Arcuate Uterus as an Independent Risk Factor for Adverse Pregnancy Outcomes

OBJECTIVE

 The aim of the study is to estimate the association between arcuate uterus and pregnancy outcomes using controls selected from a similarly high-risk cohort.

STUDY DESIGN

 This is a retrospective cohort study of women with an arcuate uterus cared for by a single maternal-fetal medicine practice from 2005 to 2020. We included all women with a singleton pregnancy ≥20 weeks and diagnosis of arcuate uterus and randomly selected (3:1) patients with a singleton pregnancy and no uterine anomaly from the same practice as controls. Baseline characteristics and pregnancy outcomes were compared between the two groups. Chi-square, Fisher's exact, and independent samples t-test were used for data analysis, as indicated.

RESULTS

 A total of 37 women with an arcuate uterus (55 independent singleton pregnancies) and 165 controls were included. There were no differences in baseline characteristics. Women with an arcuate uterus had a significantly higher rate of spontaneous preterm birth less than 37 weeks (10.9 vs. 3.0%, p = 0.031) and were more likely to require vaginal progesterone (5.5 vs. 0.6%, p = 0.049) and administration of antenatal corticosteroids (16.4 vs. 5.5%, p = 0.020). Arcuate uterus was also associated with lower birthweight (3,028.1 ± 528.0 vs. 3257.2 ± 579.9 g, p = 0.010) and higher incidence of intrauterine fetal growth restriction (20.0 vs. 7.3%, p = 0.008), despite similar starting body mass index (BMI) and weight gain throughout pregnancy. There were no differences in preeclampsia, malpresentation, cesarean delivery, blood transfusion, retained placenta, or morbidly adherent placenta.

CONCLUSION

 Arcuate uterus is associated with a significantly increased risk of spontaneous preterm birth (<37 weeks), need for vaginal progesterone for short cervix and antenatal corticosteroids, fetal growth restriction, and lower mean birthweight. These findings suggest that arcuate uterus is not just a normal variant of uterine anatomy but rather a risk factor for poor fetal growth, short cervix, and a higher risk pregnancy.

KEY POINTS

· Arcuate uterus is associated with increased risk of preterm birth and fetal growth restriction.. · Women with arcuate uteri had higher rates of vaginal progesterone use during pregnancy.. · Arcuate uterus should be treated as a true finding rather than a normal anatomical variant..

National and international guidelines on the management of twin pregnancies: a comparative review

Twin gestations are associated with increased risk of pregnancy complications. However, high-quality evidence regarding the management of twin pregnancies is limited, often resulting in inconsistencies in the recommendations of various national and international professional societies. In addition, some recommendations related to the management of twin gestations are often missing from the clinical guidelines dedicated to twin pregnancies and are instead included in the practice guidelines on specific pregnancy complications (eg, preterm birth) of the same professional society. This can make it challenging for care providers to easily identify and compare recommendations for the management of twin pregnancies. This study aimed to identify, summarize, and compare the recommendations of selected professional societies from high-income countries on the management of twin pregnancies, highlighting areas of both consensus and controversy. We reviewed clinical practice guidelines of selected major professional societies that were either specific to twin pregnancies or were focused on pregnancy complications or aspects of antenatal care that may be relevant for twin pregnancies. We decided a priori to include clinical guidelines from 7 high-income countries (United States, Canada, United Kingdom, France, Germany, and Australia and New Zealand grouped together) and from 2 international societies (International Society of Ultrasound in Obstetrics and Gynecology and the International Federation of Gynecology and Obstetrics). We identified recommendations regarding the following care areas: first-trimester care, antenatal surveillance, preterm birth and other pregnancy complications (preeclampsia, fetal growth restriction, and gestational diabetes mellitus), and timing and mode of delivery. We identified 28 guidelines published by 11 professional societies from the 7 countries and 2 international societies. Thirteen of these guidelines focus on twin pregnancies, whereas the other 16 focus on specific pregnancy complications predominantly in singletons but also include some recommendations for twin pregnancies. Most of the guidelines are recent, with 15 of the 29 guidelines published over the past 3 years. We identified considerable disagreement among guidelines, primarily in 4 key areas: screening and prevention of preterm birth, using aspirin to prevent preeclampsia, defining fetal growth restriction, and the timing of delivery. In addition, there is limited guidance on several important areas, including the implications of the "vanishing twin" phenomenon, technical aspects and risks of invasive procedures, nutrition and weight gain, physical and sexual activity, the optimal growth chart to be used in twin pregnancies, the diagnosis and management of gestational diabetes mellitus, and intrapartum care.This consolidation of key recommendations across several clinical practice guidelines can assist healthcare providers in accessing and comparing recommendations on the management of twin pregnancies and identifies high-priority areas for future research based on either continued disagreement among societies or limited current evidence to guide care.

