Membrane stripping in group B streptococcus carriers does not impede adequate intrapartum antibiotic prophylaxis: a retrospective study.

Objective: Membrane stripping in group B streptococcus (GBS) carriers poses an increased risk of inadequate antibiotic prophylaxis, potentially due to accelerated labor, thereby potentially impacting the management of GBS colonization during delivery. We compared the adequacy of intrapartum antibiotic prophylaxis between pregnant women colonized with GBS, who underwent membrane stripping and those who did not. The study aimed to determine whether the performance of membrane stripping, by potentially shortening labor duration, increases the risk of inadequate antibiotic prophylaxis dispensation. Study design: A retrospective cohort study was conducted on GBS screen-positive women with a full-term singleton pregnancy in cephalic presentation, who were eligible for vaginal delivery. The exposed group consisted of women who underwent membrane stripping, while the unexposed group consisted of women who did not undergo membrane stripping. The primary outcome was defined as inadequate duration of antibiotic prophylaxis during labor, wherein less than 4 h of beta-lactam antibiotics were administered prior to delivery. Neonatal outcome was compared between the groups. Results: This retrospective cohort study comprised 1,609 women, with 129 in the exposed group (stripping group) and 1,480 in the unexposed group (no stripping group). Adequate intrapartum antibiotic prophylaxis was received by 64.3% (83/129) of the exposed group, compared to 46.9% (694/1,480) of the unexposed group (p = 0.003). Membrane stripping was associated with increased odds of receiving adequate prophylaxis (OR 1.897, 95% CI 1.185-3.037, p = 0.008). After excluding women who presented to the labor ward in active labor and delivered in less than 4 h, both the exposed and unexposed groups had similarly high rates of adequate intrapartum antibiotic prophylaxis (87.5% vs. 85.8%, respectively). No significant difference was observed in adverse neonatal outcomes between the groups. Conclusion: The provision of membrane stripping did not impede adequate intrapartum antibiotic prophylaxis and was correlated with a higher rate of sufficient prophylaxis in comparison to non-swept patients. These observations suggest that membrane stripping can be considered a safe option for ensuring adequate antibiotic prophylaxis in women colonized with GBS.

Assessing the Clinical Significance of Third-Trimester Post-Coital Bleeding.

Introduction - This study aims to evaluate the impact of third-trimester post-coital bleeding (PCB) on pregnancy outcomes. Methods - A retrospective cohort study was conducted at two tertiary medical centers, including all pregnant women between 24-34 weeks of gestation referred due to vaginal bleeding over an eleven-year period. The study population includes all singleton deliveries; within this population, women were further classified into three groups: those admitted due to vaginal bleeding related to PCB, those admitted due to vaginal bleeding not related to PCB, and those who did not report vaginal bleeding. The primary outcome measure was delivery prior to 37 weeks of gestation, while secondary outcome measures included maternal and neonatal complications. Baseline characteristics of the two groups were compared. Results - During the study period, there were a total of 51,698 deliveries. Among these, 230 cases involved bleeding between 24-34 weeks of gestation, 34 (14.8%) were identified as PCB, and 196 as bleeding unrelated to intercourse. In addition, 51,468 pregnancies without bleeding were analyzed as the general population for comparison. The incidence of preterm labor before 37 weeks of gestation was notably higher in both women with post-coital bleeding (14.7%) and those with bleeding unrelated to coitus (20.9%) compared to the general population (5.6%); however, there was no statistically significant difference between the two bleeding groups (p=0.403) while both were significantly different from the general population (p<0.001). The odds ratio for preterm birth before 37 weeks of gestation after post-coital bleeding was 3.29 (95% CI: 1.26 to 8.56, p=0.0149). There were no significant differences between the PCB and bleeding unrelated to intercourse groups in terms of maternal and neonatal complications. Conclusion - This study found that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the general population without bleeding. These findings challenge the assumption that PCB is benign.

Validating staging criteria for sonographic and physical examination for cervical changes at <24 weeks' gestation to predict preterm birth.

