Prior Term Birth Decreases the Risk of Preterm Birth in a Subsequent Twin Gestation.

OBJECTIVE: The aim of the study is to examine the association between the risk of preterm delivery among women with twin pregnancies and their obstetric history. STUDY DESIGN: We designed a retrospective cohort study of live twin births in 2008 in the United States that delivered after 240/7 weeks. Women were categorized into nulliparas, multiparas with prior term delivery, and multiparas with prior preterm delivery. The incidence of preterm birth was compared using Chi-square test and multivariable logistic regression models. RESULTS: A total of 32,895 nulliparous and 64,701 multiparous women with twin pregnancies were included in the study. Of the multiparous women, 2,505 (4%) had a history of a prior preterm delivery. Multiparous women with prior term birth were more likely to deliver at term (: 43%): in the index twin pregnancy than nulliparous women (40%) and multiparous women with a prior preterm birth (21%; p < 0.001). Compared with nulliparous women, prior term birth was protective against preterm delivery (adjusted odds ratio [aOR] = 0.67 [95% confidence interval: 0.60-0.74] for delivery <28 weeks and aOR = 0.79 [0.71-0.77] for delivery <34 weeks). CONCLUSION: Among multiparous women with twins, a prior term delivery appeared to be protective against preterm delivery compared with nulliparous women with twins. KEY POINTS: · Prior term birth is protective against preterm birth in subsequent twin pregnancy.. · A prior term birth confers an OR of 0.66 for delivery prior to 28 weeks in twin pregnancies.. · A prior preterm birth renders a twin pregnancy nearly twice as likely to deliver before 28 weeks..

Disparities in Trial of Labor among Women with Twin Gestations in the United States.

OBJECTIVE: The aim of the study is to examine clinical and demographic factors associated with trial of labor (TOL) among women with twin gestations eligible for a vaginal delivery. STUDY DESIGN: This was a population-based cohort study of women giving birth to twin gestations in the United States (2012-2014). Inclusion criteria for the analysis included live births greater than 23 weeks' gestation and a cephalic presenting twin. Women with prior cesarean delivery were excluded. Women were categorized by whether they underwent a TOL. Clinical and demographic characteristics associated with TOL status were evaluated using multivariable logistic regression analyses. Secondary analyses with stratification by parity and by second twin presentation were performed. RESULTS: Of 90,000 women eligible for inclusion, a minority (39.3%) underwent TOL. Women who had a greater gestational age at delivery were more likely to have a TOL. In contrast, several demographic factors were associated with decreased likelihood of TOL, including maternal age >35 years and identifying as Hispanic or Asian compared with non-Hispanic White. No differences in odds of TOL were observed for women who were identified as non-Hispanic Black versus non-Hispanic White, nor were other demographic factors such as marital status, insurance status, or educational attainment associated with undergoing TOL. Clinical factors associated with decreased odds of TOL included nulliparity, obesity, and hypertensive disorders of pregnancy. Results did not substantively change when stratified by parity or second twin presentation, nor did findings differ in the subgroup who delivered at 32 weeks of gestation or greater. CONCLUSION: In this large population of women with twins who were eligible for a TOL, a minority of individuals attempted a vaginal delivery. Demographic and clinical factors such as older maternal age, Asian or Hispanic racial or ethnic identification, nulliparity, and obesity are associated with decreased odds of undergoing TOL. KEY POINTS: · Understanding disparities in trial of labor among patients with twins is key to promoting equity.. · Older maternal age and identifying as Hispanic or Asian were associated with lower odds of TOL.. · Nulliparity, obesity, and hypertension were associated with decreased odds of TOL..

Perinatal Outcomes of Twin Gestations with and without Gestational Diabetes Mellitus.

