Identifying ChatGPT-written Patient Education Materials Using Text Analysis and Readability.

OBJECTIVE: Artificial intelligence (AI)-based text generators such as Chat Generative Pre-Trained Transformer (ChatGPT) have come into the forefront of modern medicine. Given the similarity between AI-generated and human-composed text, tools need to be developed to quickly differentiate the two. Previous work has shown that simple grammatical analysis can reliably differentiate AI-generated text from human-written text. STUDY DESIGN: In this study, ChatGPT was used to generate 25 articles related to obstetric topics similar to those made by the American College of Obstetrics and Gynecology (ACOG). All articles were geared towards patient education. These AI-generated articles were then analyzed for their readability and grammar using validated scoring systems and compared to real articles from ACOG. RESULTS: Characteristics of the 25 AI-generated articles included fewer overall characters than original articles (mean 3,066 vs. 7,426; p < 0.0001), a greater average word length (mean 5.3 vs. 4.8; p < 0.0001), and a lower Flesch-Kincaid score (mean 46 vs. 59; p < 0.0001). With this knowledge, a new scoring system was develop to score articles based on their Flesch-Kincaid readability score, number of total characters, and average word length. This novel scoring system was tested on 17 new AI-generated articles related to obstetrics and 7 articles from ACOG, and was able to differentiate between AI-generated articles and human-written articles with a sensitivity of 94.1% and specificity of 100% (Area Under the Curve [AUC] 0.99). CONCLUSION: As ChatGPT is more widely integrated into medicine, it will be important for health care stakeholders to have tools to separate originally written documents from those generated by AI. While more robust analyses may be required to determine the authenticity of articles written by complex AI technology in the future, simple grammatical analysis can accurately characterize current AI-generated texts with a high degree of sensitivity and specificity. KEY POINTS: · More tools are needed to identify AI-generated text in obstetrics, for both doctors and patients.. · Grammatical analysis is quick and easily done.. · Grammatical analysis is a feasible and accurate way to identify AI-generated text..

A Low-Cost, High-Fidelity Simulator for Transabdominal Chorionic Villus Sampling.

INTRODUCTION: Chorionic villus sampling (CVS) remains essential for first-trimester genetic diagnosis, yet clinical volume may be insufficient to train new clinicians in the technique. Available simulation models are expensive, require animal parts or specialized resins, and cannot be stored for repeated use. METHODS: We present a model for trans-abdominal CVS (TA-CVS) which is constructed from readily available materials costing less than $10 and can be refrigerated and re-used to train maternal-fetal medicine fellows in CVS. RESULTS: All three attending physicians performing TA-CVS at our institution described the model as an accurate visual and tactile simulation, prompting its integration into our fellowship curriculum. To date, two senior fellows have achieved competency on the simulator and begun to perform clinical CVS under supervision, one of whom is an author on this paper. Both fellows and attendings indicated that the simulator provided a valuable tool for repeated practice prior to clinical CVS. Simulators are now maintained on the unit and have been re-used for 3 months and dozens of simulated procedures each without any apparent qualitative degradation in performance. DISCUSSION/CONCLUSION: We describe a low-cost easily constructed, durable, high-fidelity simulator for TA-CVS.

Delivery Mode among Patients with Oligohydramnios with or without Fetal Growth Restriction by Induction Method.

OBJECTIVE: This study aimed to evaluate the association of induction method on delivery mode in pregnancies complicated by oligohydramnios with and without fetal growth restriction (FGR). STUDY DESIGN: This was a secondary analysis of a National Institutes of Health funded retrospective cohort study of singleton deliveries at a tertiary-care hospital between 2002 and 2013 with diabetes, mild hypertension, and/or FGR. Chart abstraction was performed by trained research nurses. Patients with a diagnosis of fetal oligohydramnios with and without FGR were identified. Our analytic cohort was further stratified into three groups per initial induction agent: prostaglandins (PGEs) alone, PGE plus mechanical ripening, or oxytocin only. Primary outcome was mode of delivery. Secondary outcomes included indications for cesarean delivery and neonatal morbidity. RESULTS: Out of 4,929 patients in the original database, 546 subjects with fetal oligohydramnios were identified; of these, 270 were induced and included for analysis. Outcomes were compared between 171 patients who had fetuses with isolated oligohydramnios and 99 patients who had fetuses with oligohydramnios and FGR. There were no significant differences in demographic characteristics between the groups. Patients with fetuses with isolated oligohydramnios had similar rates of spontaneous vaginal delivery (SVD) when PGEs were used (n = 44/79, 55.7% PGE alone, n = 44/76, 57.9% PGE with mechanical ripening) and when they were not used (n = 5/13, 38.5% oxytocin alone; p = 0.43). Similarly, the majority of patients in both cohorts underwent SVD regardless of induction method (n = 30/44, 68.2% PGE alone, n = 30/44, 68.2% PGE with mechanical ripening, and n = 6/10, 60% oxytocin alone; p = 0.90). There was no significant difference in composite neonatal morbidity. CONCLUSION: In patients with fetuses with oligohydramnios with and without FGR, most patients delivered by SVD regardless of induction method. In this population, PGE use was associated with a high chance of SVD in patients with fetuses with suspected placental insufficiency regardless of the presence of absence of FGR. KEY POINTS: · The majority of fetuses with oligohydramnios with or without FGR deliver vaginally.. · The use of prostaglandins did not increase rates of cesarean for fetal distress in oligohydramnios.. · Prostaglandin use did not increase rate of neonatal intensive care unit admission among pregnancies with oligohydramnios..

