Evaluating Standard of Care and Obstetrical Outcomes in a Reduced Contact Prenatal Care Model in the COVID-19 Pandemic.

INTRODUCTION: We aimed to investigate the impact of reduced contact prenatal care necessitated by the COVID-19 pandemic on meeting standards of care and perinatal outcomes. METHODS: This was a retrospective case-control study of patients in low-risk obstetrics clinic at a tertiary care county facility serving solely publicly insured patients comparing reduced in-person prenatal care (R) over 12 weeks with a control group (C) receiving traditional prenatal care who delivered prior. RESULTS: Total 90 patients in reduced contact (R) cohort were matched with controls (C). There were similar rates of standard prenatal care metrics between groups. Gestational age (GA) of anatomy ultrasound was later in R (p = 0.017). Triage visits and missed appointments were similar, though total number of visits (in-person and telehealth) was higher in R (p = 0.043). R group had higher GA at delivery (p = 0.001). Composite neonatal morbidity and length of stay were lower in R (p = 0.017, p = 0.048). Maternal and neonatal outcomes did not otherwise differ between groups. Using Kotelchuck Adequacy of Prenatal Care Utilization index, R had higher rates of adequate prenatal care (45.6% R vs. 24.4% C, p = 0.005). DISCUSSION: Our study demonstrates the non-inferiority of a hybrid, reduced schedule prenatal schedule to traditional prenatal scheduling. In a reduced contact prenatal care model, more patients met criteria for adequate prenatal care, likely due to higher attendance of telehealth visits. These findings raise the question of revising the prenatal care model to mitigate disparities in disadvantaged populations.

Reproductive genetic carrier screening in pregnancy: improving health outcomes and expanding access.

Reproductive genetic carrier screening (RGCS) serves to screen couples for their risk of having children affected by monogenic conditions. The included conditions are mostly autosomal recessive or X-linked with infantile or early-childhood onset. Cystic fibrosis, spinal muscular atrophy, and hemoglobinopathies are now recommended by the American College of Obstetricians and Gynecologists (ACOG) for universal screening. Recommendations for further RGCS remain ethnicity based. The American College of Medical Genetics and Genomics and the National Society of Genetic Counselors in recent years have recommended universal expanded-panel RGCS and moving towards a more equitable approach. ACOG guidelines state that offering RGCS is an acceptable option, however it has not provided clear guidance on standard of care. Positive results on RGCS can significantly impact reproductive plans for couples, including pursuing in vitro fertilization with preimplantation genetic testing, prenatal genetic testing, specific fetal or neonatal treatment, or adoption. RGCS is a superior approach compared to ethnicity-based carrier screening and moves away from single race-based medical practice. We urge the obstetrics and gynecology societies to adopt the guidelines for RGCS put forward by multiple societies and help reduce systemic inequalities in medicine in our new genetic age. Having national societies such as ACOG and the Society for Maternal-Fetal Medicine officially recommend and endorse RGCS would bolster insurance coverage and financial support by employers for RGCS. The future of comprehensive reproductive care in the age of genomic medicine entails expanding access so patients and families can make the reproductive options that best fit their needs.

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis.

OBJECTIVE: Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. STUDY DESIGN: We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). RESULTS: In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. CONCLUSION: Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. KEY POINTS: · Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..

Pregnancy and Pulmonary Hypertension: From Preconception and Risk Stratification Through Pregnancy and Postpartum.

Pulmonary hypertension is one of the highest risk medical conditions in pregnancy and carries significant maternal morbidity and mortality as well as neonatal morbidity. Diagnosis is commonly delayed due to the nonspecific nature of early symptoms. Disease progression can lead to right ventricular failure, which carries mortality rates as high as 25% to 56%. Pregnancy-related complications arise from cardiac inability to accommodate increased plasma volume and cardiac output, decreased systemic vascular resistance, and hypercoagulability. Patients in this high-risk cohort necessitate preconception risk stratification and multidisciplinary care throughout their pregnancy and delivery planning.

Rates of Cesarean Conversion and Associated Predictors and Outcomes in Planned Vaginal Twin Deliveries.