Maternal Morbidity with Repeated Cesarean Deliveries

OBJECTIVE

This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice.

STUDY DESIGN

Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used.

RESULTS

A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001).

CONCLUSION

Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population.

KEY POINTS

· Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..

Morbidity of Repeat Cesarean Delivery after a Trial of Labor as Compared with Elective Repeat Cesarean Delivery

OBJECTIVE

 This study aimed to evaluate if a secondary repeat cesarean after a trial of labor (TOLAC) without uterine rupture is associated with increased morbidity as compared with a scheduled elective repeat cesarean delivery (ERCD).

STUDY DESIGN

 This was a retrospective cohort study of repeat cesarean delivery (CD) in a single obstetrical practice between 2005 and 2022. Patients were included if they had a singleton pregnancy at term with one prior CD and had a repeat CD this pregnancy resulting in live birth. Patients were excluded if they had a prior myomectomy, more than one prior CD, uterine rupture in a prior or current pregnancy, or placenta previa in this pregnancy. We compared baseline characteristics and outcomes between patients who had a repeat cesarean after TOLAC and ERCD. The primary outcome was a composite of maternal morbidity that included hysterectomy, blood transfusion, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, or maternal mortality.

RESULTS

 A total of 930 women met inclusion criteria. A total of 176 (18.9%) patients intended to labor and 754 (81.1%) planned an ERCD. There was no difference in the primary outcome between patients with a repeat cesarean after TOLAC compared with patients with ERCD (2.8 vs. 1.2%, p = 0.158). Patients with repeat cesarean after labor had significantly more 1-minute Apgar scores less than 7, but no difference in 5-minute Apgar scores. We were powered to detect a difference in the primary outcome from 1.2% in the ERCD group to 3.3% in the repeat cesarean after labor group. Results did not differ when we analyzed patients who intended to TOLAC versus patients who actually labored prior CD.

CONCLUSION

 For women with one prior CD the morbidity of repeat cesarean after labor is not more than the morbidity of planned repeat CD. Our study can be helpful in delivery planning counseling for patients with one prior CD.

KEY POINTS

· Uterine rupture is a known risk of TOLAC.. · This study aimed to understand morbidity associated with labor.. · No added morbidity of repeat cesarean after labor is inferred in this study..

Is increasing parity associated with adverse perinatal outcomes in dichorionic twin gestations?

OBJECTIVES

Dichorionic twins have increased risk of preterm birth and hypertensive disorders of pregnancy. Grand multiparity may be associated with adverse perinatal outcomes in singleton pregnancies, although the effect of increasing parity in twins is unclear. This study aimed to elucidate whether grand multiparity leads to adverse outcomes in dichorionic twins compared to multiparity and nulliparity.

STUDY DESIGN

This was a retrospective review of dichorionic twins at a single institution between January 2008-December 2019 comparing pregnancy outcomes among grand multiparity, multiparity, and nulliparity. Primary outcome was preterm birth less than 37 weeks. Multivariable regression controlled for differing demographics, prior preterm birth, use of reproductive technologies, and hypertensive disorders of pregnancy. Chi square and Fisher's Exact were used for categorical variables and Kruskal-Wallis was used for continuous variables.

