Appendicitis and Cholecystitis in Pregnancy.

Up to 2% of pregnant women develop a disease that requires nonobstetrical operative intervention during pregnancy. We discuss the issues unique to pregnant patients as they pertain to the presentation, diagnosis, and management of nonobstetric surgical disease, with an emphasis on 2 of the most common diseases that affect pregnant women: appendicitis and cholecystitis. Surgery has been demonstrated to be safe and effective during pregnancy, provided proper precautions are taken into account. It is the consensus of multiple professional committees and societies that no pregnant women should be delayed or denied a necessary surgery because of pregnancy.

Universal cervical length screening with a cervicometer to prevent preterm birth <34 weeks: a decision and economic analysis.

Background: Preterm birth is a leading cause of neonatal morbidity and mortality worldwide; evidence-based strategies to decrease preterm birth are desperately needed.Objective: The purpose of this study was to estimate which of three strategies for screening for shortened cervix in asymptomatic low-risk women is the most cost-effective in terms of prevention of preterm birth and associated morbidity.Study design: A decision analysis model was developed from available published evidence comparing three strategies in screening asymptomatic low-risk women for shortened cervix: (1) cervicometer with subsequent referral for transvaginal ultrasound, (2) transvaginal ultrasound screening, and (3) no screening. The cost and effectiveness of each strategy was assessed in terms of quality-adjusted life-years (QALYs), and cost in US dollars.Results: Screening with a cervicometer with referral was the most cost-effective strategy and represented a savings of $999.65 ($11,617.28 versus $12,616.93) over screening with ultrasound, and a savings of $15,601.62 ($11,617.28 versus $27,218.90) over no screening. Costs for outcomes ranged from $3528 for a healthy neonate ≥34 weeks to $717,467.5 for a neonate <34 weeks with severe morbidity. The cervicometer strategy avoided 11.68 neonatal deaths per 1000 deliveries (3.59 deaths versus 15.27 deaths) compared with no screening, and avoided 0.73 neonatal deaths per 1000 deliveries (3.59 deaths versus 4.32 deaths) compared with ultrasound strategy. The cervicometer strategy prevented 82.44 preterm births per 1000 deliveries (22.56 versus 105.00) compared with no screening, and 5.10 preterm births per 1000 deliveries (22.56 versus 27.66) compared with ultrasound strategy. Per QALY, cervicometer screening cost $386.57, transvaginal ultrasound cost $420.31, and no screening cost $922.73. Sensitivity analyses confirmed the robustness of these findings, including evaluation across the range of quoted transvaginal ultrasound costs ($43-$300).Conclusion: A simulation of universal screening of asymptomatic low-risk women with a cervicometer with subsequent referral for ultrasound for those with a cervix <25 mm is cost-effective and yields the greatest reduction in preterm births at <34 weeks. A risk simulation trial noted that a cervicometer strategy may be more expensive than a universal transvaginal ultrasound strategy, but both are less expensive than a no screening strategy.

Obstetric management of women with opioid use disorder.

Pregnancy presents a window of opportunity for effecting positive change in the lives of women with opioid use disorder (OUD). Care should be empathetic and nonjudgmental with a focus on counseling for initiation and maintenance of beneficial health behaviors as well as development of a strong patient-provider relationship.1 These include adherence to treatment of OUD through pharmacotherapy and behavioral counseling, smoking cessation, healthy nutrition, treatment of coexisting medical and psychosocial conditions, as well as preparation for the postpartum period through breastfeeding education and antenatal discussion of contraception. Women will also benefit from anticipatory guidance with regard to neonatal abstinence syndrome (see Chapter 7). This may include a consultation with pediatric or neonatal providers who will be caring for their infants. In the absence of other obstetric indications, minimal additional fetal assessment outside that of standard prenatal care is recommended for OUD.

Detection of microbial invasion of the amniotic cavity by analysis of cervicovaginal proteins in women with preterm labor and intact membranes.

