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.

Second stage duration and delivery outcomes among women laboring after cesarean with no prior vaginal delivery.

BACKGROUND: We aimed to evaluate the association of the duration of the second stage with labor after cesarean (LAC) success and other outcomes among women with one prior cesarean delivery (CD) and no prior vaginal births. METHODS: All women undergoing LAC that reached the second stage of labor from March 2011 to March 2020 were included in this retrospective cohort study. The primary outcome was the mode of delivery by second stage duration. The secondary outcomes included adverse maternal and neonatal outcomes. We allocated the study cohort into five groups of second stage duration. Further analysis compared <3 to ≥3 h of second stage based on prior studies. LAC success rates were compared. Composite maternal outcome was defined as the presence of uterine rupture/dehiscence, postpartum hemorrhage, or intrapartum/postpartum fever. RESULTS: One thousand three hundred ninety seven deliveries were included. Vaginal birth after cesarean (VBAC) rates decreased as the second stage length time interval increased: 96.4% at <1 h, 94.9% at 1 to <2 h, 94.6% at 2 to <3 h, 92.1% at 3 to <4 h and 79.5% at ≥4 h (p < 0.001). Operative vaginal and CDs were significantly more likely as second stage duration time interval increased (p < 0.001). The composite maternal outcome was comparable among groups (p = 0.226). When comparing the outcomes of deliveries at <3 h versus ≥3 h, the composite maternal outcome and neonatal seizure rates were lower in the <3 h group (p = 0.041 and p = 0.047, respectively). CONCLUSION: Vaginal birth after cesarean rates decreased as second stage time interval length increased. Even with prolonged second stage, VBAC rates remained relatively high. Increased risk of composite adverse maternal outcomes and neonatal seizures were observed when the second stage lasted 3 h or more.

Vaginal Progesterone Is Associated with Intrahepatic Cholestasis of Pregnancy.

OBJECTIVE: The frequency of intrahepatic cholestasis of pregnancy (ICP) peaks during the third trimester of pregnancy when plasma progesterone levels are the highest. Furthermore, twin pregnancies are characterized by higher progesterone levels than singletons and have a higher frequency of cholestasis. Therefore, we hypothesized that exogenous progestogens administered for reducing the risk of spontaneous preterm birth may increase the risk of cholestasis. Utilizing the large IBM MarketScan Commercial Claims and Encounters Database, we investigated the frequency of cholestasis in patients treated with vaginal progesterone or intramuscular 17α-hydroxyprogesterone caproate for the prevention of preterm birth. STUDY DESIGN: We identified 1,776,092 live-born singleton pregnancies between 2010 and 2014. We confirmed second and third trimester administration of progestogens by cross-referencing the dates of progesterone prescriptions with the dates of scheduled pregnancy events such as nuchal translucency scan, fetal anatomy scan, glucose challenge test, and Tdap vaccination. We excluded pregnancies with missing data regarding timing of scheduled pregnancy events or progesterone treatment prescribed only during the first trimester. Cholestasis of pregnancy was identified based on prescriptions for ursodeoxycholic acid. We used multivariable logistic regression to estimate adjusted (for maternal age) odds ratios for cholestasis in patients treated with vaginal progesterone, and in patients treated with 17α-hydroxyprogesterone caproate compared with those not treated with any type of progestogen (the reference group). RESULTS: The final cohort consisted of 870,599 pregnancies. Among patients treated with vaginal progesterone during the second and third trimester, the frequency of cholestasis was significantly higher than the reference group (0.75 vs. 0.23%, adjusted odds ratio [aOR]: 3.16, 95% confidence interval [CI]: 2.23-4.49). In contrast, there was no significant association between 17α-hydroxyprogesterone caproate and cholestasis (0.27%, aOR: 1.12, 95% CI: 0.58-2.16) CONCLUSION: Using a robust dataset, we observed that vaginal progesterone but not intramuscular 17α-hydroxyprogesterone caproate was associated with an increased risk for ICP. KEY POINTS: · Previous studies have been underpowered to detect potential association between progesterone and ICP.. · Vaginal progesterone was significantly associated with ICP.. · Intramuscular 17α-hydroxyprogesterone was not associated with ICP..

Reconsidering the effectiveness of low-dose aspirin in prevention of pre-eclampsia among otherwise low risk twin gestations: A historical cohort study.

