The relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes: a retrospective cohort study.

BACKGROUND: Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse perinatal outcomes remains controversial. OBJECTIVE: This study aimed to compare maternal and neonatal outcomes of women with prolonged rupture of membranes (≥12 hours) at term between those with low-grade fever and those with normal body temperature. STUDY DESIGN: This retrospective study included women hospitalized in a tertiary university-affiliated hospital between July 2021 and May 2023 with singleton term and rupture of membranes ≥12 hours. Women were classified as having intrapartum low-grade fever (37.5°C-37.9°C) or normal body temperature (<37.5°C). The co-primary outcomes, postpartum endometritis and neonatal intensive care unit admission rates, were compared between these groups. The secondary maternal outcomes were intrapartum leukocytosis (>15,000/mm2), cesarean delivery rate, postpartum hemorrhage, postpartum fever, surgical site infection, and postpartum length of stay. The secondary neonatal outcomes were early-onset sepsis, 5-minute Apgar score of <7, umbilical artery cord pH<7.2 and pH<7.05, neonatal intensive care unit admission length of stay, and respiratory distress. The data were analyzed according to rupture of membranes 12 to 18 hours and rupture of membranes ≥18 hours. In women with rupture of membranes ≥18 hours, intrapartum ampicillin was administered, and chorioamniotic membrane swabs were obtained. The likelihood ratios and 95% confidence intervals were calculated for the co-primary outcomes. A multivariate logistic regression model was used to predict puerperal endometritis controlled for rupture of membranes duration, low-grade fever (compared with normal body temperature), positive group B streptococcus status, mechanical cervical ripening, cervical ripening by prostaglandins, artificial rupture of membranes, meconium staining, epidural analgesia, and cesarean delivery. A multivariate logistic regression model was used to predict neonatal intensive care unit admission controlled for rupture of membranes duration, low-grade fever, positive group B streptococcus status, mechanical cervical ripening, artificial rupture of membranes, meconium staining, cesarean delivery, and neonatal weight of <2500 g. RESULTS: This study included 687 women with rupture of membranes 12 to 18 hours and 1109 with rupture of membranes ≥18 hours. In both latency groups, the rates were higher for cesarean delivery, endometritis, surgical site infections, umbilical cord pH<7.2, neonatal intensive care unit admission, and sepsis workup among those with low-grade fever than among those with normal body temperature. Among women with low-grade fever, the positive likelihood ratios were 12.7 (95% confidence interval, 9.6-16.8) for puerperal endometritis and 3.2 (95% confidence interval, 2.0-5.3) for neonatal intensive care unit admission. Among women with rupture of membranes ≥18 hours, the rates were higher of Enterobacteriaceae isolates in chorioamniotic membrane cultures for those with low-grade fever than for those with normal intrapartum temperature (22.0% vs 11.0%, respectively; P=.006). Low-grade fever (odds ratio, 9.0; 95% confidence interval, 3.7-21.9; P<.001), artificial rupture of membranes (odds ratio, 4.2; 95% confidence interval, 1.5-11.7; P=.007), and cesarean delivery (odds ratio, 5.4; 95% confidence interval, 2.2-13.4; P<.001) were independently associated with puerperal endometritis. Low-grade fever (odds ratio, 3.2; 95% confidence interval, 1.7-6.0; P<.001) and cesarean delivery (odds ratio, 1.9; 95% confidence interval, 1.1-13.1; P=.023) were independently associated with neonatal intensive care unit admission. CONCLUSION: In women with rupture of membranes ≥12 hours at term, higher maternal and neonatal morbidities were reported among those with low-grade fever than among those with normal body temperature. Low-grade fever was associated with a higher risk of Enterobacteriaceae isolates in chorioamniotic membrane cultures. Moreover, low-grade fever may be the initial presentation of peripartum infection.

Bacteriology and clinical outcomes of urine mixed bacterial growth in pregnancy.

INTRODUCTION AND HYPOTHESIS: The objective was to analyse the risk of significant bacteriuria in repeat urine cultures from pregnant women, following initial mixed bacterial results. METHODS: This retrospective study examined maternal characteristics and clinical features of women who repeated urine cultures due to previous mixed cultures results. RESULTS: Of 262 women included, 80 (30.5%) had negative cultures and 125 (47.7%) had mixed bacterial growth in their repeat cultures. Positive results (≥104 CFU/ml of a urinary pathogen) were obtained for 57 women (21.8% [95% CI 17.1-27.0]). For 37 (14.1%), the repeat specimen grew 104-105 CFU/ml of microorganisms; whereas for 20 women (7.6% [95% CI 4.9-11.3]), it grew ≥105 CFU/ml. Among women with positive (>104 CFU/ml) compared with those with negative or mixed growth, rates of urinary symptoms were higher (38.6% vs 23.4%, p=0.028), abnormal dipstick results (49.1% vs 21.0%, p<0.001) and hydronephrosis, as demonstrated by renal ultrasound (12.3% vs 2.0, p=0.003). In a multivariate logistic regression analysis, hydronephrosis was associated with the occurrence of a positive repeat culture (aOR = 10.65, 95% CI 2.07-54.90). The sensitivity and specificity for predicting a repeat urine culture with ≥105 CFU/ml were 12.9% and 94.3% respectively, for urinary symptoms; and 19.7% and 97.4% respectively, for abnormal dipstick results. CONCLUSIONS: Mixed bacterial growth might represent a true urinary tract infection in a considerable proportion of women who are symptomatic and have an abnormal dipstick urinalysis.