OBJECTIVE: Microbial invasion of the amniotic cavity (MIAC) is common in early preterm labor and is associated with maternal and neonatal infectious morbidity. MIAC is usually occult and is reliably detected only with amniocentesis. We sought to develop a noninvasive test to predict MIAC based on protein biomarkers in cervicovaginal fluid (CVF) in a cohort of women with preterm labor (phase 1) and to validate the test in an independent cohort (phase 2). STUDY DESIGN: This was a prospective study of women with preterm labor who had amniocentesis to screen for MIAC. MIAC was defined by positive culture and/or 16S ribosomal DNA results. Nine candidate CVF proteins were analyzed by enzyme-linked immunosorbent assay. Logistic regression was used to identify combinations of up to 3 proteins that could accurately classify the phase 1 cohort (N = 108) into those with or without MIAC. The best models, selected by area under the curve (AUC) of the receiver operating characteristic curve in phase 1, included various combinations of interleukin (IL)-6, chemokine (C-X-C motif) ligand 1 (CXCL1), alpha fetoprotein, and insulin-like growth factor binding protein-1. Model performance was then tested in the phase 2 cohort (N = 306). RESULTS: MIAC was present in 15% of cases in phase 1 and 9% in phase 2. A 3-marker CVF model using IL-6 plus CXCL1 plus insulin-like growth factor binding protein-1 had AUC 0.87 in phase 1 and 0.78 in phase 2. Two-marker models using IL-6 plus CXCL1 or alpha fetoprotein plus CXCL1 performed similarly in phase 2 (AUC 0.78 and 0.75, respectively), but were not superior to CVF IL-6 alone (AUC 0.80). A cutoff value of CVF IL-6 ≥463 pg/mL (which had 81% sensitivity in phase 1) predicted MIAC in phase 2 with sensitivity 79%, specificity 78%, positive predictive value 38%, and negative predictive value 97%. CONCLUSION: High levels of IL-6 in CVF are strongly associated with MIAC. If developed into a bedside test or rapid laboratory assay, cervicovaginal IL-6 might be useful in selecting patients in whom the probability of MIAC is high enough to warrant amniocentesis or transfer to a higher level of care. Such a test might also guide selection of potential subjects for treatment trials.

Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery.

BACKGROUND: Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate. OBJECTIVES: To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS: We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection. AUTHORS' CONCLUSIONS: Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.

Implementation of a universal cervical length screening program for the prevention of preterm birth.

OBJECTIVE: The objective of this article is to evaluate the implementation and acceptability of a universal cervical length (CL) screening program for prediction and prevention of preterm birth (PTB). STUDY DESIGN: We performed a prospective observational study to evaluate the implementation and acceptability of a universal CL screening program. Between January 1, 2012, and December 31, 2012, women with singleton gestations, without a cerclage or prior spontaneous PTB, were offered transvaginal ultrasound (TVU) for CL between 18(0/7) and 23(6/7) weeks' gestation. Sonographers and medical staff received education before implementation. Intervention for a short CL was interpreted according to a standard protocol. On June 1, 2012, our program was modified from "opt-in" to "opt-out." SPSS 20.0 (released 2011, IBM statistics for Windows version 20, IBM Corp., Armonk, NY) was used for analysis. RESULTS: Over 12 months, 1,484 (87%) of 1,706 eligible women were offered CL screening, and 1,119 (75%) were actually screened. Women were more likely to accept CL screening if they were nulliparous versus multiparous (83 vs. 68%, p < 0.001) and if the sonographer was female versus male (83 vs. 42%, p < 0.001). Implementation of an "opt-out" protocol did not increase the overall number of women accepting CL screening compared with an "opt-in" approach (76 vs. 75%, p = 0.81) CONCLUSION: Universal CL screening can be feasibly implemented and is acceptable to most women.

Cost and cost effectiveness of vaginal progesterone gel in reducing preterm birth: an economic analysis of the PREGNANT trial.

BACKGROUND: Preterm birth (PTB) is a costly public health problem in the USA. The PREGNANT trial tested the efficacy of vaginal progesterone (VP) 8 % gel in reducing the likelihood of PTB among women with a short cervix. OBJECTIVE: We calculated the costs and cost effectiveness of VP gel versus placebo using decision analytic models informed by PREGNANT patient-level data. METHODS: PREGNANT enrolled 459 pregnant women with a cervical length of 10-20 mm and randomized them to either VP 8 % gel or placebo. We used a cost model to estimate the total cost of treatment per mother and a cost-effectiveness model to estimate the cost per PTB averted with VP gel versus placebo. Patient-level trial data informed model inputs and included PTB rates in low- and high-risk women in each study group at <28 weeks gestation, 28-31, 32-36, and ≥37 weeks. Cost assumptions were based on 2010 US healthcare services reimbursements. The cost model was validated against patient-level data. Sensitivity analyses were used to test the robustness of the cost-effectiveness model. RESULTS: The estimated cost per mother was $US23,079 for VP gel and $US36,436 for placebo. The cost-effectiveness model showed savings of $US24,071 per PTB averted with VP gel. VP gel realized cost savings and cost effectiveness in 79 % of simulations. CONCLUSION: Based on findings from PREGNANT, VP gel was associated with cost savings and cost effectiveness compared with placebo. Future trials designed to include cost metrics are needed to better understand the value of VP.

