Integrating technologies to provide comprehensive remote fetal surveillance: A prospective pilot study.

OBJECTIVE: To determine the feasibility of extending remote maternal-fetal care to include fetus well-being. METHODS: The authors performed a prospective pilot study investigating low-risk pregnant participants who were recruited at the time of their first full-term in-person visit and scheduled for a follow-up telemedicine visit. Using novel self-operated fetal monitoring and ultrasound devices, fetal heart monitoring and amniotic fluid volume measurements were obtained to complete a modified biophysical profile (mBPP). Total visit length was measured for both the in-person first visit and the subsequent telemedicine encounter. A patient satisfaction survey form was obtained. RESULTS: Ten women between 40 + 1 and 40 + 6 weeks of gestation participated in telemedicine encounters. Nine women (90%) were able to complete remote mBPP assessment. For one participant, fetal assessment was not completed due to technically inconclusive fetal monitoring. Another participant was referred for additional assessment in the delivery room. Satisfactory amniotic fluid volume measurements were achieved in 100% of participants. The telemedicine encounter was significantly shorter (93.1 ± 33.1 min) than the in-person visit (247.2 ± 104.7 min; P < 0.001). We observed high patient satisfaction. CONCLUSION: Remote fetal well-being assessment is feasible and time-saving and results in high patient satisfaction. This novel paradigm of comprehensive remote maternal and fetal assessment is associated with important clinical, socioeconomic, and logistics advantages.

Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment.

OBJECTIVE: This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. STUDY DESIGN: A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. RESULTS: The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. CONCLUSION: Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. KEY POINTS: · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..

Utilizing machine learning to predict unplanned cesarean delivery.

OBJECTIVE: To develop a comprehensive machine learning (ML) model predicting unplanned cesarean delivery (uCD) among singleton pregnancies based on features available at admission to labor. METHODS: A retrospective cohort study from a tertiary medical center. Women with singleton vertex pregnancy of 34 weeks or more admitted for vaginal delivery between March 2011 and May 2019 were included. The cohort was divided into training (80%) and validation (20%) data sets. A separate cohort between June 2019 and April 2021 served as a test data set. Features selection was performed using a Random Forest ML algorithm. RESULTS: The study population included 73 667 women, of which 4125 (6.33%) underwent uCD. The final model consisted of 13 features, based on prediction importance. The XGBoost model performed best with areas under the curve for the training, validation, and test data sets of 0.874, 0.839, and 0.840, respectively. The model showed a 65% positive predictive value for uCD among women in the 100th centile group, and a 99% or more negative predictive value in the less than 50th centile group. Positive and negative predictive values remained high among subgroups with high pretest probability of uCD. CONCLUSION: An ML model for the prediction of uCD provides clinically useful risk stratification that remains accurate across gestational weeks 34-42 and among clinical risk groups. The model may be clinically useful for physicians and women admitted for labor. SYNOPSIS: A machine learning model predicts unplanned cesarean delivery and can inform women's individualized decision making.

Trial of labor after cesarean delivery for estimated large for gestational age fetuses: A retrospective cohort study.

OBJECTIVE: Although ultrasonographic estimation of fetal weight ≥90th percentile is not associated with a greater risk for uterine rupture, trial of labor after cesarean delivery (TOLAC) is considered relatively contraindicated for macrosomic fetuses. Hence, when an estimated fetal weight of 4000 g is detected, TOLAC is usually avoided.Our aim was to evaluate the obstetrical outcome and safety of TOLAC in women with estimated large for gestational age fetuses (eLGA) (≥90th percentile). STUDY DESIGN: Our retrospective cohort study encompassed all pregnant women with an estimated fetal weight ≥90th percentile for gestational age, admitted to a single tertiary care center between January 2012-July 2017 for TOLAC. RESULTS: 1949 women met the inclusion criteria; 78 (4%) eLGA and 1871 (96%) controls. Fifty-five (70.5%) women in the study group had experienced a successful vaginal delivery compared to 1506 (80.5%) of the controls (p = 0.03). The rate of obstetrical complications, including scar dehiscence, uterine rupture, a 3rd/4th degree perineal tear or shoulder dystocia were comparable. The rate of post-partum hemorrhage (PPH) increased in the study group compared to the controls (7.7 % vs.1.7%; p = 0.001). CONCLUSION: TOLAC for eLGA fetuses can be considered safe, however, lower successful rates of vaginal births after a cesarean delivery and an increased PPH rate, may be expected.