OBJECTIVE: Existing data suggest that obstetric outcomes for individuals with twin gestations, who have gestational diabetes mellitus (GDM), may be comparable to those who do not have GDM, yet studies are limited by small sample sizes. The aim of this study was to examine differences in maternal and neonatal outcomes of individuals with twin gestations based on presence of GDM. METHODS: This was a population-based retrospective cohort study of individuals giving birth to twins in the United States between 2012 and 2014. Inclusion criteria were live births (≥24 weeks) and available information on GDM status; individuals with pregestational diabetes were excluded. Participants were categorized as either having had or not had GDM. Multivariable logistic regression was utilized to assess the independent association of GDM with adverse maternal outcomes, whereas generalized estimating equation models were used to estimate associations with neonatal outcomes to account for clustering. RESULTS: Of 173,196 individuals meeting inclusion criteria, 13,194 (7.6%) had GDM. Individuals with GDM were more likely to be older, identify as Hispanic or Asian race and ethnicity, married, college educated, privately insured, and obese than those without GDM. After adjusting for potential confounding variables, those with GDM were more likely to have hypertensive disorders (18.0 vs. 10.2%) and undergo cesarean delivery (51.2 vs. 47.3%). Neonates born to individuals with GDM were more likely to require mechanical ventilation for greater than 6 hours (6.5 vs. 5.6%) and experience neonatal intensive care unit (NICU) admission (41.1 vs. 36.2%), but were less likely to be low birth weight or have small for gestational age status (16.2 vs. 19.5%). Findings were confirmed in a sensitivity analysis of neonates born at 32 weeks of gestation or greater. CONCLUSION: Odds of poor obstetric and neonatal outcomes are increased for individuals with twin gestations complicated by GDM. KEY POINTS: · Individuals with GDM and twin gestation have higher odds of developing hypertensive disorders during pregnancy and of undergoing cesarean delivery.. · Neonates of such pregnancies are less likely to be low birth weight or small for gestational age.. · Neonates of pregnancies complicated by GDM and twin gestation are more likely to require mechanical ventilation and experience NICU admission..

Association between weighted adverse outcome score and race/ethnicity in women and neonates.

OBJECTIVE: To examine the association between the Weighted Adverse Outcome Score (WAOS) and race/ethnicity among a large and diverse population-based cohort of women and neonates in the United States. STUDY DESIGN: This was a retrospective cohort study of women who delivered in the United States between 2011 and 2013. We identified mother-infant pairs with adverse maternal and/or neonatal outcomes. These outcomes were assigned weighted scores to account for relative severity. The association between race/ethnicity and WAOS was examined using chi-square test and multivariable logistic regression. RESULTS: Compared to White women and their neonates, Black women and their neonates were at higher odds of an adverse outcome. CONCLUSION(S): The vast majority of women and neonates had no adverse outcome. However, Black women and their neonates were found to have a higher WAOS. This tool could be used to designate hospitals or regions with higher-than-expected adverse outcomes and target them for intervention.

Hospital-Level Variation in the Frequency of Cesarean Delivery Among Nulliparous Women Who Undergo Labor Induction.

OBJECTIVE: To evaluate the use of administrative data for identification of labor induction and to estimate the variation in cesarean delivery rates among low-risk women who underwent labor induction. METHODS: A cross-sectional study was performed examining live births in California hospitals during 2016 and 2017 using birth certificate data linked with maternal patient discharge records. Initially, eight hospitals performed medical record reviews by using reVITALize definitions on 46,916 deliveries to assess the validity of induction identification by birth certificate or discharge diagnosis records or both. Hospital-level variation in cesarean delivery rates was then assessed among all California hospitals for women with low-obstetric-risk first births before and after further risk adjustment and after the exclusion of potential medical and obstetric indications for induction. Variation in physician-level cesarean delivery rates after induction at four large hospitals also was examined. The relationships between cesarean delivery rates among women with induced labors compared with noninduced labors and with the hospital rate of induction also were explored. RESULTS: Identifying induction by a combination of discharge diagnosis codes and birth certificate data had the highest accuracy (92.9%, 95% CI 92.7-93.2). Among 917,225 births at 238 birthing hospitals, there were 99,441 nulliparous women with term, singleton, vertex pregnancies who were induced. The median cesarean delivery rate after labor induction for nulliparous women with term, singleton, vertex pregnancies was 32.2%, with a range of 18.5-84.6%. This wide variation was not reduced after risk adjustment or after exclusion of all women with induction indications. A similar wide variation was noted within geographic regions, neonatal intensive care levels, and among individual physicians in the same facility. Only very weak associations were found for the cesarean delivery rate after labor induction and either the rate after noninduced labor (R<0.08) or the rate of nulliparous labor induction (R<0.12). CONCLUSION: The large variation of cesarean delivery rates after induction of labor suggests that clinical management plays an important role in achieving induction success.