OBJECTIVE: Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to investigate the rates of conversion to CD for planned twin VDs and identify predictors and outcomes of conversion. STUDY DESIGN: A retrospective cohort study of all women who underwent a planned twin VD at two large academic medical centers over 4 years. Demographic and outcome data were chart abstracted. Various statistical tests were used to evaluate the influence of perinatal variables on mode of delivery and identify possible predictors of conversion. RESULTS: Eight hundred and eighty-five twin deliveries were identified, of which 725 (81.9%) were possible candidates for VD. Of those, 237 (32.7%) underwent successful VD of twin A. Ninety-five (40.1%) had a nonvertex second twin at time of delivery. Conversion to CD occurred in 10 planned VDs (4.2%). Conversions were higher with spontaneous labor (relative risk [RR]: 2.1; 95% confidence interval [CI] 1.6-2.7; p = 0.003), and having an intertwin delivery interval greater than 60 minutes (RR: 5.1; 95% CI: 2.5-10.8; p < 0.001). Nonvertex presentation of twin B, type of delivery provider, or years out in practice of delivery provider were not significantly different between groups. There were no significant differences in neonatal outcomes between VD and conversion groups. There was a significant association between use of forceps for twin B and successful VD (p = 0.02), with 84.6% in the setting of a nonvertex twin B. CONCLUSION: Successful VD was achieved in planned VD of twins in 95.8% of cases, and there were no significant differences in maternal and fetal outcomes between successful VD and conversion to CD for twin B. With the optimal clinical scenario and shared decision-making, performing vaginal twin deliveries in labor and delivery rooms should be discussed. KEY POINTS: · There is a propensity to perform twin vaginal deliveries in the operating room.. · Rates of conversion to cesarean section are very low.. · There are no significant differences in perinatal outcomes with conversion..

Ultrasound for the Pregnant Person With Diabesity.

Diabetes and obesity increase the risk of congenital anomalies, but the putative mechanisms of this increased risk are not fully elucidated. In this chapter, we delve into sonographic characteristics associated with diabetes and obesity, including fetal structural anomalies, functional cardiac alterations, and growth abnormalities. We will also discuss the technical challenges of imaging in the patient with diabesity and propose methodologies for optimizing imaging. Lastly, we will address the prevention of workplace-associated musculoskeletal disorders injury for sonographers.

Impact of Gestational Weight Gain on Trial of Labor after Cesarean Success.

OBJECTIVE: Excessive gestational weight gain (GWG) has been associated with adverse pregnancy outcomes, including increased risk of cesarean delivery (CD). Data are limited on associations between GWG and outcomes in women undergoing trial of labor after cesarean (TOLAC). We aimed to investigate whether appropriate GWG impacts TOLAC outcomes. STUDY DESIGN: We performed a retrospective cohort study of women undergoing TOLAC at a single institution from May 2007 to April 2016. Women were divided into three groups based on GWG as compared with the Institute of Medicine recommendations. The primary outcome was successful vaginal birth after cesarean (VBAC). Secondary outcomes included various perinatal morbidity markers. RESULTS: A total of 614 women underwent TOLAC, of whom 444 (72.3%) had successful VBACs. When grouped by GWG in accordance with the Institute of Medicine guidelines, 149 (24.3%) women had GWG below guidelines, 224 (36.5%) met guidelines, and 241(39.3%) exceeded guidelines. There was no difference in the rate of VBAC success among the three groups. We also found no differences in secondary perinatal morbidity markers. CONCLUSION: We found no difference in TOLAC success rates with excess GWG. Providers should not consider excess GWG a risk factor for failed TOLAC, even in obese patients.

Birth plans-Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study.

OBJECTIVE: To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction. METHODS: This was a prospective cohort study of singleton pregnancies greater than 34 weeks' gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi-squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables. RESULTS: Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61-2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan. CONCLUSION: Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth-related patient satisfaction.