OBJECTIVE: To investigate the effectiveness of low-dose aspirin (LDA) in the prevention of pre-eclampsia (PE) among otherwise low-risk twin gestations. METHODS: A historical cohort study consisting of all pregnant individuals with dichorionic diamniotic (DCDA) twin pregnancy who delivered between 2014 and 2020. Patients treated with LDA were matched by a 1:4 ratio to individuals who were not treated with LDA by age, body mass index and parity. RESULTS: During the study period, 2271 individuals carrying DCDA pregnancies delivered at our center. Of these, 404 were excluded for one or more additional major risk factors. The remaining cohort consisted of 1867 individuals of whom 142 (7.6%) were treated with LDA and were compared with a 1:4 matched group of 568 individuals who were not treated. The rate of preterm PE did not differ significantly between the two groups (18 [12.7%] in the LDA group vs. 55 [9.7%] in the no-LDA group; P = 0.294, adjusted odds ratio 1.36, 95% confidence interval 0.77-2.40). There were no other significant between-group differences. CONCLUSIONS: Low-dose aspirin treatment in pregnant individuals with DCDA twin gestations without additional major risk factors was not associated with a reduction in the rate of preterm PE.

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..

Length of the second stage of labor among women achieving vaginal birth after cesarean.

OBJECTIVE: To characterize the length of the second stage of labor among women completing a first vaginal birth after a cesarean (VBAC), according to the stage of labor during primary cesarean delivery (CD). METHODS: A retrospective cohort study of VBACs between 2011 and 2020. Study groups were divided as follows: CD not in labor, CD in the first stage of labor, and CD in the second stage of labor. The primary outcome was the length of the second stage. RESULTS: A total of 1310 VBACs were included. The timing of the primary CD was not associated with the duration of the second stage. The median second stage of duration of VBACs with previous first stage CD versus previous CD not in labor was 81 versus 106 min, respectively (P = 0.050). In multivariable linear regression, maternal age, birth weight, and epidural were independently associated with second-stage length. Maternal and neonatal outcomes did not differ between study groups and were not affected by the second-stage length. CONCLUSION: When stratified according to the labor stage of the primary CD, second-stage duration among women completing VBACs was not associated with labor stage at the primary CD. Extremes of the second-stage duration were not associated with increased morbidity.

Trial of labor after cesarean in women with hypertensive disorders and no prior vaginal delivery.

KEY MESSAGE: Trial of labor among women who never delivered vaginally with hypertensive disorder is associated with nearly half the success rate of the general population. PURPOSE: To study the trial of labor after cesarean (TOLAC) among women with hypertensive disorders and no prior vaginal delivery. METHODS: A retrospective cohort study was conducted including women with no prior vaginal delivery undergoing TOLAC during 2010-2020. Women with hypertensive disorder were compared to those without. RESULTS: A total of 54/2,144 (2.5%) TOLACs had a hypertensive disorder: 32 (59%) had gestational hypertension, 16 (30%) had chronic hypertension and 6 (11%) had preeclampsia. Women with hypertensive disorders had higher BMI and higher proportion of diabetic disorders. TOLAC success rate was lower among hypertensive mothers: 32 (59%) vs. 1,605 (76.8%), p=0.003 odds ratio (OR), 95% confidence interval (CI) 0.44 (0.25-0.76). The rate of uterine rupture was 23/2,144 (1.1%). In a multivariable logistic regression analysis, hypertensive disorder was independently negatively associated with TOLAC success, adjusted OR (95% CI) 0.47 (0.26-0.85). Other factors negatively independently associated with TOLAC failure were maternal age, predelivery body mass index, dystocia at primary CD, gestational age at TOLAC, induction of labor and birth weight. Epidural was independently positively associated with TOLAC success, adjusted OR (95% CI) 1.54 (1.18-1.99). CONCLUSION: TOLAC in hypertensive women with no prior vaginal delivery is safe. Success rate is impaired in comparison to non-hypertensive women.

Methods of induction of labor after cesarean with no prior vaginal delivery-Perinatal outcomes.