BACKGROUND: Preterm birth represents a significant clinical challenge, and the ability to predict it effectively is a priority in obstetrics. The cervix undergoes specific changes during pregnancy, and staging these changes may offer a valuable predictive model for preterm birth, particularly among women with a midtrimester short cervical length. OBJECTIVE: The study aimed to validate a proposed staging model for asymptomatic women with midtrimester short cervical length and to evaluate its potential for predicting preterm birth. The integration of cervical examination and inspection with cervical length measurement was a novel approach to be assessed. STUDY DESIGN: This was a multicenter, retrospective cohort study that included 925 pregnant women with a singleton fetus and a midtrimester cervical length measurement of ≤25 mm. Cervical conditions were assessed using ultrasonography, a speculum, and a physical examination and were classified into 1 of 5 cervical stages to correlate with the likelihood of preterm birth. Statistical analyses included Kaplan-Meier survival analysis to illustrate the time-to-event characteristics across the 5 stages and density plot evaluation to visualize the distribution of the gestational ages within the stages. RESULTS: The staging model included 5 stages based on cervical length, appearance, and dilatation. Among the 925 participants, 649 were classified as being stage 1, 245 as stage 2, 18 as stage 3, 10 as stage 4, and 3 as stage 5. The observed rates of preterm birth before 37 weeks for individuals classified in stages 1, 2, 3, 4, and 5 were 22.3%, 26.5%, 44.4%, 60%, and 66.7%, respectively (P=.005). The overall observed rates of preterm birth before 28, 32, 34, and 37 weeks' gestation were 5.5%, 9.9%, 12.2%, and 24.1%, respectively (P=.005). CONCLUSION: This study validated the proposed staging criteria as an effective predictor of preterm birth caused by cervical insufficiency. The results demonstrate a significant increase in the preterm birth rate with advancing stage classification, indicating that the staging effectively stratified women based on their risk for preterm birth and highlighting the potential use for targeted interventions. Implementing these staging criteria can potentially improve the counseling and management of pregnant women at risk for preterm birth.

Comparing the efficacy of vaginal micronized progesterone gel and capsule for prevention of preterm birth in singleton pregnancies with short cervical length at midtrimester: an indirect comparison meta-analysis.

Objective: To evaluate the effectiveness of vaginal progesterone in preventing preterm birth in women with a singleton gestation and short cervical length and to determine which of the two formulations, micronized progesterone vaginal capsule versus vaginal gel containing micronized progesterone, is more effective for preventing preterm birth. Data sources: A systematic search was performed in the following databases: EMBASE, PubMed (MEDLINE), The Cochrane Library, and the Clinical Trials Registry (clinicaltrials.gov). Study eligibility criteria: Randomized controlled trials (RCTs), prospective and retrospective observational studies were included. We searched for progesterone administration to prevent preterm birth in asymptomatic women with a shortened cervix (<25 mm) measured by ultrasound in the second trimester of singleton pregnancy. Study appraisal and synthesis methods: Assessments of the risk of bias of RCTs were performed by applying the Cochrane Collaboration's Risk of Bias Tool; non-randomized control trials were evaluated with the Newcastle-Ottawa Scale (NOS). The primary outcome was preterm birth ≤33 weeks of gestation. Pooled relative risks (RR) and 95% CI's were calculated for dichotomous outcomes. Heterogeneity of treatment effect was assessed with the I2 statistic. We pooled results of the primary outcome for individual studies using a random-effect model. We then performed a network meta-analysis to pool indirect comparisons between the two formulations (gel vs capsule). This analysis was performed using the network meta-analysis package within the R environment. Results: Five studies met the inclusion criteria (4 RCTs, one cohort study) including 1,048 women. The meta-analysis demonstrated that vaginal micronized progesterone significantly reduces preterm birth risk, Risk Ratio = 0.63; 95% CI, 0.48-0.82; p = 0.0006; with no heterogeneity between the studies: I 2 = 0%. In the network meta-analysis, no significant difference was demonstrated (OR = 0.85; 95% CI, 0.43-1.69) between the effect of the two formulations of vaginal micronized progesterone (vaginal gel versus vaginal capsules) on the risk of PTB. Conclusion: Vaginal progesterone is associated with a decreased risk of premature birth in women with a shortened cervix in the second trimester of pregnancy. No differences were found between vaginal micronized progesterone in gel or capsule formulations. Systematic Review Registration: PROSPERO, identifier CRD42020165198.