RESULTS

843(60.3%) pregnancies were nulliparous, 499(35.7%) multiparous, and 57(4.1%) grand multiparous. Univariate analysis indicated that multiparous women had lower incidence of preterm birth less than 37, 34, and 32 weeks (57% vs 51%, p=0.04; 19.2% vs 14.0%, p=0.02; 9.6% vs 5.6%, p=0.01) and that grand multiparous women had lower incidence of preterm birth less than 34 weeks (19.2% vs 5.3%, p=0.008) compared to nulliparous women. Multivariable regression confirmed multiparous women had lower odds of preterm birth less than 34 and 32 weeks compared to nulliparous women (<34 weeks: OR 0.69, 95% CI 0.49-0.97, p=0.03; <32 weeks: OR 0.48, 95% CI 0.29-0.79, p=0.004) and that multiparous women (OR: 0.57, 95% CI 0.42-0.77, p=0.0002) and grand multiparous women (OR: 0.23, 95% CI 0.08-0.68, p=0.0074) had lower incidence of hypertensive disorders of pregnancy when compared to nulliparous women.

CONCLUSION

Grand multiparity is not associated with adverse perinatal outcomes compared to nulliparity or multiparity in dichorionic twins. Increasing parity may protect against incidence of preterm birth and hypertensive disorders of pregnancy even among grand multiparous women.

Association Between Mental Health and Reproductive System Disorders in Women: A Systematic Review and Meta-analysis

Importance

Reproductive system and mental health disorders are commonly comorbid in women. Although the causes of this overlap remain elusive, evidence suggests potential shared environmental and genetic factors associated with risk.

Objective

To investigate the comorbidity between psychiatric and reproductive system disorders, both as broad diagnostic categories and among specific pairs of diagnoses.

Data Source

PubMed.

Study Selection

Observational studies published between January 1980 and December 2019 assessing prevalence of psychiatric disorders in women with reproductive system disorders and prevalence of reproductive system disorders in women with psychiatric disorders were included. The study did not include psychiatric and reproductive disorders triggered by life events (eg, trauma, infection, surgery) to address potential confounding.

Data Extraction and Synthesis

A search yielded 1197 records, of which 50 met the inclusion criteria for the qualitative and 31 for the quantitative synthesis in our study. A random-effects model was used for data synthesis and Egger test and I2 to assess study bias and heterogeneity. Data were analyzed from January to December 2022. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline.

Main Outcomes and Measures

Psychiatric and reproductive system disorders.

Results

A total of 1197 records were identified, of which 50 met the inclusion criteria for qualitative and 31 for quantitative synthesis. Diagnosis of a reproductive system disorder was associated with a 2- to 3-fold increased odds of having a psychiatric disorder (lower bound odds ratio [OR], 2.00; 95% CI, 1.41-2.83; upper bound OR; 2.88; 95% CI, 2.21-3.76). The analysis focused on specific diagnoses described in the literature and found that polycystic ovary syndrome was associated with increased odds of depression (population-based studies OR, 1.71; 95% CI, 1.19-2.45; clinical studies OR, 2.58; 95% CI, 1.57-4.23) and anxiety (population-based studies OR, 1.69; 95% CI, 1.36-2.10; clinical studies OR, 2.85; 95% CI, 1.98-4.09). Chronic pelvic pain was also associated with both depression (OR, 3.91; 95% CI, 1.81-8.46) and anxiety (OR, 2.33; 95% CI, 1.33-4.08). Few studies investigated risk of other reproductive system disorders in women with psychiatric disorders, or reverse associations (risk of reproductive system disorder among women with a psychiatric diagnosis).

Conclusions and Relevance

In this systematic review and meta-analysis, a high rate of reported co-occurrence between psychiatric and reproductive disorders overall was observed. However, data for many disorder pairs were limited. The available literature focused overwhelmingly on affective disorders in polycystic ovary syndrome, overlooking a substantial portion of disease overlap. As such, the associations between the majority of mental health outcomes and conditions of the female reproductive system are largely unknown.

