Clinical factors associated with unexpected poor or suboptimal response in Poseidon criteria patients.

RESEARCH QUESTION: What clinical factors are associated with 'unexpected' poor or suboptimal responses to IVF ovarian stimulation per POSEIDON's criteria, and which AMH and AFC threshold values distinguish this population? DESIGN: Tri-centre retrospective cohort study (2015-2017) involving first-time IVF and ICSI cycles with conventional ovarian stimulation (≥150 IU/day of FSH). Eligibility criteria included sufficient ovarian reserve markers according to POSEIDON's classification (AMH ≥1.2 ng/ml; AFC ≥5). Ovarian response categories were poor (<4 oocytes), suboptimal (4-9 oocytes) and normal (≥9 oocytes). Primary outcomes included clinical factors associated with an unexpected poor or suboptimal response to conventional ovarian stimulation using logistic regression analyses, and the threshold values of AMH and AFC predicting increased risk of such responses using ROC curves. RESULTS: A total of 7625 patients met the inclusion criteria: 204 (9.3%) were poor and 1998 (90.7%) were suboptimal responders. Logistic regression identified significant clinical predictors for a poor or suboptimal response, including AFC, AMH, total gonadotrophin dose, gonadotrophin type and trigger type (P ≤ 0.02). The ROC curves indicated that AMH 2.87 ng/ml (AUC 0.740) and AFC 12 (AUC 0.826) were the threshold values predicting a poor or suboptimal response; AMH 2.17 ng/ml (AUC 0.741) and AFC 9 (AUC 0.835) predicted a poor response; and AMH 2.97 ng/ml (AUC 0.722) and AFC 12 (AUC 0.801) predicted a suboptimal response. CONCLUSIONS: The threshold values of AMH and AFC predicting 'unexpected' poor or suboptimal response were higher than expected. These findings have critical implications for tailoring IVF stimulation regimens and dosages.

Clinical significance of true umbilical cord knot: a propensity score matching study.

OBJECTIVE: True umbilical cord knot (TUCK) is a rare finding that often leads to intensified surveillance and patient anxiety. This study sought to evaluate the incidence, risk factors, and obstetric and neonatal outcomes of TUCK. METHODS: A retrospective cohort study was conducted at a tertiary university medical center in 2007-2019. Patients with singleton pregnancies diagnosed postnatally with TUCK were identified and compared to women without TUCK for obstetric and neonatal outcomes using propensity score matching (PSM). RESULTS: TUCK was diagnosed in 780 of the 96,766 deliveries (0.8%). Women with TUCK were older than those without TUCK (32.57 vs. 31.06 years, P < 0.001) and had higher gravidity (3 vs. 2, P < 001) and a higher rate of prior stillbirth (1.76% vs. 0.43%, P < 0.01). Following covariate adjustment, 732 women with TUCK were compared to 7320 matched controls. TUCK was associated with emergency cesarean delivery due to non-reassuring fetal heart rate (2.54% vs. 4.35%, P = 0.008, OR 1.71, 95%CI 1.14-2.56) and intrapartum meconium-stained amniotic fluid (19.26% vs. 15.41%, P = 0.022, OR 1.31, 95%CI 1.04-1.65). Neonatal outcomes were comparable except for higher rates of 1-min Apgar score < 7 and neonatal seizures in the TUCK group. The stillbirth rate was higher in the TUCK group, but the difference was not statistically significant (1.23% vs 0.62%, P = 0.06, OR 1.96, 95%CI 0.96-4.03). CONCLUSIONS: TUCK has several identifiable risk factors. Pregnant women with TUCK may cautiously be informed of the relatively low risks of major obstetric or perinatal complications. The lower occurrence of stillbirth in the TUCK group warrants further study.

Risk factors for relaparotomy after a cesarean delivery: a case-control study.

BACKGROUND: Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center. METHODS: A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders. RESULTS: During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h. CONCLUSION: We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

The effect of bariatric surgery on polycystic ovary syndrome patients' obstetric and neonatal outcomes: a population-based study.

