Perinatal Outcomes in Obese Women with One Abnormal Value on 3-Hour Oral Glucose Tolerance Test.

OBJECTIVE: This study aimed to determine if one abnormal value of four on the diagnostic 3-hour oral glucose tolerance test (OGTT) is associated with adverse perinatal outcomes in obese women. STUDY DESIGN: This is a secondary analysis of a prospective study of nulliparous women in eight geographic regions. Women with body mass index <30 kg/m2 and pregestational diabetes mellitus (GDM) were excluded. Four groups were compared: (1) normal 50-g 1-hour glucose screen, (2) elevated 1-hour glucose screen with normal 100-g 3-hour diagnostic OGTT, (3) elevated 1-hour glucose screen and one of four abnormal values on 3-hour OGTT, and (4) GDM. Using multivariable logistic regression adjusting for covariates, the women in the groups with dysglycemia were compared with those in the normal screen group for maternal and neonatal outcomes. RESULTS: Among 1,713 obese women, 1,418 (82.8%) had a normal 1-hour glucose screen, 125 (7.3%) had a normal 3-hour diagnostic OGTT, 72 (4.2%) had one abnormal value on their diagnostic OGTT, and 98 (5.7%) were diagnosed with GDM. The one abnormal value group had increased risk of large for gestational age (LGA) neonates (adjusted odds ratio [aOR] = 2.24, 95% confidence interval [CI]: 1.31-3.82), cesarean delivery (aOR = 2.19, 95% CI: 1.34-3.58), and hypertensive disorders of pregnancy (aOR = 2.19, 95% CI: 1.32-3.63) compared with normal screens. The one abnormal value group also had an increased risk of preterm birth <37 weeks (aOR = 2.63, 95% CI: 1.43-4.84), neonatal respiratory support (aOR = 2.38, 95% CI: 1.23-4.60), and neonatal hyperbilirubinemia (aOR = 2.00, 95% CI: 1.08-3.71). There was no association between one abnormal value with shoulder dystocia and neonatal hypoglycemia. CONCLUSION: For obese women, one abnormal value on the 3-hour OGTT confers increased perinatal adverse outcomes. These women should be studied further to determine if nutrition counseling and closer fetal monitoring improve outcomes even in the absence of a diagnosis of GDM. KEY POINTS: · Study of obese women with one abnormal value on OGTT.. · Adverse maternal and neonatal outcomes were found, including more LGA neonates.. · Neonates were not at increased risk of hypoglycemia..

The Impact of Hepatitis C Virus Infection on Buprenorphine Dose in Pregnancy.

OBJECTIVE: Buprenorphine (BUP) is commonly used for opioid maintenance therapy in pregnancy. Our goal was to determine whether liver dysfunction related to hepatitis C virus (HCV) infection impacts BUP dosing requirements in pregnancy. STUDY DESIGN: This was a retrospective cohort study of pregnant women with antenatal exposure to BUP to compare dosing between individuals positive versus negative for HCV infection. Spearman correlation tests were used to assess the relationship between BUP dose and HCV status. RESULTS: HCV infection was present in 103 (39%) of the patients. Patients with HCV infection required lower dose increases of BUP throughout pregnancy (p = 0.02). HCV viral load was positively correlated with the liver enzymes aspartate transaminase (r = 0.30, p = 0.003) and alanine transaminase (r = 0.25, p = 0.01). There was a negative correlation between HCV viral load and BUP dose during the second trimester (r = -0.27, p = 0.01) and third trimester (r = -0.20, p = 0.04). CONCLUSION: Women with HCV infection required less of an increase in BUP dose throughout pregnancy compared with women without HCV infection. Severity of HCV infection, as measured by viral load and liver enzymes, was also associated with BUP dosing.

Patterns of leisure-time physical activity across pregnancy and adverse pregnancy outcomes.