Predictive value of new onset versus primary meconium-stained amniotic fluid.

BACKGROUND: Transition of clear amniotic fluid to meconium-stained fluid is a relatively common occurrence during labor. However, data regarding the clinical significance and the prognostic value of the presence of meconium-stained amnionic fluid (MSAF) are scarce. This study aimed to investigate delivery and neonatal outcomes according to the presence of MSAF and the timing of the meconium passage. METHODS: We used an historical cohort study at a single tertiary medical center in Israel between the years 2011 and 2018. Women were divided into two groups according to timing of meconium passage: primary MSAF (MSAF present at membrane rupture) and secondary MSAF (clear amnionic fluid that transitioned to MSAF during labor). Neonatal complication rates were compared between groups. Composite adverse neonatal outcome was defined as arterial cord blood pH <7.1, 5 min Apgar score ≤7, and/or neonatal intensive care unit admission. RESULTS: The study cohort included 56 863 singleton term births. Of these, 9043 (15.9%) were to women who had primary MSAF, and 1484 (2.6%) to those with secondary MSAF. Secondary MSAF compared with primary MSAF increased the risks of cesarean birth and operative vaginal delivery, increased the risks of low one- and five-minute Apgar scores and low arterial cord blood pH, and increased hospital stay duration. Multivariate analysis revealed that secondary MSAF was independently associated with an increased risk of composite adverse neonatal outcome (OR1.68, 95% CI 1.25-2.24, p < 0.001) compared with primary MSAF. CONCLUSIONS: In this sample, secondary MSAF was associated with more adverse neonatal outcomes than primary MSAF. Closer monitoring of fetal well-being may be prudent in these cases.

Implementation of machine learning models for the prediction of vaginal birth after cesarean delivery.

OBJECTIVE: Accurate prediction of vaginal birth after cesarean is crucial for selecting women suitable for a trial of labor after cesarean (TOLAC). We sought to develop a machine learning (ML) model for prediction of TOLAC success and to compare its accuracy with that of the MFMU model. METHODS: All consecutive singleton TOLAC deliveries from a tertiary academic medical center between February 2017 and December 2018 were included. We developed models using the following ML algorithms: random forest (RF), regularized regression (GLM), and eXtreme gradient-boosted decision trees (XGBoost). For developing the ML models, we disaggregated BMI into height and weight. Similarly, we disaggregated prior arrest of progression into prior arrest of dilatation and prior arrest of descent. We applied a nested cross-validation approach, using 100 random splits of the data to training (80%, 792 samples) and testing sets (20%, 197 samples). We used the area under the precision-recall curve (AUC-PR) as a measure of accuracy. RESULTS: Nine hundred and eighty-nine TOLAC deliveries were included in the analysis with an observed TOLAC success rate of 85.6%. The AUC-PR in the RF, XGBoost and GLM models were 0.351±0.028, 0.350±0.028 and 0.336±0.024, respectively, compared to 0.325±0.067 for the MFMU-C. The algorithms performed significantly better than the MFMU-C (p-values = .0002, .0004, .0393 for RF, XGBoost, GLM respectively). In the XGBoost model, eight variables were sufficient for accurate prediction. In all ML models, previous vaginal delivery and height were among the three most important predictors of TOLAC success. Prior arrest of descent contributed to prediction more than prior arrest of dilatation, maternal height contributed more than weight. CONCLUSION: All ML models performed significantly better than the MFMU-C. In the XGBoost model, eight variables were sufficient for accurate prediction. Prior arrest of descent and maternal height contribute to prediction more than prior arrest of dilation and maternal weight.

