Morbidity associated with the use of Foley balloon for cervical ripening in women with prior cesarean delivery.

OBJECTIVE: We evaluated the morbidity of Foley balloon for cervical ripening in comparison to oxytocin alone in women with a prior cesarean delivery. STUDY DESIGN: A four-hospital retrospective review of all women with viable singleton pregnancies and history of a single prior cesarean delivery presenting for cervical ripening between 1994 and 2015. Exposure groups were either Foley balloon or oxytocin, at the treating physician's discretion. The primary outcome was defined as maternal morbidity, evaluated by a composite that included hemorrhage, and/or uterine infection, and/or uterine rupture. We defined two secondary outcomes: neonatal morbidity, and vaginal delivery rate. Neonatal morbidity was evaluated by a composite that included five-minute APGAR score <7 and/or NICU admission. We adjusted results for potential confounding variables, including hospital site, maternal age and race, initial cervical dilation, and gestational age at delivery. RESULTS: We identified 688 patients who received ripening, 276 by Foley balloon and 412 by oxytocin. There was no significant difference in the primary outcome of maternal morbidity between groups: 38 (13.8%) in the Foley balloon group and 79 (19.2%) in the oxytocin group (aOR 1.43; 95% CI, 0.90-2.27). There was no significant difference in the secondary outcome of neonatal morbidity: 31 (11.3%) in the Foley balloon group and 51 (12.4%) in the oxytocin group (aOR 1.02; 95% CI, 0.57-1.80). The rate of vaginal delivery was significantly less in the Foley balloon group compared to the oxytocin group: 56.2% vs 64.1%, p = .037. CONCLUSION: When cervical ripening with either Foley balloon or oxytocin was utilized at the physician's discretion in women with prior cesarean, there was no identified difference in maternal and neonatal morbidity, but the rate of successful vaginal delivery was lower.

Placental endothelin-converting enzyme-1 is decreased in preeclampsia.

Endothelin-converting enzyme-1(ECE-1) is a key regulatory enzyme in the processing of endothelin-1 (ET-1). We quantified and localized ECE-1 in normal and preeclamptic placentas. Normal (n=6) and preeclamptic (n=6) placentas were serially sectioned for immunofluorescence (IF). Cell type specific markers identified endothelial, trophoblast, macrophage, smooth muscle, and fibroblast cells. Quantitative analyses were performed by western blot and ELISA. IF identified ECE-1 expression within the stroma and villous space. Cellular localization of ECE-1 was limited to endothelial membranes. There was significantly less ECE-1 in preeclamptic placentas, suggesting ECE-1 is important for proper regulation of ET-1 within the placenta.

The Impact of Fetal Anomalies on Contemporary Labor Patterns.

OBJECTIVE: To compare labor patterns in pregnancies affected by fetal anomalies to low-risk singletons. STUDY DESIGN: Labor data from the Consortium on Safe Labor, a multicenter retrospective study from 19 U.S. hospitals, including 98,674 low-risk singletons compared with 6,343 pregnancies with fetal anomalies were analyzed. Repeated-measures analysis constructed mean labor curves by parity, gestational age, and presence of fetal anomaly in women who reached full dilation. Interval-censored regression analysis adjusted for covariables was used to determine the median traverse times for labor progression. RESULTS: Labor curves for all groups indicated slower labor progress for patients with fetal anomalies. The most significant trends in median traverse times were observed in the preterm nulliparous and term multiparous groups. The median traverse times from 4 cm to complete dilation in the preterm nulliparous control versus anomaly groups were 5.0 and 5.4 hours (p < 0.0001). CONCLUSION: Labor proceeds at a slower rate in pregnancies affected by anomalies.

SMFM Consult Series #46: Evaluation and management of polyhydramnios.