BACKGROUND: Although leisure-time physical activity (PA) contributes to overall health, including pregnancy health, patterns across pregnancy have not been related to birth outcomes. We hypothesized that women with sustained low leisure-time PA would have excess risk of adverse pregnancy outcomes, and that changing patterns across pregnancy (high to low and low to high) may also be related to risk of adverse pregnancy outcomes. METHODS: Nulliparous women (n = 10,038) were enrolled at 8 centers early in pregnancy (mean gestational age in weeks [SD] = 12.05 [1.51]. Frequency, duration, and intensity (metabolic equivalents) of up to three leisure activities reported in the first, second and third trimesters were analyzed. Growth mixture modeling was used to identify leisure-time PA patterns across pregnancy. Adverse pregnancy outcomes (preterm birth, [PTB, overall and spontaneous], hypertensive disorders of pregnancy [HDP], gestational diabetes [GDM] and small-for-gestational-age births [SGA]) were assessed via chart abstraction. RESULTS: Five patterns of leisure-time PA across pregnancy were identified: High (35%), low (18%), late decreasing (24%), early decreasing (10%), and early increasing (13%). Women with sustained low leisure-time PA were younger and more likely to be black or Hispanic, obese, or to have smoked prior to pregnancy. Women with low vs. high leisure-time PA patterns had higher rates of PTB (10.4 vs. 7.5), HDP (13.9 vs. 11.4), and GDM (5.7 vs. 3.1, all p < 0.05). After adjusting for maternal factors (age, race/ethnicity, BMI and smoking), the risk of GDM (Odds ratio 2.00 [95% CI 1.47, 2.73]) remained higher in women with low compared to high patterns. Early and late decreasing leisure-time PA patterns were also associated with higher rates of GDM. In contrast, women with early increasing patterns had rates of GDM similar to the group with high leisure-time PA (3.8% vs. 3.1%, adjusted OR 1.16 [0.81, 1.68]). Adjusted risk of overall PTB (1.31 [1.05, 1.63]) was higher in the low pattern group, but spontaneous PTB, HDP and SGA were not associated with leisure-time PA patterns. CONCLUSIONS: Sustained low leisure-time PA across pregnancy is associated with excess risk of GDM and overall PTB compared to high patterns in nulliparous women. Women with increased leisure-time PA early in pregnancy had low rates of GDM that were similar to women with high patterns, raising the possibility that early pregnancy increases in activity may be associated with improved pregnancy health. TRIAL REGISTRATION: Registration number NCT02231398 .

A comprehensive severity score for the morbidly adherent placenta: combining ultrasound and magnetic resonance imaging.

BACKGROUND: Ultrasound (US) is the first-line imaging modality to assess the morbidly adherent placenta, but sensitivity and specificity are lacking. OBJECTIVE: This investigation aims to improve diagnostic accuracy with a comprehensive score using clinical history, US, and magnetic resonance imaging (MRI). MATERIALS AND METHODS: We conducted a retrospective cohort study of pregnant women who received both transvaginal US and MRI with suspicion for morbidly adherent placenta between 2009 and 2016. US was scored with the following metrics: (i) previa, (ii) hypervascularity, (iii) loss of retroplacental clear space and (iv) lacunae. MRI was evaluated for (i) intraparenchymal vessels, (ii) abnormally dilated vessels, (iii) fibrin deposition, (iv) placental bulge and (v) bladder dome irregularity. Bayesian analysis was used to estimate the probability of morbidly adherent placenta for a given score. Diagnostic testing parameters were calculated. RESULTS: Among the 41 women with concerning imaging, histologically identified disease was confirmed in 16. The probability of morbidly adherent placenta increased with the score. At the highest US score, the probability of disease was 63.7%. With the highest MRI score, the probability of adherent placentation was 90.5%. Combining the US and MRI findings had a sensitivity of 56% and a specificity of 92%. CONCLUSION: A combined scoring system using MRI and US may accurately identify patients at risk for morbidity associated with morbidly adherent placenta.

Advanced Maternal Age and the Risk of Major Congenital Anomalies.

