Time to Delivery after Scheduled Shirodkar Cerclage Removal in Singleton Gestations based on the Original Indication for Cerclage Placement.

OBJECTIVE: To estimate the time to delivery after elective cerclage removal and evaluate whether there is a difference based on the indication for cerclage placement. STUDY DESIGN: This was a retrospective cohort of singleton pregnancies that underwent Shirodkar cerclage placement at a single maternal-fetal medicine practice between June 2005 and June 2017. We included all scheduled elective cerclage removals >36 weeks. The primary outcome was latency to delivery. We further compared time to delivery based on the original indication for cerclage. Data were analyzed using the one-way analysis of variance and chi-square test. RESULTS: A total of 143 patients met the inclusion criteria. Of these, 40.6% were history indicated, 51.0% ultrasound indicated, and 8.4% exam indicated. The mean time from removal to delivery was 13.3 ± 8.4 days; 12.6% (18/136) of patients delivered within 24 hours of removal. When stratified by indication for cerclage, there were no significant differences for all delivery outcomes. Delaying cerclage removal to >37 weeks resulted in a statistically significantly later gestational age at delivery compared with removal between 36 and 366/7 weeks (39.0 vs. 38.3 weeks, p = 0.001). CONCLUSION: The mean time from elective Shirodkar cerclage removal to delivery is 13 days with only 12.6% of patients delivering within 24 hours of removal.

The Association between Fetal Fibronectin, Cervical Length, and Amniotic Fluid Sludge with Histological Indicators of Placental Inflammation in Twin Gestations.

OBJECTIVE: The objective of this study was to evaluate the association of screening tests for preterm birth (short cervical length [CL], positive fetal fibronectin (FFN), and amniotic fluid [AF] sludge) in twin gestations with histologic evidence of placental inflammation. STUDY DESIGN: Historical cohort study of 596 twin gestations delivered in a single maternal-fetal medicine practice with CL and FFN testing from 22 to 256/7 weeks. A short CL was defined as ≤25 mm. Placental lesions evaluated were chronic and acute membrane inflammation and funisitis. Fischer's exact test and logistic regression were used. RESULTS: None of the screening tests was associated with chronic inflammation. All were associated with acute inflammation. On regression analysis, a short CL and positive FFN remained independently associated with acute inflammation (adjusted odds ratio [aOR]: 5.66 and 2.51, respectively) and funisitis (aOR: 5.66 and 7.17, respectively). AF sludge was not independently associated with acute inflammation nor funisitis. CONCLUSION: In twin gestations, a short CL and a positive FFN at 22 to 26 weeks are associated with acute but not chronic inflammation on placental histology. These findings imply that mechanisms underlying preterm birth in twins that result in positive screening tests weeks prior to delivery are not reflected as chronic placental inflammation. Therefore, pathologic interpretation of etiologic mechanisms for preterm birth may be limited using solely histologic reports.

Risk factors for blood transfusion in patients undergoing high-order Cesarean delivery.

BACKGROUND: The objective was to identify risk factors associated with blood transfusion in patients undergoing high-order Cesarean delivery (CD). STUDY DESIGN AND METHODS: This was a retrospective cohort study of patients undergoing third or more CD by a single maternal-fetal medicine practice between 2005 and 2016. We compared risk factors between women who did and did not receive a red blood cell transfusion during the operation or before discharge. Repeat analysis was performed after excluding women with placenta previa. RESULTS: A total of 514 patients were included, 18 of whom (3.5%; 95% confidence interval [CI], 2.2%-5.5%) received a blood transfusion. Placenta previa was the most significant risk factor for transfusion (61.1% of patients who received a transfusion vs. 1% of patients who did not; p < 0.001). Patients with a placenta previa had a 68.8% likelihood of requiring a blood transfusion. After women who had placenta previa were excluded, the incidence of blood transfusion was seven of 498 (1.4%; 95% CI, 0.7%-2.9%). Risk factors significantly associated with blood transfusion in the absence of previa were prophylactic anticoagulation during pregnancy and having labored. The incidence of transfusion in patients with no placenta previa, no anticoagulation, and no labor was 0.7% (95% CI, 0.3%-2.1%). Placenta previa was the most predictive risk factor for transfusion with a positive predictive value of 68.8% and a negative predictive value of 98.4%. CONCLUSION: In patients undergoing a third or more CD, only placenta previa, prophylactic anticoagulation during pregnancy, and having labored are independently associated with requiring a blood transfusion. These data can be used to guide physician ordering of prepared blood products preoperatively.