Polyhydramnios, or hydramnios, is an abnormal increase in the volume of amniotic fluid. Identification of polyhydramnios should prompt a search for an underlying etiology. Although most cases of mild polyhydramnios are idiopathic, the 2 most common pathologic causes are maternal diabetes mellitus and fetal anomalies, some of which are associated with genetic syndromes. Other causes of polyhydramnios include congenital infection and alloimmunization. The purpose of this document is to provide guidance on the evaluation and management of polyhydramnios. The following are Society for Maternal-Fetal Medicine recommendations: (1) we suggest that polyhydramnios in singleton pregnancies be defined as either a deepest vertical pocket of ≥8 cm or an amniotic fluid index of ≥24 cm (GRADE 2C); (2) we recommend that amnioreduction be considered only for the indication of severe maternal discomfort, dyspnea, or both in the setting of severe polyhydramnios (GRADE 1C); (3) we recommend that indomethacin should not be used for the sole purpose of decreasing amniotic fluid in the setting of polyhydramnios (GRADE 1B); (4) we suggest that antenatal fetal surveillance is not required for the sole indication of mild idiopathic polyhydramnios (GRADE 2C); (5) we recommend that labor should be allowed to occur spontaneously at term for women with mild idiopathic polyhydramnios; that induction, if planned, should not occur at <39 weeks of gestation in the absence of other indications; and that mode of delivery should be determined based on usual obstetric indications (GRADE 1C); and (6) we recommend that women with severe polyhydramnios deliver at a tertiary center due to the significant possibility that fetal anomalies may be present (GRADE 1C).

New Insights in Peripartum Cardiomyopathy.

Significant progress in understanding the pathophysiology of peripartum cardiomyopathy, especially hormonal and genetic mechanisms, has been made. Specific criteria should be used for diagnosis, but the disease remains a diagnosis of exclusion. Both long-term and recurrent pregnancy prognoses depend on recovery of cardiac function. Data from large registries and randomized controlled trials of evidence-based therapeutics hold promise for future improved clinical outcomes.

Antenatal Treatment with Intravenous Immunoglobulin to Prevent Gestational Alloimmune Liver Disease: Comparative Effectiveness of 14-Week versus 18-Week Initiation.

BACKGROUND: Antenatal therapy with high-dose intravenous immunoglobulin (IVIG) may prevent gestational alloimmune liver disease (GALD). OBJECTIVE: The objective of this study was to determine the effectiveness of this approach in a large cohort of women at risk for poor pregnancy outcome due to GALD. METHODS: Women with a history of affected offspring were provided antenatal IVIG treatment and data were acquired prospectively from 1997 to 2015. The outcomes of treated pregnancies were compared to those of untreated pregnancies, and the effectiveness of starting at 14 weeks was compared to that of starting at 18 weeks. RESULTS: A total of 188 treated pregnancies in 151 women were analyzed. Only 30% (n = 105) of untreated gestations resulted in healthy offspring as compared to 94% (n = 177) of treated pregnancies (p < 0.0001). Treated gestations of both the 14-week (n = 108) and the 18-week (n = 80) start cohort showed a decreased rate of fetal loss relative to untreated gestations (p < 0.0001). Equivalent outcomes were recorded in the 18-week versus the 14-week start cohort (p > 0.05). Few adverse events or complications of antenatal therapy were recorded. CONCLUSION: Antenatal therapy with high-dose IVIG initiated at either 18 or 14 gestational weeks effectively prevents poor outcome of pregnancies at risk for GALD.

Hypertension and patterns of induced labor at term.

OBJECTIVE: To study patterns of induced labor at term in hypertensive women. STUDY DESIGN: We performed a retrospective cohort study using the Consortium on Safe Labor database; a multicenter study of labor and delivery practices from electronic medical records in 19 hospitals. 55,572 women were studied: 28,254 nulliparas and 27,318 multiparas, undergoing induction of labor at term without a prior cesarean with a singleton vertex live born fetus. Four hypertensive groups were defined: chronic hypertension (n=1164), gestational hypertension (n=1861), preeclampsia (n=1513) and superimposed preeclampsia (n=655), compared to controls (no hypertension, n=50,379). Labor characteristics and patterns were compared among the groups, stratified by parity. MAIN OUTCOME MEASURES: Interval-censored regression analysis estimated median and 95th% duration of labor, stratified by centimeter-by-centimeter dilation. Repeated-measures analysis established mean labor curves. RESULTS: Time to progress from 4 to 10 cm was 7.5, 6.4, 4.9 and 4.6h in nulliparous women with superimposed preeclampsia, chronic hypertension, preeclampsia and gestational hypertension respectively, which differed from controls (4.9h; p<0.05 for chronic hypertension and superimposed preeclampsia). Multiparous women required 3.8, 3.9, 3.2 and 3.3h, respectively, compared to controls (3.2h, p<0.05 except preeclampsia p=0.1) to progress from 4 to 10cm. Second stage of labor without epidural was longer for all nulliparous groups compared to controls except for women with chronic hypertension, but second stage did not differ in multiparas. CONCLUSION: Regardless of parity, women with chronic disease, chronic hypertension and superimposed preeclampsia, labor longer whereas those with relatively acute disease, gestational hypertension and preeclampsia, progress more rapidly.