PURPOSE: To examine the effect of bariatric surgery (BS) on obstetric and neonatal outcomes in patients with polycystic ovary syndrome (PCOS). METHODS: A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, including women who delivered in the third trimester or had a maternal death in the USA (2004-2014). We compared obstetric and neonatal outcomes between groups in three analyses: (1) Primary analysis-women with an ICD-9 PCOS diagnosis who underwent BS compared to pregnant PCOS patients without BS. (2) Sub-group analysis-PCOS women with BS compared to obese PCOS women (body mass index (BMI) ≥ 30 kg/m2) without BS. (3) Women with and without PCOS who underwent BS. RESULT: In the primary analysis, pregnant PCOS women who underwent BS (N = 141), compared to pregnant PCOS women without BS (N = 14,741), were less likely to develop pregnancy-induced hypertension (PIH) (9.2% vs. 16.2%, respectively, aOR 0.39, 95% CI 0.21-0.72) and gestational diabetes mellitus (GDM) (9.9% vs. 18.8, aOR 0.40, 95% CI 0.23-0.70). In the sub-group analysis, PCOS women with BS, compared to obese PCOS women without BS (N = 3231), were less likely to develop gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension (P < 0.05). Lastly, PCOS patients with BS had a higher cesarean section rate when compared to non-PCOS patients with BS (N = 9197) (61.7% vs. 49.2%, aOR 1.48, 95% CI 1.05-2.09), with otherwise comparable obstetric and neonatal outcomes. CONCLUSIONS: BS in PCOS patients was associated with reduced risks for GDM and PIH when compared to PCOS controls without BS and reduced risk for gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension when compared to obese PCOS controls without BS. Moreover, BS was associated with reduced inherent pregnancy risks of PCOS, almost equating them to those of non-PCOS counterparts.

Significance of serum AMH and antral follicle count discrepancy for the prediction of ovarian stimulation response in Poseidon criteria patients.

PURPOSE: To determine the risk of not being a poor responder in ovarian stimulation (OS) for in vitro fertilization (IVF) when ovarian reserve markers are discordant-one falling within Poseidon's criteria normal range (e.g., anti-Müllerian hormone (AMH) ≥ 1.2 ng/mL or antral follicle count (AFC) ≥ 5), and the other in the poor ovarian reserve range. METHODS: A tri-center retrospective cohort study (2015-2017) involving women with discordant AMH and AFC values undergoing their first IVF/ICSI cycle using conventional OS (cOS, ≥ 150 IU/day of follicle-stimulating hormone). Discordant serum AMH and AFC values were defined according to Poseidon's criteria (AMH < 1.2 ng/mL and AFC ≥ 5 or AMH ≥ 1.2 ng/mL and AFC < 5). Poor ovarian response (POR) was < 4 retrieved oocytes. Receiver operating characteristic (ROC) curves were used to determine AMH and AFC cut-offs for non-POR. Logistic regression analysis evaluated factors associated with non-POR. RESULTS: Out of 8797 patients who underwent assessment with both AMH and AFC, 1172 (13.3%) exhibited discordant values. Of these, 854 (72.9%) had ≥ 4 oocytes retrieved. Within this group, 726 (85.0%) had "low" AMH values, whereas 128 (15.0%) had "low" AFCs. An AFC of 6 had 77% sensitivity and 52% specificity (AUC = 0.700), while AMH of 1.19 ng/mL had 31% sensitivity and 85% specificity (AUC = 0.492) for non-POR. AFC and the use of recombinant gonadotropins were positive predictors of non-POR. CONCLUSIONS: When serum AMH is < 1.19 ng/mL, but AFC is ≥ 6, there is a moderate likelihood of a non-POR during stimulation. Conversely, if AFC is < 5 but serum AMH is ≥ 1.19 ng/mL, the chances of non-POR are low. Among patients with discordant markers, AFC emerges as the primary predictor of oocyte yield.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience.

PURPOSE: To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy. METHODS: A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture. RESULTS: During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01). CONCLUSION: Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Pregnancy, delivery and neonatal outcomes among women with hypoparathyroidism-A population-based study.