OBJECTIVE: To study the association between the method of induction of labor (IOL) and perinatal outcomes, among women undergoing labor after cesarean (LAC) with no prior vaginal delivery. METHOD: A retrospective study including all women with no prior vaginal delivery undergoing IOL for LAC between March 2011 and January 2021. Oxytocin administration following prelabor rupture of membranes (PROM), oxytocin administration only, extra-amniotic balloon, and amniotomy were compared. RESULTS: Overall, 363 women met the inclusion criteria: extra-amniotic balloon (157, 43.3%), oxytocin following PROM (95, 26.2%), amniotomy (72, 19.8%), and oxytocin (39, 10.7%). LAC success rate did not differ among study groups (P = 0.114), varying between 62.1% and 79.5%. There were three uterine ruptures (0.8%) in the entire cohort. The rate of uterine rupture, postpartum hemorrhage, and the composite of both were similar in all study groups. Neonatal outcomes did not differ between study groups, with composite adverse neonatal outcomes varying between 7.4% in the oxytocin following PROM to 1.9% in the extra-amniotic balloon group (P = 0.141). The following factors were independently associated with LAC success: taller maternal height, lower body mass index, earlier gestational age, and epidural analgesia. CONCLUSIONS: All examined IOL methods with an unfavorable cervix carried similar outcomes. The clinical practice should be individualized.

Fetal malpresentation following mechanical labor induction.

OBJECTIVE: To evaluate whether the risk of fetal malpresentation following mechanical labor induction could be accurately predicted. METHODS: A retrospective study, including all individuals who underwent labor induction at a single tertiary medical center between March 2011 and May 2021. Cohorts of pharmacological (n = 16 480) and mechanical labor induction (n = 6864) were compared, determining malpresentation rate following induction. Individuals with and without fetal malpresentation following balloon placement were compared. RESULTS: Malpresentation following balloon placement occurred in 62 patients (0.9%). Those patients with malpresentation following balloon placement were older, had higher body mass index during labor, higher parity, polyhydramnios, higher fetal station at the start of labor induction, and delivered at an earlier gestational age compared with control patients. The combined presence of at least three of these risk factors was associated with a malpresentation rate of 8% (7/88) and yielded a positive likelihood ratio of 9.48 (95% confidence interval [CI] 4.57-19.7). A prediction model using these variables was not sufficiently accurate to predict the risk of malpresentation following balloon labor induction; a calculated area under the generated receiver operating characteristic curve was 0.78 (95% CI 0.72-0.84). CONCLUSION: Several risk factors were identified for malpresentation following mechanical labor induction, although these were of low predictive value.

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.

Transplantation of small ovarian tissue fragments using pipelle device is effective: method evaluation and reproductive outcomes.

PURPOSE: To assess the feasibility, effectiveness, and reproductive outcomes of transplantation of tiny cryopreserved ovarian pieces through a pipelle cannula during laparoscopic surgery. METHODS: A retrospective study of patients who underwent ovarian tissue transplantation for fertility restoration between 2004 and 2022. The "pipelle group" had their ovarian cortex cut into tiny pieces of ~ 1-2 mm3 before cryopreservation. The pieces were too small to be handled and transplanted via standard laparoscopic tools. Transplantation was performed using a pipelle cannula during laparoscopic surgery. The "control group" underwent transplants of ovarian cortex pieces 1-2 mm thick, measuring approximately 25-50 mm2 pieces, using standard procedures. RESULTS: The pipelle group consisted of 4 patients aged 19, 21, 27, and 28 years old at ovarian tissue cryopreservation (OTC). The control group consisted of 14 patients aged 21-30 years old. All pipelle patients restored their endocrine activity, and all of them conceived. FSH levels dropped during the first 3 months following the pipelle transplant. IVF cycle outcomes were similar for both groups. All patients from the pipelle group conceived, resulting in 5 pregnancies and 4 live births (one patient had 2 deliveries, and one additional pregnancy is ongoing), compared to the control group, where 8 patients achieved a total of 20 pregnancies and 18 live births. CONCLUSION: Pipelle transplantation for tiny cryopreserved ovarian pieces is feasible and effective. This study opens a door for patients who had their ovaries cut into small pieces and may even simplify the procedure in some instances, making ovarian transplant more accessible. TRIAL REGISTRATION: (#6531-19-SMC) [18/09/2019].

Obstetric and Neonatal Outcomes following COVID-19 Vaccination in Pregnancy.