Outcomes of Elective Compared to Non-Elective Fetal Reduction by Radiofrequency Ablation in Monochorionic Multifetal Pregnancies

INTRODUCTION

Higher order fetal gestation is associated with adverse pregnancy outcomes, and monochorionic (MC) pregnancies have unique complications. Multifetal pregnancy reduction (MPR) by radiofrequency ablation (RFA) may be used to optimize the outcomes of a single fetus. The purpose of this study was to determine whether pregnancy outcomes differ for elective reduction compared to reduction for medically complicated MC multifetal pregnancies.

METHODS

This was a retrospective cohort of patients with MC twins and higher order multiples who underwent MPR via RFA at a single institution between 2008 and 2021. Patients undergoing elective reduction were compared to patients undergoing reduction due to a complication of MC pregnancy. Pregnancy outcomes were evaluated.

RESULTS

Forty-eight patients who underwent RFA reduction between 2008 and 2021 were included in the analysis. Sixteen patients (33.3%) underwent elective RFA for MPR, and 32 (66.7%) underwent an RFA procedure for a complicated pregnancy. All pregnancies with RFA performed for elective indication had a continuing pregnancy (live birth rate 100%). There were no reported pregnancy losses within 4 weeks of the procedure when performed for a solely elective indication (n = 0) compared to 6.3% of complicated multifetal pregnancy (n = 2; 6.3%) (p = 0.001).

CONCLUSION

In this retrospective cohort study, elective reduction of MC twins using RFA was associated with no cases of fetal loss or PPROM within 4 weeks of the procedure and a 100% live birth rate.

Trial of labor of vertex-nonvertex twins following a previous cesarean delivery

BACKGROUND

Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor.

OBJECTIVE

To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation.

STUDY DESIGN

A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥32^0/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture.

RESULTS

A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores.

CONCLUSION

Our data show that trial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery. Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.

Incidence and Risk Factors for a Malpositioned Intrauterine Device Detected on Three-Dimensional Ultrasound Within Eight Weeks of Placement

OBJECTIVES

To estimate the incidence of intrauterine device (IUD) malpositioning detected on three-dimensional (3D) transvaginal ultrasound within 8 weeks of placement and identify risk factors for malpositioning.

METHODS

Retrospective study of women who had an IUD placed at a large obstetrics and gynecology practice from January 1, 2015, to December 31, 2020. All patients underwent two-dimensional ultrasound at the time of insertion and routine three-dimensional ultrasound within 8 weeks. Baseline characteristics and potential risk factors were compared between women with correctly positioned and malpositioned IUDs. Odds ratios were calculated by logistic regression to identify risk factors independently associated with malpositioning.

RESULTS

A total of 763 IUD placements were included, and 127 malpositioned IUDs were identified representing an overall rate of malpositioning of 16.6% (95% confidence interval [CI] 14.0-19.3) with 8.8% (95% CI 6.8-10.8) requiring removal. Patients with malpositioned IUD had higher rates of morbid obesity (13.4% versus 3.8%, adjusted odds ratio [aOR] 2.46, 95% CI 1.10-5.50), prior uterine window or rupture (9.0% versus 2.2%, aOR 2.78, 95% CI 1.06-7.30), copper IUD placement (64.2% versus 47.4%, aOR 1.99, 95% CI 1.31-3.03), and symptoms such as bleeding or pain at follow-up (35.8% versus 20.1%, aOR 2.58, 95% CI 1.67-3.98). Parity, breastfeeding, difficult insertion, and uterine size and positioning were not significant.

CONCLUSIONS

The incidence of malpositioned IUD within 8 weeks of placement on 3D ultrasound is 16.6%, with 8.8% requiring removal. Significant risk factors for malpositioning include morbid obesity, prior uterine window or rupture, and copper IUD placement. These findings support the importance of routine follow-up 3D ultrasound after seemingly successful IUD placement.

Should twin-specific growth charts be used to assess fetal growth in twin pregnancies?