Influence of graft source and configuration on revision rate and patient-reported outcomes after MPFL reconstruction: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to determine the influence of graft source (allograft vs. autograft) and configuration (single-limbed vs. double-limbed) on failure rate and disease-specific patient-reported outcome (Kujala score) after medial patellofemoral ligament (MPFL) reconstruction for patellar instability. METHODS: A systematic review of PubMed, Scopus, and the Cochrane Library was performed. A total of 31 studies met inclusion/exclusion criteria and were used to extract cohorts of patients who underwent ligament reconstruction with various allograft, autograft, single-limbed, and double-limbed constructs. Failure rates and postoperative improvements in Kujala scores were compared between cohorts using inverse-variance weighting in a random-effects analysis model and appropriate comparative statistical analyses (Chi-squared and independent samples t tests). RESULTS: A total of 1065 MPFL reconstructions were identified in 31 studies. Autograft reconstructions were associated with greater postoperative improvements in Kujala scores when compared to allograft (32.2 vs. 22.5, p < 0.001), but there was no difference in recurrent instability (5.7 vs. 6.7 %, p = 0.74). Double-limbed reconstructions were associated with both improved postoperative Kujala scores (37.8 vs. 31.6, p < 0.001) and lower failure rate (10.6 vs. 5.5 %, p = 0.030). CONCLUSION: MPFL reconstructions should be performed using double-limbed graft configurations. While autograft tendon may be associated with higher patient-reported outcomes in the absence of associated connective tissue disorders or ligamentous laxity, patient factors and allograft processing techniques should be carefully considered when selecting an MPFL graft source, as revision rates were no different between graft sources. LEVEL OF EVIDENCE: IV.

Birth Plans: What Matters for Birth Experience Satisfaction.

BACKGROUND: To categorize individual birth plan requests and determine if number of requests and request fulfillment is associated with birth experience satisfaction. METHODS: This is a sub-analysis of a prospective cohort study of 302 women with singleton pregnancies with and without birth plans. Women with a hard copy of their birth plans who completed a postdelivery satisfaction survey were included in this study. We described the number and type of birth plan requests and associated the number of requests and request fulfillment with overall satisfaction, expectations met, and sense of control. Differences between groups were analyzed using chi-square, Spearman rank correlation, and logistic regression. RESULTS: One hundred and nine women presented to Labor and Delivery with a hard copy of their prewritten birth plan. We identified 23 unique requests. The most common requests were no intravenous analgesia (82%) and exclusive breastfeeding (74%). The requests most fulfilled were avoidance of episiotomy (100%) and no operative vaginal delivery (89%). Having a higher number of requests fulfilled correlated with greater overall satisfaction (p = 0.03), higher chance of expectations being met (p < 0.01), and feeling more in control (p < 0.01). Having a high number of requests was associated with an 80 percent reduction in overall satisfaction with the birth experience (p < 0.01). CONCLUSIONS: Having a higher number of requests fulfilled was positively associated with birth experience satisfaction, while having a high number of requests was inversely associated with birth experience satisfaction. Further research is needed to understand how to improve birth plan-related birth experience satisfaction.

Primary achalasia diagnosed during pregnancy: rare cause of nausea and vomiting.

Nausea and vomiting during pregnancy are very common; however, when persistent symptoms lead to severe malnutrition, other conditions should be considered. We present a patient with severe postprandial nausea and vomiting resulting in 120 lb weight loss. She was treated for presumed hyperemesis gravidarum but diagnosed with achalasia type 1 upon further work-up. The pregnancy was further complicated by fetal growth restriction, shortened cervix and preterm premature rupture of membranes, and resulted in delivery at 26 weeks of gestation. Postpartum, she underwent a peroral endoscopic myotomy procedure and has returned to normal body mass index.The differential for nausea/vomiting is broad, and major medical conditions can manifest for the first time during pregnancy. Severe malnutrition adversely affects maternal and fetal health. Further work-up should be pursued when symptoms cannot otherwise be explained.

Smartwatch detection of new-onset monomorphic ventricular tachycardia in pregnancy.