Amniotic fluid infection, inflammation, and colonization in preterm labor with intact membranes.

OBJECTIVE: The purpose of this study was to compare intraamniotic inflammation vs microbial invasion of the amniotic cavity (MIAC) as predictors of adverse outcome in preterm labor with intact membranes. STUDY DESIGN: Interleukin-6 (IL-6) was measured in prospectively collected amniotic fluid from 305 women with preterm labor. MIAC was defined by amniotic fluid culture and/or detection of microbial 16S ribosomal DNA. Cases were categorized into 5 groups: infection (MIAC; IL-6, ≥11.3 ng/mL); severe inflammation (no MIAC; IL-6, ≥11.3 ng/mL); mild inflammation (no MIAC; IL-6, 2.6-11.2 ng/mL); colonization (MIAC; IL-6, <2.6 ng/mL); negative (no MIAC; IL-6, <2.6 ng/mL). RESULTS: The infection (n = 27) and severe inflammation (n = 36) groups had similar latency (median, <1 day and 2 days, respectively) and similar rates of composite perinatal morbidity and mortality (81% and 72%, respectively). The colonization (n = 4) and negative (n = 195) groups had similar outcomes (median latency, 23.5 and 25 days; composite morbidity and mortality rates, 21% and 25%, respectively). The mild inflammation (n = 47) groups had outcomes that were intermediate to the severe inflammation and negative groups (median latency, 7 days; composite morbidity and mortality rates, 53%). In logistic regression adjusting for gestational age at enrollment, IL-6 ≥11.3 and 2.6-11.2 ng/mL, but not MIAC, were associated significantly with composite morbidity and mortality rates (odds ratio [OR], 4.9; 95% confidence interval [CI], 2.2-11.2, OR, 3.1; 95% CI, 1.5-6.4, and OR, 1.8; 95% CI, 0.6-5.5, respectively). CONCLUSION: We confirmed previous reports that intraamniotic inflammation is associated with adverse perinatal outcomes whether or not intraamniotic microbes are detected. Colonization without inflammation appears relatively benign. Intraamniotic inflammation is not simply present or absent but also has degrees of severity that correlate with adverse outcomes. We propose the designation amniotic inflammatory response syndrome to denote the adverse outcomes that are associated with intraamniotic inflammation.

Evidence-based surgery for cesarean delivery: an updated systematic review.

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.

The utility of screening for historical risk factors for preterm birth in women with known second trimester cervical length.

OBJECTIVE: To evaluate for the presence of risk factors (RFs) for preterm birth (PTB) in women without prior PTB having second trimester cervical length (CL) screening, and to estimate the utility of RF screening. METHODS: "Low-risk" singletons were prospectively screened with midtrimester transvaginal ultrasound CL. Prior PTB, intrauterine fetal demise and lethal anomalies were excluded. Women were analyzed based on second trimester CL (<25 mm versus ≥25 mm) and the presence of RFs for PTB. A p-value of < 0.05 was considered significant. RESULTS: A total of 639 women were screened; 8% had CL <25 mm. Ninety-eight percent of women with CL <25 mm and 95% of women with CL ≥25 mm had RFs for PTB. Five percent of women with a CL ≥25 mm delivered preterm as compared to 18% with CL <25 mm (p < 0.01). Treatment of cervical dysplasia, drug use during the pregnancy and unmarried status were significantly more common in women with CL <25 mm than CL ≥25 mm. When data were analyzed by CL, the presence of additional RFs did not add to the prediction of PTB <37 weeks. DISCUSSION: Over 95% of singleton gestations without prior PTB have ≥1 other RF for PTB. In women without prior PTB, assessment of other PTB RFs does not add to prediction of PTB provided by CL alone.