Uterine exteriorization versus intraperitoneal repair in primary and repeat cesarean delivery: a randomized controlled trial.

PURPOSE: The aim of this study is to evaluate the effect of uterine exteriorization versus intraperitoneal repair, in first compared to repeat cesarean delivery. METHODS: A prospective randomized control single-blinded trial conducted in a single tertiary center between March 2014 and March 2015, including 32 and 63 women in first and recurrent cesarean sections, respectively. Inclusion criteria were elective operation and gestational age ≥37 weeks. Operative outcomes were compared between the groups including mean operative time, blood loss, hypotension, perioperative nausea and pain. Post-operative outcomes were further compared, including post-operative analgesia demand, first recognized bowel movement, nausea, length of hospital stay, fever, endometritis surgical site infection rate, and total satisfaction. RESULTS: During the study period, 45 and 50 women were designated for uterine exteriorization and intraperitoneal uterine repair, respectively. Mean blood loss was 452 cc (±10.44) for the extraperitoneal compared to 540 cc (±29.83) for the intraperitoneal uterine repair group (p = .004). No other significant differences in either intraoperative or postoperative complications were demonstrated in and between the groups. CONCLUSION: Intraperitoneal repair of uterine incision is associated with higher operative blood loss compared to uterine exteriorization. No other differences in operative and postoperative complication rates were found between the groups.

The Influence of Cesarean Delivery on Ovarian Reserve: a Prospective Cohort Study.

To assess the association between cesarean delivery and ovarian reserve, as compared to vaginal delivery. A prospective case control study conducted at a single tertiary medical center between June 2018 and June 2019. Study population included women with singleton pregnancy that underwent first cesarean delivery that were compared to women undergoing normal vaginal delivery. Women with low ovarian reserve, endometriosis, previous pelvic surgery, chronic maternal disease, and active labor were excluded. Ovarian reserve was estimated by Anti-Mullerian hormone (AMH) levels that was determined twice for each participant: up to a week before and 3 months after delivery. Primary outcome was defined as the delta in AMH levels. Data were analyzed by non-parametric tests. During the study period, 135 women were enrolled, of them 63 (47%) underwent cesarean delivery and 72 (53%) had vaginal delivery. Women in the cesarean delivery group were older (34 (31-38) vs. 32 (29-35); p = 0.001); nevertheless, AMH levels measured before delivery were comparable between the two groups (0.92 (0.51-1.79) vs. 0.95 (0.51-1.79) pg/mL; p = 0.42). AMH levels measured after delivery were more than doubled in the study and control groups (2.15 (1.24-3.05) vs. 2.62 (1.05-5.09); p = 0.50), and delta AMH levels were also found comparable (1.25 (0.61-2.22) vs. 1.59 (0.63-3.41), respectively; p = 0.43). Linear regression analysis including age, mode of delivery, gestational age at delivery, and delta hemoglobin levels revealed that only maternal age was significantly associated with delta in AMH levels (B = - 0.09, p = 0.04). Cesarean delivery does not decrease ovarian reserve as estimated by AMH.

The influence of lifestyle of OB/GYN female residents on gynecological and obstetrical outcomes: A cross-sectional study.