The Independent Association of a Short Cervix, Positive Fetal Fibronectin, Amniotic Fluid Sludge, and Cervical Funneling with Spontaneous Preterm Birth in Twin Pregnancies.

Objective To estimate the independent association of a short cervical length (CL), positive fetal fibronectin (fFN), amniotic fluid (AF) sludge, and cervical funneling with spontaneous preterm birth in twin pregnancies. Methods Retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from June 2005 to February 2014. All patients underwent transvaginal sonographic CL and fFN testing. We reviewed all images from the first CL at 22(0/7) to 25(6/7) weeks for the presence of (1) a short CL, which is defined as ≤25 mm, (2) AF sludge, and (3) cervical funneling, and also recorded (4) the fFN result from that time. Image reviewers were blinded to pregnancy outcomes. Patients with cerclage were excluded. Using logistic regression, we calculated the independent association between these four biomarkers and spontaneous preterm birth. Results A total of 635 patients with twin pregnancies were included. The markers independently associated with spontaneous preterm birth <35 weeks were short CL (adjusted odds ratio [aOR]: 10.73; 95% confidence interval [CI]: 3.21-35.81), positive fFN (aOR: 3.25; 95% CI: 1.13-9.33), and AF sludge (aOR: 2.11; 95% CI: 1.04-4.27). Similarly, these three markers were independently associated with earlier gestational ages at delivery. Cervical funneling was not independently associated with spontaneous preterm birth <35 weeks nor gestational age at delivery. The risk of spontaneous preterm birth increased significantly with the number of positive biomarkers (short CL, positive fFN, and AF sludge). Conclusion In twin pregnancies, a short CL, positive fFN, and AF sludge are independently associated with spontaneous preterm birth. Cervical funneling is not independently associated with spontaneous preterm birth in twins.

Outcomes in twin pregnancies reduced to singleton pregnancies compared with ongoing twin pregnancies.

OBJECTIVE: Multifetal pregnancy reduction has been shown to improve outcomes in triplet and higher-order multiple pregnancies. The data for fetal reduction of twin pregnancies are limited. The purpose of this study was to compare adverse pregnancy outcomes in ongoing twin pregnancies compared with twin pregnancies reduced to singletons. STUDY DESIGN: This was a retrospective cohort study comparing dichorionic diamniotic twin pregnancies with dichorionic diamniotic twin pregnancies reduced to singleton gestations between 11 and 24 weeks' gestation in a single maternal-fetal medicine practice over a 9 year period. Adverse pregnancy outcomes after 24 weeks were compared, with a value of P < .05 used for significance. RESULTS: Five hundred one ongoing twin pregnancies and 63 twin pregnancies reduced to singletons were included. Patients with reductions to singletons had a significantly lower risk of preterm delivery before 37 weeks' gestation (10% vs 43%; P < .001) but no difference in the risk of preterm delivery before 34 weeks' or 28 weeks' gestation. Patients with reductions to singletons also had a lower risk of infant birthweight less than the 10% (23% vs 49%; P < .001) but no difference in the risk of infant birthweight less than the 5%. There was no difference in the risk of fetal demise after 24 weeks' gestation. CONCLUSION: Fetal reduction of twin pregnancies decreases the risk of late preterm birth and birthweight less than the 10% but not the risks of more severe complications such as early preterm birth or birthweight less than the 5%.

Risk factors for cesarean delivery in twin pregnancies attempting vaginal delivery.

OBJECTIVE: The purpose of this study was to estimate independent risk factors for cesarean delivery in patients with twin pregnancies who attempt vaginal delivery. STUDY DESIGN: This was an historic cohort of twin pregnancies that were delivered in 1 practice from June 2005 to February 2014. Baseline characteristics were compared between women who delivered vaginally and women who underwent cesarean delivery in labor. Logistic regression analysis was performed to estimate independent risk factors for cesarean delivery. RESULTS: Two hundred eighty-six women with twin pregnancies who had attempted vaginal delivery were included in the study. The overall modes of delivery were vaginal delivery (82.2%), cesarean delivery (17.8%), and combined vaginal-cesarean delivery (0%). The most common indication for cesarean delivery in labor was an arrest disorder (82.4%). The risk factors that were associated independently with cesarean delivery were nulliparity (adjusted odds ratio, 5.78; 95% confidence interval, 2.24-14.88) and advanced maternal age of ≥35 years (adjusted odds ratio, 2.36; 95% confidence interval, 1.16-4.80). The patients at highest risk for cesarean delivery (nulliparous, advanced maternal age, induced labor) still had a 48.6% likelihood of vaginal delivery. CONCLUSION: In patients with twin pregnancies who attempt labor, nulliparity and advanced maternal age are associated independently with cesarean delivery in labor. However, even the patients at highest risk for cesarean delivery have nearly a 50% likelihood of successful vaginal delivery and therefore should be allowed to attempt vaginal delivery if it is desired and not otherwise contraindicated.