Objective This study aims to determine if advanced maternal age (AMA) is a risk factor for major congenital anomalies, in the absence of aneuploidy. Study Design Retrospective cohort study of all patients with a singleton gestation presenting for second trimester anatomic survey over a 19-year study period. Aneuploid fetuses were excluded. Study groups were defined by maternal age ≤ 34 and ≥ 35 years. The primary outcome was the presence of one or more major anomalies diagnosed at the second trimester ultrasound. Univariable and multivariable logistic regression analyses were used to estimate the risk of major anomalies in AMA patients. Results Of 76,156 euploid fetuses, 2.4% (n = 1,804) were diagnosed with a major anomaly. There was a significant decrease in the incidence of major fetal anomalies with increasing maternal age until the threshold of age 35 (p < 0.001). Being AMA was significantly associated with an overall decreased risk for major fetal anomalies (adjusted odds ratio: 0.59, 95% confidence interval: 0.52-0.66). The subgroup analysis demonstrated similar results for women ≥ 40 years of age. Conclusion AMA is associated with an overall decreased risk for major anomalies. These findings may suggest that the "all or nothing" phenomenon plays a more robust role in embryonic development with advancing oocyte age, with anatomically normal fetuses being more likely to survive.

Acute Appendicitis in Pregnancy: Predictive Clinical Factors and Pregnancy Outcomes.

Objective The objective of this study was to identify clinical factors predictive of appendicitis in pregnant women and associated obstetric outcomes. Study Design We performed a single-center, retrospective cohort study of pregnant women who underwent magnetic resonance imaging for suspected appendicitis from 2007 to 2012. Rates and odds of appendicitis based on presenting signs and symptoms were estimated. We also estimated rates and odds of adverse obstetric outcomes among women with a diagnosis of appendicitis. Results Of 171 pregnant women evaluated, 14 (8.2%) had pathology-confirmed appendicitis. White blood cell (WBC) count on admission was moderately predictive of appendicitis (area under the receiver operating characteristic curve, 0.74). A WBC count > 18,000 made the diagnosis of appendicitis more than 10 times more likely (adjusted odds ratio, 10.51; 95% confidence interval, 1.67-43.1). Of 127 women with complete pregnancy follow-up, women with appendicitis had a higher rate of pregnancy loss < 20 weeks (2/13 [15.4%] vs. 3/104 [2.9%], p < 0.01) and < 24 weeks (3/13 [23.1%] vs. 4/104 [3.8%]) than those without appendicitis. Appendicitis diagnosed in the first trimester was associated with increased risk of pregnancy loss < 24 weeks. Conclusion WBC count > 18,000 on admission is significantly associated with appendicitis in pregnant women undergoing evaluation for appendicitis. Appendicitis during the first trimester of pregnancy is associated with previable pregnancy loss.

Treatment Utility of Postpartum Antibiotics in Chorioamnionitis Study.

Objective To determine if postpartum antibiotics are necessary for patients with chorioamnionitis after a cesarean delivery (CD). Study Design Multicenter randomized controlled trial. Laboring patients with singleton gestations and chorioamnionitis who underwent CD were eligible. Patients were treated with ampicillin and gentamicin per standard protocol, then given clindamycin prior to skin incision. Patients were randomized to either postpartum antibiotic prophylaxis or no treatment following delivery. The primary outcome was the rate of endometritis. Assuming a 30% risk of endometritis in patients with chorioamnionitis who undergo CD, 119 patients per arm would be required to detect a 50% decrease in endometritis. Results The trial was stopped for futility following a planned interim analysis after 80 patients were randomized. There was no difference in the rate of the primary outcome between the two groups (9.8 vs. 7.7%, relative risk [RR]: 1.27; 95% confidence interval [CI]: 0.30, 5.31). A meta-analysis comparing post-CD antibiotics versus no treatment did not find a statistically significant difference between the groups (16.7 vs. 12.0%, pooled RR: 1.43; 95% CI: 0.72, 2.84). Conclusion Additional postpartum antibiotics do not decrease the rate of endometritis in patients with chorioamnionitis who undergo CD. The current preoperative antibiotic regimen including clindamycin should remain the standard of care in these patients.