Do Different Modes of Labor Induction Affect the Overall Success and Risk of Trial of Labor After Cesarean Section?

OBJECTIVE: To determine whether different modes of labor induction impact the success rate and perinatal morbidity in women undergoing trial of labor after cesarean (TOLAC). STUDY DESIGN: Retrospective review of the Consortium on Safe Labor electronic database from 2002�2008; women with a prior cesarean birth, desiring TOLAC, and requiring induction of labor were included. Oxytocin and Foley bulb induction methods were compared to amniotomy alone. Prostaglandin use was also reviewed but, given the small numbers, was not the focus of this study. RESULTS: Univariate analysis showed significantly greater incidence of hemorrhage >1,000 mL (p=0.0030) and transfusion (p=0.0076) with Foley bulb use. All methods of induction for TOLAC decreased repeat cesarean sections (OR 0.34, 95% CI 0.23�0.52, p<0.01). CONCLUSION: Induction of labor does not alter the success rate for TOLAC candidates, regardless of mode of induction. When choosing induction methods, one should be mindful of the apparent additional risk of increased blood loss and transfusion with intracervical Foley bulb usage.

Outcomes With Cerclage Alone Compared With Cerclage Plus 17α-Hydroxyprogesterone Caproate.

OBJECTIVE: To examine the differences in perinatal outcomes among women with a prior preterm birth who received cerclage compared with cerclage plus 17α-hydroxyprogesterone caproate. METHODS: Women with transvaginal cerclage placement and a prior delivery between 16 and 36 weeks of gestation were identified over a 10-year period (July 2002 to May 2012) in this retrospective cohort study. Exclusion criteria were delivery at another institution, abdominal cerclage, multiple gestations, and major fetal anomalies. Maternal demographics, gestational age at cerclage, gestational age at delivery, preterm prelabor rupture of membranes (PROM), and birth weight were compared between women with a cerclage and cerclage plus 17α-hydroxyprogesterone caproate. The primary outcome was delivery at less than 24 weeks of gestation. RESULTS: Of the 411 women who had a cerclage, 260 met inclusion criteria. Of these, 171 received a cerclage alone and 89 received cerclage plus 17α-hydroxyprogesterone caproate. The two groups were not different with respect to maternal demographics and gestational age at cerclage. There was a significant difference among those who received indomethacin at the time of cerclage, betamethasone administration, and history of a loop electrosurgical excision procedure-cold knife cone and cerclage. Delivery at less than 24 weeks of gestation occurred in 6% of women receiving both 17α-hydroxyprogesterone caproate and cerclage compared with 16% in the cerclage only group (odds ratio [OR] 0.31, 95% confidence interval 0.10-0.78, P=.01). In the multivariate analysis controlling for indomethacin use, prior cerclage, and loop electrosurgical excision procedure-cold knife cone there was a 73% reduction in delivery in the combined treatment group compared with cerclage alone (adjusted OR 0.26, P=.02). A multivariant analysis was conducted with correction for indomethacin at the time of cerclage, prior cerclage, and loop electrosurgical excision procedure-cold knife cone and cerclage surgery. Even after controlling for significant variables, there remained a 73% reduction in delivery at less than 24 weeks of gestation in the cerclage plus 17α-hydroxyprogesterone caproate cohort (adjusted OR 0.26, P=.02). CONCLUSION: Women receiving transvaginal cerclage plus 17α-hydroxyprogesterone caproate had a 69% relative reduction in delivery at less than 24 weeks of gestation when compared with women receiving cerclage alone. We found no difference in overall preterm delivery or preterm PROM. In this cohort, compared with cerclage alone, the likelihood of a viable neonate improves with both treatments.

Does Induction with Misoprostol Impact the Small for Gestational Age Neonate?