One of the hallmarks of twin pregnancies is the slower rate of fetal growth when compared with singleton pregnancies during the third trimester. The mechanisms underlying this phenomenon and whether it represents pathology or benign physiological adaptation are currently unclear. One important implication of these questions relates to the type growth charts that should be used by care providers to monitor growth of twin fetuses. If the slower growth represents pathology (ie, intrauterine growth restriction caused uteroplacental insufficiency), it would be preferable to use a singleton growth chart to identify a small twin fetus that is at risk for perinatal mortality and morbidity. If, however, the relative smallness of twins is the result of benign adaptive mechanisms, it is likely preferable to use a twin-based charts to avoid overdiagnosis of intrauterine growth restriction in twin pregnancies. In the current review, we addressed this question by describing the differences in fetal growth between twin and singleton pregnancies, reviewing the current knowledge regarding the mechanisms responsible for slower fetal growth in twins, summarizing available empirical evidence on the diagnostic accuracy of the 2 types of charts for intrauterine growth restriction in twin pregnancies, and addressing the question of whether uncomplicated dichorionic twins are at an increased risk for fetal death when compared with singleton fetuses. We identified a growing body of evidence that shows that the use of twin charts can reduce the proportion of twin fetuses identified with suspected intrauterine growth restriction by up to 8-fold and can lead to a diagnosis of intrauterine growth restriction that is more strongly associated with adverse perinatal outcomes and hypertensive disorders than a diagnosis of intrauterine growth restriction based on a singleton-based chart without compromising the detection of twin fetuses at risk for adverse outcomes caused by uteroplacental insufficiency. We further found that small for gestational age twins are less likely to experience adverse perinatal outcomes or to have evidence of uteroplacental insufficiency than small for gestational age singletons and that recent data question the longstanding view that uncomplicated dichorionic twins are at an increased risk for fetal death caused by placental insufficiency. Overall, it seems that, based on existing evidence, the of use twin charts is reasonable and may be preferred over the use of singleton charts when monitoring the growth of twin fetuses. Still, it is important to note that the available data have considerable limitations and are primarily derived from observational studies. Therefore, adequately-powered trials are likely needed to confirm the benefit of twin charts before their use is adopted by professional societies.

Prevention of preterm birth in twin pregnancies

Twins represent 3.2% of all livebirth, however they account for 20% of all preterm deliveries, with 60% of then deliver before 37 weeks, and 10.7% before 32 weeks. Twin pregnancies have five times higher risk of early neonatal and infant death related to prematurity. Monochorionic twins have higher incidence of both indicated and spontaneous preterm delivery compared with dichorionic twins. Transvaginal cervical length before 24 weeks is the best tool to predict preterm birth, independent of other risk factors. Among all the evaluated therapies to decrease or prevent preterm birth in twin pregnancies, vaginal progesterone in women with transvaginal cervical length < 25mm decreased neonatal morbidity and physical exam indicated cerclage in women with cervical dilation > 1 cm have shown a significant decrease in preterm birth at different gestational ages and decreased perinatal mortality.

Screening for preterm birth in twin pregnancies

Twins represent 3.2% of all live births. However, they account for 20% of all preterm deliveries, with 60% delivered before 37 weeks and 10.7% before 32 weeks of gestation. Twin pregnancies have a 5 times higher risk of early neonatal and infant death related to prematurity. Monochorionic twins have a higher incidence of both indicated and spontaneous preterm delivery than dichorionic twins. Additional risk factors include a history of preterm delivery and cervical surgery. The transvaginal cervical length before 24 weeks is the best factor to predict preterm birth, independent of other risk factors.

The Association between Shirodkar Cerclage and Preterm Premature Rupture of Membranes in Singleton Pregnancies

OBJECTIVE

The aim of this study was to estimate if preterm premature rupture of membranes in women with cerclage is due to the cerclage itself or rather the underlying risk factors for preterm birth in this population.

STUDY DESIGN

This was a retrospective cohort study of singleton pregnancies who underwent Shirodkar cerclage by a single maternal-fetal medicine practice between 2005 and 2019. The control group was an equal number of randomly selected women with a singleton gestation who had a prior preterm birth and were treated with 17-OH-progesterone but no cerclage. Patients with major uterine anomalies or fetal anomalies were excluded. The primary outcome was preterm premature rupture of membranes prior to 34 weeks. Chi-square and logistic regression were used.