Accuracy of Estimated Blood Loss in Predicting Need for Transfusion after Delivery.

OBJECTIVE: The definition of postpartum hemorrhage (PPH) was developed more than 50 years ago. Since then, the obstetric population has changed dramatically. We sought to determine how well we estimated blood loss (EBL) and find thresholds predicting need for transfusion. STUDY DESIGN: We performed a prospective cohort study from 2010 to 2012, comparing those who needed transfusion postpartum and those who did not. EBL, calculated EBL (cEBL), and change in hematocrit were calculated for patients who did not receive transfusion, and EBL was calculated for those who did receive transfusion, stratified by delivery type. Receiver operator curves were created and optimal thresholds of EBL to predict transfusion were estimated. RESULTS: Among 4,804 patients, transfusion was required for 0.65% of vaginal and 8.7% of cesarean deliveries. Median EBL was higher in women requiring transfusion. A weak correlation was noted between EBL and cEBL for all deliveries. Thresholds of 500 mL blood loss for vaginal delivery and 1,000 mL for cesarean had the best predictive ability for transfusion. CONCLUSION: In this modern obstetric, cohort EBL is weakly correlated with cEBL, suggesting that accuracy of clinical estimates of blood loss is modest. However, EBL predicts need for transfusion, with optimal thresholds of 500 mL for a vaginal delivery and 1,000 mL in a cesarean. This validates the traditional definitions of PPH in our modern population.

Interpreting category II fetal heart rate tracings: does meconium matter?

OBJECTIVE: Category II fetal heart rate (FHR) tracings are considered indeterminate; thus, improved risk stratification of category II FHR tracings is needed. We estimated whether the presence of meconium increased the risk of adverse neonatal outcomes. STUDY DESIGN: This study was conducted within a prospective cohort of 5000 women with singleton pregnancies who were admitted in labor at term. Pregnancies with category II FHR in the 60 minutes before delivery were included. FHR data were extracted by trained nurses who were blinded to clinical outcome. The exposure was the presence of meconium. The primary outcome was a composite neonatal morbidity defined as ≥1 of the following: neonatal death, neurologic morbidity, respiratory morbidity, hypotension that required treatment, and sepsis. Secondary outcomes were nursery admission, cord pH, 5-minute Apgar score, and components of the composite. Logistic regression was used to adjust for confounders. RESULTS: Of the 3257 women with category II FHR tracings, 693 women (21.3%) had meconium, and 2564 women (78.7%) did not. Meconium was associated with higher risk of the composite morbidity (adjusted odds ratio, 2.49; 95% confidence interval, 1.78-3.48) and increased risks of the secondary outcomes. The associations remained significant when infants with meconium aspiration syndrome were excluded. Thick meconium was associated significantly with the composite morbidity. CONCLUSION: The presence of meconium is associated with an increased risk of neonatal morbidity in women with category II FHR pattern. This clinical factor may assist clinicians in managing category II FHR patterns in labor.

The risks and benefits of internal monitors in laboring patients.