OBJECTIVE: To compare outcomes in small for gestational age neonates induced with misoprostol to other cervical ripening agents. We hypothesized that misoprostol use will demonstrate no significant difference in outcomes compared with alternative agents. STUDY DESIGN: Small for gestational age neonates (<10th percentile for gestational age) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) sponsored Consortium on Safe Labor database were analyzed. Neonates induced with misoprostol ± oxytocin (n = 451) were compared with neonates induced with prostaglandin E2 ± oxytocin and/or mechanical dilation ± oxytocin (n = 663). Primary outcomes included intrapartum fetal distress, cesarean section for fetal distress, cesarean section for any reason, neonatal intensive care unit admission, low 5-minute Apgar, and composite neonatal morbidity. Multiple logistic regression was used to calculate adjusted odds ratios (aORs). Data were analyzed using SAS. RESULTS: Small for gestational age neonates induced with misoprostol ± oxytocin compared with alternative agents had decreased low 5-minute Apgar scores (aOR 0.27 [0.10-0.71]). No significant differences were demonstrated among very small for gestational age neonates (<5th percentile for gestational age). CONCLUSION: Our results suggest that misoprostol does not increase risk of adverse outcomes in small for gestational age neonates; however, prospective studies are warranted to further assess optimal cervical ripening agents in this population.

Placenta previa: an outcome-based cohort study in a contemporary obstetric population.

OBJECTIVE: The objective of the study is to characterize the maternal and neonatal morbidities of women with placenta previa. STUDY DESIGN: This retrospective group study used the Consortium on Safe Labor electronic database, including 12 clinical centers, and 19 hospitals. Patients with placenta previa noted at the time of delivery were included. Maternal and neonatal variables were compared to a control group of women undergoing cesarean delivery with no previa. Logistic regression and general linear regression were used for the analysis, with p < 0.05 significance. RESULTS: There were 19,069 patients in the study: 452 in the placenta previa group and 18,617 in the control group. Neonates born to mothers with placenta previa had lower gestational ages and birth weights. In univariate analysis only, these neonates were at increased risk of lower 5 min Apgar scores, neonatal intensive care unit admission, anemia, respiratory distress syndrome, mechanical ventilation, and intraventricular hemorrhage. There was no association of placenta previa with small for gestational age infants, congenital anomalies or death. As previously shown, women with placenta previa have significantly more maternal morbidities. CONCLUSION: Increased maternal morbidity was noted; however, only those neonatal morbidities associated with preterm delivery occurred in the placenta previa group.

Nonclinical parameters affecting primary cesarean rates in the United States.

OBJECTIVE: Cesarean is the single most common operation in United States and has reached epidemic proportions in recent decades. Our objective was to study the effect of nonclinical parameters on primary cesarean rates in a large contemporary population. STUDY DESIGN: We designed a retrospective multicenter study using data obtained from electronic medical records from 19 U.S. hospitals between 2005 and 2007 (Consortium on Safe Labor Database), which included 145,764 term, singleton, nonanomalous, vertex, live births that included labor. The impact of nonclinical parameters (patient and provider characteristics, time of delivery, institutional policies, and insurance type) was investigated using modified Poisson regression methodology and classification and regression tree analysis. RESULTS: There were 125,517 vaginal and 20,247 cesarean deliveries. Using the multivariable model, the nonclinical parameters with statistical significance for primary cesarean were delivery during evening hours, a male provider, public insurance, and nonwhite race (p < 0.001). CONCLUSIONS: Cesarean rates are associated with several nonclinical factors. Further investigation into these factors might help to develop strategies to reduce their influence and hence the rates of cesarean.

Contemporary labor patterns and maternal age.

OBJECTIVE: To evaluate labor progress and length according to maternal age. METHODS: Data were abstracted from the Consortium on Safe Labor, a multicenter retrospective study from 19 hospitals in the U.S. We studied 120,442 laboring gravid women with singleton, term, cephalic fetuses with normal outcomes and without a prior cesarean delivery from 2002 to 2008. Maternal age categories were younger than 20 years of age, 20-29 years of age, 30-39 years of age, and 40 years of age or older with the reference being younger than 20 years of age. Interval-censored regression analysis was used to determine median traverse times (progression centimeter by centimeter) with 95th percentiles adjusting for covariates (race, admission body mass index, diabetes, gestational age, induction, augmentation, epidural use, and birth weight). A repeated-measures analysis with an eighth-degree polynomial model was used to construct mean labor curves for each maternal age category stratified by parity. RESULTS: Traverse times for nulliparous women demonstrated the time to progress from 4 to 10 cm decreased as age increased up to age 40 years (median 8.5 hours compared with 7.8 hours in those 20-29 years of age group and 7.4 hours in the 30-39 years of age group, P<.001); the length of the second stage with and without epidural increased with age (P<.001). For multiparous women, time to progress from 4 to 10 cm decreased as age increased (median 8.8 hours, 7.5, 6.7, and 6.5 from the youngest to oldest maternal age groups, P<.001). Labor progressed faster with increasing maternal age in both nulliparous and multiparous women in the labor curves analysis. CONCLUSION: The first stage of labor progressed more quickly with increasing age for nulliparous women up to age 40 years and all multiparous women. Contemporary labor management should account for maternal age. LEVEL OF EVIDENCE: II.