Outcomes among Neonates after a Diagnosis of Persistent or Transient Fetal Growth Restriction Delivered at Term.

OBJECTIVE: This study aimed to evaluate whether transient fetal growth restriction (FGR) that resolves prior to delivery confers a similar risk of neonatal morbidity as uncomplicated FGR that persists at term. STUDY DESIGN: This is a secondary analysis of a medical record abstraction study of singleton live-born pregnancies delivered at a tertiary care center between 2002 and 2013. Patients with fetuses that had either persistent or transient FGR and delivered at 38 weeks or later were included. Patients with abnormal umbilical artery Doppler studies were excluded. Persistent FGR was defined as estimated fetal weight (EFW) <10th percentile by gestational age from diagnosis through delivery. Transient FGR was defined as EFW <10th percentile on at least one ultrasound, but not on the last ultrasound prior to delivery. The primary outcome was a composite of neonatal morbidity: neonatal intensive care unit admission, Apgar's score <7 at 5 minutes, neonatal resuscitation, arterial cord pH <7.1, respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, sepsis, or death. Baseline characteristics and obstetric and neonatal outcomes were compared using Wilcoxon's rank-sum and Fisher's exact test. Log binomial regression was used to adjust for confounders. RESULTS: Of 777 patients studied, 686 (88%) had persistent FGR and 91 (12%) had transient FGR. Patients with transient FGR were more likely to have a higher body mass index, gestational diabetes, diagnosed with FGR earlier in pregnancy, have spontaneous labor, and deliver at later gestational ages. There was no difference in the composite neonatal outcome (relative risk = 1.03, 95% confidence interval [CI] 0.72, 1.47) for transient versus persistent FGR after adjusting for confounders (adjusted relative risk = 0.79, 95% CI 0.54, 1.17). There were no differences in cesarean delivery or delivery complications between groups. CONCLUSION: Neonates born at term after transient FGR do not appear to have differences in composite morbidity compared with those where uncomplicated FGR persists at term. KEY POINTS: · No differences in neonatal outcomes in uncomplicated persistent versus transient FGR at term.. · Transient FGR pregnancies more likely to deliver at later gestational ages.. · No differences in mode of delivery or obstetric complications in persistent versus transient FGR at term..

Waterpipe Tobacco (Hookah) Use in Pregnancy: Associations with Nausea and Vomiting of Pregnancy.

OBJECTIVE: Waterpipe tobacco (WPT) use is common among reproductive age patients and is often perceived as safer than cigarette use. Prior studies have shown a decrease in nausea and vomiting symptoms among pregnant women who use cigarettes, but no studies to date have examined these symptoms in pregnant women who use WPT. This study was aimed to investigate the extent of symptoms of nausea/vomiting of pregnancy among participants who self-reported WPT use during pregnancy. STUDY DESIGN: Secondary analysis of a prospective cohort study examining WPT use during pregnancy. Participants completed the Pregnancy-Unique Quantification of Emesis (PUQE) during first and third trimesters. Medical conditions were determined by medical record review. Participants were evaluated by sole WPT use versus dual/polysubstance WPT use and frequency of WPT use. RESULTS: Ninety-nine (100%) participants completed the PUQE questionnaire during first trimester and 82 (82.8%) completed the PUQE during third trimester. Almost all (91.9%) participants reported moderate nausea/vomiting symptoms at both assessments. There was no difference in frequency of WPT use in pregnancy or rates of dual/polysubstance WPT use in participants with all levels of the PUQE questionnaire. There was also no difference in rates of WPT use or PUQE scores between sole WPT users and dual/polysubstance users. When comparing low and high WPT use, those who were in the higher frequency use group had higher waterpipe dependence scale scores (7.2 vs. 5.3, p < 0.02). With regard to maternal medical comorbidities, the only difference between groups was that sole WPT users were more likely to have a diagnosis of asthma than dual/polysubstance users (36.8 vs. 14.9%, p < 0.02). CONCLUSION: There were no differences in symptoms of nausea and vomiting of pregnancy or medical conditions in pregnant women who use WPT with any frequency during pregnancy. However, sole WPT users had higher rates of asthma than dual/polysubstance WPT users. KEY POINTS: · Waterpipe tobacco use is one of the most common forms of tobacco use among reproductive age patients.. · Waterpipe tobacco use was not associated with any changes in nausea/vomiting of pregnancy symptoms.. · Future research on the use of waterpipe tobacco in pregnancy can aid in public health responses..