Monochorionic twins with selective fetal growth restriction: insight from placental whole-transcriptome analysis.

BACKGROUND: The underlying pathomechanism in placenta-related selective fetal growth restriction in monochorionic diamniotic twin pregnancy is not known. OBJECTIVE: This study aimed to investigate any differences in placental transcriptomic profile between the selectively growth-restricted twins and the normally grown cotwins in monochorionic diamniotic twin pregnancies. STUDY DESIGN: This was a prospective study of monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction. Placental biopsy specimens were obtained from the subjects in the delivery suite. The placental transcriptome of the selectively growth-restricted twin was compared with that of the normally grown cotwin. This study was divided into 2 stages: (1) gene discovery phase in which placental tissues from 5 monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction plus 2 control twin pregnancies underwent transcriptome profiling, and transcriptome profiling was carried out using whole-genome RNA sequencing; and (2) validation phase in which placental tissues from 13 monochorionic diamniotic twin pregnancies with selective fetal growth restriction underwent RNA and protein validation. RNA and protein expression levels of candidate genes were determined using quantitative real-time polymerase chain reaction and immunohistochemistry staining. RESULTS: A total of 1429 transcripts were differentially expressed in the placentae of selectively growth-restricted twin pairs, where 610 were up-regulated and 819 were down-regulated. Endoplasmic reticulum lectin and mannose 6-phosphate receptor were consistently differentially up-regulated in all placentae of selectively growth-restricted twins. Quantitative real-time polymerase chain reaction and immunohistochemistry staining were used to validate the results (P<.05). CONCLUSION: The expression of endoplasmic reticulum lectin and mannose 6-phosphate receptor, which are important for angiogenesis and fetal growth, was significantly increased in the placentae of selectively growth-restricted twin of a monochorionic twin pair.

Placental microRNA dataset of monochorionic twin pregnancies with and without selective fetal growth restriction.

To compare the whole genomic microRNA (miRNA) between the selective fetal growth restriction (sFGR) twin and the normally growing (control) co-twin in monochorionic (MC) twin pregnancies. MC twin pregnancies with or without sFGR were recruited, and their placental miRNAs were profiled by microarray. The ratio of the placental miRNA of the sFGR twin to that of the normally larger co-twin were calculated and compared to that of the control twin pairs. The miRNA microarray intensity amongst normal and sFGR large and small twins are shown. The expression data presented here will facilitate other researchers who are working on placental regulation and mechanism in pregnancy complicated by fetal growth restriction. The dataset supports the research article entitle "Whole genome miRNA profiling revealed miR-199a as potential placental pathogenesis of selective fetal growth restriction in monochorionic twin pregnancies" [1].

Whole genome miRNA profiling revealed miR-199a as potential placental pathogenesis of selective fetal growth restriction in monochorionic twin pregnancies.