Cesarean skin closure preferences: a survey of obstetricians.

OBJECTIVE: In light of the limited evidence directing cesarean skin closure techniques, we evaluated the factors guiding obstetricians' preferences for closure method. METHODS: From 07/11 to 12/11, an online survey was sent to obstetricians in ACOG Regions I and II. Obstetricians were asked to indicate their cesarean skin closure preferences when considering various factors and to rank the importance of these factors in their decision. Practice type, experience and usual method of closure were also assessed. RESULTS: Responses were received from 470 of 1400 surveyed (34% response rate), of which 422 were analyzed. Similar proportions reported primarily using sutures (39%) or staples (48%); 13% use both methods equally. More obstetricians at community hospitals primarily use sutures (48% versus 39%, p < 0.001), while more at university hospitals primarily use staples (57% versus 30%, p < 0.001). Listed in decreasing order of importance, sutures were preferred when considering patient satisfaction, keloid susceptibility, cosmesis, first Pfannenstiel incisions or cost. Staples were preferred when considering wound infections, obese patients, chorioamnionitis, HIV/AIDS or busy labor floors (p < 0.001). CONCLUSION: The limited evidence to guide cesarean skin closure forces obstetricians to rely on personal experience. Our survey indicates that despite this limitation, obstetricians have specific preferences for cesarean skin closure method.

Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates.

OBJECTIVE: The objective of the study was to identify maternal variables predicting length of treatment for neonatal abstinence syndrome (NAS). STUDY DESIGN: This was a retrospective cohort study of infants treated for NAS during 2000-2006 whose mothers were on methadone maintenance at delivery. Mixed-effects linear regression was used to examine the interaction of maternal and neonatal variables with length of treatment. RESULTS: Of 204 neonates born to methadone exposed mothers, the average dose at delivery was 127 mg daily (25-340 mg) with median length of treatment 32 days (1-122 days). Trimester of initial exposure (P = .33), methadone dose at delivery (P = .198), body mass index (P = .31), antidepressant use (P = .40), cigarette use (P = .76), race (P = .78), and maternal age (P = .84) did not predict length of treatment. In the multivariate analysis, gestational age at delivery and benzodiazepine use were significant predictors of length of treatment. CONCLUSION: Later gestational age and concomitant benzodiazepine use were associated with longer treatment.

Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes.

OBJECTIVE: We aimed to determine whether obstetrician-gynecologists provided postpartum type 2 diabetes mellitus screening for women with a history of gestational diabetes. STUDY DESIGN: We identified women diagnosed with gestational diabetes, and then assessed whether obstetrician-gynecologists provided postpartum diabetes mellitus screening by ordering American Diabetes Association-recommended glucose tests or by referring women to primary care physicians for such testing. RESULTS: Of 2617 gravid women with a 1-hour glucose challenge test, 90 had gestational diabetes and postpartum follow-up. Only 20.0% (18/90) of women with a history of gestational diabetes had documented orders from obstetrician-gynecologists for American Diabetes Association-recommended postpartum diabetes mellitus screening tests. Even when we broadened our definition of "providing postpartum diabetes mellitus screening" to also include referrals to primary care physicians, only 33.3% (30/90) of women met such criteria. CONCLUSION: Obstetrician-gynecologists at an academic medical center did not provide postpartum diabetes mellitus screening for 66.7% of women with a history of gestational diabetes.

Gestational age at cervical length measurement and incidence of preterm birth.