Vaginal progesterone vs intramuscular 17-hydroxyprogesterone caproate for prevention of recurrent preterm birth: a randomized controlled trial.

BACKGROUND: Preterm birth is the leading cause of neonatal morbidity and mortality, and previous preterm birth is one of the strongest risk factors for preterm birth. National and international obstetrical societies have different recommendations regarding progesterone formulation for the prevention of recurrent preterm birth. OBJECTIVE: This study aimed to determine whether vaginal progesterone is superior to 17-hydroxyprogesterone caproate in the prevention of recurrent preterm birth in patients with singleton pregnancies who had a previous spontaneous preterm birth. STUDY DESIGN: This was an open-label multicenter pragmatic randomized controlled trial at 5 US centers of patients with singleton pregnancies at <24 weeks of gestation who had a previous spontaneous preterm birth randomized 1:1 to either 200 mg vaginal progesterone suppository nightly or 250 mg intramuscular 17-hydroxyprogesterone caproate weekly from 16 to 36 weeks of gestation. Based on the estimated recurrent preterm birth rate of 36% with 17-hydroxyprogesterone caproate, 95 participants were needed in each arm to detect a 50% reduction in preterm birth rate with vaginal progesterone, with 80% power and 2-sided alpha of 0.05. The primary outcome was preterm birth at <37 weeks of gestation. Prespecified secondary outcomes included preterm birth at <34 and <28 weeks of gestation, mean gestational age at delivery, neonatal morbidity and mortality, and measures of adherence. Analysis was by intention to treat. The chi-square test and Student t test were used as appropriate. P<.05 was considered significant. RESULTS: Overall, 205 participants were randomized; 94 participants in the vaginal progesterone group and 94 participants in 17-hydroxyprogesterone caproate group were included. Although gestational age at enrollment was similar, those assigned to vaginal progesterone initiated therapy earlier (16.9±1.4 vs 17.8±2.5 weeks; P=.001). Overall continuation of assigned formulation until delivery was similar (73% vs 69%; P=.61). There was no significant difference in preterm birth at <37 (31% vs 38%; P=.28; relative risk, 0.81 [95% confidence interval, 0.54-1.20]), <34 (9.6% vs 14.9%; P=.26; relative risk, 0.64 [95% confidence interval, 0.29-1.41]), or <28 (1.1% vs 4.3%; P=.37; relative risk, 0.25 [95% confidence interval, 0.03-2.20]) weeks of gestation. Participants in the vaginal progesterone group had a later mean gestational age at delivery than participants in the 17-hydroxyprogesterone caproate group (37.36±2.72 vs 36.34±4.10 weeks; mean difference, 1.02 [95% confidence interval, 0.01-2.01]; P=.047). CONCLUSION: Vaginal progesterone did not reduce the risk of recurrent preterm birth by 50% compared with 17-OHPC; however, vaginal progesterone may lead to increased latency to delivery. This trial was underpowered to detect a smaller, but still clinically significant, difference in the efficacy of preterm birth prevention. Patient factors that impact adherence and ability to obtain medication in a timely fashion should be included in counseling on progesterone selection.

A Novel Simulation Model for Resident Education in Mechanical Cervical Ripening.