INTRODUCTION: Placental-related mechanism of fetal growth restriction (FGR) is still unknown. Here we aimed to profile whole-genome miRNA between selective FGR twin (sFGR-T) and normally larger co-twin (sL-T) in monochorionic (MC) twin pregnancies and to further investigate effect of the miRNA on placental pathogenesis, including angiogenesis and mitochondrial functions. METHODS: MC twin pregnancies with or without sFGR were recruited, and their placental miRNAs were profiled (n = 3 vs 5). Ratio of placental miRNAs in the sFGR twin pairs (sFGR-T/sL-T) were calculated and compared to that in the control twin pairs (cS-T/cL-T). Differentially expressed miRNAs and associated markers were validated qRT-PCR, immunohistochemistry staining (n = 8 vs 13) and electron microscopy (n = 3 vs 3). RESULTS: Placental miR-199a-5p was significantly upregulated in sFGR-T (p = 0.004), which was validated by qRT-PCR (1.03 vs 0.56; p = 0.020). Compared to control twin pairs, ratio of CD31-positive vessels and volume density of vessels in sFGR twin pairs was lower (0.65 vs 0.92 and 18.7% vs 36.3%; both p < 0.001), while that of cyclooxygenase 2 (COX2)-positive trophoblast cells was higher (3.50 vs 2.22; p = 0.001), indicating an impaired angiogenesis and oxidative stress in the sFGR placenta. In addition, ratio of mitochondrial DNA (mtDNA) mitochondrial encoded NADH dehydrogenase 1 (MTND1) copy numbers (2.10 vs 0.90; p = 0.013), H-score ratios of mitochondrial markers citrate synthase (CS) and cytochrome c oxidase subunit 4 isoform 1 (COX4, 0.53 vs 0.95, p < 0.001; 0.29 vs 1.06, p < 0.001) in trophoblast cells of sFGR twin pairs were also altered significantly and correlated with angiogenesis. Furthermore, ratio of mitochondrial numbers per trophoblasts (8.67 vs 18.67; p = 0.006) and percentage of swollen mitochondria (84.33 vs 11.33; p = 0.003) were converted significantly, indicating mitochondrial damage. DISCUSSION: Our results suggested miR-199a-5p may play a role in the placental angiogenesis, oxidative stress and mitochondrial damage and dysfunction as an underlying pathogenesis of sFGR.

Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial.

BACKGROUND: Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide. OBJECTIVE: To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death. RESULTS: Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024-2388] mL vs 1454 [888-2300] mL; P = .945), the median length of surgery (49 [30-62] min vs 37 [30-51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results. CONCLUSION: The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.

The predictive value of cervical shear wave elastography in the outcome of labor induction.

INTRODUCTION: Bishop score, the traditional method to assess cervical condition, is not a promising predictive tool of the outcome of labor induction. As an objective assessment tool, many cervical ultrasound measurements have been proposed to represent the individual components of the Bishop score, but none of them can measure the cervical stiffness. Cervical shear wave elastography is a novel tool to assess the cervical stiffness quantitatively. MATERIAL AND METHODS: A total of 475 women who required labor induction were studied prospectively. Prior to routine digital assessment of the Bishop score, transvaginal sonographic measurement of cervical length, posterior cervical angle, angle of progression and shear wave elastography was performed. Shear wave elastography measurement was made at the inner, middle and outer regions of the cervix to assess homogeneity. Association of labor induction outcomes including the overall cesarean section and subgroups of cesarean section for failure to enter active phase, with cervical sonographic parameters and the Bishop score, were assessed using multivariate regression analyses. The predictive accuracy of the outcomes using models based on ultrasound measurement and the Bishop score was compared using the area under the receiver-operating characteristics curves. RESULTS: Among 475 women, 82 (17.3%) required cesarean section. Shear wave elasticity was significantly higher in the inner cervical region than in other regions, indicating a greater stiffness (P < 0.001). Both inner cervical shear wave elasticity and cervical length were independent predictors of overall cesarean section (respective adjusted odds ratio [95% CI] 1.338 [1.001-1.598] and 1.717 [1.077-1.663]) and cesarean section for failure to enter active phase (respective adjusted odds ratio [95% CI] 1.689 [1.234-2.311] and 2.556 [1.462-4.467]), after adjusting for other covariates. Outcome prediction models using inner cervical shear wave elasticity and cervical length, had increased area under curve compared with models using the Bishop score (0.888 vs 0.819, P = 0.009). CONCLUSIONS: The cervix is not a homogenous structure, with the inner cervix having the highest stiffness, which is an independent predictor of overall cesarean section, and specifically for those indicated because of failure to enter active phase. Models based on shear wave elastography and cervical length had higher predictive accuracy than models based on the Bishop score.