Antenatal Surveillance in Twin Pregnancies Using the Biophysical Profile.

Objectives-The nonstress test is currently the most widely used modality for antenatal surveillance in twin pregnancies, with a quoted false-positive rate of 11%-12%. Our objective was to report our experience with the sonographic portion of the biophysical profile in twin pregnancies as the primary screening modality.Methods-Women with twin pregnancies delivered by a single maternal-fetal medicine practice from 2005 to 2013 were included. We excluded monoamniotic twins. Twin pregnancies began weekly sonography for the biophysical profile starting at 32 to 33 weeks, or earlier if indicated. The nonstress test was performed if the sonographic biophysical profile score was less than 8 of 8. We reviewed biophysical profile scores and outcomes for all patients who delivered at 33 weeks or later to assess the false-positive rate for the biophysical profile, as well as the incidence of intrauterine fetal death (IUFD) after initiation of antenatal surveillance.Results-A total of 539 twin pregnancies were included. The incidence of IUFD per patient was 2 per 539 (0.4%; 95% confidence interval [CI], 0.1%-1.3%), and the incidence of IUFD per fetus was 2 per 1078 (0.19%; 95% CI, 0.05%-0.7%). The overall positive screen rate was 24 per 539 (4.45%; 95% CI, 3.0%-6.5%). The false-positive screen rate, defined as an abnormal biophysical profile that did not diagnose an IUFD or lead to delivery, was 10 per 539 (1.9%; 95% CI, 1.0%-3.4%).Conclusions-In twin pregnancies the use of the sonographic biophysical profile for routine antenatal surveillance has a low false-positive rate, with a very low incidence of IUFD. The sonographic biophysical profile should be considered as a primary mode for antenatal surveillance in twin pregnancies, with a reflex nonstress test for an abnormal score.

Gestational age at cervical length and fetal fibronectin assessment and the incidence of spontaneous preterm birth in twins.

OBJECTIVES: To estimate the risk of spontaneous preterm birth in twin pregnancies based on transvaginal sonographic cervical length, fetal fibronectin (fFN) testing, and the gestational age at which these tests were performed. METHODS: Women with twin pregnancies, cervical length assessment, and fFN testing between 22 weeks and 31 weeks 6 days in a single maternal-fetal medicine practice from 2005 to 2013 were included. All testing was done on asymptomatic women on an out-patient basis. Women with monochorionic monoamniotic twins and twin-twin transfusion were excluded. Logistic regression analysis was used to estimate the risk of spontaneous preterm birth before 35, 32, and 28 weeks. RESULTS: Six hundred eleven patients were included and underwent a total of 2406 cervical length measurements and 2279 fFN tests over the course of the study period. The likelihood values for spontaneous preterm birth before 35, 32, and 28 weeks were 19.1%, 6.3%, and 2.3%, respectively. The risk of spontaneous preterm birth before 35 weeks increased with a decreasing cervical length (coefficient for the log of the odds ratio [OR coefficient], -0.13; P < .01; 95% confidence interval [CI], -0.22 to -0.037), a positive fFN result (OR coefficient, 1.04; P < .01; 95% CI, 0.45 to 1.64), as well as earlier gestational ages at testing (OR coefficient, -0.214; P < .01; 95% CI, -0.33 to -0.10). Similar results were seen for spontaneous preterm birth before 32 and 28 weeks. CONCLUSIONS: In asymptomatic patients with twin pregnancies, the cervical length, fFN, and gestational age are all significantly associated with spontaneous preterm birth.

Abnormal Biochemical Analytes Used for Aneuploidy Screening and Adverse Pregnancy Outcomes in Twin Gestations.