Smartwatches provide health tracking in various ways and there has been a recent rise in reporting cardiac arrhythmias. While original studies focused on atrial fibrillation, fewer reports have been made on other arrhythmias especially in pregnancy. We report a pregnant patient who presented at 34 weeks' gestation with palpitations. An ECG recorded through her Apple Watch showed ventricular tachycardia. Hospital ECG confirmed monomorphic ventricular tachycardia likely caused by increased sympathetic tone from the gravid state. She was admitted to the cardiac intensive care unit for close monitoring with intravenous anti-arrhythmic agents; however, the rhythm persisted. She underwent a caesarean delivery and the arrhythmia resolved post partum. She later underwent a catheter ablation, after which she discontinued all anti-arrhythmic medications with no recurrence. This case highlights the importance of requesting relevant digital health information, if available, from patients in our modern era. Controlled clinical studies are needed to validate such practices.

Group B Streptococcus in Pregnancy.

To decrease risk of early-onset neonatal sepsis from group B streptococcus (GBS), pregnant patients should undergo screening between 36 0/7 and 37 6/7 weeks' gestation. Patients with a positive vaginal-rectal culture, GBS bacteriuria , or history of newborn with GBS disease should receive intrapartum antibiotic prophylaxis (IAP) with an agent targeting GBS. If GBS status is unknown at time of labor, IAP should be administered in cases of preterm birth, rupture of membranes for >18 hours, or intrapartum fever. The antibiotic of choice is intravenous penicillin; alternatives should be considered in cases of penicillin allergy depending on allergy severity.

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension.

OBJECTIVE: To evaluate the effect of a postpartum hypertension standardized clinical assessment and management plan on postpartum readmissions and emergency department (ED) visits. METHODS: We conducted a prospective cohort study of patients with postpartum hypertension (either chronic hypertension or hypertensive disorders of pregnancy) who delivered at a single tertiary care center for 6 months after enacting an institution-wide standardized clinical assessment and management plan (postintervention group). Patients in the postintervention group were compared with patients in a historical control group. The standardized clinical assessment and management plan included 1) initiation or uptitration of medication for any blood pressure (BP) higher than 150/100 mm Hg or any two BPs higher than 140/90 mm Hg within a 24-hour period, with the goal of achieving normotension (BP lower than 140/90 mm Hg) in the 12 hours before discharge; and 2) enrollment in a remote BP monitoring system on discharge. The primary outcome was postpartum readmission or ED visit for hypertension. Multivariable logistic regression was used to evaluate the association between standardized clinical assessment and management plan and the selected outcomes. A sensitivity analysis was performed with propensity score weighting. A planned subanalysis in the postintervention cohort identified risk factors associated with requiring antihypertensive uptitration after discharge. For all analyses, the level of statistical significance was set at P <.05. RESULTS: Overall, 390 patients in the postintervention cohort were compared with 390 patients in a historical control group. Baseline demographics were similar between groups with the exception of lower prevalence of chronic hypertension in the postintervention cohort (23.1% vs 32.1%, P =.005). The primary outcome occurred in 2.8% of patients in the postintervention group and in 11.0% of patients in the historical control group (adjusted odds ratio [aOR] 0.24, 95% CI 0.12-0.49, P <.001). A matched propensity score analysis controlling for chronic hypertension similarly demonstrated a significant reduction in the incidence of the primary outcome. Of the 255 patients (65.4%) who were compliant with outpatient remote BP monitoring, 53 (20.8%) had medication adjustments made per protocol at a median of 6 days (interquartile range 5-8 days) from delivery. Non-Hispanic Black race (aOR 3.42, 95% CI 1.68-6.97), chronic hypertension (aOR 2.09, 95% CI 1.13-3.89), having private insurance (aOR 3.04, 95% CI 1.06-8.72), and discharge on antihypertensive medications (aOR 2.39, 95% CI 1.33-4.30) were associated with requiring outpatient adjustments. CONCLUSION: A standardized clinical assessment and management plan significantly reduced postpartum readmissions and ED visits for patients with hypertension. Close outpatient follow-up to ensure appropriate medication titration after discharge may be especially important in groups at high risk for readmission.

Can prenatal ultrasound predict adverse neonatal outcomes in SARS-CoV-2-affected pregnancies?