INTRODUCTION: This study aims to evaluate resident satisfaction with a novel simulation model for learning transcervical balloon catheter placement for mechanical cervical ripening. STUDY DESIGN: A descriptive pretest and post-test survey study of Obstetrics and Gynecology (OBGYN) residents was conducted at a single academic medical center using a low-cost model. RESULTS: Of 28 residents, 14 (50%) were recruited. 100% of participants completed the pretest and post-test survey. Residents agreed that both learning and achieving correct placement of a transcervical balloon catheter are difficult. Pretest and post-test comparisons were statistically different with respect to comfort (2.8 ± 1.5 vs. 4.0 ± 1.0, p = 0.03) and ease of learning (3.1 ± 0.8 vs. 4.1 ± 0.6, p ≤ 0.001). DISCUSSION: We present a novel simulation model that can be used by OBGYN residents in training for learning transcervical balloon catheter placement for mechanical cervical ripening. KEY POINTS: · There is no current validated model for teaching placement of mechanical cervical ripening.. · This study outlines a novel and simple simulation model.. · This model is easily made, accessible, and of a low cost design..

The Association of Maternal Satisfaction with Childbirth by Length of Second Stage.

OBJECTIVE: The aim of this study was to quantify patient satisfaction by hour of second stage of labor and subsequent delivery mode. STUDY DESIGN: Pilot cross-sectional study of nulliparous women delivered at George Washington University Hospital between April 2018 and March 2019. Patients completed three survey questionnaires in the immediate postpartum period: Patient Perception Score (PPS), Consumer Satisfaction Questionnaire (CSQ), and Six Simple Questions (SSQ). Length of second stage was divided into 2 groups (≤3 hours and >3 hours). Data on maternal characteristics, maternal outcomes, and neonatal outcomes were collected in REDCap and statistical analysis was performed using SAS version 9.4. RESULTS: Survey response rate was 100% (n = 100). Seventy-one patients had a normal second stage and 29 patients had a prolonged second stage. Prolonged second stage was significantly associated with a lower proportion of NSVD (65.5 vs. 90.1%; p <0.01) and a higher proportion of epidural (82.8 vs. 60.6%; p = 0.03) in comparison to a normal second stage. Length of second stage had a statistically significant negative correlation with overall PPS scores (ρ = - 0.25, p ≤0.01). Length of second stage was not correlated with the SSQ (ρ = 0.05, p = 0.25) or CSQ (ρ = - 0.18, p = 0.11) surveys. CSQ scores were statistically significantly lower in women who underwent second stage cesarean delivery. CONCLUSION: Maternal satisfaction with childbirth and health care experience was high regardless of length of second stage. Only the PSS survey showed that shorter length of second stage was correlated with higher satisfaction. Cesarean delivery in the second stage was significantly associated with decreased maternal satisfaction. Future studies with larger cohorts are needed to confirm our findings. KEY POINTS: · There is limited data on maternal satisfaction with childbirth.. · Mode of delivery may affect maternal satisfaction.. · Shared decision-making about delivery mode and timing is crucial..

Feasibility of QSM in the human placenta.

PURPOSE: Quantitative susceptibility mapping (QSM) is an emerging tool for the precise characterization of human tissue, including regional oxygenation. A critical function of the human placenta is oxygen transfer to the developing fetus, which remains difficult to study in utero. The purpose of this study is to investigate the feasibility of performing QSM in the human placenta in utero. METHODS: In healthy pregnant women, 3D gradient echo data of the placenta were acquired with prospective respiratory gating at 1.5 Tesla and 3 Tesla. A brief period (6-7 min) of maternal hyperoxia was induced to increase placental oxygenation in a subset of women scanned at 3 Tesla, and data were acquired before and during oxygen administration. Susceptibility and T2∗ / R2∗ maps were reconstructed from gradient echo data, and mean and SD of these measures within the whole placenta were calculated. RESULTS: A total of 54 women were studied at a mean gestational age of 30.7 ± 4.2 (range: 24 5/7-38 4/7) weeks. Susceptibility and T2∗ maps demonstrated lobular contrast reflecting regional oxygenation difference at both field strengths. SD of susceptibilities, mean R2∗ , and SD of R2∗ of the placenta showed a linear relationship with gestational age (P < .01 for all). These measures were also responsive to maternal hyperoxia, and there was an increasing response with advancing gestational age (P < .01 for all). CONCLUSION: This study demonstrates the feasibility of performing placental QSM in pregnant women and supports the potential for placental QSM to provide noninvasive in vivo assessment of placental oxygenation.

Lysosomal storage disorders as an etiology of nonimmune hydrops fetalis: A systematic review.