OBJECTIVE: The objective of this study was to determine if first- and second-trimester biochemical markers for aneuploidy have an association with adverse pregnancy outcomes in twin gestations. STUDY DESIGN: A retrospective cohort study of patients who presented with dichorionic diamniotic twin gestations was performed. Patients with first-trimester low pregnancy-associated plasma protein A (PAPP-A) or low free ß human chorionic gonadotropin (ß-hCG), or second-trimester elevated α-fetoprotein (AFP), elevated inhibin A, elevated hCG, or low unconjugated estradiol were identified. The rates of adverse pregnancy outcomes were compared between patients with or without abnormal analytes with p < 0.05 used as significance. RESULTS: In this study, 340 pregnancies were included. Patients with a low PAPP-A had an increased risk for delivery < 37 weeks. Patients with an elevated second-trimester hCG had an increased risk for spontaneous delivery < 28 weeks and neonatal intensive care unit (NICU) admission. Patients with an elevated inhibin A had an increased risk of spontaneous delivery at < 37 and NICU admission. Patients with an elevated AFP had an increased risk of a NICU admission. CONCLUSION: Certain abnormal aneuploidy markers are associated with an increased risk of adverse pregnancy outcomes in twin gestations.

Is MSAFP still a useful test for detecting open neural tube defects and ventral wall defects in the era of first-trimester and early second-trimester fetal anatomical ultrasounds?

INTRODUCTION: To evaluate whether maternal serum α-fetoprotein (MSAFP) improves the detection rate for open neural tube defects (ONTDs) and ventral wall defects (VWD) in patients undergoing first-trimester and early second-trimester fetal anatomical survey. MATERIAL AND METHODS: A cohort of women undergoing screening between 2005 and 2012 was identified. All patients were offered an ultrasound at between 11 weeks and 13 weeks and 6 days of gestational age for nuchal translucency/fetal anatomy followed by an early second-trimester ultrasound at between 15 weeks and 17 weeks and 6 days of gestational age for fetal anatomy and MSAFP screening. All cases of ONTD and VWD were identified via query of billing and reporting software. Sensitivity and specificity for detection of ONTD/VWD were calculated, and groups were compared using the Fisher exact test, with p < 0.05 as significance. RESULTS: A total of 23,790 women met the criteria for inclusion. Overall, 15 cases of ONTD and 17 cases of VWD were identified; 100% of cases were diagnosed by ultrasound prior to 18 weeks' gestation; none were diagnosed via MSAFP screening (p < 0.001). First-trimester and early second-trimester ultrasound had 100% sensitivity and 100% specificity for diagnosing ONTD/VWD. DISCUSSION: Ultrasound for fetal anatomy during the first and early second trimester detected 100% of ONTD/VWD in our population. MSAFP is not useful as a screening tool for ONTD and VWD in the setting of this ultrasound screening protocol.

The relationship between preeclampsia and intrauterine growth restriction in twin pregnancies.

OBJECTIVE: Preeclampsia and intrauterine growth restriction (IUGR) are correlated in singleton pregnancies. The objective of this study was to estimate their relationship in twin pregnancies. STUDY DESIGN: Cohort of 578 patients with twin pregnancies delivered by 1 maternal fetal medicine practice from 2005-2013. Patients with chronic hypertension, monochorionic-monoamniotic placentation, twin-twin transfusion, and major congenital anomalies were excluded. Standard definitions were used for gestational hypertension and preeclampsia. We defined IUGR as any twin birthweight less than the 5th percentile for gestational age, as well as any twin birthweight less than the 10th percentile for gestational age. RESULTS: The incidence of preeclampsia was 14.9%, the incidence of birthweight <10% was 50.0%, and the incidence of birthweight <5% was 27.5%. Comparing patients with and without preeclampsia, the rate of birthweight <5th percentile did not differ (27.9% vs 27.4%, P = .929), nor did the rate of birthweight <10th percentile (48.8% vs 50.2%, P = .815). We had 80% power with an alpha error of 5% to show a difference in the likelihood of IUGR <10th percentile from 50% to 66% and a difference in the likelihood of IUGR <5th percentile from 27% to 42% in patients without and with preeclampsia. CONCLUSION: In patients with twin pregnancy, there is no correlation between preeclampsia and IUGR. This suggests that in twin pregnancies, as opposed to singleton pregnancies, the pathophysiology may differ between these 2 common conditions.

Screening approach for gestational diabetes in twin pregnancies.