Association of Widespread Adoption of the 39-Week Rule With Overall Mortality Due to Stillbirth and Infant Death.

Importance: To improve neonatal morbidity, efforts have been made to reduce elective deliveries prior to 39 weeks' gestation, also known as the 39-week rule. Prolonging pregnancies also prolongs exposure to the risk of stillbirth. The true association of a 39-week rule with mortality is unknown and studies to date have shown conflicting results. Objective: To determine if widespread adoption of a 39-week rule, limiting elective deliveries prior to 39 weeks' gestation, is associated with an increase or decrease in overall mortality when considering both stillbirths and infant deaths. Design, Setting, and Participants: This historical cohort study used birth certificate and infant death certificate data in the United States to compare years before and after the adoption of the 39-week rule. Births between 2008 and 2009 were considered to be in the preadoption period (n = 7 322 234), and those between 2011 and 2012 were considered to be in the postadoption period (n = 6 972 626). Included births were singleton, nonanomalous births between 37 0/7 weeks' and 42 6/7 weeks' gestation. Statistical analysis was performed from July 19, 2016, through June 27, 2019. Exposures: The exposure of interest was the Joint Commission adoption of the 39-week rule as a quality measure. Main Outcomes and Measures: The primary outcomes of interest were stillbirth and infant death. Results: A total of 7 322 234 births (49.0% girls and 51.0% boys) were included in the preadoption period and 6 972 626 births (49.1% girls and 50.9% boys) were included in the postadoption period. Compared with the preadoption period, there was a decrease in the proportion of deliveries at 37 weeks (-0.06%) and 38 weeks (-2.5%) and an increase in the proportion of deliveries at 39 weeks (6.8%) and 40 weeks (0.2%) in the postadoption period (P < .001). The stillbirth rate increased in the postadoption cohort compared with preadoption (0.09% vs 0.10%; P < .001). The infant death rate decreased in the postadoption period compared with preadoption (0.21% vs 0.20%; P < .001). An overall mortality rate of 0.31% was calculated for the preadoption period and 0.30% for the postadoption period (P = .06). Additional analysis in a counterfactual model suggests that up to 34.2% of the difference in mortality could be associated with the 39-week rule. Conclusions and Relevance: Stable overall perinatal mortality rates were observed in the 2-year period immediately after adoption of the 39-week rule, despite an increase in stillbirth.

Inter-manufacturer comparison of automated immunoassays for the measurement of soluble FMS-like tyrosine kinase-1 and placental growth factor.

OBJECTIVE: To assess inter-manufacturer automated immunoassays for soluble FMS-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF). METHODS: sFlt-1 and PlGF levels were measured using the AutoDelfia PlGF1-2-3 (PerkinElmer Inc. Turku, Finland), BRAHMS Kryptor sFlt-1, PlGF plus and PlGF-2 (BRAHMS ThermoFisher, Germany) and Cobas e411 Elecsys® sFlt-1 and PLGF (Roche Diagnostics GmbH, Mannheim, Germany) in 965 asymptomatic pregnancies between 20 and 39 weeks of gestation and in in-vitro samples with predefined levels of glycosylated PlGF isomers (1, 2 and 3), sFlt-1 in human male serum. Percentage PlGF isoform recovery and cross-reactivities were determined. Paired Bland-Altman and Passing-Bablok analyses were performed to determine bias, precision and accuracy. Inter-manufacturer sFlt-1:PlGF ratio were compared. RESULTS: PlGF-1 isomer recovery ranged from 36 to 39% for Elecsys® to 52-60% for PlGF plus and PlGF-1-2-3 assays. PlGF-2 and PlGF-3 isoform cross-reactivity was assay dependent, ranging from 10 to 21% and 16-36% respectively. BRAHMS PlGF-2 assay had high cross-reactivity to PlGF-1 (37-41%) and PlGF-3 isomers (48-65%). Elecsys® recovery of sFlt-1 was 13% vs 6% for BRAHMS. Passing-Bablok indicated significant proportional and systematic differences between all paired PlGF assay comparisons. PlGF Bland-Altman percentage biases ranged from 12 to 37% for PlGF and 18% for sFlt-1. A linear relationship existed between log transformed sFlt-1:PlGF ratios. The clinical equivalent of the BRAHMS sFlt-1:PlGF plus to the Elecsys® sFlt-1:PlGF ratios of 38 and 110 are 55 and 188 respectively. CONCLUSION: Inter-manufacture immunoassay differences are significantly different. sFlt-1:PlGF rule in/rule out criteria are manufacturer specific, not interchangeable and require separate clinical validation.