We performed a systematic review of the literature to evaluate the incidence and types of lysosomal storage disorders (LSD) in case series of nonimmune hydrops fetalis (NIHF). PubMed, Ovid, and clinicaltrials.gov were reviewed for case series evaluating the workup of NIHF diagnosed in utero or in the neonatal period in human subjects from 1979 to August 2020. Retrospective case series with at least five cases of fetal and/or neonatal NIHF with its workup mentioned were identified. Idiopathic NIHF was defined as NIHF without an apparent cause after initial standard-of-care workup. In total, 22 case series with 2678 total cases of NIHF were identified. The overall incidence of LSD was 6.6% (177/2663) in NIHF cases that were tested for any LSD, and 8.2% (177/2151) in idiopathic NIHF cases. The most common LSD identified in cases of NIHF were mucopolysaccharidosis type VII, galactosialidosis, infantile sialic acid storage disease, Gaucher disease, GM1 gangliosidosis, and sialidosis. More than 40% of the most common LSD causes of NIHF have a potential postnatal treatment. LSD testing for NIHF allows for early diagnosis, better counseling and appropriate management, planning for possible early treatment, and counseling for recurrence risk.

Hemorrhage Risk Assessment on Admission: Utility for Prediction of Maternal Morbidity.

OBJECTIVE: Hemorrhage is a major cause of maternal morbidity and mortality prompting creation of innovative risk assessment tools to identify patients at highest risk. We aimed to investigate the association of hemorrhage risk assessment with maternal morbidity and to evaluate maternal outcomes after implementation of the risk assessment across hospital sites. STUDY DESIGN: We conducted a retrospective cohort analysis of a multicenter database including women admitted to labor and delivery from January 2015 to June 2018. The Association of Women's Health, Obstetric and Neonatal Nurses risk assessment tool was used to categorize patients as low, medium, or high risk for hemorrhage. Multivariate logistic regression was used to describe the association between hemorrhage risk score and markers of maternal morbidity and evaluate maternal outcomes before and after standardized implementations of the risk assessment tool. RESULTS: In this study, 14,861 women were categorized as low risk (26%), 26,080 (46%) moderate risk, and 15,730 (28%) high risk (N = 56,671 births). For women with high-risk scores, the relative risk (RR) ratio compared with low-risk women was 4.9 (RR: 95% confidence interval [CI]: 3.2-7.4) for blood transfusion and 5.2 (RR: 95% CI: 4.6-5.9) for estimated blood loss (EBL) ≥ 1,000 mL. For the second objective, 110,633 women were available for pre- and postimplementation analyses (39,027 and 71,606, respectively). A 20% reduction in rates of blood transfusion (0.5-0.4%, p = 0.02) and EBL ≥ 1,000 mL (6.3-5.9%, p = 0.014) was observed between pre- and postimplementations of the admission hemorrhage risk assessment tool. CONCLUSION: Women who were deemed high risk for hemorrhage using a hemorrhage risk assessment tool had five times higher risk for blood transfusion and EBL ≥ 1,000 mL compared with low-risk women. Given the low incidence of the outcomes explored, the hemorrhage risk assessment works moderately well to identify patients at risk for peripartum morbidity. KEY POINTS: · This study aimed to understand the utility of the AWOHNN hemorrhage risk assessment tool for predicting hemorrhage-related morbidity and to evaluate maternal outcomes before and after tool implementations.. · A high score using a hemorrhage risk assessment tool on admission is associated with five times higher risk for blood transfusion and/or estimated blood loss ≥ 1,000 mL, compared with a low score.. · Use of a hemorrhage risk assessment tool works moderately well to identify patients at highest risk for hemorrhage-related morbidity..

Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial.