OBJECTIVE: To learn the influence of obstetrics and gynecology (OB/GYN) female residents' lifestyle on obstetric and gynecological characteristics compared to women matched by age from the general population. STUDY DESIGN: A cross-sectional multicenter study including OB/GYN female residents from ten different hospitals in Israel, who completed an internet questionnaire published during 2017-2018, that were compared to women matched by age from the general population. Questions dealt with lifestyle habits, obstetrical and gynecological outcomes. Data are presented as median and inter-quartile range. RESULTS: During the study period 97 women completed the questionnaire, of them 56 (57.7%) OB/GYN female residents and 41(42.3%) controls. No statistically significant differences were found between the groups regarding age, marital status, gravidity and parity. However, lifestyle characteristics reported by OB/GYN female residents differed compared to controls: OB/GYN female residents found their work more stressogenic [53 (94.6%) vs. 20 (48.8%); p = 0.001], suffered from deprived sleep [42(75.6%) vs. 13(31.8%); p = 0.001], were less punctilious on dental hygiene [13(23.2%) vs. 27(65.8%); p = 0.001] and reported maintaining a less healthy diet [35(62.5%) vs. 15(36.6%); p = 0.003]. Despite these differences, general happiness reported by both groups was comparable (35(62.5%) vs. 27(65.9%) for OB/GYN and control women respectively; p = 0.73). Pregnancy rate was found to be more than double in the resident's group [30 (53.6%) vs. 9 (22%); p = 0.002], with no differences in the rates of: complications during pregnancy [51(91.1%) vs. 38(92.7%); p = 0.78]; abortions [10 (17.9%) vs. 8 (19.5%); p = 0.84]; augmentation of labor [5 (9%) vs. 7 (17.1%); p = 0.18]; or cesarean deliveries [7(12.5%) vs. 7(17%); p = 0.48]. Logistic regression analysis found both parity and residency as independent variables significantly associated with pregnancy rate [(B = 0.69, p = 0.047), (B = 1.95, p = 0.016), respectively]. CONCLUSION: Although resident women in OB/GYN reported on more adverse lifestyle parameters, comparable obstetric and gynecological outcomes were seen, with residency and parity being independently associated with higher pregnancy rate.

The effect of polyhydramnios on the success of trial of labor after cesarean delivery (TOLAC): A retrospective cohort.

OBJECTIVE: Prediction of success of trial of labor after cesarean delivery (TOLAC) is of major importance. We investigated the impact of polyhydramnios on the success rate of TOLAC. STUDY DESIGN: A retrospective cohort study of all women with singleton pregnancies ≥ 34th weeks of gestation who underwent TOLAC after one previous cesarean delivery, between 2011 and 2016 in a single tertiary care center. Polyhydramnios was defined as amniotic fluid index ≥ 240 mm. Primary outcome was defined as the rate of successful TOLAC. RESULTS: 31,245 women gave birth during the study period, of them 1637 (5.3 %) women underwent TOLAC and met inclusion criteria. 39 (2.4 %) women with polyhydramnios were compared to a control group of 1598 (97.6 %) women with amniotic fluid index < 240 mm. Polyhydramnios significantly reduced the rate of successful TOLAC: 69.2 % (27/39) in the study group compared to 85.8 % (1371/1598) in the control group (P = 0.009). In a subgroup analysis based on amniotic fluid index, women with AFI > 270 mm had substantially lower TOLAC success rate [9/19 (47.4 %) vs 18/20 (90 %); P = 0.006]. There was no difference in the rate of uterine rupture between the groups (0/39 (o%) vs 9/1598 (0.56 %); P = 0.64). Logistic regression analysis revealed that polyhydramnios remained significantly associated with higher rates of cesarean delivery [OR 3.09 (95 % CI, 1.37-6.98)] after adjustment for confounding factors. CONCLUSION: Polyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling.

Outcome of two sequential singleton pregnancies and twin pregnancies among primiparous women at advanced age undergoing IVF.