Labor patterns in twin gestations.

OBJECTIVE: To compare labor progression in twin vs singleton gestations. STUDY DESIGN: Retrospective review of electronic database created by Consortium on Safe Labor, reflecting labor and delivery information from 12 clinical centers 2002-2008. Women with twin gestations, cephalic presentation of presenting twin, gestational age ≥34 weeks, with ≥2 cervical examinations were included. Exclusion criteria were fetal anomalies or demise. Singleton controls were selected by the same criteria. Categorical variables were analyzed by χ(2); continuous by Student t test. Interval censored regression was used to determine distribution for time of cervical dilation in centimeters, or "traverse times," and controlled for confounding factors. Repeated-measures analysis constructed mean labor curves by parity and number of fetuses. RESULTS: A total of 891 twin gestations were compared with 100,513 singleton controls. Twin gestations were more often older, white or African American, earlier gestational age, increased prepregnancy body mass index, and with lower birthweight. There was no difference in number of prior cesarean deliveries, induction, or augmentation, or epidural use. Median traverse times increased at every centimeter interval in nulliparous twins, in both unadjusted and adjusted analysis (P < .01). A similar pattern was noted for multiparas in both analyses. Labor curves demonstrated a delayed inflection point in the labor pattern for nulliparous and multiparous twin gestations. CONCLUSION: Both nulliparous and multiparous women have slower progression of active phase labor with twins even when controlling for confounding factors.

Gestational weight gain and obesity: is 20 pounds too much?

OBJECTIVE: To compare maternal and neonatal outcomes in obese women according to weight change and obesity class. STUDY DESIGN: Cohort study from the Consortium on Safe Labor of 20,950 obese women with a singleton, term live birth from 2002-2008. Risk for adverse outcomes was calculated by multiple logistic regression analysis for weight change categories (weight loss [<0 kg], low [0-4.9 kg], normal [5.0-9.0 kg], high weight gain [>9.0 kg]) in each obesity class (I 30.0-34.9 kg/m(2), II 35.0-39.9 kg/m(2), and III ≥40 kg/m(2)) and by predicted probabilities with weight change as a continuous variable. RESULTS: Weight loss was associated with decreased cesareans for class I women (nulliparas odds ratio [OR], 0.21; 95% confidence interval [CI], 0.11-0.42; multiparas OR, 0.61; 95% CI, 0.45-0.83) and increased small for gestational age infants (class I OR, 1.8; 95% CI, 1.3-2.5; class II OR, 2.2; 95% CI, 1.5-3.2; class III OR, 1.7; 95% CI, 1.1-2.6). High weight gain was associated with increased large for gestational age infants (class I OR, 2.4; 95% CI, 1.9-2.9; class II OR, 1.7; 95% CI, 1.3-2.1; class III OR, 1.6; 95% CI, 1.3-2.1). As weight change increased, the predicted probability for cesareans and large for gestational age infants increased. The predicted probability of low birthweight never exceeded 4% for all obesity classes, but small for gestational age infants increased with decreased weight change. The lowest average predicted probability of adverse outcomes (cesarean, postpartum hemorrhage, small for gestational age, large for gestational age, neonatal care unit admission) occurred when women (class I, II, III) lost weight. CONCLUSION: Optimal maternal and neonatal outcomes appear to occur when weight gain is less than current Institute of Medicine recommendations for obese women. Further study of long-term outcomes is needed with respect to gestational weight changes.

Eclampsia: Maternal and neonatal outcomes.