BACKGROUND: Women with twin pregnancies and a dilated cervix in the second trimester are at increased risk of pregnancy loss and early preterm birth; there is currently no proven therapy to prevent preterm birth in this group of women. OBJECTIVE: This study aimed to determine whether physical examination-indicated cerclage reduces the incidence of preterm birth in women with a diagnosis of twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation. STUDY DESIGN: Multicenter, parallel group, open-label, randomized controlled trial of women with twin pregnancies and asymptomatic cervical dilation of 1 to 5 cm between 16 weeks 0/7 days of gestation and 23 weeks 6/7 days of gestation were enrolled from July 2015 to July 2019 in 8 centers. Eligible women were randomized in a 1:1 ratio into either cerclage or no cerclage groups. We excluded women with monochorionic-monoamniotic twin pregnancy, selective fetal growth restriction, twin-twin transfusion syndrome, major fetal malformation, known genetic anomaly, placenta previa, signs of labor, or clinical chorioamnionitis. The primary outcome was the incidence of preterm birth at <34 weeks of gestation. Secondary outcomes were preterm births at <32, <28, and <24 weeks of gestation, interval from diagnosis to delivery, and perinatal mortality. Data were analyzed by intention-to-treat methods. RESULTS: After an interim analysis was performed, the Data and Safety Monitoring Board recommended stopping the trial because of a significant decrease in perinatal mortality in the cerclage group. We randomized 34 women, with 4 women being excluded because of expired informed consent. A total of 17 women were randomized to physical examination-indicated cerclage and 13 women to no cerclage. Whereas 4 women randomized to cerclage did not receive the surgical procedure, no women in the no cerclage group received cerclage. Maternal demographics were not significantly different. All women in the cerclage group also received indomethacin and antibiotics. When comparing the cerclage group vs the no cerclage group, the incidence of preterm birth was significantly decreased as follows: preterm birth at <34 weeks of gestation, 12 of 17 women (70%) vs 13 of 13 women (100%) (risk ratio, 0.71; 95% confidence interval, 0.52-0.96); preterm birth at <32 weeks of gestation, 11 of 17 women (64.7%) vs 13 of 13 women (100%) (risk ratio, 0.65; 95% confidence interval, 0.46-0.92); preterm birth at <28 weeks of gestation, 7 of 17 women (41%) vs 11 of 13 women (84%) (risk ratio, 0.49; 95% confidence interval, 0.26-0.89); and preterm birth at <24 weeks of gestation, 5 of 17 women (30%) vs 11 of 13 women (84%) (risk ratio, 0.35; 95% confidence interval, 0.16-0.75). The mean gestational age at delivery was 29.05±1.7 vs 22.5±3.9 weeks (P<.01), respectively; the mean interval from diagnosis of cervical dilation to delivery was 8.3±5.8 vs 2.9±3.0 weeks (P=.02), respectively. Perinatal mortality was also significantly reduced in the cerclage group compared with the no cerclage group as follows: 6 of 34 women (17.6%) vs 20 of 26 women (77%) (risk ratio, 0.22; 95% confidence interval, 0.1-0.5), respectively. CONCLUSION: In women with twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation, a combination of physical examination-indicated cerclage, indomethacin, and antibiotics significantly decreased preterm birth at all evaluated gestational ages. Most importantly, cerclage in this population was associated with a 50% decrease in early preterm birth at <28 weeks of gestation and with a 78% decrease in perinatal mortality.

National trends in tranexamic acid use in the peripartum period, 2015-2019.

BACKGROUND: The purpose of this study was to measure trends in the use of tranexamic acid (TXA) during delivery in the United States and to evaluate demographic data and morbidity outcomes among these patients. METHODS: This retrospective cohort study includes data from 19 hospitals in the Universal Health Services network. We compared rates of TXA use between January 2015 and June 2019 across geographic sectors. We also evaluated associations of demographic variables and perinatal outcomes of women who received TXA. RESULTS: 209 cases of TXA use were found from analysis of 101,564 deliveries. TXA use increased over time and rates were higher in the West than in Central and East; the slope of increase over years did not differ between regions. Women who received TXA were more likely to have a history of postpartum hemorrhage (59 (28.2%) vs. 2290 (2.2%), P < 0.0001) but were not more likely to have a chronic disease, including diabetes mellitus, hypertension and heart disease. Women who received TXA were more likely to have estimated blood loss greater than or equal to 1000 mL (adjusted odds ratio (aOR) 15.3; 95% CI 11.1-21.1; P < 0.0001). Likelihood of venous thromboembolism was not significantly increased in TXA recipients (aOR 2.0; 95% CI 0.3-14.6; P = 0.49). CONCLUSION: Increasing national trends of TXA use in the peripartum period was observed, with variable increases by geographic region. Likelihood of venous thromboembolism was not significantly increased among women who received TXA. Increasing TXA use throughout the country suggests that updated hemorrhage guidelines from national obstetrical organizations can shape clinical practice.

Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines.