Birth outcomes associated with a natural delivery approach in a perinatal center: A comparative retrospective study.

OBJECTIVES: At our center, natural home-like delivery settings have been established in or near conventional labor wards, for the care of pregnant women who prefer little or no medical intervention during labor and birth. We compared obstetrical and neonatal outcomes of women in active spontaneous labor, between those who chose to deliver in a natural-delivery setup and those who chose a conventional setting. METHODS: This retrospective study included low-risk women who delivered at term between March 1, 2020 and December 31, 2022, in a single tertiary university affiliated medical center. Birth outcomes were compared between 124 women who delivered by natural birth (the study group) and 244 who gave birth in a conventional setting (the control group). RESULTS: No cesarean deliveries were performed in the study group, compared to 18 (7.4%) of the control group, p = 0.004. Intrapartum fever, postpartum hemorrhage, and uterotonic administration were similar between the groups. For the study compared to the control group, breastfeeding was more common (71.3% vs. 12.3%, p < 0.001), analgesia administration within 48 h delivery was lower (4.1% vs. 10.7%, p = 0.033), and maternal and neonatal length of hospitalization were shorter. Of the women initially admitted to the natural-delivery room, 14 (11.5%) were transferred to a conventional-delivery room. CONCLUSIONS: Birth in a hospital natural-delivery setting was associated with increased likelihood of vaginal birth, increased immediate breastfeeding and breastfeeding at discharge, and lower postpartum pain.

The Impact on Birth Outcomes of Sonographic Fetal Weight Estimation in Neonatal Macrosomia.

OBJECTIVE: Our objective was to examine the association between sonographic estimated fetal weight (EFW) and obstetrical and neonatal outcomes in women with neonatal macrosomia. STUDY DESIGN: This study, conducted at a tertiary university-affiliated hospital from 2017 to 2021, compared obstetrical and neonatal outcomes between two groups of women who delivered macrosomic newborns (actual birthweight ≥ 4,000 g): (1) those with EFW ≥ 3,800 g (suspected impending macrosomia) and (2) those with EFW < 3,800 g (unsuspected impending macrosomia). RESULTS: During the study period, 854 women with neonatal macrosomia attempted vaginal delivery. Only 9.2% had a sonographic EFW ≥ 4,000 g. Among women with EFW ≥ 3,800 g (n = 317) compared with EFW < 3,800 g (n = 537), the cesarean delivery (CD) rate was higher (17.0 vs. 10.5%, p = 0.004) and the operative delivery rate was lower (3.2 vs. 0.6%, p = 0.015). Among primiparous women, the CD rate was higher among those with EFW ≥ 3,800 versus <3,800 g (37.3 vs. 23.2%, p = 0.033). EFW ≥3,800 g was associated with CD, regardless of predelivery body mass index, parity, diabetes mellitus, maximal fetal weight at previous deliveries, actual birthweight, and labor induction (p = 0.014). EFW ≥ 3,800 g and diabetes mellitus were independent predictors of CD. Among women with EFW ≥3,800 g and diabetes mellitus, the risk of CD was double that of those without diabetes and with EFW ≥ 3,800 g (31.4% vs. 15.2%, p = 0.02), although their actual birthweights were similar. Obstetrical and neonatal outcomes were similar between those with sonographic EFW ≥ 3,800 and < 3,800 g. CONCLUSION: Larger EFW increased CD risk among pregnancies with actual neonatal macrosomia. Antenatally suspected macrosomia might alter labor management due to concerns for potential complications, especially when associated with primiparity, diabetes mellitus, or maternal obesity. The increase in the CD rate did not show an association with improved maternal and neonatal outcomes. KEY POINTS: · Antenatally suspected macrosomia might alter labor management due to concerns about complications.. · Larger EFW increased cesarean delivery risk among pregnancies with actual neonatal macrosomia.. · The increase in the cesarean delivery rate was not associated with improved outcomes..

Fetal major anomalies and related maternal, obstetrical, and neonatal outcomes.