OBJECTIVE: The purpose of this study was to estimate the impact of internal monitors (fetal scalp electrode [FSE] and intrauterine pressure catheter [IUPC]) on maternal and neonatal outcomes. STUDY DESIGN: The study comprised a retrospective cohort of all women who were admitted for labor from 2004-2008. Women with internal monitors (FSE, IUPC, or both) were compared with women without internal monitors. Maternal outcomes were maternal fever and cesarean delivery. Neonatal outcomes were a composite of 5-minute Apgar score of ≤3, cord pH <7.1, cord base excess ≤-12, or admission to level 3 nursery. Logistic regression was performed to estimate the impact of internal monitors with adjustment for confounding variables, including time in labor. RESULTS: Of 6445 subjects, 3944 women (61.2%) had internal monitors. Women with internal monitors were more likely to have a fever than women without internal monitors (11.7% vs 4.5%; adjusted odds ratio [AOR], 2.0; 95% confidence interval [CI], 1.6-2.5). FSE alone was not associated with an increased risk of fever (AOR, 1.5; 95% CI, 1.0-2.1), but IUPC alone was (AOR, 2.4; 95% CI, 1.8-3.2). The risk of cesarean delivery was higher in women with internal monitors (18.6% vs 9.7%; AOR, 1.3; 95% CI, 1.0-1.5). Risk of cesarean delivery was lower in women with an FSE alone (AOR, 0.5; 95% CI, 0.4-0.7) but higher in women with both an FSE and an IUPC (AOR, 1.6; 95% CI, 1.4-2.0). Risk of the composite neonatal outcome was not higher in women with internal monitors (3.3% vs 3.6%; AOR, 0.8; 95% CI, 0.6-1.1). CONCLUSION: Routine use of an IUPC in laboring patients should be avoided because of an increased risk of maternal fever.

Fibroid tumors are not a risk factor for adverse outcomes in twin pregnancies.

OBJECTIVE: Uterine fibroid tumors have been associated with adverse outcomes in singleton pregnancies. We aimed to estimate risk for adverse obstetric outcomes that are associated with fibroid tumors in twin pregnancies. STUDY DESIGN: A retrospective cohort study of twin pregnancies with ≥1 fibroid tumor on second trimester ultrasound examination. Outcomes included small-for-gestational-age fetal growth, preterm delivery, preterm rupture of membranes, abruption, preeclampsia, and intrauterine fetal death. Univariable and multivariable analyses were used to evaluate the impact of fibroid tumors on outcomes in twin pregnancies compared with twin pregnancies without fibroid tumors. RESULTS: Of 2378 nonanomalous twin pregnancies, 2.3% had fibroid tumors. Twin pregnancies with fibroid tumors were no more likely to have small-for-gestational-age growth (40.0% vs. 36.0%; adjusted odds ratio, 1.1; 95% confidence interval, 0.7-2.0) or preterm delivery at <34 weeks' gestation (25.0% vs. 24.0%; adjusted odds ratio, 1.0; 95% confidence interval, 0.5-1.9) than twin pregnancies without fibroid tumors. Other adverse outcomes were no more likely to occur in twin pregnancies with fibroid tumors than in twin pregnancies without fibroid tumors. Post hoc power calculations suggested >97% power to detect 2-fold differences in small for gestational age and preterm delivery at <34 weeks' gestation. CONCLUSION: In contrast to data that suggest an increased risk for adverse outcomes in singleton pregnancies with fibroid tumors, twin pregnancies with fibroid tumors do not appear to be at increased risk for complications compared with those pregnancies without fibroid tumors.

Adverse outcomes in twin pregnancies complicated by early vaginal bleeding.

OBJECTIVE: We sought to estimate the risks of adverse pregnancy outcomes associated with early vaginal bleeding in twin pregnancies. STUDY DESIGN: In a retrospective cohort study of consecutive twin pregnancies undergoing anatomic survey, we compared women who reported vaginal bleeding at <22 weeks to those who did not. Exclusion criteria included monoamniotic pregnancies, twin-to-twin transfusion syndrome, and placenta previa. Primary outcomes included preeclampsia, abruption, preterm premature rupture of membranes (PPROM), preterm birth <34 weeks, and intrauterine growth restriction. RESULTS: Of 2106 pregnancies meeting inclusion criteria, 175 reported vaginal bleeding. Twin pregnancies with early vaginal bleeding had significantly higher risks of abruption, PPROM, and preterm birth compared to twin pregnancies without bleeding. The findings were similar when twin pairs were stratified by parity or maternal comorbidities. CONCLUSION: Twin pregnancies complicated by vaginal bleeding in early pregnancy have an increased risk of abruption, PPROM, and preterm birth <34 weeks.