BACKGROUND: Guidelines for management of the second stage have been proposed since the 1800s and were created largely by expert opinion. Current retrospective data are mixed regarding differences in maternal and neonatal outcomes with a prolonged second stage. There are no randomized controlled trials that have evaluated whether extending the second stage of labor beyond current American College of Obstetricians and Gynecologists recommendations is beneficial. OBJECTIVE: The purpose of this study was to evaluate whether extending the length of labor in nulliparous women with prolonged second stage affects the incidence of cesarean delivery and maternal and neonatal outcomes. STUDY DESIGN: We conducted a randomized controlled trial of nulliparous women with singleton gestations at 36 0/7 to 41 6/7 weeks gestation who reached the American College of Obstetricians and Gynecologists definition of prolonged second stage of labor, which is 3 hours with epidural anesthesia or 2 hours without epidural anesthesia. Women were assigned randomly to extended labor for at least 1 additional hour, or to usual labor, which was defined as expedited delivery via cesarean or operative vaginal delivery. The exclusion criteria were intrauterine fetal death, planned cesarean delivery, age <18 years, and suspected major fetal anomaly. Primary outcome was incidence of cesarean delivery. Maternal and neonatal outcomes were compared secondarily. Statistical analysis was done by intention-to-treat. RESULTS: Seventy-eight nulliparous women were assigned randomly. All of the women had epidural anesthesia. Maternal demographics were not significantly different. The incidence of cesarean delivery was 19.5% (n = 8/41 deliveries) in the extended labor group and 43.2% (n = 16/37 deliveries) in the usual labor group (relative risk, 0.45; 95% confidence interval, 0.22-0.93). The number needed-to-treat to prevent 1 cesarean delivery was 4.2. There were no statistically significant differences in maternal or neonatal morbidity outcomes. CONCLUSION: Extending the length of labor in nulliparous women with singleton gestations, epidural anesthesia, and prolonged second stage decreased the incidence of cesarean delivery by slightly more than one-half, compared with usual guidelines. Maternal or neonatal morbidity were not statistically different between the groups; however, our study was underpowered to detect small, but potentially clinical important, differences.

How many procedures does it take? Success of a CVS training program for Maternal Fetal Medicine fellows.

OBJECTIVES: To quantify the learning curve for a training program for Maternal Fetal Medicine (MFM) fellows in obtaining successful transvaginal chorionic villus sampling (CVS) results in women with early pregnancy failure (EPF). METHODS: Retrospective observational cohort study of transvaginal CVS and subsequent manual vacuum aspiration (MVA) performed by MFM fellows. CVS samples were sent for karyotype, and products of conception (POC) were sent if CVS sample did not yield a result. Success was defined as karyotype result on CVS specimen. RESULTS: A total of 130 women with EPF up to 9 weeks of gestation underwent transvaginal CVS and MVA from December 2011 to April 2015. CVS samples were successful in 53 (40.8%) cases, POC were analyzed for karyotype in 68 (52.3%) cases, and maternal decidua was obtained in 9 (6.9%) cases. Nine MFM fellows performed the CVS and MVA procedures. The mean number of procedures per fellow was 14 (5-24). The average success rate of transvaginal CVS sample was 33.3% after the first procedure and 50% at the 14th procedure. One procedure was performed per patient. CONCLUSIONS: Success increased over time from 33.3% to 50.0%. Given the gestational age and failed pregnancy status, this is a reasonable success rate for CVS at time of EPF. © 2016 John Wiley & Sons, Ltd.

Trial of labor after myomectomy and uterine rupture: a systematic review.

INTRODUCTION: There is concern about the risk of uterine rupture in the subsequent pregnancy after myomectomy. This risk is reported in literature to be around 0.7-1%. The aim of this study was to evaluate the incidence of uterine rupture and associated risk factors in women who had a trial of labor after prior myomectomy. MATERIAL AND METHODS: A systematic review of the literature was performed including all cohort studies with at least five cases reporting outcomes of pregnancies after prior myomectomy. The terms "myomectomy", "pregnancy", "trial of labor" and "uterine rupture" were used in PubMed and EMBASE searches for identification purposes. Every reference was reviewed for possible inclusion and all eligible cases of uterine rupture were considered. RESULTS: Twenty-three studies with at least five cases of pregnancy after myomectomy were identified, with an overall incidence of uterine rupture of 0.6% (0.3-1.1%) (n = 11/1825). Of these 23 studies, 11 studies reported detailed data about trial of labor after myomectomy and related pregnancy outcomes, including 1034 pregnancies and 756 viable (≥24 weeks) deliveries. The overall incidence of uterine rupture after myomectomy in the included studies was 0.93% (0.45-1.92%) (n = 7/756); specifically, it was 0.47% (0.13-1.70%) (n = 2/426) in women undergoing trial of labor after myomectomy, and 1.52% (0.65-3.51%) (n = 5/330) in women before the onset of labor. Of the seven uterine ruptures, five (71%) occurred within 36 weeks (range 24-40 weeks). CONCLUSIONS: Trial of labor after myomectomy is associated with a 0.47% risk of uterine rupture. There were no identified risk factors among the variables studied. The present systematic review of the literature revealed that uterine rupture after prior myomectomy occurred mainly before 36 weeks and before labor.