Health professionals' involvement and information provision in genetic counseling following prenatal diagnosis of sex chromosome aneuploidy in Hong Kong.

This study supports training in genetic counseling for obstetricians and adoption of a multidisciplinary approach in the counseling process following prenatal diagnosis of sex chromosome aneuploidy.

Body mass index at 11-13 weeks' gestation and pregnancy complications in a Southern Chinese population: a retrospective cohort study.

OBJECTIVE: To assess the association between body mass index (BMI) and adverse pregnancy outcomes. MATERIALS AND METHODS: A multicentre retrospective cohort study was conducted in three hospitals in Hong Kong including 67,248 women with singleton pregnancy at 11-13 weeks between 2010 and 2016. The relationship between maternal BMI and (1) miscarriage or stillbirth, (2) development of preeclampsia (PE), (3) gestational hypertension (GH), (4) development of gestational diabetes mellitus (GDM), (5) spontaneous preterm delivery (sPTD) <34 and <37 weeks, (6) delivery of a small for gestational age (SGA) or large for gestational age (LGA) neonate, (7) caesarean section (CS), and (8) postpartum haemorrhage (PPH) were examined after adjusting for confounding factors. RESULTS: The prevalence of maternal overweight (BMI 25-29.9 kg/m2) and obesity (BMI ≥30 kg/m2) were 13.2% and 2.9%, respectively. Women with a BMI ≥30 kg/m2 were nine times more likely to develop GH (95%CI 7.3-11.7), five times more likely to develop PE (95%CI 4.3-6.8) and GDM (95%CI 5.0-6.5) and 1.5-2 times more likely to deliver SGA/LGA neonate. sPTD, required delivery by CS and developed PPH, than those with a BMI of 18.5-22.9 kg/m2, and that maternal underweight (BMI <18.5 kg/m2) significantly reduced the risk of GDM, delivery by CS, and PPH. Increased risk of subsequent development of adverse outcomes was observed when BMI was ≥23.0 kg/m2. CONCLUSIONS: Maternal overweight and obesity are associated with an increased risk for subsequent development of various pregnancy complications. The need of increased awareness and health surveillance is essential when BMI ≥23 kg/m2.

Hypermucoviscosity, rmpA, and aerobactin are associated with community-acquired Klebsiella pneumoniae bacteremic isolates causing liver abscess in Singapore.