COVID-19 infection imposes a risk for pregnant individuals and may lead to adverse maternal and obstetric outcomes. This is a retrospective cohort study of all women giving birth between March and July 2021 at a single tertiary center. Obstetric and neonatal outcomes were compared between vaccinated and non-vaccinated pregnant women with singleton pregnancies. Women with prior COVID-19 infection, multiple gestations and stillbirth were excluded from the study. Of 4708 women who delivered during the study period, 3700 met the eligibility criteria, of whom 3240 were vaccinated during pregnancy. Compared with the non-vaccinated group, the vaccinated group was characterized by a lower rate of smoking (3.70% vs. 6.67%, p = 0.0028), whereasother maternal characteristics were not significantly different. Multivariable analysis demonstrated that COVID-19 mRNA vaccination was not significantly associated with increased risk of preterm birth as well as other adverse obstetric outcomes including hypertensive diseases of pregnancy, cesarean delivery and small for gestational age. However, a significantly lower risk for meconium-stained amniotic fluid was observed among the vaccinated group (adjusted odds ratio 0.63; 95% confidence interval, 0.46-0.86, p = 0.0039). Moreover, the vaccine was not significantly associated with increased risk of neonatal adverse outcomes including respiratory complications and NICU hospitalization. In conclusion, BNT162b2 messenger RNA vaccination during pregnancy was not associated with an increased rate of adverse obstetric and neonatal outcomes. Therefore, in view of its safety on one hand, and the risk associated with COVID-19 disease in pregnancy on the other hand, BNT 162b2 COVID-19 vaccine should be recommended for pregnant women.

Innovation in Gastroenterology-Can We Do Better?

The health system can reap significant benefits by adopting and implementing innovative measures, as was recently demonstrated and emphasized during the COVID-19 pandemic. Herein, we present our bird's eye view of gastroenterology's innovative technologies via utilizing a text-mining technique. We analyzed five research fields that comply with innovation: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy. According to gastroenterology literature, the two most innovative fields were the microbiome and advanced endoscopy. Though artificial intelligence (AI), virtual reality (VR), and telemedicine trailed behind, the number of AI publications in gastroenterology has shown an exponential trend in the last couple of years. While VR and telemedicine are neglected compared to other fields, their implementation could improve physician and patient training, patient access to care, cost reduction, and patient outcomes.

Sonographic fetal head circumference is associated with trial of labor after cesarean section success.

PURPOSE: The purpose is to study the association of the fetal sonographic head circumference (SHC) with trial of labor after cesarean (TOLAC) success rate, among women with no prior vaginal deliveries. METHODS: A retrospective case-control study including all women with no prior vaginal delivery undergoing TOLAC during 3/2011-6/2020 with a sonographic estimated fetal weight within one week from delivery. TOLAC success and failure groups were compared. RESULTS: Of 1232 included women, 948 (76.9%) delivered vaginally. The mean fetal SHC was smaller in the TOLAC success group (330 ± 10 vs. 333 ± 11 mm, p < 0.001). In a multivariate regression analysis, predelivery BMI, hypertensive disorders, gestational age at prior CD, SHC and epidural analgesia administration were independently associated with TOLAC success. A ROC analysis of the multivariable model composed of the factors found independently associated with TOLAC success, excluding SHC, yielded an area under curve of 0.659 (95% CI 0.622-0.697) compared with 0.668 (95% CI 0.630-0.705) with SHC included. CONCLUSION: Smaller SHC is independently associated with TOLAC success among women that did not deliver vaginally before, and has additive clinical value for the prediction of TOLAC success when combined with non-sonographic factors.

Prediction of successful trial of labor after cesarean among grand-multiparous women.

PURPOSE: To determine the factors associated with successful trial of labor after cesarean (TOLAC) among grand-multiparous (GMP) women. METHODS: A retrospective cohort study was conducted, including all GMP women (≥ 5 deliveries) undergoing TOLAC during 3/2011 and 6/2020, delivering a singleton cephalic newborn. Factors associated with successful vaginal delivery were examined by multivariable analysis. RESULTS: Overall, 381/413 (92.2%) GMP succeeded TOLAC. Maternal characteristics did not differ between TOLAC success and TOLAC failure groups. Previous cesarean delivery characteristics did not differ between study groups. The median number of previous vaginal births after cesarean was 2 [interquartile range 1-4]. Gestational age at TOLAC was lower in the success group (mean 371/7 ± 36/7 vs. 385/7 ± 31/7 weeks, p = 0.028). A lower rate of modified Bishop score < 4 was associated with TOLAC success [149 (39.1%) vs. 22 (69%), odds ratio (OR) 95% confidence interval (CI) 0.29 (0.13-0.64), p = 0.001]. The rate of induction of labor was higher in the TOLAC failure group [120 (31.5%) vs. 17 (53%), OR 95% CI 0.40 (0.19-0.83), p = 0.013]. The rate of oxytocin administration was higher in the TOLAC failure group [94 (24.7%) vs. 15 (47%) OR (95% CI) 0.37 (0.17-0.77), p = 0.006]. The duration of rupture of membranes was negatively associated with TOLAC success. Neonatal and maternal adverse outcomes did not differ between study groups. In multivariable logistic regression analysis, only the duration of rupture of membranes and modified Bishop score < 4 were independently associated with TOLAC success [adjusted OR (95% CI) 0.98 (0.96-0.99), p = 0.027 and 0.40 (0.16-0.97), p = 0.044]. CONCLUSION: TOLAC among GMP has a very-high success rate. Shortening the duration of ruptured membranes is a modifiable factor that may be associated with increased TOLAC success rates.