OBJECTIVE: Data are inconclusive regarding pregnancy complications associated with maternal chronic hypoparathyroidism. Therefore, we aimed to compare pregnancy, delivery and neonatal outcomes in patients affected by chronic hypoparathyroidism to those without chronic hypoparathyroidism. DESIGN: A retrospective population-based study utilising data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database over 11 years from 2004 to 2014 inclusively. Multivariate logistic regression was used to control for confounders. PATIENTS: Patients with chronic hypoparathyroidism compared with those without. MEASUREMENTS: Obstetric and neonatal outcomes. RESULTS: We identified 204 pregnancies in mothers with chronic hypoparathyroidism and 9,096,584 pregnancies without chronic hypoparathyroidism. After adjusting for age, insurance plan type, obesity, chronic hypertension, thyroid disease, pregestational diabetes mellitus, and previous caesarean section, patients in the hypoparathyroidism group, compared with those without hypoparathyroidism, were found to have an increased rate of preterm birth (<37 weeks) (19.1% vs. 7.2%, aOR: 2.49, 95% confidence interval [CI]: 1.74-3.54, p < 0.0001, respectively); and blood transfusions (4.9% vs. 1.0%, aOR: 4.07, 95% CI: 2.15-7.73, p < -0.0001). Neonates to mothers with chronic hypoparathyroidism had a higher rate of congenital anomalies (4.4% vs. 0.4%, aOR: 6.50, 95% CI: 3.31-12.75, p < 0.0001), with comparable rates of small-for-gestational-age neonates and intrauterine foetal death. CONCLUSION: This is the largest study of chronic hypoparathyroidism in pregnancy to date. We found significant increases in the rates of preterm birth, blood transfusions and congenital anomalies in chronic hypoparathyroidism. Our findings highlight the importance of identifying chronic hypoparathyroidism as a risk factor for pregnancy and neonatal complications, although it remains unknown if maintaining calcium in the target range will mitigate these risks.

How does IVF conception affect pregnancy complications in an older cohort of women, at least 38 years of age? Study of a population database.

PURPOSE: To compare perinatal outcomes in in-vitro fertilization (IVF) pregnancies versus spontaneous conceptions in woman of advanced maternal age (AMA), and to evaluate the effect of increasing age on IVF pregnancies' outcomes. METHODS: A retrospective population-based cohort study including pregnant women who delivered between 2008-2014 in the US. First, we included women aged 38-43 years and compared those with IVF conceptions (cases) to women with spontaneous conceptions (controls). Thereafter, we compared IVF pregnancies in women aged 38-43 years to IVF pregnancies at < 38 years of age. Multivariate logistic regression was performed to compare both groups regarding pregnancy,delivery, and neonatal outcomes after adjusting for plausible confounders. RESULTS: Three hundred nine thousand five hundred sixty-seven pregnant women aged 38-43 years were identified, with 2,762 composing the IVF group, and 306,805 composing the control group. After adjusting for confounders, the IVF group had a higher risk of several adverse obstetrical outcomes, including hypertensive disorders of pregnancy (aOR 1.31,95%CI 1.06-1.62), gestational diabetes (aOR 1.26,95%CI 1.13-1.41),preterm delivery (aOR 1.45,95%CI 1.16-1.81), cesarean section (CS) (aOR 1.84,95%CI 1.55- 2.19),postpartum hemorrhage (aOR 1.68,95%CI 1.27- 2.24), and maternal infection (aOR 1.90,95%CI 1.31-2.77), with comparable neonatal outcomes. For the second analysis, 9712 IVF pregnancies were included (n = 6950 < 38 years, and n = 2762 ≥ 38 years). Women ≥ 38 years who underwent IVF were more likely to experience hypertensive disorders of pregnancy, CS, hysterectomy and blood transfusion, with comparable neonatal outcomes. CONCLUSION: IVF AMA pregnancies have a significant increase in myriad perinatal complications compared to spontaneous AMA pregnancies. Younger women undergoing IVF have mildly less complications than their older counterparts.

The association between hypothyroidism and perinatal outcomes in patients with polycystic ovary syndrome.