The effectiveness of vaginal progesterone in reducing preterm birth in high-risk patients diagnosed with short cervical length after 24 weeks: A retrospective cohort study.

Objective: To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation. Methods: A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group. Results: The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions (OR 0.20, 95% CI 0.05-0.74) and in the neonatal hospitalization period (mean difference in days 2.43, 95% CI 0.44-4.42). The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment. Conclusion: Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation.

The role of secure instant messaging applications in medical education: Evaluating student satisfaction in a case-based learning program using Siilo.

Background: Instant messaging applications for mobile phones have recently grown in popularity among medical personnel, including both physicians and medical students. During the COVID-19 pandemic, medical education was largely transferred to virtual platforms, making such applications an increasingly important tool for medical education. "Siilo" is a secure instant messaging application that was designed for medical professionals, and offers several advantages over other instant messaging services that are vital for its use in medical settings, including information security, data encryption, and a built-in blurring tool to maintain patient privacy. In addition, Siilo allows for the creation of individual folders for each case, enabling users to conduct separate discussions about multiple patients simultaneously. Objective: To evaluate student satisfaction in a case-based learning program using Siilo as a medical education tool in improving student learning outcomes and motivation. Methods: A case-based learning program was conducted with 24 fifth-year medical students using Siilo to evaluate its effectiveness as a medical education tool. The program was evaluated through the use of pre- and post-program questionnaires and focus group discussions to assess student satisfaction. Results: The majority of students (83.3%) were highly satisfied with the Siilo platform and felt that it enhanced their learning experience, and a majority of students (79.1%) reported that the program was highly effective. Students reported that the platform was easy to use and provided a clear and organized way to follow discussions about cases. The focus group discussions further revealed that students appreciated the real-time communication and felt that the use of Siilo helped to improve the quality of communication and collaboration during the learning process. The use of Siilo as a medical education tool was found to contribute to positive relationships between doctors and students and improve student motivation for learning and outcomes. Conclusion: These findings suggest that Siilo can be a valuable resource for medical education, particularly due to its secure and convenient features, which are well-suited for use in medical settings. The use of Siilo in a case-based learning program was found to be effective in improving student satisfaction and learning outcomes and contributed to positive relationships between doctors and students. These results highlight the potential for utilizing mobile instant messaging apps as a tool for enhancing clinical teaching in medical education.

Partogram of Grandmultiparous Parturients: A Multicenter Cohort Study.

Sparse and conflicting data exist regarding the normal partogram of grand-multiparous (GMP, defined as parity of 6+) parturients. Customized partograms may potentially lower cesarean delivery rates for protraction disorders in this population. In this study, we aim to construct a normal labor curve of GMP women and compare it to the multiparous (MP, defined as parity of 2-5) partogram. We conducted a multicenter retrospective cohort analysis of deliveries between the years 2003 and 2019. Eligible parturients were the trials of labor of singletons ≥37 + 0 weeks in cephalic presentation with ≥2 documented cervical examinations during labor. Exclusion criteria were elective cesarean delivery without a trial of labor, preterm labor, major fetal anomalies, and fetal demise. GMP comprised the study group while the MP counterparts were the control group. A total of 78,292 deliveries met the inclusion criteria, comprising 10,532 GMP and 67,760 MP parturients. Our data revealed that during the first stage of labor, cervical dilation progressed at similar rates in MPs and GMPs, while head descent was a few minutes faster in GMPs compared to MPs, regardless of epidural anesthesia. The second stage of labor was faster in GMPs compared to MPs; the 95th percentile of the second stage duration of GMPs (48 min duration) was 43 min less than that of MPs (91 min duration). These findings remained similar among deliveries with and without epidural analgesia or labor induction. We conclude that GMPs' and MPs' cervical dilation progression in the active phase of labor was similar, and the second stage of labor was shorter in GMPs, regardless of epidural use. Thus, GMPs' uterus function during labor corresponds, and possibly surpasses, that of MPs. These findings indicate that health providers can use the standard partogram of the active phase of labor when caring for GMP parturients.

The role of vaginal progesterone for preterm birth prevention in women with threatened labor and shortened cervix diagnosed after 24 weeks of pregnancy.