Neonatal outcome of second-stage cesarean delivery versus vacuum extraction among neonates <34 weeks.

OBJECTIVE: Among deliveries <34 weeks, there is inconclusive evidence regarding the preferred route of delivery when there is a need to expedite delivery during the second stage of labor. As it is unreasonable that future randomized controlled trials will be conducted to settle this query, every clinical data concerning this topic, may be helpful. We aim to compare neonatal outcomes among women undergoing emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) during the second stage of labor among singleton gestations <34 weeks. METHODS: A retrospective cohort study including all women who underwent either ECD or VAD at the second stage of labor between 30°/7 and 336/7 weeks, during 2011-2019. The primary outcome was the rate of adverse neonatal outcomes, defined as intrapartum death, mechanical ventilation, asphyxia, respiratory distress syndrome, subgaleal hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, and phototherapy. RESULTS: Of the 153,672 live singleton deliveries during the study period, 2871 (1.9%) delivered before 34°/7. Of those 1674 (58.3%) delivered vaginally unassisted and 1137 (39.6%) delivered by a CD during the first stage of labor. A total of 60 deliveries were analyzed, with a median gestational age of 32 weeks, interquartile range (IQR) 31-33. Median birth weight at delivery was 1845 g, IQR 1574-2095. Overall 25 (42%) of women were delivered by VAD and 35 by CD (58%). Indications for expeditious delivery did not differ between the study groups. Neonates delivered by VAD had a higher median birth weight (1940 vs. 1620 g, p = .02). Second stage of labor was longer in the ECD group as compared to the VAD group (median 200 vs. 52 min, p = .01). The rate of Apgar score at 1 min <7 was higher among the CD group (10 (40%) vs. 5 (14%), OR [95% CI]: 4.0 (1.1-13.8), p = .03). Longer length of stay was evident in the CD group as compared to the VAD group (median 30 vs. 21 days, p = .001). The rate of composite neonatal adverse outcome was comparable between the study groups. Adverse outcomes were associated with lower body mass index (median 27.7 vs. 34.9, p = .04), higher rate of premature preterm rupture of membranes (40 (91%) vs. 5 (31%), OR [95% CI]: 22.0 (5.0-91.1), p < .001) and labor dystocia as the indication for expedited delivery (38 (86%) vs. 7 (44%), OR [95% CI]: 8.1 (2.1-30.1), p = .001). CONCLUSIONS: Cesarean delivery during the second stage of labor of gestations <34 weeks was associated with a higher rate of lower Apgar scores and longer length of stay. SYNOPSIS: Delivery by second stage CD of premature neonates <34 weeks is associated with a higher rate of lower Apgar score.

The effect of fetal weight on the accuracy of sonographic weight estimation among women with diabetes.

OBJECTIVE: The assessment of sonographic estimated fetal weight (EFW) enables identification of fetuses in the extremes of weight, thus aiding in the planning and management of peripartum care. There are conflicting reports regarding the accuracy of EFW in diabetic mothers. We aimed to study the factors associated with the accuracy of EFW at term, specifically the role of gestational and pre-gestational diabetes in this setting. METHODS: A retrospective study including all women carrying singleton term gestations who delivered within a week following a sonographic fetal weight estimation between 2011 and 2019. Accurate EFW was defined as within 10% of the actual birthweight. We allocated the study cohort into two groups: (1) Accurate EFW (2) inaccurate EFW. Both groups were compared in order to identify factors associated with the inaccuracy of EFW. RESULTS: Overall, 41,263 deliveries were available for evaluation, including 412 (1.0%) deliveries among women with pre-gestational diabetes and 4,735 (11.5%) among women with gestational diabetes. Of them, 7,280 (17.6%) had inaccurate EFW. Inaccurate EFW was associated with nulliparity, OR 0.82 [95% CI] (0.78-0.87), oligohydramnios, OR 0.81 [95% CI] (0.71-0.93), pregestational diabetes, OR [95% CI] 0.61 (0.50-0.79), and extremity of fetal weight; <2,500 grams-OR [95% CI] 0.37 (0.33-0.41) and >4,000 grams OR [95% CI] 0.52 (0.48-0.57). On multiple regression analysis, the following factors were independently associated with inaccurate EFW: pregestational diabetes, OR [95% CI] 0.58 (0.46-0.73), p < .001, nulliparity, OR [95% CI] 0.86 (0.82-0.91), p < .001 and higher fetal weight (for each 500 grams), OR [95% CI [1.25 (1.21-1.30), p < .001. On analysis of different weight categories, pregestational diabetes was associated with inaccurate EFW only in those with birthweight >3,500 grams, OR [95% CI] 0.37 (0.24-0.56) (p < .001). CONCLUSION: Among pregestational diabetic women, the accuracy of sonographic EFW when assessed to be >3,500 grams is questionable. This should be taken into consideration when consulting women and planning delivery management. SYNOPSIS: Among pregestational diabetic women, the accuracy of estimated sonographic fetal weight higher than 3,500 grams is of limited accuracy.