PURPOSE: To examine maternal, obstetrical, and neonatal outcomes of pregnancies complicated by major fetal anomalies. METHODS: A 10 year retrospective cohort study at a tertiary university hospital compared maternal and obstetrical outcomes between women with singleton pregnancies complicated by major fetal anomalies, and a control group with non-anomalous fetuses. RESULTS: For the study compared to the control group, the median gestational age at delivery was lower: 37.0 vs. 39.4 weeks (p < 0.001); and the preterm delivery rates were higher, both at < 37 weeks (46.2 vs. 6.2%, p < 0.001) and < 32 weeks (15.4 vs. 1.2%, p < 0.001). For the study compared to the control group, the placental abruption rate was higher (6.8 vs. 0.9%, p = 0.002); 87.5 vs. 100% occurred before labor. For the respective groups, the mean gestational ages at abruption were 32.8 ± 1.3 and 39.9 ± 1.7 weeks (p = 0.024); and cesarean section and postpartum hemorrhage rates were: 53.8 vs. 28.3% (p < 0.001) and 11.3 vs. 2.8% (p = 0.001), respectively. For the respective groups, hypertensive disorders of pregnancy rates were 9.5 vs. 2.1% (p = 0.004), stillbirth rates were 17.1 vs. 0.3% (p < 0.001), and neonatal death rates 12.5 vs. 0.0% (p < 0.001). Major fetal anomalies were found to be associated with adverse maternal outcomes (OR = 2.47, 95% CI 1.50-4.09, p < 0.001). Polyhydramnios was identified as an independent risk factor in a multivariate analysis that adjusted for fetal anomalies, conception by IVF, and primiparity for adverse maternal outcomes (OR = 4.7, 95% CI 1.7-13.6, p < 0.001). CONCLUSIONS: Pregnancies with major fetal anomalies should be treated as high-risk due to the increased likelihood of adverse maternal and neonatal outcomes.

Maternal and perinatal infectious morbidity in term prelabor rupture of membrane according to two induction of labor protocols.

PURPOSE: The optimal labor-induction protocol in women with prelabor rupture of membranes (PROM) is unknown. Whether the management of women with a previous cesarean delivery (CD) with PROM is different remains controversial. We investigated maternal and perinatal outcomes according to two induction protocols of 24 h vs. 12 h. METHODS: In July 2021, our protocol of induction of labor in term-PROM was extended from 12 h to 24 h post-PROM. We compared obstetrical and neonatal outcomes before and after the change. A subgroup analysis of women with previous CD was performed. Results were compared using a univariate analysis. A multivariable model was described to predict neonatal intensive care unit admission (NICU) and clinical chorioamnionitis. RESULTS: The 24 h and 12 h ROM-to-induction protocol groups included 962 and 802 women, respectively. In the 24 h group, a higher proportion of women labored spontaneously (p < 0.001), the rate of chorioamnionitis was higher (p = 0.017), and the CD rate was similar. Admission to the NICU (p = 0.012), antibiotic administration (p = 0.003), and respiratory distress (p = 0.002) were also greater in the 24 h induction group. Among women with a history of CD (n = 143), the need for oxytocin (p = 0.003) and delivery by CD (p = 0.016) were lower in the 24 vs. 12 h group. CONCLUSION: Our results advocate shared decision-making in the expectant management of term-PROM. Women should be informed of the lower chance for induction and the higher risk of infections and neonatal complications with a 24-h induction approach. Longer expectant management in women with a previous CD resulted in significantly lower induction and CD rates.

The utility of inpatient anemia workup in hemoglobin < 10 g/dL diagnosed randomly in the third trimester: a retrospective study.

PURPOSE: About 40% of pregnant women are anemic and at an increased risk for complications. We examined the efficacy of inpatient anemia workup and treatment in pregnant women diagnosed with moderate-severe anemia (hemoglobin < 10 mg/dL), during hospitalization in the late second-trimester and third-trimester. METHODS: This retrospective study, conducted between March 2020 and November 2022, included women at ≥ 24 gestational weeks who were hospitalized due to various indications and diagnosed with anemia (hemoglobin < 10 mg/dL). The study group comprised women who underwent an inpatient anemia workup and initiation of anemia treatment. The comparison group comprised women who did not undergo an inpatient anemia investigation. The primary outcome was the rate of pre-delivery hemoglobin > 11 g/dL. RESULTS: The most frequent etiology of anemia in the study group (n = 188) was iron-deficiency anemia (30.2%), followed by mixed anemia of iron, folate and vitamin-B12 deficiencies (20.7%). In the study vs. the comparison group (n = 179), the rate of pre-delivery hemoglobin > 11 g/dL was higher, and the increase in hemoglobin from intervention to delivery was greater. The ideal timing for anemia intervention for maximizing the increase in pre-delivery hemoglobin was 6-weeks or more prior to delivery. The rates of postpartum hemorrhage and blood transfusions were similar. The rate of postpartum hemoglobin < 10 g/dL was lower in the study than the comparison group. CONCLUSION: Inpatient anemia investigation and treatment resulted in higher peri-delivery hemoglobin. In women randomly diagnosed with anemia at hospitalization, the rate of pre-delivery hemoglobin > 11 g/dL was increased among those who underwent a simple anemia investigation and treatment initiation.

The role of the cerebroplacental ratio in predicting pregnancy outcomes at 40-42 gestational weeks: a prospective observational trial.

