; adjusted odds ratio, 0.154; 95% confidence interval, 0.027-0.877), and an increased incidence of cesarean delivery in women who attempted vaginal delivery (30.6% vs 0%; P=.012). There was no difference in the rates of small for gestational age, preeclampsia, blood transfusion, retained placenta, or morbidly adherent placenta. CONCLUSION: In nulliparous women with viable pregnancies, hysteroscopic resection of a uterine septum is associated with a decreased incidence of preterm birth and an increased incidence of cesarean delivery. These findings need to be confirmed in a well-designed randomized trial before uterine septum resection is recommended routinely.

Are Women with a History of Low PAPP-A at Risk for Adverse Perinatal Outcomes in a Subsequent Pregnancy?

OBJECTIVE: To determine if patients with a history of low pregnancy-associated plasma protein A (PAPP-A) in an initial pregnancy are at higher risk for adverse obstetric outcomes in a subsequent pregnancy. STUDY DESIGN: This was a retrospective cohort study in patients who underwent first trimester screening for PAPP-A in two consecutive pregnancies. Two groups were examined: patients who had low PAPP-A in the first pregnancy followed by normal PAPP-A in the second pregnancy and patients who had recurrent low PAPP-A. Maternal and neonatal outcomes were compared between the groups, with the primary outcome being intrauterine growth restriction (IUGR) or preeclampsia. RESULTS: A total of 124 patients were included, representing 248 pregnancies. Ninety-two (74.2%) patients had normal PAPP-A in the second pregnancy, and 32 (12.9%) patients had recurrent low PAPP-A. Patients with recurrent low PAPP-A had a higher rate of IUGR or preeclampsia compared with patients with normal PAPP-A in the second pregnancy but this was not significantly different (12.5 vs. 10.9%, p = 0.51). There were no significant differences for all other outcomes. CONCLUSION: Among patients with a history of low PAPP-A, patients with normal PAPP-A in the subsequent pregnancy have a similar risk of adverse neonatal outcomes compared with patients with recurrent low PAPP-A.

The Association between Intended Mode of Delivery and Maternal Morbidity in Twin Pregnancies.

OBJECTIVE: To compare maternal morbidity between women undergoing delivery of twins who intend to labor with those women who do not intend to labor. STUDY DESIGN: This was a retrospective cohort study of women undergoing delivery of twins in a single maternal-fetal medicine practice between January 2005 and February 2018. We identified women with a twin delivery at gestational age ≥24 weeks and determined if they intended or did not intend to labor. Maternal outcomes were compared between the groups. RESULTS: A total of 788 patients were included, of whom 404 (51.3%) intended to labor and 384 (48.7%) did not intend to labor. Women who intended to labor had a high rate of vaginal delivery (VD; 79.7%). Overall, 45 (5.7%) women required blood transfusion; this was not significantly different between the groups (6.2 vs. 5.2%, p = 0.54). Women who intended to labor had a shorter hospital stay and lower blood loss. There were no significant differences for all other maternal outcomes. CONCLUSION: In patients undergoing twin delivery, women who intend to labor have similar maternal morbidity compared with women who do not intend to labor. This supports current guidelines recommending providers offer a trial of VD for twin pregnancies.

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.