The incidence of isolated single umbilical artery in twins and adverse pregnancy outcomes.

OBJECTIVES: The aim of this study was to estimate the incidence of single umbilical artery (SUA) in twin pregnancies and to investigate whether SUA in twin gestations is associated with adverse obstetric outcomes. METHODS: We performed a retrospective cohort study of consecutive twin pregnancies over 17 years at a tertiary care hospital. Primary exposure was SUA in one or both twins documented at routine second trimester anatomic survey. Adverse obstetric outcomes included small for gestational age (SGA), placental abruption, and preterm birth, evaluated in univariable and multivariable analyses. Analysis was performed both at the pregnancy level and at the fetal level using paired analyses to account for the non-independence of twin pairs. RESULTS: Of the 2378 twin pregnancies without major anatomic abnormalities, 1.7% (n = 40) had SUA. Only one pregnancy (one monochorionic twin pair) was complicated by both twins having SUA. Twin fetuses with SUA are at increased risk for SGA (aOR = 2.1 (1.2-4.1), p = 0.03) after adjusting for pertinent confounding factors, similar to the findings of previous studies in singleton pregnancies. In addition, twins with SUA may be at increased risk for preterm delivery before 28 weeks compared with twin pregnancies with normal three-vessel umbilical cords (adjusted odds ratio (aOR) 3.2 (1.3-7.89.4), p = 0.01). CONCLUSIONS: The incidence of SUA in twin gestations in this cohort is significantly less than the recently published data. Similar to reports in singleton gestations, SUA appears to be associated with an increased risk for SGA in twins.

Medical and nonmedical factors influencing utilization of delayed pushing in the second stage.

OBJECTIVE: To evaluate factors impacting selection to delayed pushing in the second stage of labor. STUDY DESIGN: This case-control study was a secondary analysis of a large retrospective cohort study. Cases included women who delayed pushing for 60 minutes or more in the second stage of labor. Controls began pushing prior to 60 minutes from the time of diagnosis of complete dilation. Demographic, labor, and nonmedical factors were compared among cases and controls. Logistic regression modeling was used to identify factors independently associated with delayed pushing. RESULTS: We identified 471 women who delayed pushing and 4819 controls. Nulliparity, maternal body mass index > 25, high fetal station at complete dilation, regional anesthesia use, and start of second stage during staffing shift change were independent factors associated with increased use of delayed pushing. On the other hand, black race and second-stage management during night shift were associated with lower odds of employing delayed pushing. Delayed pushing was more commonly employed in nulliparous women, but 38.9% of multiparous women also delayed pushing. CONCLUSION: We identified multiple factors associated with use of delayed pushing. This study helps to define current patterns of second-stage labor management.

Impact of an Online Question Bank on Resident In-Training Exam Performance.

OBJECTIVE: In-training exams (ITEs) are administered annually to Obstetrics and Gynecology (OBGYN) residents and have been demonstrated to correlate with success on licensing examinations. Our study objective was to determine the impact of a question bank and mock exam on the performance of Council on Resident Education in Obstetrics and Gynecology (CREOG) ITEs. Secondarily, we investigated the correlation between the extent of question bank usage and performance on the exam. METHODS: Pre-post intervention study of resident performance on CREOG ITE before and after implementation of the question bank and mock ITE at Indiana University in 2018. Performance was measured as year-to-year improvement in percent correct on ITE exams. Scores were excluded if a resident did not have a prequestion bank score report or if they did not sit for all eligible ITE exams. RESULTS: There were 51 OBGYN residents at Indiana University during the study period, with 38 available for analysis (75%). Before implementation, average year-to-year improvement for PGY1-2, PGY2-3 and PGY3-4 classes were 0.60%, 1.0% and -1.6%, respectively. After implementation, all resident classes had significant improvements in ITE scores of 6.6% (P < .01), 9.0% (P < .01), and 7.2% (P < .01), respectively. There was a moderate program-wide correlation between the number of questions completed and the percent improvement on the ITE of R = 0.36 (P = .046). CONCLUSIONS: Our study demonstrated that access to a question bank and mock ITE significantly improved CREOG ITE performance of OBGYN residents at Indiana University.