PURPOSE: The cerebroplacental ratio is a sonographic tool used to predict poor pregnancy outcomes. Data are insufficient regarding its use in postdate pregnancy. We evaluated the cerebroplacental ratio's prediction of unfavorable pregnancy outcomes in women at 40-42 weeks gestation with normal amniotic fluid index. METHODS: This prospective observational study included 101 women with low-risk singleton pregnancy and gestational age > 40 weeks who delivered in a university affiliated hospital during 2020-2021. The middle cerebral artery pulsatility index, the umbilical artery pulsatility index, and the cerebroplacental ratio, which is their quotient, were compared between women with favorable and unfavorable pregnancy outcomes. The latter included: meconium-stained amniotic fluid, cesarean or vacuum-assisted delivery due to pathological cardiotocography (category 2 or 3), 5-min Apgar score < 7, umbilical cord pH < 7.1, neonatal intensive care unit admission, and neonatal death. RESULTS: Fetal Doppler, performed at a median gestational age of 40.3 (40.0-41.6), did not differ between 75 (74.3%) women with favorable obstetrical outcomes and 26 (25.7%) with unfavorable outcomes. In multivariate analysis, advanced maternal age and a history of a cesarean section were correlated with unfavorable outcomes, while Doppler indices were not found to be predictive. Among women at 41-42 weeks' gestation, for those with intrapartum fetal monitor category 2-3 vs. category 1, the mean umbilical artery pulsatility index was higher: 0.92 ± 0.34 vs. 0.71 ± 0.11 (p = 0.044). CONCLUSION: According to the study results, fetal Doppler indices, including the cerebroplacental ratio, are not predictive of unfavorable outcome in women with pregnancies exceeding 40 weeks. Larger prospective studies are needed.

Obstetrical outcomes of women with new-onset isolated proteinuria diagnosed after 24 weeks' gestation.

PURPOSE: To assess a possible association between marked proteinuria and the risk of preeclampsia with severe features, as defined by the American College of Obstetricians and Gynecologists. METHODS: This retrospective study included data recorded at a tertiary university-affiliated hospital between 2017 and 2022. Women at or beyond 24 weeks of gestation with proteinuria (protein levels > 300 mg in a 24 h urine collection) and normal blood pressure during the initial 48 h of admission were included. Obstetrical and neonatal outcomes were compared between women with mild proteinuria (300-1000 mg/24 h) and marked proteinuria (≥ 1000 mg/24 h). RESULTS: Among the women with marked proteinuria (n = 48) compared to those with mild proteinuria (n = 108), the incidences were higher of preeclampsia (50.0% vs. 22.2%, p = 0.001) and of preeclampsia with severe features (18.8% vs. 2.8%, p < 0.001). In multivariate analysis that adjusted for maternal age, primiparity, multiple pregnancy, uric acid level > 6 mg/dL and aspirin treatment, marked proteinuria was a risk factor for preeclampsia with severe features (adjusted odds ratio [aOR] = 10.2, confidence interval [CI] 95% 1.9-54.0, p = 0.007) and for small-for-gestational-age infants (aOR = 2.4, 95% CI 1.02-5.6, p = 0.001). Among women with marked compared to mild proteinuria, rates were also higher of labor induction (58.3% vs. 25.9%, p < 0.001), indicated preterm delivery (41.7% vs. 25.0%, p = 0.04) and admission to the neonatal intensive care unit (44.1% vs. 25.8%, p = 0.017). CONCLUSIONS: Women with marked compared to mild isolated proteinuria showed higher risk of developing preeclampsia with severe features and of delivering small-for-gestational-age neonates.

The Effect of Maternal Lower Limb Compression on Amniotic Fluid Index, Uteroplacental Perfusion, and Fetal Blood Flow in Isolated Oligohydramnios.

INTRODUCTION: The aim of this study was to examine the efficacy of pneumatic compression of the maternal lower extremities in increasing the amniotic fluid index (AFI) in pregnancies complicated by isolated oligohydramnios. METHODS: Women with isolated oligohydramnios (AFI <5 cm) at 32-41 weeks of pregnancy were connected to a sequential compression device for 60 min. Prior and after the application, AFI and the pulsatility index (PI) of a number of arteries were measured. RESULTS: The median (interquartile range) maternal age of the 21 women included was 29 years (26.50-32.00), the median parity was 1 (1-2), and the median gestational age at intervention was 37.60 weeks (37.00-39.40). The median AFI increased after the application from 4.00 (3.62-4.50) to 6.08 cm (4.90-7.03) (p < 0.001). The median PI of the fetal renal artery decreased from 2.30 (2.01-2.88) to 2.26 (1.68-2.71) (p = 0.01). The hourly fetal urine production did not increase. Changes were not significant in the PI of the umbilical artery, the middle cerebral artery, and the bilateral uterine arteries. CONCLUSION: Short-term activation of pneumatic compression on maternal lower extremities could increase the AFI in women with isolated oligohydramnios.

Colposcopy-A Valuable Diagnostic Tool for Pregnant Women With Unexplained Vaginal Bleeding.