Neonatal and maternal outcome of small-for-gestational-age neonates delivered by vacuum-assisted delivery.

OBJECTIVE: To evaluate the association between neonatal weight centile and neonatal and maternal morbidity following vacuum-assisted delivery (VAD) among term nulliparous women. METHODS: A retrospective cohort study of all nulliparous women who delivered at term by VAD between 2011 and 2019. Deliveries were allocated into two groups and compared: (1) delivery of an small-for-gestational-age (SGA) neonate, and (2) delivery of an appropriate-for-gestational-age (AGA) neonate. RESULTS: Overall, 3116 women were included in the study; 2878 (92.4%) were AGA and 163 (5.2%) were SGA and comprised the study groups. Neonatal and maternal adverse outcomes did not vary between groups. Rates of composite neonatal adverse outcome for SGA and AGA neonates were 26 (16.0%) versus 462 (16.1%), respectively (P = 0.972). Duration of the second stage of labor and rate of prolonged second stage were significantly lower among the SGA group compared with the AGA group (P < 0.001 for both comparisons). Maternal rates of anal sphincter injury and postpartum hemorrhage did not differ between groups. CONCLUSION: Neonatal outcomes among SGA neonates delivered by VAD at term did not differ from those of AGA neonates. Maternal outcome did not differ. These data provide reassurance for practitioners to perform VAD in SGA neonates at term.

Isolated oligohydramnios - should induction be offered after 36 weeks?

OBJECTIVE: Isolated oligohydramnios (IO) - oligohydramnios in the absence of maternal or gestational comorbidity is debated as an indication for induction of labor. Previous meta-analyses regarding perinatal outcomes of IO at term have yielded conflicting results. We aimed to investigate the neonatal outcomes among gestations with IO delivered at 36°/7-396/7. METHODS: The study cohort included all women undergoing a trial of labor between during 2011 and 2019 of a singleton gestation with cephalic presentation between 36°/7 and 40°/7. We allocated the study groups into women with IO and those with normal amniotic fluid volume. Neonatal outcomes were compared between the groups and in relation to gestational age and induction of labor. RESULTS: Overall, there were 529/17,709 (3.0%) IO cases. IO was associated with maternal age <25 years (OR [95% CI] 1.62 (1.20-2.20), p = .001). Induction of labor was more common with IO (OR [95% CI] 1.33 (1.05-1.69) p = .01. IO was associated with preterm delivery (OR [95% CI] 1.81 (1.36-2.40), p < .001). The rate of neonatal adverse outcome did not differ between study groups. Overall composite adverse neonatal outcome occurred among 1,399/17,709 (7.9%) deliveries. Adverse neonatal outcome was associated with induction of labor (OR [95% CI] 1.61 (1.40-1.86), p < .001) and low birth weight (OR [95% CI] 7.41 (6.27-8.75), p < .001). When Stratified by gestational age, neonatal adverse outcome did not differ between IO and no IO groups. When examining cases of induction of labor per gestational age, induction of labor at 36 weeks among IO gestations, was associated with adverse neonatal outcome as compared to no IO group (OR [95% CI] 5.7 (1.23-26.3), p = .04). CONCLUSIONS: Induction of labor in gestations complicated by IO at 36 weeks gestational age is associated with an increased risk for adverse neonatal outcome. Our study results adds to the current literature regarding outcomes of IO and time of delivery. SYNOPSIS: Induction of labor in gestations complicated by IO at 36 weeks gestational age is associated with an increased risk for adverse neonatal outcome.

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.