Lysosomal storage disease as an etiology of nonimmune hydrops.

We performed a systematic review of the literature to evaluate the incidence and types of lysosomal storage disorders (LSDs) in case series of nonimmune hydrops (NIH). PubMed and Ovid were reviewed for case series evaluating the workup of NIH diagnosed in utero or in the neonatal period in human subjects. Search terms were as follows: nonimmune hydrops, non immune hydrops, metabolic genetic disorders, and lysosomal storage disorders. The time period searched was 1979 through January 2014. Retrospective case series with at least 5 cases of fetal and/or neonatal NIH with its workup mentioned were identified. Idiopathic NIH was defined as NIH without an apparent cause after an initial workup. Exclusion criteria included studies published in languages other than English and review articles. The 3 authors screened all abstracts and manuscripts independently. Metaanalysis of Observational Studies in Epidemiology guidelines were followed. Fifty-four case series with 678 total cases of NIH were identified. The overall incidence of LSD was 5.2% (35 of 678) in all NIH cases that tested for any LSD and 17.4% (35 of 201) in idiopathic NIH cases. The 3 most common LSDs identified in cases of NIH, in order of decreasing incidence, were Mucopolysaccharidosis type VII, Gaucher's disease, and GM1-gangliosidosis. LSDs occur in 5.2% of all NIH cases and in 17.4% of idiopathic NIH cases and so should be screened for in this clinical scenario. Additionally, if a comprehensive LSD workup is completed on idiopathic cases, 29.6% of those would be reclassified as LSD. LSD testing does not only allow diagnosis but also ensures better counseling, appropriate management, and planning for possible early intervention. Moreover, their detection may aid in a prenatal diagnosis in subsequent pregnancies.

Fetal neuroimaging applications for diagnosis and counseling of brain anomalies: Current practice and future diagnostic strategies.

Advances in fetal brain neuroimaging, especially fetal neurosonography and brain magnetic resonance imaging (MRI), allow safe and accurate anatomical assessments of fetal brain structures that serve as a foundation for prenatal diagnosis and counseling regarding fetal brain anomalies. Fetal neurosonography strategically assesses fetal brain anomalies suspected by screening ultrasound. Fetal brain MRI has unique technological features that overcome the anatomical limits of smaller fetal brain size and the unpredictable variable of intrauterine motion artifact. Recent studies of fetal brain MRI provide evidence of improved diagnostic and prognostic accuracy, beginning with prenatal diagnosis. Despite technological advances over the last several decades, the combined use of different qualitative structural biomarkers has limitations in providing an accurate prognosis. Quantitative analyses of fetal brain MRIs offer measurable imaging biomarkers that will more accurately associate with clinical outcomes. First-trimester ultrasound opens new opportunities for risk assessment and fetal brain anomaly diagnosis at the earliest time in pregnancy. This review includes a case vignette to illustrate how fetal brain MRI results interpreted by the fetal neurologist can improve diagnostic perspectives. The strength and limitations of conventional ultrasound and fetal brain MRI will be compared with recent research advances in quantitative methods to better correlate fetal neuroimaging biomarkers of neuropathology to predict functional childhood deficits. Discussion of these fetal sonogram and brain MRI advances will highlight the need for further interdisciplinary collaboration using complementary skills to continue improving clinical decision-making following precision medicine principles.

Psyche: The 5th 'P' and its Associated Impact on the Second Stage of Labor.

OBJECTIVE: Patients with depression during labor display dysregulated patterns of oxytocin release and this may impact second stage of labor. The objective of this study was to evaluate the association between maternal preconception and antenatal depressive disorders on the duration of second stage of labor and perinatal outcomes. STUDY DESIGN: Secondary analysis of patients enrolled in the Behavioral and Mood in Mothers, Behavior in Infants study who reached the second stage of labor. Participants were assigned to: pre-conception only major depressive disorder (MDD), prenatal major depressive disorder, and non-depressed controls. Primary outcome was prolonged second stage of labor. Secondary outcomes included perinatal morbidities. RESULTS: 172 patients were included. 24.4% (42/172) participants had preconception-only MDD, 42.4% (73/172) patients had prenatal MDD, and 33.1% (57/172) patients had as non-depressed controls. The adjusted pair-wise analysis between groups showed no significant difference in the duration of second stage. No statistically significant differences were noted between groups for adverse neonatal outcomes. CONCLUSION: Maternal depressive disorders did not impact length of second stage of labor or immediate perinatal outcomes.