OBJECTIVES: We aimed to examine the diagnostic value of colposcopy in a large cohort of pregnant women with unexplained vaginal bleeding during the second or third trimester. MATERIALS AND METHODS: This retrospective study included women who underwent colposcopy due to vaginal bleeding in the second and third trimesters during 2012-2022 at a tertiary care hospital. Demographics, obstetric data, bleeding characteristics, colposcopy results, cervical cytology testing, a sonogram directed at the placenta, and birth details were collected. RESULTS: In total, 364 women were included. The mean maternal age was 29.7 years and the mean gestational age at examination was 30.7 weeks. Vaginal bleeding was mild in 80.8%, moderate in 14.6%, and severe in 4.7%. Only 3.3% had been vaccinated against human papilloma virus and 25.5% underwent a Pap smear study before pregnancy. Colposcopy diagnosed the bleeding source in 83 women (22.8%). The colposcopic examination revealed vaginal bleeding due to contact bleeding from ectropion in 46 (12.6%), a decidual/cervical polyp in 37 (10.2%), acetowhite epithelium in 12 (3.3%), herpes genetalis in 2 (0.5%), and bleeding from vaginal varices in 2 (0.5%). Of those who were recommended a follow-up examination after the postpartum period, only 49.1% completed such.Among women with compared to without postcoital bleeding ( N = 72), the risk of abnormal colposcopic findings was higher (24 [33.3%] vs 54 [19.7%], p = .017) and the rate of abnormal Pap smear was higher (7 [13.2%] vs 7 [3.2%], p = .008). CONCLUSIONS: Colposcopy can be a valuable diagnostic tool for women with unexplained vaginal bleeding in the second or third trimester.

Volume Measurement of the Cavum Septi Pellucidi: Normative Values Between 20 and 40 Weeks of Gestation.

BACKGROUND: The cavum septi pellucidi (CSP) is a brain-enclosed cavity located on the midline between the two leaflets of the septum pellucidum that separates the lateral ventricles. This structure develops in the fetus from week 18 and can be seen up to week 37 in almost all cases and then begins to disappear. OBJECTIVES: To measure and determine the normative values of the CSP volume in fetuses between 20 to 40 weeks of gestation. METHODS: The study comprised 161 consecutive pregnant women between 20 to 40 weeks of gestation with single viable fetuses. All patients had normal, disease-free pregnancies. Transvaginal or transabdominal ultrasound was used according to the fetal presentation. The fetal head was assessed in mid-sagittal sections. Once the CSP was visualized, its volume was measured using three-dimensional ultrasound with Virtual Organ Computer-aided Analysis software. The width of the CSP was also measured at the biparietal diameter (BPD) plane. RESULTS: Of the 161 fetuses, the CSP volume was measured in 158. In three patients the CSP was not identified. The CSP volume correlated poorly with gestational age (r=0.229) and with the BPD (r=0.295). The mean CSP volume was 0.508 ± 0.372 ml (range: 0.03-1.78 ml). The simple measurement of the CSP width correlated better with gestational age (r=0.535) and the BPD (r=0.484). CONCLUSIONS: The CSP volume had a poor correlation with gestational age; however, the volume did not exceed 2 ml regardless of gestational age. This information can be used to assess pathologies involving the CSP.

Antibiotic treatment of women with isolated intrapartum fever vs clinical chorioamnionitis: maternal and neonatal outcomes.

BACKGROUND: Clinical chorioamnionitis refers to the presence of maternal fever (≥38°C) and at least 2 clinical signs: (1) maternal tachycardia (>100 bpm), (2) fetal tachycardia (>160 bpm), (3) maternal leukocytosis >15,000/mm2, (4) purulent vaginal discharge, and (5) uterine tenderness. Few data exist to guide the appropriate management of women with isolated intrapartum fever in the absence of other clinical signs suggesting chorioamnionitis. OBJECTIVE: This study compared maternal and neonatal infectious outcomes and microbiological outcomes between women with isolated intrapartum fever and women with clinical chorioamnionitis. STUDY DESIGN: This 10-year retrospective study included all the laboring women at our institution, at ≥34 weeks of gestation, with a singleton pregnancy and body temperature of ≥38.0°C, with or without other evidences of infection. According to our department protocol, women with isolated intrapartum fever received intravenous ampicillin, whereas women with clinical chorioamnionitis received intravenous ampicillin plus gentamicin. The primary outcome was puerperal endometritis, compared between women with isolated intrapartum fever (treated with ampicillin) and women with clinical chorioamnionitis (treated with ampicillin plus gentamicin). The secondary maternal outcomes consisted of (1) maternal clinical outcomes, such as cesarean delivery, surgical site infection, postpartum hemorrhage, and postpartum length of stay, and (2) microbiological studies, including positive chorioamniotic membrane swabs and blood culture. Among the secondary neonatal outcomes were early-onset sepsis, neonatal intensive care unit admission, and length of stay. Of note, 2 multivariate logistic regression models were created. A model aimed to predict puerperal endometritis controlled for gestational age of >41 weeks, diabetes mellitus, obesity, positive group B streptococcus status, rupture of membrane ≥18 hours, meconium staining, positive chorioamniotic membrane swabs, cesarean delivery, and empiric postdelivery antibiotic administration. A model aimed to predict neonatal early-onset sepsis controlled for gestational age of 34 to 37 weeks, positive group B streptococcus status, rupture of membrane ≥18 hours, and positive chorioamniotic membrane swabs. RESULTS: Overall, 458 women met the inclusion criteria. Compared with women with clinical chorioamnionitis (n=231), women with isolated intrapartum fever (n=227) had higher rates of puerperal endometritis (3.9% vs 8.8%; P=.03), early-onset sepsis (0.4% vs 4.4%; P=.005), positive chorioamniotic membrane swabs (46.3% vs 63.9%; P<.001), and ampicillin-resistant Escherichia coli (35.5% vs 48.9%; P=.033). The rate of group B streptococcus-positive chorioamniotic membrane swabs was similar between the groups. In a subanalysis of women with negative or unknown group B streptococcus status, the puerperal endometritis and neonatal early-onset sepsis rates were higher among women with isolated intrapartum fever than women with suspected chorioamnionitis (8.7% vs 3.3% [P=.041] and 4.1% vs 0% [P<.001], respectively). In 2 multivariate analysis models, among women with isolated intrapartum fever treated with ampicillin compared with those with clinical chorioamnionitis treated with ampicillin and gentamicin, the odds ratio of antibiotic treatment of endometritis was 2.65 (95% confidence interval, 1.06-6.62; P=.036), and the odds ratio of neonatal early-onset sepsis was 8.33 (95% confidence interval, 1.04-60.60; P=.045). CONCLUSION: Women with intrapartum fever, with or without other signs of infection, were at increased risk of maternal and neonatal complications. The use of ampicillin as a sole agent in isolated intrapartum fever might promote ampicillin-resistant E coli growth in the chorioamniotic membranes and consequently lead to puerperal endometritis and early-onset sepsis. In this context, a broad-range antibiotic should be considered.