OBJECTIVE: To estimate the risk of spontaneous preterm birth based on transvaginal ultrasound cervical length and gestational age at which cervical length was measured. METHODS: Women at high risk for spontaneous preterm birth and with transvaginal ultrasound cervical length measurements between weeks 12 and 32 were identified at one institution between July 1995 and June 2005. Inclusion criteria for women at high risk for spontaneous preterm birth were prior spontaneous preterm birth at 14 to 35 weeks, cone biopsy, müllerian anomaly, or two or more dilation and evacuations. Women with multiple gestations, cerclage, indicated preterm birth, or fetal anomalies were excluded. Logistic regression was used to estimate the spontaneous preterm birth risk before 35, 32, and 28 weeks. RESULTS: Seven hundred five women received 2,601 transvaginal ultrasound measurements for cervical length. The incidences of spontaneous preterm birth before 35, 32, and 28 weeks were 17.7, 10.6, and 6.7%, respectively. The risk of spontaneous preterm birth before 35 weeks decreased by approximately 6% for each additional millimeter of cervical length (odds ratio 0.94, 95% confidence interval, 0.92-0.95, P=.001) and by approximately 5% for each additional week of pregnancy at which the cervical length was measured (odds ratio 0.95, 95% confidence interval 0.92-0.98, P=.004). Similar results were obtained for spontaneous preterm birth before 32 and 28 weeks. CONCLUSION: Gestational age at which transvaginal ultrasound cervical length is measured significantly affects the calculation of risk of spontaneous preterm birth. The spontaneous preterm birth risk increases as the length of the cervix declines and as the gestational age decreases. These spontaneous preterm birth risks are important for counseling and management for women with various degrees of short cervical length at different gestational ages. LEVEL OF EVIDENCE: II.

Folate supplementation and twinning in patients with sickle cell disease.

Patients with sickle cell disease routinely take folic acid daily as a supplement to maintain effective erythropoiesis. One of the controversial effects of folic acid is its effect on twin gestation rates. In this report, we present our experience in patients with sickle cell disease and twin pregnancy. Our data show that twin pregnancies seem to be associated with folate supplementation.

Evidence-based surgery for cesarean delivery.

OBJECTIVE: The purpose of this study was to provide evidenced-based guidance for surgical decisions during cesarean delivery. STUDY DESIGN: We performed MEDLINE, PubMed, EMBASE, and COCHRANE searches with the terms cesarean section, cesarean delivery, cesarean, pregnancy, randomized trials, and each technical aspect of cesarean delivery. All randomized trials that covered a surgical aspect of cesarean delivery were included in the review. Each surgical step of cesarean delivery was reviewed separately. RESULTS: US Preventive Services Task Force recommendations favor blunt uterine incision expansion, prophylactic antibiotics (either ampicillin or first-generation cephalosporin for just 1 dose), spontaneous placental removal, non-closure of both visceral and parietal peritoneum, and suture closure or drain of the subcutaneous tissue when thickness is > or =2 cm. CONCLUSION: Cesarean delivery techniques that are supported by good quality recommendations should be performed routinely. All technical aspects that have recommendations with lower quality should be researched with adequately powered and designed trials.

Thoracoamniotic shunts: fetal treatment of pleural effusions and congenital cystic adenomatoid malformations.

OBJECTIVE: To determine whether fetuses that underwent thoracoamniotic shunt placement for treatment of pleural effusion (PE) or macrocystic congenital cystic adenomatoid malformation (CCAM) have an improved outcome as compared with an untreated population. METHODS: A retrospective review from a single tertiary center was performed using thoracoamniotic shunt placement to treat PE or macrocystic CCAM between 1998 and 2001. Thoracoamniotic shunts were used on 26 occasions in 19 pregnancies. RESULTS: The average gestational age at the diagnosis of PE and CCAM was 22 + 4 and 20 + 0 weeks, respectively. Shunts were offered in pregnancies complicated by hydrops or at significant risk for pulmonary hypoplasia. Shunts were placed at 26 + 2 weeks (average) and 23 + 1 weeks (average) in the PE and CCAM groups, respectively. In CCAM patients, the mean pre- and postshunting mass volumes were 50.5 and 25.7 cm(3), representing a 51% reduction in mass volume following shunt placement. In the PE group, the average delivery age was 33 + 5 weeks, with an average shunt placement to delivery time of 7 + 3 weeks. In the CCAM group, the average delivery was 33 + 3 weeks, with an average shunt placement to delivery time of 10 + 2 weeks. The postnatal survival rates were 67% (6/9) and 70% (7/10) in the PE and CCAM groups, respectively. CONCLUSIONS: (1) Thoracoamniotic shunts should be considered as a treatment option for selected PE or macrocystic CCAM fetuses with hydrops or a significant risk for pulmonary hypoplasia; (2) the neonatal survival with shunting was similar for PE and CCAM groups and was improved as compared with literature reports, and (3) fetuses with CCAM presented earlier with hydrops than those with PE. Successful shunting resulted in a prolongation of pregnancy into the 3rd trimester in both groups.