PURPOSE: To compare the obstetrical and detailed neonatal outcomes of primipara of advanced maternal age conceiving two sequential singleton pregnancies by IVF with those of primipara conceiving twins by IVF. METHODS: A retrospective study of all primiparous women aged ≤ 38 years and conceived by IVF who delivered sequential singletons or delivered twins at a single tertiary university affiliated medical center between 2011 and 2019. We performed two main comparisons: 1. First vs. second singleton pregnancies. 2. Two singleton pregnancies vs. twin pregnancies. RESULTS: Overall, there were 63 women with consecutive singleton IVF pregnancies. The median age was 40.0 at first pregnancy and 42.0 in the second pregnancy. Pregnancy and delivery complications rates did not differ significantly between the first and the second singleton pregnancies, including gestational hypertensive disorders (7 (11.1%) vs. 4 (6.3%), p = 0.530), gestational diabetes mellitus (13 (20.6%) vs 18 (28.5%), p = 0.410), intrauterine growth restriction (6 (9.5%) vs. 4 (6.3%), p = 0.744), or cesarean delivery (25 (39.7%) vs. 29 (46%), p = 0.589). Rates of delivery before 32 weeks gestation were similar for both first and second singleton pregnancies (1.6%, p > 0.999). The proportion of neonatal adverse outcome in both first and second singleton pregnancies groups was low and did not differ between the groups. Compared with women who delivered sequential singletons, women with twin pregnancies had significantly higher cesarean delivery rates (113 (83.7%) vs. 29 (46%), p < 0.001) and lower gestational ages at delivery (36.2 vs. 38.4, p < 0.001) than women with two singleton deliveries. Adverse neonatal outcomes were significantly higher for twin pregnancies, including birthweight < 1500 g (17 (12.6%) vs. 2 (3.2%), p = 0.036), neonatal intensive care unit admission (57 (42.2%) vs. 4 (6.3%), p < 0.001), neonatal hypoglycemia (23 (17%) vs. 3 (4.8%), p = 0.017), and respiratory distress syndrome (14 (10.4%) vs. 1 (1.6%), p = 0.040). Length of neonatal hospitalization was significantly longer for twins (9 vs. 5 days, p < 0.001). The rate of gestational hypertensive disorders (preeclampsia and gestational hypertension) was similar between the groups, but the rates of severe preeclampsia trended higher among women who carried twins (8 (5.9%) vs. 0, p = 0.057). CONCLUSIONS: Sequential singleton pregnancies at primipara women of advanced maternal age have an overall very good outcome, with no clinically significant difference between the pregnancies. In addition, their outcome is much better compared with twins.

Laboratory characteristics of pregnant compared to non-pregnant women infected with SARS-CoV-2.

KEY MESSAGE: Laboratory characteristics of SARS-CoV-2 infection did not differ between pregnant and non-pregnant women. A trend of lower lymphocyte count was observed in the pregnant women group PURPOSE: Laboratory abnormalities, which characterize SARS-CoV-2 infection have been identified, nevertheless, data concerning laboratory characteristics of pregnant women with SARS-CoV-2 are limited. The aim of this study is to evaluate the laboratory characteristics of pregnant compared to non-pregnant women with SARS-CoV-2 infection. METHODS: A retrospective cohort study of all pregnant women with SARS-CoV-2 who were examined at the obstetric emergency room in a tertiary medical center between March and April 2020. Patients were compared with non-pregnant women with SARS-CoV-2 matched by age, who were examined at the general emergency room during the study period. All patients were confirmed for SARS-CoV-2 on admission. Clinical characteristics and laboratory results were compared between the groups. RESULTS: Study group included 11 pregnant women with SARS-CoV-2, who were compared to 25 non-pregnant controls. Respiratory complaints were the most frequent reason for emergency room visit, and were reported in 54.5% and 80.0% of the pregnant and control groups, respectively (p = 0.12). White blood cells, hemoglobin, platelets, and liver enzymes counts were within the normal range in both groups. Lyphocytopenia was observed in 45.5% and 32% of the pregnant and control groups, respectively (p = 0.44). The relative lymphocyte count to WBC was significantly reduced in the pregnant group compared to the controls [13.6% (4.5-19.3) vs. 26.5% (15.7-29.9); p = 0.003]. C-reactive protein [20(5-41) vs. 14 (2-52) mg/dL; p = 0.81] levels were elevated in both groups but without significant difference between them. CONCLUSION: Laboratory characteristics of SARS-CoV-2 infection did not differ between pregnant and non-pregnant women, although a trend of lower lymphocyte count was observed in the pregnant women group.