OBJECTIVE: To determine whether vaginal progesterone treatment for women with a short cervix, diagnosed after 24 weeks of pregnancy, reduces preterm birth rates. METHODS: A retrospective cohort study that included women with a singleton pregnancy, threatened preterm labor, and a short cervix measured between 24+0 and 33+6 weeks. Women who received vaginal progesterone were compared with women who did not receive progesterone. The primary outcome was spontaneous preterm birth before 37 weeks of pregnancy. RESULTS: Patients who received vaginal progesterone had a lower rate of preterm delivery at less than 37 weeks of pregnancy (18.2% [22/121] versus 28.9% [73/253]; adjusted hazard ratio 0.50; 95% confidence interval 0.28-0.73, P = 0.001). The diagnosis-to-delivery interval was significantly greater in patients who received progesterone than in those who did not-median time to delivery in weeks: 8.2 (interquartile range [IQR] 6.2-9.8) versus 6.6 (4.8-8.8), (P < 0.001). The frequency of neonatal intensive care unit admission was significantly lower in patients who received progesterone than in those who did not (8.3% [10/121] versus 16.2% [41/253], P = 0.04). CONCLUSIONS: The administration of vaginal progesterone to patients with an episode of threatened premature labor and a short cervix presenting after 24 weeks of pregnancy was associated with lower rates of premature births.

Exome sequencing for structurally normal fetuses-yields and ethical issues.

The yield of chromosomal microarray analysis (CMA) is well established in structurally normal fetuses (0.4-1.4%). We aimed to determine the incremental yield of exome sequencing (ES) in this population. From February 2017 to April 2022, 1,526 fetuses were subjected to ES; 482 of them were structurally normal (31.6%). Only pathogenic and likely pathogenic (P/LP) variants, per the American College of Medical Genetics and Genomics (ACMG) classification, were reported. Additionally, ACMG secondary findings relevant to childhood were reported. Four fetuses (4/482; 0.8%) had P/LP variants indicating a moderate to severe disease in ATP7B, NR2E3, SPRED1 and FGFR3, causing Wilson disease, Enhanced S-cone syndrome, Legius and Muenke syndromes, respectively. Two fetuses had secondary findings, in RET and DSP. Our data suggest that offering only CMA for structurally normal fetuses may provide false reassurance. Prenatal ES mandates restrictive analysis and careful management combined with pre and post-test genetic counseling.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial.

BACKGROUND: External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial. OBJECTIVE: This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version. RESULTS: The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference. CONCLUSION: This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

Long-term gynecological complications after conservative treatment of placenta accreta spectrum.

Objective: To examine the association between conservative treatment for PAS (placenta accreta spectrum) and subsequent gynecological and fertility complications. Methods: All women who underwent conservative treatment for PAS between January 1990 and December 2000 were included in this retrospective cohort study conducted in a tertiary teaching hospital. Gynecological and fertility complications experienced after the index delivery were collected from the medical records and telephone questionnaires. This data was compared to an age and parity-matched control group of women without PAS. Results: The study group included 134 women with PAS managed conservatively and 134 controls with normal deliveries matched by parity and age. Women in the PAS group required significantly more postpartum operative procedures such as hysteroscopy or D&C (OR = 6.6; 95%CI: 3.36-13.28; P = <0.001). Following the index delivery, there were 345 pregnancies among 107 women who attempted conception following conservative treatment for PAS vs. 339 pregnancies among 105 women who attempted conception in the control group. Among women who attempted conception following conservative treatment for PAS 99 (92.5%) delivered live newborns (a total of 280 deliveries) vs. 94 (89.5%) in the control group, (a total of 270 live newborns, p = 0.21). The need for fertility treatments was not different between the two groups (OR = 1.22; 95%CI: 0.51-2.93; P = 0.66). Conclusion: After conservative treatment for PAS, significantly more women required complementary procedures due to retained placenta and/or heavy vaginal bleeding. There was no evidence of fertility impairment in women post-conservative treatment for PAS.

Case report: An unusual presentation of puerperal sepsis.