PURPOSE: To compare pregnancy, delivery, and neonatal outcomes in patients with polycystic ovary syndrome (PCOS) with and without concomitant hypothyroidism. METHODS: A retrospective population-based cohort study including all women with an ICD-9 diagnosis of PCOS in the US between 2004 and 2014, who delivered in the third trimester or had a maternal death. We compared women with a concomitant diagnosis of hypothyroidism to those without. Women with hyperthyroidism were excluded. Pregnancy, delivery, and neonatal outcomes were compared between the two groups. RESULTS: Overall, 14,882 women met inclusion criteria. Among them, 1882 (12.65%) had a concomitant diagnosis of hypothyroidism, and 13,000 (87.35%) did not. Women with concomitant hypothyroidism, compared to those without, were characterized by increased maternal age (25.5% ≥ 35 years vs. 18%, p < 0.001, respectively), and had a higher rate of multiple gestations (7.1% vs. 5.7%, p = 0.023). Interestingly, pregnancy, delivery and neonatal outcomes were comparable between the groups, except for a higher rate of small-for-gestational-age (SGA) neonates in the group with hypothyroidism (4.1% vs. 3.2%, p = 0.033) (Tables 2 and 3). In a multivariate logistic regression adjusting for potential confounders, hypothyroidism was no longer found to be associated with SGA (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 0.99-1.75, p = 0.057), but was found to increase the odds for preeclampsia (aOR 1.30, 95% CI 1.06-1.59, p = 0.012). CONCLUSIONS: In patients with PCOS, concomitant hypothyroidism significantly increases the risk for preeclampsia. Unexpectedly, other pregnancy complications commonly increased by hypothyroidism were not increased in women with PCOS, likely due to the inherent elevated baseline pregnancy risks of PCOS.

Intrauterine Blood Transfusion for Parvo B19-Induced Fetal Anemia: Neuroimaging Findings and Long-Term Neurological Outcomes.

INTRODUCTION: We aimed to evaluate the neuroimaging findings and long-term neurodevelopmental outcomes of fetuses and children following intrauterine blood transfusion (IUT) for parvo B19 infection-induced anemia compared to those with RBC alloimmunization. METHODS: We conducted a retrospective cohort study including women who underwent an IUT due to fetal anemia between 2006 and 2019 in a tertiary, university-affiliated medical center. The cohort was divided into two groups: a study group - fetuses affected by congenital parvo B19 infection; and a control group - fetuses affected by RBC alloimmunization. Retrospective data such as antenatal sonographic evaluations, fetal brain MRI results, and short-term fetal and neonatal outcomes were collected. All children underwent a neurodevelopmental evaluation after birth using a Vineland questionnaire. Primary outcome was defined as the presence or absence of neurodevelopmental delay. Secondary outcome was defined as the presence of abnormal fetal neuroimaging findings such as cerebellar hypoplasia, polymicrogyria, intracranial hemorrhage, or severe ventriculomegaly. RESULTS: Overall, 71 fetuses requiring at least one IUT were included in the study. Of these, 18 were affected by parvo B19 infection and 53 by RBC alloimmunization with various associated antibodies. Fetuses in the parvo B19 group presented at an earlier gestational age (22.91 ± 3.36 weeks vs. 27.37 ± 4.67 weeks, p = 0.002) and were more affected by hydrops (93.33% vs. 16.98%, p < 0.001). Three fetuses out of the 18 (16.67%) fetuses in the parvo B19 group died in utero following the IUT. Abnormal neuroimaging findings were detected in 4/15 (26.7%) of the parvo B19 survivors versus 2/53 (3.8%) of fetuses affected by RBC alloimmunization (p = 0.005). There was no difference in long-term neurodevelopmental delay rates between the children in the study and control groups, as assessed at the average age of 3.65 and 6.53 years, accordingly. CONCLUSION: Fetal anemia due to parvo B19, treated with IUT, might be associated with increased rates of abnormal neurosonographic findings. The correlation between those findings and long-term adverse neurodevelopmental outcomes requires further investigation.

Fetal congenital heart disease - mode of delivery and obstetrical complications.