Cesarean delivery with and without uterine artery embolization for the management of placenta accreta spectrum disorder-A comparative study.

INTRODUCTION: The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder. MATERIAL AND METHODS: A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used. RESULTS: During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups. CONCLUSIONS: Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.

Uterine Artery Pseudoaneurysm in a Pregnant Patient with Retrocervical Endometriosis.

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks' gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks' gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size.

Maternal morbidity following caesarean deliveries with barbed suture for uterine closure.

PURPOSE: Information regarding the use of barbed suture in gynecologic surgery is limited. Our aim was to compare maternal morbidity following caesarean deliveries performed with barbed compared with non-barbed suture for uterine closure. METHODS: A historical cohort study from a single tertiary institution. The study group composed of all women that underwent term, uncomplicated singleton caesarean deliveries, where uterine closure was performed with ETHICON's Stratafix®, a polydioxanone barbed suture, compared with caesarean deliveries where uterine closure was performed with ETHICON's VICRYL®, a Polyglactin 910 non-barbed suture. The primary outcomes were the rate of maternal morbidity including the rate of red packed cells transfusion and a composite of infectious morbidity. Operation duration was also evaluated. An analysis restricted to elective caesarean deliveries was performed comparing the suture types. RESULTS: Three thousand and sixty patients were included in the study; 1337 in the study group and 1723 in the control group. There was no significant difference in the rate of the primary outcomes (red packed cells transfusion: 2.5% in the barbed suture vs. 2.1% in the non-barbed suture groups; p = 0.47; composite maternal morbidity: 3.8% vs. 4.8%, respectively; p = 0.18). Barbed suture was associated with reduced risk of postoperative ileus compared with the non-barbed suture (0.3% vs. 1.0%, respectively; p = 0.02) and a longer operation time (31 vs. 29 min, respectively; p < 0.001). In the analysis restricted to elective caesarean deliveries only the duration of operation remained significantly different between the groups. CONCLUSIONS: The rate of short term maternal morbidities among patients undergoing uterine closure with barbed suture during caesarean delivery is similar to the non-barbed suture.

Ovarian reserve after uterine artery embolization in women with morbidly adherent placenta: A cohort study.

OBJECTIVE: To evaluate ovarian reserve in women after preservative cesarean delivery using uterine artery embolization due to morbidly adherent placenta. STUDY DESIGN: A historical cohort study including all women admitted to a single tertiary care center, with morbidly adherent placenta that had preservative cesarean delivery with bilateral uterine artery embolization. Inclusion criteria included gestational age >24 weeks, singleton pregnancy and placenta increta / percreta. Exclusion criteria included maternal age > 43 years old and cesarean hysterectomy. Control group included women attending the infertility clinic due to male factor or single women conceiving via sperm donation, matched by age. Blood samples were collected on day 2-5 of menstruations for hormonal profile and Anti Mullarian Hormone (AMH) levels. Primary outcome was ovarian reserve evaluated by the levels of AMH. RESULTS: 59 women underwent preservative cesarean delivery using uterine artery embolization during the study period. 21 women met inclusion criteria (33.9%) and were matched controls (n = 40). Circulating levels of E2 and FSH did not differ significantly between the two groups (p = 0.665, p = 0.396, respectively). AMH was lower in the study group (median 0.8 IQR 0.44-1.80) compared to the controls (median 2.08 IQR 1.68-3.71) (p = 0.001). This finding was consistent in linear multivariate regression analysis where the group of cesarean delivery using bilateral artery embolization due to placenta accrete was significantly predictive for the levels of AMH (B = -1.308, p = 0.012). CONCLUSION: Women post preservative cesarean delivery using uterine artery embolization due to placenta accrete have lower ovarian reserve compare to controls matched by age.