BACKGROUND: On the basis of available data, at least 1 ultrasound assessment of pregnancies recovering from SARS-CoV-2 infection is recommended. However, reports on prenatal imaging findings and potential associations with neonatal outcomes following SARS-CoV-2 infection in pregnancy have been inconclusive. OBJECTIVE: This study aimed to describe the sonographic characteristics of pregnancies after confirmed SARS-CoV-2 infection and assess the association of prenatal ultrasound findings with adverse neonatal outcomes. STUDY DESIGN: This was an observational prospective cohort study of pregnancies diagnosed with SARS-CoV-2 by reverse transcription polymerase chain reaction between March 2020 and May 2021. Prenatal ultrasound evaluation was performed at least once after diagnosis of infection, with the following parameters measured: standard fetal biometric measurements, umbilical and middle cerebral artery Dopplers, placental thickness, amniotic fluid volume, and anatomic survey for infection-associated findings. The primary outcome was the composite adverse neonatal outcome, defined as ≥1 of the following: preterm birth, neonatal intensive care unit admission, small for gestational age, respiratory distress, intrauterine fetal demise, neonatal demise, or other neonatal complications. Secondary outcomes were sonographic findings stratified by trimester of infection and severity of SARS-CoV-2 infection. Prenatal ultrasound findings were compared with neonatal outcomes, severity of infection, and trimester of infection. RESULTS: A total of 103 SARS-CoV-2-affected mother-infant pairs with prenatal ultrasound evaluation were identified; 3 cases were excluded because of known major fetal anomalies. Of the 100 included cases, neonatal outcomes were available in 92 pregnancies (97 infants); of these, 28 (29%) had the composite adverse neonatal outcome, and 23 (23%) had at least 1 abnormal prenatal ultrasound finding. The most common abnormalities seen on ultrasound were placentomegaly (11/23; 47.8%) and fetal growth restriction (8/23; 34.8%). The latter was associated with a higher rate of the composite adverse neonatal outcome (25% vs 1.5%; adjusted odds ratio, 22.67; 95% confidence interval, 2.63-194.91; P<.001), even when small for gestational age was removed from this composite outcome. The Cochran Mantel-Haenszel test controlling for possible fetal growth restriction confounders continued to show this association (relative risk, 3.7; 95% confidence interval, 2.6-5.9; P<.001). Median estimated fetal weight and birthweight were lower in patients with the composite adverse neonatal outcome (P<.001). Infection in the third trimester was associated with lower median percentile of estimated fetal weight (P=.019). An association between placentomegaly and third-trimester SARS-CoV-2 infection was noted (P=.045). CONCLUSION: In our study of SARS-CoV-2-affected maternal-infant pairs, rates of fetal growth restriction were comparable to those found in the general population. However, composite adverse neonatal outcome rates were high. Pregnancies with fetal growth restriction after SARS-CoV-2 infection were associated with an increased risk for the adverse neonatal outcome and may require close surveillance.

Pregnancy care in solid organ transplant recipients.

Recipients of solid organ transplants who become pregnant represent an obstetrically high-risk population. Preconception planning and effective contraception tailored to the individual patient are critical in this group. Planned pregnancies improve both maternal and neonatal outcomes and provide a window of opportunity to mitigate risk and improve lifelong health. Optimal management of these pregnancies is not well defined. Common pregnancy complications after transplantation include hypertension, preterm birth, infection, and metabolic disease. Multidisciplinary preconception and prepartum management, and counseling decrease complications and benefit the maternal-neonatal dyad.

Gender representation of speakers at the Society for Maternal-Fetal Medicine postgraduate courses: a 20-year review.