BACKGROUND: The optimal mode of delivery in cases of fetal congenital heart disease (CHD) is not established. The few relevant studies did not address operative vaginal delivery. The aim of this study was to assess the impact of fetal CHD on mode of delivery during a trial of labor, and to secondarily describe some obstetric complications. METHODS: The database of a tertiary medical center was searched for women who gave birth to a singleton, liveborn neonate in 2015-2018. Mode of delivery was compared between women carrying a fetus with known CHD and women with a healthy fetus matched 1:5 for maternal age, parity, body mass index, and gestational age. RESULTS: The cohort included 616 women, 105 in the CHD group and 511 in the control group. The rate of operative vaginal delivery was significantly higher in the CHD group (18.09% vs 9.78%, OR 2.03, 95% CI 1.13-3.63, p = 0.01); the difference remained significant after adjustment for nulliparity and gestational age at delivery (aOR 2.58, 95% CI 1.36-4.9, p < 0.01). There was no difference between the CHD and control group in rate of intrapartum cesarean delivery (9.52% vs 10.76%, respectively, OR 0.97, 95% CI 0.47-1.98, p = 0.93). The most common indication for operative vaginal delivery was non-reassuring fetal heart rate (78.94% vs 64%, respectively). Median birth weight percentile was significantly lower in the CHD group (45th vs 53rd percentile, p = 0.04). CONCLUSIONS: Our findings suggest that operative vaginal delivery, performed mostly because of non-reassuring fetal heart rate, is more common in pregnancies complicated by a prenatal diagnosis of CHD than non-anomalous pregnancies.

Fetal and neonatal brain lesions following laser ablation for twin-to-twin-transfusion-syndrome as detected by pre- and post-natal brain imaging.

OBJECTIVE: To determine the rate of and risk factors for fetal and neonatal brain lesions following laser ablation for twin-to-twin transfusion syndrome (TTTS). METHODS: A retrospective cohort study of 83 women with monochorionic twin pregnancies who underwent ablation for TTTS at a single tertiary hospital. Post-laser survivors were followed-up with fetal neurosonogram every 2 weeks and fetal brain MRI at 28-32 weeks of gestation; post-natal brain imaging included neurosonogram. Cases with pre- and post-natal brain lesions were compared to those without. RESULTS: 153 fetuses survived the immediate post-laser period and underwent brain imaging. Of these, 17 (11.11%) exhibited brain lesions on prenatal imaging studies, and 36 (32.4%) on post-natal ultrasound. Later gestational age (GA) at the time of ablation (23.0 vs. 21.4 weeks, p = 0.0244), post-laser twin-anemia-polycythemia-sequence (TAPS) (29.41% vs. 9.56%, p = 0.035) and birthweight discordancy (30% vs. 9%, p = 0.0025) were associated with prenatal brain lesions. Earlier GA at delivery (31.0 weeks vs. 32.2, p = 0.0002) and post-laser TAPS (25% vs. 9.33%, p = 0.038) were associated with post-natal brain lesions. CONCLUSIONS: Survivors of ablation for TTTS are at risk for brain lesions, which can be detected prenatally. Incorporation of neurosonogram and fetal brain MRI into the routine surveillance of such pregnancies should be considered.

Frozen-thawed embryo transfer is an independent risk factor for third stage of labor complications.

PURPOSE: Third stage of labor complications are more prevalent following singleton vaginal deliveries of gestations conceived through in vitro fertilization (IVF) and fresh embryo transfer. This study aimed to evaluate these complications in pregnancies conceived through frozen-thawed embryo transfer (FET), in which endometrial preparation differs from fresh cycles. METHODS: A cohort study of all singleton pregnancies conceived through IVF-FET who delivered vaginally at a tertiary medical center during 2007-2017. The study group consisted of 88 IVF-FET gestations (cases) that were matched to 176 spontaneous pregnancies based on age, gravidity, parity and gestational week at delivery (controls). The association between mode of conception and third stage of labor complication rate was examined. RESULTS: Baseline characteristics were similar between groups, except for a lower prevalence of induction of labor in the control group (23.3% vs. 36.3%, p = 0.03). The rate of post-partum hemorrhage (PPH), manual lysis and revision of the uterine cavity were all higher in pregnancies conceived through IVF-FET versus spontaneously (13.6% vs. 5.7%, p = 0.018; 17% vs. 2.3%, p < 0.001; and 21.6% vs. 6.8%, p < 0.001, respectively). Multivariate analysis adjusting for age, previous cesarean section, induction of labor, neonatal weight and use of analgesia demonstrated that deliveries following IVF-FET were independently associated with an increased risk for third stage of labor complications (estimated OR = 3.45, p = 0.0002). CONCLUSION: IVF-FET is an independent risk factor for PPH, need for manual lysis and revision of the uterine cavity. Precautionary measures should be undertaken in the third stage in deliveries following IVF-FET, even if no other risk factors are present.