OBJECTIVE: The objective of this study was to evaluate the ideal cutoff for the glucose challenge test (GCT) in twin pregnancies undergoing screening for gestational diabetes mellitus (GDM). STUDY DESIGN: A historical cohort of patients with twin pregnancies were identified from 1 maternal-fetal medicine practice from 2005 through 2013. All patients were administered a 1-hour, 50-g GCT between 24-28 weeks' gestation. All patients with a GCT of ≥130 mg/dL underwent a 3-hour, 100-g oral glucose tolerance test. The diagnosis of GDM was made if 2 of the 4 values on the oral glucose tolerance test were abnormal (Carpenter and Coustan). The testing characteristics of the GCT for diagnosis of GDM were evaluated using 3 selected cutoffs: ≥130, ≥135, and ≥140 mg/dL. We excluded all patients diagnosed with GDM <24 weeks. RESULTS: In all, 475 patients with twin pregnancies underwent a GCT between 24-28 weeks. The incidence of GDM was 6.5%. The positive screen rate using the 3 selected cutoffs were: ≥130 mg/dL, 34.7%; ≥135 mg/dL, 28.6%; and ≥140 mg/dL, 23.4%. A GCT cutoff of ≥135 mg/dL maintained 100% sensitivity, with a specificity of 76.4%. Using this cutoff, the positive predictive value was 22.8% and the negative predictive value was 100%. Compared to a cutoff of ≥130 mg/dL, a cutoff of ≥135 mg/dL resulted in 6.1% less patients testing positive while maintaining the same 100% sensitivity. CONCLUSION: In twin pregnancies, the optimal 1-hour, 50-g GCT screening cutoff appears to be ≥135 mg/dL.

Early second-trimester sonography to improve the fetal anatomic survey in obese patients.

OBJECTIVES: Fetal anatomic surveys are difficult to perform on obese patients. However, there are limited data available on methods to improve the rate of complete anatomy scans in these patients. The objective of this study was to determine whether the addition of an early second-trimester fetal anatomy scan improves the rate of complete anatomy scans in obese patients. METHODS: We conducted a prospective cohort study of 100 obese patients at a city hospital who were scheduled for a fetal anatomy scan using transvaginal and transabdominal sonography at 14 to 16 weeks (early anatomy scan) and an anatomy scan at 18 to 22 weeks ("routine" anatomy scan). Inclusion criteria were a body mass index of 30 kg/m(2) or higher, singleton pregnancy, and presentation for prenatal care before 16 weeks. Data for the routine anatomy scan alone versus a combination of early and routine anatomy scans was calculated by the McNemar χ(2) test for categorical variables and the Wilcoxon signed ranks test for continuous variables. RESULTS: The addition of the early anatomy scan significantly increased the rate of complete anatomy scans from 42% to 51% (P < .01). It also significantly improved visualization of the head, thorax, and abdomen and significantly increased the mean number of items seen (P < .05). CONCLUSIONS: The addition of an early second-trimester fetal anatomy scan to a routine anatomy scan performed later in the second trimester significantly improves the rate of complete anatomy scans in obese patients.

Factors related to corticosteroid utilization in preterm birth.

We sought to determine the rate of corticosteroid administration in preterm births in our institution and to describe factors associated with lack of corticosteroid exposure. We performed a retrospective case-control analysis. Of the 312 eligible women who delivered between 24 and 34 weeks' gestation, maternal corticosteroid administration was documented in 262 (84%) and no exposure in 50 (16%). A shorter admission to delivery interval (< 48 hours) decreased the likelihood of corticosteroid administration (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.03 to 0.28, P < 0.001). Use of tocolytics was associated with a lower risk of corticosteroid nonexposure (OR 0.21, 95% CI 0.04 to 0.69, P = 0.006). Lack of prenatal care was associated with an increased risk of corticosteroid nonexposure (OR 3.18, 95% CI 1.01 to 9.15, P = 0.01). The likelihood of corticosteroid administration was also decreased by gestational ages at the upper limit of the spectrum (33 to 34 weeks; OR 0.22, 95% CI 0.09 to 0.53, P < 0.001). The latter effect persisted after exclusion of premature rupture of membranes cases. In our population, factors associated with no maternal corticosteroid administration were shorter interval between admission and delivery, gestational age at the upper limit of the currently recommended interval for corticosteroid administration, and lack of prenatal care.

Change in cervical length and spontaneous preterm birth in nulliparous women with a history of loop electrosurgical excision procedure.