Third trimester re-screening for gestational diabetes in morbidly obese women despite earlier negative test can reveal risks for obstetrical complications.

AIM: We investigated associations of maternal obesity with late gestational diabetes mellitus (GDM) diagnosis (>34 weeks) in women with previous normal glucose screening, and associations of late GDM with obstetrical outcomes. METHODS: This retrospective cohort study assessed obstetrical and neonatal outcomes of 238 women with normal (24-28 week) glucose screening results, who underwent late repeat oral glucose tolerance tests (OGTT) (>34 weeks) due to a suspected LGA fetus (54.6%) or polyhydramnios (45.4%). A sub-analysis was performed of outcomes of women with late versus mid-trimester GDM. RESULTS: The GDM rate in repeat OGTT screening was 22.2% for the total sample, and 33% among women with morbid obesity. Among women with late GDM versus without late GDM, rates were higher for macrosomia, large-for-gestational-age fetus induction of labor, neonatal hypoglycemia, jaundice, and the need for phototherapy. Among women with late GDM, a higher pregestational BMI was associated with adverse maternal and perinatal outcomes. Higher risks for macrosomia and CS due to macrosomia were demonstrated in women with late vs. mid-trimester GDM. CONCLUSION: Late screening in pregnancy may reveal GDM among women with previous normal glucose screening, particularly among those with late third trimester BMI ≥ 35 kg/m2 , GDM in a previous pregnancy or fasting glucose >95 mg/dl. Women diagnosed with GDM at >34 weeks following normal glucose screening at 24-28 weeks are at higher risk for adverse perinatal outcomes. For women with morbid obesity, or suspected macrosomia or polyhydramnios in the late third trimester, and normal glucose screening in the second trimester, retesting should be considered.

Maternal and Cord Anti-SARS-CoV-2-Spike IgG following COVID-19 Vaccination versus Infection during Pregnancy: A Prospective Study, Israel October 2021-March 2022.

OBJECTIVE: Defining how pregnant women respond to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vaccination is critical to optimize vaccination strategies that protect mother and infant at the epidemic. This study aimed to compare anti-SARS-CoV-2-spike immunoglobulin G (IgG) of vaccinated versus infected women and to determine the optimal timing of maternal vaccination during pregnancy at the time of epidemic. STUDY DESIGN: We collected maternal/cord blood at delivery (October 2021-March 2022) and measured anti-SARS-CoV-2-spike IgG geometric mean concentrations (IgG-GMCs) using a quantitative immunoassay. We compared groups according to timing and number of doses and correlated maternal and fetal IgG levels. We described the proportion of women with IgG levels above the 150 AU/mL positivity threshold according to the timing of infection/vaccination and performed a subanalysis for maternal IgG-GMC levels pre- and during the Omicron wave. RESULTS: We included 238 vaccinated women, 125 who received two doses and 113 three doses, and 48 unvaccinated infected women. All groups infected/vaccinated in the second or third trimester had an IgG-GMC above the positivity threshold. Third-trimester vaccination (second/third dose) resulted in higher maternal and cord-blood IgG-GMC compared to the second trimester (maternal-IgG: 102,32 vs. 4,325 AU/mL, p < 0.001; cord-IgG: 12,113 vs. 8,112 AU/mL, p < 0.001). Compared with infected-only women, a higher proportion of vaccinated women with ≥2 doses and their newborns had IgG levels above the positivity threshold at all time points. In vaccinated women, there were higher maternal IgG-GMC levels during the Omicron wave than pre-Omicron. CONCLUSION: At the time of epidemic, receiving an additional COVID-19 vaccine dose in the third trimester resulted in a higher IgG-GMC compared to the second trimester. Relatively higher levels of maternal and cord IgG-GMC were achieved following vaccination than infection. Women infected during or before the first trimester might benefit from an additional third-trimester dose to prevent peripartum infection and to passively immunize their newborn. The higher levels of maternal IgG-GMC in the Omicron period are suggestive of hybrid immunity. KEY POINTS: · Higher maternal anti-SARS-IgGs in vaccinated → infected.. · Higher cord anti-SARS-IgGs in vaccinated → infected.. · Third-trimester vaccine resulted in high-cord IgG levels..