Imaging of the Fetal Zygomatic Bone: A Key Role in Prenatal Diagnosis of First Branchial Arch Syndrome.

OBJECTIVES: First arch syndromes are congenital defects caused by failure of neural crest cells to migrate into the first branchial arch. First arch syndrome is classified into 2 main clinical manifestations: Treacher Collins syndrome, characterized by bilateral underdevelopment of the zygomatic bones; and Pierre Robin sequence. The aim of this study was to describe the feasibility of visualization of the fetal zygomatic bone and assess its application in cases referred for features suggestive of first arch syndrome. METHODS: A prospective cohort study was conducted. The feasibility of visualization of the zygomatic bone was performed in 50 sequential fetuses with a normal anatomic scan between 12 and 24 weeks' gestation using 3-dimensional sonography. Following this, cases referred for targeted scans for suspected first branchial arch syndrome were assessed for the presence or absence of the zygomatic bones. RESULTS: Visualization of the fetal zygomatic bone was feasible in all low-risk cases. Cases referred for targeted scans included 11 isolated cases of micrognathia or retrognathia, 3 cases of microtia, and 3 cases of auricular or facial vestiges. Within this group, the zygomatic bones were visualized in all but 2 cases. No associated extrafacial malformations were detected; therefore, this phenotype was consistent with Treacher Collins syndrome. CONCLUSIONS: Prenatal imaging of the zygomatic bones offers a clinically based sonographic approach to cases referred for features suggestive of first arch syndrome and enables differentiation between the 2 main clinical manifestations: Treacher Collins syndrome and Pierre Robin sequence.

Neonatal outcomes in term pregnancies treated with antenatal corticosteroids for suspected pre-term labor.

OBJECTIVE: To evaluate the association between antenatal corticosteroid treatment and neonatal outcome when delivery occurs at term. STUDY DESIGN: A retrospective cohort study of all women with singleton gestations who delivered at term (37 + 0 to 41 + 6 weeks) in a tertiary medical center (2012-2015). Women with diabetes, suspected fetal growth restriction, antepartum fetal death, and fetal structural or chromosomal anomalies were excluded. The cohort was divided according to prior preterm (24 + 0 to 33 + 6 weeks) antenatal corticosteroids treatment due to threatened preterm labor (study group), vs. no such treatment (control group). Primary outcome was birthweight at delivery. Secondary outcomes were composites neonatal adverse outcomes. Logistic regression analysis was utilized to adjust results for potential confounders. RESULTS: Of 25,872 women who were included in the study, 722 (3%) were treated with antenatal corticosteroids. Women in the treatment group had higher rates of nulliparity compared to controls (43% vs. 38%, p = 0.002). Birth weight was significantly lower in the corticosteroid treatment group (3077 g vs. 3264 g, p = 0.001), with higher rates of small for gestational age (11% vs. 6%, p = 0.001). Multivariate analysis adjusting for parity and gestational age demonstrated that corticosteroid treatment was associated with lower birth weight (B = - 93 g, 95% CI - 123 to - 66, p = 0.001). Treatment was not found to be associated with adverse neonatal outcomes composites. CONCLUSION: Antenatal corticosteroid treatment is associated with lower birth weight and higher rates of small for gestational age neonates among women who eventually deliver at term. However, it is not associated with short-term adverse neonatal outcomes.

Perinatal outcome following induction of labor in patients with good glycemic controlled gestational diabetes: does timing matter?