BACKGROUND: Prior studies have shown an association between history of loop electrode procedures (LEEP) and spontaneous preterm delivery (SPTD) independent of mid-trimester cervical length. These studies suggest that there may be other factors beyond an individual cervical length, which contribute to identifying at-risk pregnancies. OBJECTIVE: The objective of this study is to determine the association between change in cervical length and SPTD in women with a history of LEEP. STUDY DESIGN: This is a retrospective cohort study of singleton nulliparous women with a history of LEEP who received serial cervical length measurements at a single institution between 2012 and 2016. Women with serial cervical lengths and available outcome data were included. The cervical length at different gestational ages and the rate of change in length were compared with the risk for SPTD <37 weeks using Student's t-test. RESULTS: One-hundred-thirty subjects met the inclusion criteria for the study. The mean cervical length (35.3 versus 39.8 mm, p = .042 at 16 weeks; 32.2 versus 37.8 mm, p < .01 at 20 weeks; 29.9 versus 35.6 mm, p = .027 at 24 weeks; 21.6 versus 33.4 mm, p < .01 at 28 weeks) was significantly different between women who had an SPTD <37 weeks compared to women who did not. The average rate of change in transvaginal cervical length between 16 to 28 weeks was significantly different between women who had an SPTD <37 weeks compared to women who did not (-1.4 versus 0.4 mm/week, p < .01). CONCLUSION: Women with a history of LEEP who had an SPTD <37 weeks had a shorter cervical length at 16, 20, 24, and 28 weeks' gestation and a higher rate of change in cervical length between 16 and 28 weeks than women without a history of SPTD. Our findings support the concept of the preterm birth syndrome as an evolving biophysical process rather than a distinct event, suggesting improved prediction in the setting of prior history of a LEEP with serial imaging.

Vaginal birth after a cesarean delivery for arrest of descent.

OBJECTIVE: The objective of this study is to determine vaginal birth after cesarean (VBAC) success rates for patients with a prior cesarean delivery (CD) for arrest of descent, as well as determine any predictors for success. STUDY DESIGN: This was a retrospective cohort study of all patients delivered by a single MFM practice from 2005 to 2017 with a singleton pregnancy and one prior CD for arrest of descent. We estimated the rate and associated risk factors for successful VBAC. RESULTS: We included 208 patients with one prior CD for arrest of descent, 100 (48.1%) of whom attempted a trial of labor after cesarean (TOLAC) with a VBAC success rate was 84/100 (84%, 95% CI 76-90%). Among the women who attempted TOLAC, women with a prior vaginal delivery >24 weeks' had a significantly higher VBAC success rate (91.8% versus 71.8%, p = .01). Maternal age, body mass index, estimated fetal weight, induction of labor, and cervical dilation were not associated with a higher VBAC success rate. CONCLUSIONS: For women with a prior CD for arrest of descent, VBAC success rates are high. This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.

Outcomes in patients with early-onset fetal growth restriction without fetal or genetic anomalies.

OBJECTIVE: Early-onset fetal growth restriction is associated with poor pregnancy outcomes, but frequently is due to fetal structural or chromosomal abnormalities. The objective of this study was to determine outcomes in patients with early-onset fetal growth restriction without diagnosed fetal or genetic anomalies and to identify additional risk factors for poor outcomes in these patients. METHODS: This was retrospective cohort study of singleton pregnancies in women with early-onset growth restriction defined as a sonographic estimated fetal weight <10% diagnosed between 16-28 weeks' gestation. We excluded all women with a fetal structural or chromosomal abnormality diagnosed prenatally. Data on pregnancy characteristics and outcomes were collected and analyzed for estimated fetal weight <10% and ≤5%. A nested case-control study within the cohort of patients with ongoing pregnancies was then performed to identify risk factors associated with poor pregnancy outcome using chi-squared test. RESULTS: One hundred forty-two patients were identified who met inclusion and exclusion criteria and 20 patients were found to have fetal structural or chromosomal abnormalities. In the remaining 122 patients, the incidence of intrauterine fetal demise was 5.7% and there were high rates of preterm birth <37 weeks (20%), birth weight <10% (59.3%), and gestational hypertension (14.1%). Later gestational age at diagnosis and the presence of echogenic bowel and abnormal initial umbilical artery Dopplers were associated with poor pregnancy outcome (22.56 versus 20.86 weeks, p = .046), (17.4 versus 2.2%, OR 9.68, 95%CI 1.65-56.73), and (35.3 versus 0%, OR 4.46, 95%CI 2.65-7.50) respectively. CONCLUSIONS: Patients with early-onset fetal growth restriction with no fetal structural or genetic abnormality have a high risk of poor pregnancy outcomes. Gestational age at diagnosis and certain ultrasound findings are associated with poor pregnancy outcome.