Quantitative assessment of physical activity in pregnant women with sonographic short cervix and the risk for preterm delivery: A prospective pilot study.

OBJECTIVE: Bed rest or activity restriction is a common obstetrical practice, despite a paucity of data to support its efficacy. The aim of this study was to determine whether physical activity, as assessed by a smart band activity tracker, is associated with preterm birth in pregnant women at high risk for preterm delivery. METHODS: This was a pilot prospective cohort study including pregnant women at high risk for preterm delivery between 24 and 32 weeks-of-gestation. Physical activity level was assessed by smart band activity. Patients with sonographic short cervical length (≤ 20 mm) were asked to wear the smart band activity tracker continuously for at least one week, including one weekend. Both physicians and patients were blinded to the data stored in the smart band activity tracker. No specific recommendations were given to participants as to the level or intensity of physical activity. The primary outcome was the rate of preterm birth (< 37 weeks-of-gestation). Secondary outcomes included the rate of delivery before 34 weeks of gestation and neonatal outcome. Parametric and nonparametric statistics were used for analysis. RESULTS: Study population included 49 pregnant women: 37 women (75.7%) delivered preterm and 12 (24.5%) delivered at or after 37 weeks-of-gestation. The median steps per day was significantly lower in patients who delivered preterm (3576, IQR: 2478-4775 vs. 4554, IQR: 3632-6337, p = 0.02). Regression analysis revealed that the median number of steps per day was independently inversely associated with preterm birth, after adjustment for maternal age, body mass index, gestational age at recruitment, cervical length, cervical dilatation and plurality. CONCLUSION: This pilot study represents the first quantitative assessment of the association between physical activity and preterm birth. The results of this pilot study do not support the efficacy of decreased physical activity in the prevention of preterm birth in patients with sonographic short cervical length.

Sonographic large fetal head circumference and risk of cesarean delivery.

BACKGROUND: Persistently high rates of cesarean deliveries are cause for concern for physicians, patients, and health systems. Prelabor assessment might be refined by identifying factors that help predict an individual patient's risk of cesarean delivery. Such factors may contribute to patient safety and satisfaction as well as health system planning and resource allocation. In an earlier study, neonatal head circumference was shown to be more strongly associated with delivery mode and other outcome measures than neonatal birthweight. OBJECTIVE: In the present study we aimed to evaluate the association of sonographically measured fetal head circumference measured within 1 week of delivery with delivery mode. STUDY DESIGN: This was a multicenter electronic medical record-based study of birth outcomes of primiparous women with term (37-42 weeks) singleton fetuses presenting for ultrasound with fetal biometry within 1 week of delivery. Fetal head circumference and estimated fetal weight were correlated with maternal background, obstetric, and neonatal outcome parameters. Elective cesarean deliveries were excluded. Multinomial regression analysis provided adjusted odds ratios for instrumental delivery and unplanned cesarean delivery when the fetal head circumference was ≥35 cm or estimated fetal weight ≥3900 g, while controlling for possible confounders. RESULTS: In all, 11,500 cases were collected; 906 elective cesarean deliveries were excluded. A fetal head circumference ≥35 cm increased the risk for unplanned cesarean delivery: 174 fetuses with fetal head circumference ≥35 cm (32%) were delivered by cesarean, vs 1712 (17%) when fetal head circumference <35 cm (odds ratio, 2.49; 95% confidence interval, 2.04-3.03). A fetal head circumference ≥35 cm increased the risk of instrumental delivery (odds ratio, 1.48; 95% confidence interval, 1.16-1.88), while estimated fetal weight ≥3900 g tended to reduce it (nonsignificant). Multinomial regression analysis showed that fetal head circumference ≥35 cm increased the risk of unplanned cesarean delivery by an adjusted odds ratio of 1.75 (95% confidence interval, 1.4-2.18) controlling for gestational age, fetal gender, and epidural anesthesia. The rate of prolonged second stage of labor was significantly increased when either the fetal head circumference was ≥35 cm or the estimated fetal weight ≥3900 g, from 22.7% in the total cohort to 31.0%. A fetal head circumference ≥35 cm was associated with a higher rate of 5-minute Apgar score ≤7: 9 (1.7%) vs 63 (0.6%) of infants with fetal head circumference <35 cm (P = .01). The rate among fetuses with an estimated fetal weight ≥3900 g was not significantly increased. The rate of admission to the neonatal intensive care unit did not differ among the groups. CONCLUSION: Sonographic fetal head circumference ≥35 cm, measured within 1 week of delivery, is an independent risk factor for unplanned cesarean delivery but not instrumental delivery. Both fetal head circumference ≥35 cm and estimated fetal weight ≥3900 g significantly increased the risk of a prolonged second stage of labor. Fetal head circumference measurement in the last days before delivery may be an important adjunct to estimated fetal weight in labor management.