PURPOSE: To compare maternal and neonatal outcomes in women with good glycemic controlled gestational diabetes mellitus (GDM) undergoing induction of labor at early and late term. METHODS: A retrospective cohort study of all women with singleton pregnancies and well-controlled GDM undergoing induction of labor for non-GDM indications in the early (37 + 0-38 + 6 gestational weeks) and late term (39 + 0-40 + 6 weeks), in a single university-affiliated medical center (2014-2016). Exclusion criteria included: pre-gestational diabetes, multiple gestations and elective cesarean delivery. Maternal and neonatal outcomes were compared between groups. Composite maternal outcome included: post-partum hemorrhage, blood products transfusion, and cesarean or instrumental delivery. Composite neonatal outcome included: neonatal intensive care unit admission, respiratory distress syndrome, hypoglycemia and jaundice. RESULTS: Overall, 430 women met inclusion criteria. Amongst them, 193 (44.88%) were induced at early term and 237 (55.11%) were induced at late term. There were higher rates of hypertensive complications of any kind and pre-eclampsia, in women induced at early term (11.04% vs. 4.26%, p = 0.021, and 5.92% vs. 1.60%, p = 0.04, respectively). There were no differences in maternal and neonatal outcomes between groups. Rates of composite maternal outcome and composite neonatal outcome did not differ between groups (OR 0.92, 95% CI 0.59-1.44, p = 0.73 and OR 0.78, 95% CI 0.47-1.3, p = 0.36, respectively). CONCLUSION: Women with good glycemic controlled GDM may be safely induced at early term, when other indications exist, without an increased risk for adverse maternal or neonatal outcomes.

Neonatal outcome in gestational-diabetic mothers treated with antenatal corticosteroids delivering at the late preterm and term.

OBJECTIVE: To determine the association between antenatal corticosteroid treatment and neonatal complications in diabetic mothers delivering after 34 weeks of gestation. METHODS: A retrospective cohort study of women with singleton pregnancies diagnosed with gestational diabetes who delivered after 34 weeks of gestation in a university-affiliated medical center (2012-2016). Mothers treated with corticosteroids prior to 34 + 0 weeks of gestation were divided according to gestational age at delivery: late-preterm (34 + 0 to 36 + 6) and term (37 + 0 to 41 + 6). Each group was compared to women delivering at the same gestational age who were not treated with corticosteroids. Primary outcome was defined as a neonatal adverse composite outcome. Birth weight was amongst secondary outcomes measured. Logistic regression analysis was utilized to adjust results to potential confounders. RESULTS: During the study period, 161 diabetic mothers delivered at late-preterm. Amongst them, 47 (30%) were treated with corticosteroids. 2101 diabetic mothers delivered at term, amongst them 82 (4%) were treated with corticosteroids. Primary outcome did not differ between groups. Multivariate analysis demonstrated that corticosteroid treatment was not associated with neonatal adverse composite outcome when delivery occurred at the late preterm, nor at term (adjusted odds ratio (aOR) = 0.708, 95% CI 0.2-2.3, p = 0.572, and aOR = 1.6, 95% CI 0.2-12.7, p = 0.635, respectively). Birth weight was significantly lower in women treated with corticosteroids (2486 vs. 2675 g, p = 0.02 at late-preterm, and 3160 vs. 3319 g, p < 0.001 at term). CONCLUSION: Corticosteroid treatment for diabetic mothers was not associated with neonatal adverse outcomes, but was found associated with a lower birth weight, when delivery occurs after 34 weeks of gestation.

The effect of socioeconomic status on adverse obstetric and perinatal outcomes in women with polycystic ovary syndrome-An evaluation of a population database.

OBJECTIVE: To evaluate the modifying effect of low socioeconomic status (SES) on polycystic ovary syndrome (PCOS) women's pregnancy and neonatal complications. METHODS: A retrospective population-based cohort study including all women with an ICD-9 diagnosis of PCOS in the US between 2004 and 2014, who delivered in the third trimester or had a maternal death. SES was defined according to the total annual family income quartile for the entire population studied. We compared women in the lowest income quartile (<$39 000 annually) to those in the higher income quartiles combined (≥$39 000 annually). Pregnancy, delivery, and neonatal outcomes were compared between the two groups. RESULTS: Overall, 9 096 788 women delivered between 2004 and 2014, of which 12 322 had a PCOS diagnosis and evidence of SES classification. Of these, 2117 (17.2%) were in the lowest SES group, and 10 205 (82.8%) were in the higher SES group. PCOS patients in the lowest SES group, compared to the higher SES group, were more likely to be younger, obese (body mass index ≥30 kg/m2 ), to have smoked tobacco during pregnancy, and to have chronic hypertension and pregestational diabetes mellitus (DM) (P < 0.05). In a multivariate logistic regression, women in the lowest SES group, compared to the higher SES group, had increased odds of pregnancy-induced hypertension (aOR 1.27, 95% CI: 1.12-1.46, P < 0.001), pre-eclampsia (aOR 1.37, 95% CI: 1.14-1.65, P < 0.001), and cesarean delivery (aOR 1.21, 95% CI: 1.09-1.34, P < 0.001), with other comparable pregnancy, delivery and neonatal outcomes. CONCLUSION: In PCOS patients, low SES increases the risk for pregnancy-induced hypertension, pre-eclampsia and CD, highlighting the importance of diligent pregnancy follow-up and pre-eclampsia prevention in these patients.