Clinical implications of the 100-g oral glucose tolerance test in the third trimester.

PURPOSE: The clinical implications of gestational diabetes mellitus (GDM) diagnosed in the third trimester are not well established and controversy continues regarding the performance of diagnostic tests beyond 28-week gestation. This study aimed to evaluate the incidence of abnormal third trimester oral glucose tolerance test (OGTT) results in women at high risk and to compare the obstetric and neonatal outcomes with those of women with normal OGTT results. METHODS: The study included 372 women who completed late (>29 weeks) 100-g OGTT due to suspected fetal macrosomia, polyhydramnios or a personal risk factor for GDM, diagnosed according to the Carpenter & Coustan criteria. Women with only one abnormal OGTT value were diagnosed with GDM by abnormal glucose follow-up and analyzed separately. Obstetric and neonatal outcomes were compared between the GDM and the non-GDM groups. RESULTS: GDM was diagnosed in 85/372 (22%) women, including 35 (59.3%) women with one abnormal OGTT value who were later diagnosed with GDM. Of 200 women who had a normal 1-h 50-g glucose challenge test at 24-28 weeks, late GDM was diagnosed in 33 (16.5%). Seventy-six (89.5%) of those with GDM were treated by dietary therapy and 9 (10.5%) by pharmacological therapy. Among women with GDM, large-for-gestational-age fetuses, labor induction and elective cesarean section were more prevalent than for those without GDM. Significant differences were not found between the groups in macrosomia and neonatal outcomes. CONCLUSIONS: The performance of OGTT in women with risk factors during the third trimester should be considered following further prospective trials.

Clinical implications of uterine cultures obtained during urgent caesarean section.

BACKGROUND: Postpartum endometritis (PPE) is 12-25 times more common following caesarean sections (CS) performed after labour onset than after vaginal delivery. Risk factors for PPE include prolonged rupture of membranes (ROM), chorioamnionitis, prolonged labour, multiple cervical examinations and Group B Streptococcus colonisation of the lower genital tract. AIMS: We compared uterine culture results and microbial antibiotic susceptibility according to ROM duration in emergent intrapartum CS. Secondary outcomes included PPE incidence, and identification of clinical and microbiological predictors of infectious postpartum morbidity. MATERIALS AND METHODS: In a retrospective case series of intrapartum CS in which uterine culture was performed, associations with postpartum outcomes including postpartum microbiology are reported. The results were stratified by the duration of ROM (treated as a categorical variable). Univariate analysis was performed. RESULTS: Positive uterine cultures were identified in 15% of emergent CS and correlated with prolonged ROM. Escherichia coli was the sole pathogen isolated in preterm CS; the ampicillin resistance rate was 75%. Among women with positive uterine cultures, rates were increased for postpartum fever, re-admission, PPE and surgical site infection. Cultures obtained from postpartum infections correlated with pathogens isolated from uterine cultures during CS in 46.1% of women. Positive uterine culture was related to umbilical cord pH < 7.1 (P = 0.017). CONCLUSIONS: Obtaining routine intrauterine culture during intrapartum CS is of low risk and low cost, and relatively easy to perform. Further research should investigate clinical and health economic impacts of obtaining intrauterine culture during CS, influences on postpartum antibiotic treatment, and maternal and neonatal morbidity.

Implementation of French AmbUlatory Cesarean Section (FAUCS): Establishment of a Learning Curve and Short-term Outcomes.

BACKGROUND: The French AmbUlatory Cesarean Section (FAUCS) technique was introduced to the Galilee Medical Center in September 2021. FAUCS was performed electively for interested women who meet the criteria. OBJECTIVES: To evaluate the learning curve of senior surgeons performing FAUCS, the procedure short-term outcomes, and complications. METHODS: This retrospective study included 50 consecutive women who underwent FAUCS from September 2021 until March 2022 at our facility. Preoperative, intraoperative, postoperative, and demographic data were retrieved from patient electronic charts. RESULTS: The mean duration of surgery was 53.26 ± 11.62 minutes. This time decreased as the surgical team's experience increased: from a mean 58.26 ± 12.25 minutes for the first 15 procedures to a mean 51.17 ± 9.73 minutes for subsequent procedures. The mean visual analogue scale score for 24 hours was 1.08 ± 0.84 (on a 10-point scale). The rate of neonatal cord pH < 7.2 was 6%, and there were 11.3% cases of vacuum assisted fetal extraction. In total, 44% of the women were able to mobilize and urinate spontaneously by 4-6 hours. Complications included bladder injury (n=1), endometritis (n=1), and incisional hematoma (n=1). Overall, the maternal satisfaction rate was high; 94% of the women would recommend FAUCS to others. CONCLUSIONS: FAUCS is a feasible procedure with a high satisfaction rate. Following the first 15 procedures performed by one surgical team, the operative time decreased considerably. Further randomized controlled studies are needed to compare this procedure to regular cesarean section and evaluate neonatal outcomes.