Group A Streptococcus (GAS; Streptococcus pyogenes) is a facultative gram-positive coccus, uncommonly colonizing parturient genitalia, where its presence can potentially lead to a life-threatening invasive infection after delivery. GAS infection typically occurs within the first 4 days post-partum and is characterized by high fever, chills, flashing, abdominal pain, and uterine tenderness. Nonetheless, patients with GAS puerperal sepsis may have an unusual presentation, when fever is absent, and the symptoms and signs can be mild, non-specific, and not indicative of the severity of infection. This unusual presentation may lead to a delayed diagnosis and increase the risk for severe puerperal sepsis. Therefore, in these cases, a high index of suspicion and prompt early antibiotic and surgical treatment is crucial to saving the parturient's life.

Establishment of a controlled slow freezing-based approach for experimental clinical cryopreservation of human prepubertal testicular tissues.

Objective: To develop an efficient, clinical-grade, freezing protocol toward experimental clinical cryopreservation of testicular tissues in prepubertal boys suffering from cancer. Design: Experimental cryopreservation of testicular tissue. Setting: University Medical Center. Patients: Adult patients undergoing orchiectomy for various tumors and prepubertal boys scheduled for gonadotoxic treatment. Interventions: None. Main Outcome Measures: Histopathological analysis of tissue architecture, structural integrity, and cellular morphology was performed for control and frozen-thawed cryopreserved tissues.The number of seminiferous tubules per testicular section was calculated. The survival of spermatogonial stem cells (SSCs) and Sertoli cells of the control and frozen-thawed cryopreserved tissues was analyzed by immunofluorescence staining. Results: Uncontrolled Slow Freezing, Controlled slow freezing, and vitrification similarly preserved the integrity of the adult testicular tissues and the survival of SSCs and Sertoli cells. Controlled slow freezing of prepubertal testicular tissues effectively preserved their architecture, the number of tubules, SSCs, and Sertoli cells. In addition, we observed SSC loss after chemotherapy in prepubertal boys, reemphasizing the importance of fertility preservation before gonadotoxic treatment. Conclusions: Future fertility restoration for male survivors of pediatric cancers depends on the development of an optimal prepubertal testicular tissue cryopreservation method. Our findings demonstrate the effectiveness of controlled slow freezing for cryopreservation of human prepubertal testicular tissues and may contribute to more effective banking of these tissues and potential fertility restoration. Clinical Trial Registration Number: NIH research clinical trials number: NCT02529826.

Uterine rupture risk in a trial of labor after cesarean section with and without previous vaginal births.

PURPOSE: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for the trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. METHODS: A retrospective cohort study was conducted, including women who underwent TOLACs from 2003 to 2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥ 24 weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was a uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders. RESULTS: A total of 11,235 women were included, 6795 of which had a PVD. Women with PVD had significantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p < 0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p < 0.0001), were more likely to undergo labor induction (OR 1.56, p < 0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p < 0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22. CONCLUSION: PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients.

Urinary tract injuries during cesarean delivery: long-term outcome and management.

OBJECTIVE: Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases. METHODS: We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes. RESULTS: In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae. CONCLUSION: Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries.

Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.

BACKGROUND: Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy. OBJECTIVES: (1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score. STUDY DESIGN: This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion. RESULTS: (1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion. CONCLUSION: We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.

Normal labor curve in twin gestation.

BACKGROUND: Failure to progress is one of the leading indications for cesarean delivery in trials of labor in twin gestations. However, assessment of labor progression in twin labors is managed according to singleton labor curves. OBJECTIVE: This study aimed to establish a partogram for twin deliveries that reflects normal and abnormal labor progression and customized labor curves for different subgroups of twin labors. STUDY DESIGN: This was a multicenter, retrospective cohort analysis of twin deliveries that were recorded in 3 tertiary medical centers between 2003 and 2017. Eligible parturients were those with twin gestations at ≥34 weeks' gestation with cephalic presentation of the presenting twin and ≥2 cervical examinations during labor. Exclusion criteria were elective cesarean delivery without a trial of labor, major fetal anomalies, and fetal demise. The study group comprised twin gestations, whereas singleton gestations comprised the control group. Statistical analysis was performed using Python 3.7.3 and SPSS, version 27. Categorical variables were analyzed using chi-square tests. Student t test and Mann-Whitney U test were applied to analyze the differences in continuous variables, as appropriate. RESULTS: A total of 1375 twin deliveries and 142,659 singleton deliveries met the inclusion criteria. Duration of the active phase of labor was significantly longer in twin labors than in singleton labors in both nulliparous and multiparous parturients; the 95th percentile duration was 2 hours longer in nulliparous twin labors and >3.5 hours longer in multiparous twin labors than in singleton labors. The cervical dilation progression rate was significantly slower in twin deliveries than in singleton deliveries with a mean rate in twin deliveries of 1.89 cm/h (95th percentile, 0.51 cm/h) and a mean rate of 2.48 cm/h (95th percentile, 0.73 cm/h) in singleton deliveries (P<.001). In addition, epidural use further slowed labor progression in twin deliveries. The second stage of labor was also markedly longer in twin deliveries, both in nulliparous and multiparous women (95th percentile, 3.04 vs 2.83 hours, P=.002). CONCLUSION: Twin labors are characterized by a slower progression of the active phase and second stage of labor compared with singleton labors in nulliparous and multiparous parturients. Epidural analgesia further slows labor progression in twin labors. Implementation of these findings in clinical management might lower cesarean delivery rates among cases with protracted labor in twin gestations.