Resident Research Mentoring Teams: A Support Program to Increase Resident Research Productivity.

Background: Scholarly activity is a requirement for most graduate medical education training programs. However, barriers exist for residents to accomplish projects. Objective: To evaluate the correlation between a resident research mentoring team (RRMT) program and meeting presentations and publications of resident research projects. We further plan to report feasibility of the RRMT. Methods: We performed a before-and-after study of meeting presentations and/or publication of resident research projects before institution of the RRMT (2004-2011) and post-RRMT implementation (2016-2019). The RRMT is a diverse group of faculty, statisticians, and research staff who meet regularly with residents to provide guidance for their research studies. It is part of overall research support from the department, which also includes biostatistics, database and regulatory help, travel funds, and project budget funds. Data on meeting presentations and publications were collected from Google Scholar, PubMed, Scopus, and the IUPUI ScholarWorks institutional repository, using resident and faculty names and titles of projects. Comparisons of pre- and post-RRMT groups were made. Results: Seventy-four residents were in the pre-RRMT group and 40 were in the post-RRMT group. Post-RRMT residents published, presented, and combined published or presented their projects more frequently than those in pre-RRMT group (57.5% vs 28.4%, P=.002; 50% vs 16.2%, P=.001; 67.5% vs 37.8%, P=.002). Controlling for winning a Research Day award and pursuing a fellowship, being in the post-RRMT group was independently associated with presentation or publication of the resident research project (OR 3.62, 95% CI 1.57-8.83). Conclusions: Support of resident scholarly activity, such as thorough implementation of a program like the RRMT, is associated with increased presentations and publications of research projects.

Impact of chorionicity on risk and timing of intrauterine fetal demise in twin pregnancies.

OBJECTIVE: We sought to estimate the association between chorionicity and intrauterine fetal demise (IUFD) of one or both fetuses in twin pregnancies. STUDY DESIGN: In a retrospective cohort of twins undergoing anatomic survey, risk of IUFD in monochorionic and dichorionic twins was compared. The primary outcome was IUFD of one or both fetuses; secondary outcomes included nonanomalous fetal deaths. RESULTS: Of 2161 twin pregnancies meeting inclusion criteria, 86 had at least 1 IUFD and 32 experienced a double fetal loss. Monochorionic pregnancies had an increased risk of a single demise (adjusted odds ratio, 1.69; 95% confidence interval, 1.04-2.75) and a double demise (adjusted odds ratio, 2.11; 95% confidence interval, 1.02-4.37). Of all double demises, 70% occurred <24 weeks. CONCLUSION: Monochorionic twins carry an increased risk of fetal death compared to dichorionic twins. Double demise occurs primarily <24 weeks, regardless of chorionicity.

Does delayed pushing in the second stage of labor impact perinatal outcomes?

OBJECTIVE: To estimate maternal, neonatal, and labor outcomes associated with delayed pushing. STUDY DESIGN: A retrospective cohort study of all consecutive women admitted to a single institution in labor at term who reached the second stage of labor. Pregnancies with multiple fetuses or major anomalies were excluded. Delayed pushing was defined as initiation of pushing ≥60 minutes after complete dilatation. Primary outcome was mode of delivery. Multivariable logistic regression was used to control for confounding. RESULTS: Of the 5290 women who met inclusion criteria, 471 (8.9%) employed delayed pushing, and 4819 (91.1%) pushed immediately. Delayed pushing was associated with increased rates of cesarean, operative vaginal delivery, maternal fever, and lower arterial cord pH. Duration of the second stage and length of time spent pushing were significantly longer with delayed pushing. CONCLUSION: Delayed pushing is associated with lower rates of spontaneous vaginal delivery and increased adverse maternal and neonatal outcomes.