Liver stiffness and steatosis in preeclampsia as shown by transient elastography-a prospective cohort study.

BACKGROUND: Preeclampsia is a multisystem disorder and the leading cause of severe morbidity and death in pregnancy. Liver involvement in preeclampsia ranges from elevated liver enzyme levels to hepatic infarction or rupture. Endothelial dysfunction leads to changes in blood flow and congestion and may be involved in the pathophysiology of preeclampsia. Changes in splanchnic blood flow and portal congestion can lead to altered liver stiffness. Transient elastography is a noninvasive, ultrasound-based technique that measures organ stiffness and steatosis and is therefore widely used in clinical hepatology. Previous studies reported elevated liver stiffness and liver steatosis, as measured by transient elastography, in women with preeclampsia. OBJECTIVE: This study followed changes in liver stiffness and steatosis, as measured by transient elastography, from the antepartum period to 1-week postpartum among women with preeclampsia compared with healthy controls and evaluated the association between preeclampsia severity and transient elastography results. STUDY DESIGN: This prospective cohort study was conducted from 2017 through 2021. The study group comprised women with preeclampsia, and the control group comprised healthy pregnant women hospitalized for other reasons. All the participants underwent transient elastography either on diagnosis of preeclampsia (study group) or on hospital admission (control group) and again in the postpartum period. Liver stiffness measurements are expressed in kilopascals (kPa) in the range of 2.5 to 75 kPa, and liver steatosis is expressed by controlled attenuation parameter in the range of 100 to 400 dB/m. RESULTS: The study group comprised 36 women and the control group 37. Liver stiffness scores were significantly elevated in the study when compared with the control group, both in the antepartum period (P<.001) and the postpartum period (P=.025). Liver stiffness scores decreased significantly after delivery in the study and control groups (P<.001 and P=.002, respectively). Liver steatosis scores were higher in the study group than in the control group both in the antepartum and postpartum periods (P<.001 and P<.02, respectively). In the multivariable analysis, the diagnosis of preeclampsia correlated with higher antepartum liver stiffness scores (P=.005). For the study group, postpartum liver stiffness and liver steatosis scores were increased among those with vs those without severe features of preeclampsia (P=.03 and P=.04, respectively) CONCLUSION: Reductions in liver stiffness and steatosis from the antepartum to the postpartum period were documented in both the preeclampsia and control groups. However, both these measures were higher in the preeclampsia group and correlated with preeclampsia severity. Larger studies may be able to determine whether transient elastography can predict the severity of preeclampsia or other related metabolic conditions that correlate with chronic hypertension.

Obstetrical Outcome following Diagnosis of Gestational Diabetes in the Third Trimester (>29 Weeks) versus Second Trimester (24-28 Weeks): A Retrospective Comparative Study.

OBJECTIVE: This study aimed to compare obstetrical outcomes between women diagnosed with gestational diabetes mellitus (GDM) in the third trimester after testing negative for GDM in two-step screening in the second trimester and women diagnosed in the second trimester. STUDY DESIGN: This retrospective study compared obstetrical outcomes between 375 women diagnosed with GDM in the second trimester and 125 diagnosed in the third trimester. RESULTS: Among women diagnosed with GDM in the third versus second trimester, the incidences were higher of morbid obesity (body mass index ≥35 kg/m2), macrosomia, and cesarean section (CS) due to suspected macrosomia: 23.2 versus 9.8%, p < 0.001; 44.0 versus 10.1%, p < 0.001; and 24.8 versus 6.3%, p < 0.001, respectively. For those diagnosed in the third versus second trimester, the incidences were lower of hypertensive disorders of pregnancy and intrauterine growth restriction, and a lower proportion of women needed pharmacological therapy for glucose control: 2.4 versus 9.0%, p = 0.016; 0.8 versus 8.2%, p < 0.001; and 12.0 versus 29.7%, p < 0.001, respectively. Multivariate analysis supported a correlation between third-trimester-diagnosed GDM and macrosomia, and between second-trimester-diagnosed GDM and hypertensive disorders of pregnancy. CONCLUSION: Among women diagnosed with GDM in the third compared with the second trimester, the incidence of morbid obesity was higher; accordingly, the risks were higher for large for gestational age infants and delivery by CS, and lower for hypertensive disorders. Guidelines regarding repeat oral glucose tolerance testing in the third trimester should be considered following prospective studies. KEY POINTS: · Third-trimester GDM was 29.9% among women with normal second-trimester screening.. · Morbid obesity and macrosomia were more frequent in third- versus second-trimester GDM.. · Incidence of preeclampsia was lower in third- versus second-trimester-diagnosed GDM..