The objective of our study is to define the maternal and neonatal outcomes associated with eclampsia. This retrospective cohort study was performed using the Consortium on Safe Labor, database from 12 clinical centers, including 19 hospitals, from 2002-2008. All patients admitted with a diagnosis of eclampsia or seizure in labor and delivery or postpartum were included in the analysis. Patients with history of seizure disorder were excluded. Maternal and neonatal outcomes were compared to outcomes of women with preeclampsia and their neonates. Statistical analyses were performed using SAS. Chi square and t-test were used for categorical and continuous variables, respectively. Logistic regression and general linear regression were used to calculate odds ratios and 95% confidence intervals. p<0.05 was considered significant. The eclampsia prevalence was 0.08% (n=191) in our population; the preeclampsia cohort had 7012 women. There were significantly more eclamptic women (49%) delivered by cesarean section, as compared to preeclamptic women (36%), OR 1.7 (1.28-2.28). These women were more likely to have an ICU admission OR 12.9 (7.0-23.7). The mean gestational ages and birthweights were lower in the neonates of the eclampsia group. A multivariate analysis revealed that low cord arterial pH, low 5min Apgar score, respiratory distress syndrome OR 5.5, (1.11-27.66) and seizures OR 10.3 (3.12-33.68), p<0.05, were significantly elevated in the eclampsia cohort. The prevalence of eclampsia in our contemporary obstetrics population was 0.08%. Both mothers as well as neonates of eclamptics are at significant risk for complications due to their illness.

Ambulatory arrhythmia monitoring in pregnant patients with palpitations.

UNLABELLED: OBJECTIVE To assess the frequency of rhythm disturbances (RDs) obtained following placement of a Holter monitor or an event loop recorder (ERT) in patients referred to cardiologists. STUDY DESIGN: Ninety-six gravidas were referred to the cardiology clinic for palpitations, syncope, or dizziness and had Holter monitoring or ERT after a baseline electroencephalogram. Arrhythmias were classified by severity. RESULTS: Gestational age at referral was 22.6 weeks ± 8.3 days. Sixty-five patients had ERTs performed, and 19 had Holter monitors. Seventy-six percent had benign arrhythmias. In our ERT cohort, history of arrhythmias showed a fourfold increase in serious RD during gestation (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.1 to 20.3, p = 0.01); obesity (body mass index > 30) had a fourfold increased risk (OR 4.0, 95% CI 1.0 to 1, p = 0.03). Serious RD did not result in greater chance of cesarean delivery or induction of labor, or a newborn with arrhythmias. CONCLUSION: Most pregnant women with palpitations have benign arrhythmias. ERT appears to be a better method of diagnosis in pregnant women.

What is the optimal time for delivery in women with gestational hypertension?

OBJECTIVE: To assess the optimal timing of delivery for women with gestational hypertension. STUDY DESIGN: A multicenter database that contained 228,668 deliveries was used to extract data on gravidas with gestational hypertension. The week-specific rates of maternal and neonatal morbidity/mortality were calculated after induction of labor. Point wise 95% confidence intervals were calculated around each of these gestational age-specific rates. RESULTS: After induction of labor, the rate of maternal morbidity/mortality reached a nadir of 89.9 per 1000 live births (95% confidence interval, 68.1-111.8) at 38-38 6/7 weeks' gestation, although the rate of neonatal morbidity/mortality fell to 10.5 per 1000 live births (95% confidence interval, 2.8-18.2) at 39-39 6/7 weeks. There were only 3 total stillbirths in our study cohort. CONCLUSION: In women with gestational hypertension, induction of labor between 38- and 39-weeks' balances the lowest maternal and neonatal morbidity/mortality.

Diastolic function in pregnant patients with cardiac symptoms.

OBJECTIVE: Dyspnea on exertion and peripheral edema occur routinely during normal gestational stage, making early diagnosis of congestive heart failure (CHF) during pregnancy difficult. Abnormal left ventricular (LV) diastolic function may be associated with dyspnea on exertion and peripheral edema, and brain natriuretic peptide (BNP) correlates with volume overload in nonpregnant populations. We tested the hypothesis that abnormal echocardiographic diastolic parameters and elevated BNP correlate in symptomatic pregnant patients. METHODS: Sixty-six gravidas presented to an Obstetric Cardiology Clinic were analyzed. Data including symptoms of CHF, BNP, and maternal and gestational ages were recorded. Echocardiograms were reviewed to measure the diastolic parameters E, A, e', and a' wave velocities and left atrial volume index (LAVI). Logistic regression was performed to characterize the relationship between diastolic parameters and BNP. RESULTS: Among the 66 pregnant patients included in the analysis, only 6 were found to have significant LV systolic dysfunction. LAVI, E, and E/e' ratio correlated positively with BNP in this symptomatic population (p = 0.008, 0.007, and 0.002, respectively). CONCLUSIONS: Abnormal diastolic parameters that represent increased LV filling pressures correlated with higher BNP levels in pregnant patients with symptoms of CHF. This suggests that symptoms may be due to diastolic dysfunction, and BNP levels may identify elevated LV filling pressures in symptomatic pregnant patients.