Does antenatal steroids treatment prior to elective cesarean section at 34-37 weeks of gestation reduce neonatal morbidity? Evidence from a case control study.

OBJECTIVE: To determine whether antenatal corticosteroids administration prior to an elective cesarean section (ECS) at 34-37 weeks gestation is associated with improved neonatal outcome. MATERIALS AND METHODS: A case control study of women with singleton pregnancies who underwent ECS between 34 and 37 weeks of gestation including two groups: (1) study group in which patients were treated with betamethasone prior to ECS (n = 58) and (2) control group matched for gestational age at delivery in which patients did not receive betamethasone (n = 107). Neonatal measures including respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), oxygen requirement, admission to the special care unit, hypoglycemia, hyperbilirubinemia and length of hospitalization were determined in both groups. Composite respiratory morbidity was defined as the presence of either RDS, TTN, mechanical ventilation or oxygen requirement. RESULTS: There was no significant difference in the rate of composite respiratory morbidity nor its components between patients with and without betamethasone treatment (25.9 vs. 25.2%, respectively, p = 0.9). CONCLUSION: Antenatal treatment with corticosteroids prior to ECS at 34-37 weeks of gestation did not result in significant reduction in neonatal respiratory morbidity in our cohort of patients.

The Yield of Abdominal Ultrasound in the Evaluation of Elevated Liver Enzymes during the Second and the Third Trimester of Pregnancy.

AIMS: To determine the clinical yield of abdominal ultrasound in the evaluation of elevated liver enzymes (ELEs) in the second and the third trimester of pregnancy. METHODS: A retrospective cohort study including all pregnant women admitted to a single tertiary care center was conducted between April 2011 and January 2015 with ELE. Inclusion criteria included gestational age above 24 weeks and ELEs, abdominal ultrasound report, and live fetus. Exclusion criteria included known maternal liver disease, structural or chromosomal fetal anomalies, and positive serology for viral hepatitis. All patients underwent abdominal ultrasound. A significant finding of this study led to a change in treatment. RESULTS: One hundred and twenty patients (41.8%) met inclusion criteria: 93 (77.5%) had a normal scan and 27 (22.5%) had abnormal findings. Significant ultrasound findings were found only in 2 (1.6%) patients: gallstones in the common bile duct and suspected autoimmune hepatitis. There were no significant differences between patients with and without ultrasound findings in the rate of cholestasis of pregnancy, preeclampsia, chronic hypertension, and gestation diabetes. CONCLUSION: Abdominal ultrasound examination in this population has a low clinical yield. The decision to perform an abdominal ultrasound must be individualized based on the obstetric history, clinical findings, and the level of liver enzymes.