INTRODUCTION: This retrospective study investigated the clinical etiology of community-acquired bacteremic Klebsiella pneumoniae infections, and characterized laboratory and genetic markers which may be associated with primary liver abscess (PLA). METHODS: Community-onset K. pneumoniae bacteremic episodes from 2010 to 2011 were identified from the laboratory information system. Isolates were retrieved for susceptibility testing, hypermucoviscosity testing, PCR-based serotyping (K1, K2 and K5) and PCR detection of virulence genes (rmpA, alls, kfu and aerobactin). Clinical data collected from electronic medical records included primary and secondary diagnoses, co-existing morbidities, antibiotic therapy, and in-patient mortality. RESULTS: 129 bacteremic episodes were identified. The most common primary infections were pneumonia (n = 24, 18.6%), primary liver abscess (n = 21, 16.3%) and urinary tract infections (n = 21, 16.3%). Hypermucoviscosity was present in 55 isolates (42.6%). The most commonly detected virulence genes were aerobactin (n = 63, 48.8%) and rmpA (n = 59, 45.7%). Isolates causing liver abscess were significantly associated with a positive string test, rmpA, aerobactin gene, and capsular serotype K1 (all p < 0.01), but not with capsular serotype K2, K5, kfu, or allS genes. The absence of a positive string test, rmpA, or aerobactin genes had a 97.3%-100% negative predictive value for PLA. The positive predictive values of the string test, rmpA, aerobactin genes, and serotype K1 for PLA ranged from 31.7% to 35.6%. CONCLUSION: In our study population, pneumonia and PLA were the most common sources of community-acquired bacteremia. Hypermucoviscosity, rmpA, aerobactin, and serotype K1 could be useful laboratory markers to alert clinicians to arrange abdominal imaging to detect liver abscess.

Gestational Weight Gain during Pregnancy as an Important Factor Influencing a Successful Trial of Labor following Two Previous Cesareans.

OBJECTIVE: We sought to identify factors associated with a successful trial of labor (TOL) following two cesarean deliveries (CDs) in a contemporary North American cohort. STUDY DESIGN: This is a retrospective cohort study of term, nonanomalous, singleton, vertex pregnancies attempting a vaginal birth after cesarean (VBAC) following a history of two previous CDs in the United States from 2012 to 2014. Maternal and intrapartum factors were analyzed using chi-square tests and multivariable logistic regression. RESULTS: A total of 22,762 women met the inclusion criteria and underwent TOL. Of these, 12,192 (53.6%) had a VBAC. Using multivariate logistic regression, previous vaginal delivery and delivery at 40 to 41 weeks' gestation were associated with VBAC; maternal age, education, Medicaid insurance, non-Caucasian race/ethnicity, weight (overweight or obese), and gestational weight gain above the Institute of Medicine guidelines (adjusted odds ratio: 0.88; 95% confidence interval: 0.81-0.95) were associated with CD. Induction of labor did not affect the VBAC rate. CONCLUSION: For those desiring a TOL after two previous CDs, prospective studies are needed to assess interventions that limit gestational weight gain as well as the safety and optimal timing of an induction of labor. The decision to attempt a TOL should be guided by counseling regarding the risks, benefits, and chances of a successful TOL.

Objective assessment of the fetal facial profile at second and third trimester of pregnancy.

OBJECTIVE: To investigate the intraobserver and interobserver reproducibility of a novel sonographic parameter named facial maxillary angle (FMA) and to establish nomograms of FMA, inferior facial angle (IFA), frontal nasal-mental angle (FNMA), maxilla-nasion-mandible angle (MNMA), and fetal profile line (FPL) in Chinese fetuses. METHODS: In this prospective cross-sectional study, FMA, IFA, FNMA, MNMA, and FPL were measured in 592 normal fetuses between 16 and 36 gestational weeks. FMA was measured twice by the same and another operator with a blinded method on the first 50 cases. The reference interval was defined as ±2SD. The efficacy of five sonographic markers was tested in 10 fetuses with micrognathia retrieved from the database of our unit. RESULTS: The intraclass correlation coefficient (95% CI) of intraobserver and interobserver reproducibility of FMA was 0.937 (0.890-0.964) and 0.891 (0.809-0.938), respectively. FMA, FNMA, and IFA increased slightly from 16 weeks till 28-31 weeks and decreased minimally thereafter. FMA and FNMA made correct diagnosis in all affected fetuses; MNMA and IFA identified nine and eight cases respectively, and FPL only detected five cases. CONCLUSION: A fixed cutoff of 66° for FMA and 136° for FNMA may be adopted as simple screening criteria of micrognathia.