A low total motile sperm count in donor sperm obtained from commercial banks does not affect pregnancy rates from intrauterine insemination.

Objective: Women are often concerned about the absolute quantity and quality of sperm in a thawed donor sample at the time of intrauterine insemination (IUI). The aim of this study was to determine how the total motile sperm count (TMSC) of donor sperm obtained from commercial sperm banks affects the pregnancy rate after IUI. Study design: We performed a retrospective cohort study including single women and women in same-sex relationships undergoing IUI at a single academic fertility center between January 2011 and March 2018. Our primary outcome was pregnancy rates per IUI cycle, stratified by post-washed TMSC. The data was analyzed according to TMSC and included three different groups: samples with a TMSC less than 5 million; TMSC of 5-10 million; and a TMSC greater than 10 million. Pregnancies were defined by a serum Beta-human chorionic gonadotropin (Beta-HCG) of greater than 5 mIU/mL. Chi-squared analyses and correlation coefficients were performed. Results: Overall, 9341 IUIs were conducted during the study period. Of these, 1080 (11.56%) were performed for single women and women in a same-sex relationship using commercially available donor sperm. We found that there were no differences in the pregnancy rates per insemination based on TMSC. The pregnancy rates per cycle were 15/114 (13.3%) for the group with a TMSC of less than 5 million; 34/351(9.5%) with a TMSC of 5-10 million; and 61/609 (10.0%) for samples with a TMSC greater than 10 million (p = 0.52). We found an insignificant correlation (r = -0.072) between donor sperm TMSC and pregnancy after IUI (p = 0.46). Furthermore, a reassuring beta-HCG level (>100IU/L) drawn 16 days after IUI was unrelated to TMSC (r = 0.0071, p = 0.94). Conclusion: The pregnancy rate following IUI is unaffected by the TMSC of commercially available donor sperm. This result is useful in reassuring patients when freshly thawed donor sperm is found to have a lower TMSC. Frozen sperm samples from commercial banks typically represent just a portion of an ejaculate produced by a donor who meets the banks' standards for age, health and sperm quality. As such, exaggerated sperm death caused by freezing does not result in worse outcomes with donor sperm.

Perinatal outcomes following uterine rupture during a trial of labor after cesarean: A 12-year single-center experience.

OBJECTIVE: To determine perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term. METHODS: A retrospective single-center study examining perinatal outcomes in women with term singleton pregnancies with one prior CD, who underwent a trial of labor after cesarean (TOLAC) and were diagnosed with uterine rupture, between 2011 and 2022. The primary outcome was a composite maternal outcome, and the secondary outcome was a composite neonatal outcome. Additionally, we compared perinatal outcomes between patients receiving oxytocin during labor with those who did not. RESULTS: Overall, 6873 women attempted a TOLAC, and 116 were diagnosed with uterine rupture. Among them, 63 (54.3%) met the inclusion criteria, and 18 (28%) had the maternal composite outcome, with no cases of maternal death. Sixteen cases (25.4%) had the composite neonatal outcome, with one case (1.6%) of perinatal death. No differences were noted between women receiving oxytocin and those not receiving oxytocin in the rates of maternal composite (35.7% vs 26.5%, P = 0.502, respectively) or neonatal composite outcomes (21.4% vs 26.5%, P = 0.699). CONCLUSION: Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for the mother and neonate, though possibly more favorable than previously described. Oxytocin use does not affect these risks.