A model based on routine liver tests can reliably exclude intrahepatic cholestasis of pregnancy.

OBJECTIVES: Serum bile acid (BA) levels testing is used for the diagnosis of intrahepatic cholestasis of pregnancy (ICP). We aimed to determine the performance of routine liver tests in the evaluation of ICP. METHODS: A retrospective cohort study conducted at a university hospital, including all pregnant women who underwent serum BA levels testing due to suspected ICP during 2007-2019. Liver tests were performed in all women including: aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALK), gamma-glutamyl transferase (GGT), and total bilirubin (TB). The optimal combination of laboratory values was determined by an algorithm developed in the Python programming language. RESULTS: Of 640 women who met the inclusion criteria, 22% (n = 142) were diagnosed with ICP (serum BA>10 µmol/L). A combined laboratory score of: (TB>11 µmol/L) or (ALK>255 U/L) or (GGT>32 U/L) or (AST>31 U/L), had a sensitivity of 94%, negative predictive value (NPV) of 97%, specificity of 50%, positive predictive value of 35%, and a negative likelihood ratio of 0.11 for the diagnosis of ICP. The AUC of the laboratory model alone was 0.72 (95% CI: 0.69-0.75). The addition of history of ICP to the suggested laboratory score resulted in a sensitivity of 97%, NPV of 98% and a negative likelihood ratio of 0.06. The AUC of the final model was 0.76 (95% CI: 0.72-0.79). CONCLUSIONS: A combined laboratory score incorporating AST, GGT, ALK and TB was shown to reliably exclude the diagnosis of ICP. This may be particularly useful in settings with limited access to BA levels testing.

The impact of peak and duration of maternal intrapartum fever on perinatal outcomes.

BACKGROUND: Intrapartum fever is a common perinatal complication, associated with short- and long-term adverse outcomes. Limited data exist regarding the association between the peak and duration of maternal fever and the extent and severity of maternal and neonatal complications. OBJECTIVE: This study aimed to examine the association between maternal intrapartum fever peak and duration and perinatal outcomes. STUDY DESIGN: A retrospective cohort analysis of term singleton live births in 2 medical centers between the years 2003 and 2015 was conducted. The study group included parturients who experienced intrapartum fever, defined as a temperature of ≥38.0°C (100.4°F). Fever duration was defined as the time elapsed between the first documented fever and subsequent first documented normal body temperature (<38°C or <100.4°F) or if the temperature did not return to normal until delivery. Adjusted risks for adverse perinatal outcomes were calculated using multiple logistic regression models to control for confounders. RESULTS: A cohort study of 85,713 deliveries was analyzed, of which 1517 (1.8%) parturients experienced fever during delivery. Adverse composite neonatal outcome gradually worsens, in a dose-response manner, with higher maximal maternal temperature. Similar dose-response deterioration was found when maximal parturient temperature was combined with fever duration (P=.015). Higher or longer maternal fever was not independently associated with cesarean or instrumental deliveries (P=.648). Duration alone was not significantly associated with worsening neonatal outcomes (P=.711). CONCLUSION: Maximal intrapartum maternal fever, solely and when combined with fever duration, is correlated with neonatal complications in a dose-dependent manner. Further prospective studies are needed to examine the potential benefit of rigorous maternal body temperature control on perinatal outcomes.