Marijuana use, fetal growth, and uterine artery Dopplers.

OBJECTIVE: Marijuana (MJ) use is associated with adverse effects on fetal growth. We aimed to investigate the timing of suboptimal fetal growth onset in MJ-exposed pregnancies. In addition, we aimed to explore the relationship between MJ-exposure and both abnormal uterine artery (UtA) Doppler parameters and small for gestational age (SGA). STUDY DESIGN: This was a secondary analysis of a prospective multicenter cohort that enrolled nulliparous individuals delivering non-anomalous fetuses beyond 20 weeks' gestation. Marijuana exposure was ascertained by self-report or clinical urine toxicology testing. Ultrasound estimated fetal weights (EFWs) were assessed in participants at both 16w0d-21w6d and 22w0d-29w6d. EFWs and birth weight (BW) were converted to weight percentiles (wPCT). EFW and BW wPCTs were calculated using population-based standards. Additionally, a customized standard designed to be applicable to both EFWs and BWs within the same model was also used to allow for EFW to BW percentile trajectories. The primary outcome, longitudinal wPCT, was compared between individuals with and without MJ use in a linear mixed-effects regression model adjusting for tobacco. For modeling, wPCT was smoothed across gestational age; MJ was estimated as an intercept and linear difference in the slope of gestational age. UtA Doppler notching, resistance index (RI), and pulsatility index (PI) at 16w0d-21w6d were compared using t-test and χ2. SGA at delivery was also compared. RESULTS: Nine thousand one hundred and sixty-three individuals met inclusion criteria; 136 (1.5%) used MJ during pregnancy. Individuals who used MJ were more likely to be younger, identify as non-Hispanic Black, and have had less education. Fetuses exposed to MJ had lower wPCT beginning at 28 weeks using population-based and customized standards, when compared to those without exposure. UtA notching, PI, and RI were similar between groups. SGA was more frequent in neonates exposed to MJ using both population-based (22 vs. 9%, p<.001) and customized (25 vs. 14%, p<.001) curves. CONCLUSIONS: MJ-exposed fetuses were estimated to be smaller than unexposed fetuses starting at 28 weeks' gestation across both growth standards without a difference in UtA Doppler parameters.

Echogenic intracardiac foci: associated with increased risk for fetal trisomy 21 or not?

OBJECTIVE: The purpose of this study was to evaluate the impact of an echogenic intracardiac focus (EIF) on the risk for fetal trisomy 21 (T21) in populations with differing prevalence of T21. METHODS: A retrospective cohort study of pregnancies presenting to our prenatal ultrasound units over 16 years (1990-2006) was conducted. Contingency table analysis of the presence of an EIF and diagnosis of fetal T21 was performed. The groups analyzed included the following: (1) all fetuses with EIF plus other sonographic markers, (2) EIF as an isolated sonographic marker, (3) those younger than 35 years with an isolated finding of EIF, and (4) a group with an isolated finding of EIF excluding those at increased risk for T21 on serum screening. RESULTS: Echogenic intracardiac foci were found in 2223 of 62,111 pregnancies (3.6%), and T21 was diagnosed in 218 pregnancies (0.4%). The presence of an EIF along with other markers was associated with a statistically significant risk for T21 (positive likelihood ratio [LR], 4.4; 95% confidence interval [CI], 3.2-6.0; P < .05). An isolated EIF was not associated with a statistically significant increased risk for T21 in patients younger than 35 years (positive LR, 1.7; 95%, CI 0.7-4.1) and those without abnormal serum screening results for aneuploidy (positive LR, 1.6; 95% CI, 0.8-3.1). CONCLUSIONS: The finding of an isolated EIF on prenatal sonography does not significantly increase the risk for fetal T21 in populations not otherwise at an increased risk for the disorder. An isolated EIF should be considered an incidental finding in patients younger than 35 years and in those without abnormal serum aneuploidy screening results.