BACKGROUND: The percentage of female physicians has grown significantly in past decades, with women currently making up 56% of the Society for Maternal-Fetal Medicine's board-certified membership. OBJECTIVE: We aimed to describe trends in the gender of invited speakers at postgraduate courses, panels, and debates at the annual meetings of the Society for Maternal-Fetal Medicine over the last 2 decades. STUDY DESIGN: We performed a retrospective observational study examining annual meetings of the Society for Maternal-Fetal Medicine in 1999, 2009, and 2015-2019. Invited speakers were identified through publicly available programs and examined by gender, degree, and the session of involvement. Postgraduate lectures (including courses, workshops, and forums), panels, and debates were examined. Speakers with Medicinae Doctor (or equivalent) degrees and obstetrics and gynecology training were included. RESULTS: Among the 3 time points 1999, 2009, and 2019, there were 330 speaker slots. There was a significant difference in gender representation in the 3 time points; female representation was 25% in 1999, 21.5% in 2009, and 55.7% in 2019 (P<.001). There were significantly higher odds of having a female speaker in 2019 than in 2009 (odds ratio, 4.58; 95% confidence interval, 2.40-8.72; P<.001). Between 2015 and 2019, 813 speaker slots were identified, with a significant positive correlation between increasing year and increasing female representation (correlation coefficient=0.099; P=.005). When controlling for type of session, there were higher odds of having a female speaker with a later year (adjusted odds ratio, 1.16; 95% confidence interval, 1.05-1.28; P=.003). There was a significant difference in gender representation among different sessions (P=.028), with females listed in 51.2% of lecture slots but only 42.4% of panels and 38.0% of debates. Male moderators resulted in an average female representation of 29.8%±23.7% in a given session, whereas female moderators and a combination of both genders as moderators had average female representations of 71.6%±25.0% and 43.3%±19.4%, respectively, in a given session (P<.001). There was no correlation between the gender of the postgraduate course chair and either moderator or speaker gender. CONCLUSION: There was a significant increase in the percentage of speaker slots allocated to females over the past 2 decades, a trend that moves toward reflecting the gender composition of the Society for Maternal-Fetal Medicine membership.

Vaginal birth after cesarean: Does accuracy of predicted success change from prenatal intake to admission?

BACKGROUND: There are 2 prediction nomograms for vaginal birth after cesarean delivery. The first is based on variables that are available at the first prenatal visit, and the second includes variables at the time of admission. OBJECTIVE: The purpose of this study was to compare the accuracy of prediction scores that are calculated by the intake and admission prediction nomograms in a modern cohort of racially and ethnically diverse women. STUDY DESIGN: This is a retrospective cohort study that analyzed the data for women with at least 1 previous cesarean delivery who attempted a trial of labor from 2007-2016 at a tertiary medical center. Participants were stratified into 3 probability-of-success groups: low (<35%), moderate (35-65%), and high (>65%). The primary outcome was the difference between the intake- and admission-predicted success scores in the 3 groups. Secondary outcomes were characteristics that were associated with successful vaginal birth after cesarean delivery . RESULTS: Of the 614 women included in the analysis, 444 (72.3%) had a successful vaginal birth after cesarean delivery . Predicted vaginal birth after cesarean delivery success rate ranged from 14.4-96.2%. Patients were stratified into 3 groups by intake predicted success rates: low (<35%; n=21), moderate (35-65%; n=136), and high (>65%; n=457). The change in predicted success rates was compared between the intake and admission nomograms. Women in the low and moderate groups improved their prediction score by approximately 7-8% when variables at the time of admission were included. As a result, more than one-half of these women (172/307; 56%) shifted to a higher predicted success group. The admission nomogram, as compared with the intake nomogram, more accurately predicted vaginal birth after cesarean delivery success in all groups. Analysis of admission variables showed that cervical dilation >2 cm compared with a closed cervix was the strongest predictor of successful vaginal birth after cesarean delivery (relative risk, 1.79; 95% confidence interval, 1.11-2.89). CONCLUSION: The admission prediction nomogram was more accurate and showed higher predicted success compared with the intake nomogram for the same cohort. Because prediction scores may improve at the time of admission, additional counseling on the risks and benefits of trial of labor may be helpful at that time.

First-Trimester Ultrasound.

Since the 1980s, development of high-resolution transvaginal ultrasound transducers has significantly improved ultrasound evaluation at earlier gestational ages. Although many indications exist for first-trimester ultrasound in pregnancy, more emphasis has been placed on assessment of fetal anatomy recently. In turn, congenital diagnoses can also be made earlier in pregnancy, raising the question of whether anatomic assessment in the first trimester is one of choice or obligation. Combining transvaginal and transabdominal approach yields the highest detection rate overall. Some studies have shown that more than half of all anomalies and almost all severe anomalies can be detected on early scans.