RESULTS

A total of 350 women with cerclage (154 [44%] history-indicated, 137 [39%] ultrasound-indicated, and 59 [17%] exam-indicated) and 350 controls were included. Preterm premature rupture of membranes prior to 34 weeks did not differ between the groups (8.9% in cerclage vs. 6.0% in controls, p = 0.149, adjusted odds ratio 0.62, 95% confidence interval: 0.24-1.64) nor between the different cerclage indications (9.1% of history-indicated, 7.3% of ultrasound-indicated, and 11.9% of exam-indicated, p = 0.582). This study had 80% power with an α error of 0.05 to detect an increase in preterm premature rupture of membranes prior to 34 weeks from 6.0% in the control group to 12.0% in the cerclage group.

CONCLUSION

Cerclage does not increase the risk of preterm premature rupture of membranes prior to 34 weeks compared with other women at increased risk of preterm birth. The observed association between cerclage and preterm premature rupture of membranes is likely due to underlying risk factors and not the cerclage itself. The risk of preterm premature rupture of membranes prior to 34 weeks in women with cerclage is 10% or less and does not appear to differ based on cerclage indication.

KEY POINTS

· Cerclage does not increase the risk of PPROM.. · Risk of PPROM with cerclage is approximately 10%.. · Risk does not appear to vary by indication..

Elective fetal reduction by radiofrequency ablation in monochorionic diamniotic twins decreases adverse outcomes compared to ongoing monochorionic diamniotic twins

BACKGROUND

Multifetal pregnancy reduction is a technique used to reduce the fetal number to mitigate the risks of adverse outcomes associated with multiple gestations. Monochorionic diamniotic twin pregnancies are subject to unique complications, contributing to adverse pregnancy outcomes. Thus, patients have an option to electively reduce 1 fetus to improve outcomes.

OBJECTIVE

This study aimed to compare outcomes of elective reduction of monochorionic diamniotic twins by radiofrequency ablation to planned ongoing monochorionic diamniotic twins.

STUDY DESIGN

We performed a retrospective review of 315 monochorionic diamniotic twin gestations that underwent first-trimester ultrasound within 1 institution. Planned electively reduced twins were compared with ongoing monochorionic diamniotic twins. All reductions were performed via radiofrequency ablation of the cord insertion site into the fetal abdomen. The primary outcome was preterm birth at <36 weeks' gestation. Secondary outcomes included gestational age at delivery; preterm birth at less than 37-, 34-, 32-, and 28-weeks' gestation; unintended loss; and adverse perinatal outcomes.

RESULTS

Among 315 monochorionic diamniotic pregnancies, 14 (4.4%) underwent elective multifetal pregnancy reduction, and 301 (95.6%) were planned ongoing twins. The mean gestational age of radiofrequency ablation in the elective multifetal pregnancy reduction group was 15.1±0.68 weeks. Patients who underwent elective multifetal pregnancy reduction had significantly higher maternal age (P<.01) and were more likely to be Asian (P<.01). Moreover, they were more likely to have undergone in vitro fertilization (P=.03) and chorionic villus sampling (P<.01). There was a significantly higher rate of term deliveries in the elective radiofrequency ablation group compared with ongoing twins (gestational age, 38 weeks [interquartile range, 36.1-39.1] vs 35.9 weeks [interquartile range, 34.0-36.9]; P<.01). Patients with ongoing pregnancies had a trend of increased rate of preterm birth at <36 weeks' gestation (odds ratio, 3.4; 95% confidence interval, 1.0-12.0; P=.06), a significantly increased risk of preterm birth at <37 weeks' gestation (odds ratio, 8.0; 95% confidence interval, 2.4-26.4; P<.01), and no difference at less than 34-, 32-, or 28- weeks' gestation. All patients who underwent elective radiofrequency ablation had successful pregnancies with no pregnancy losses or terminations. Of ongoing gestations, 36 required procedures, including 16 (5.3%) medically indicated radiofrequency ablation, 14 (4.6%) laser ablation, and 6 (1.9%) amnioreductions. Furthermore, 22 patients (7.3%) with planned ongoing twins had total pregnancy loss at <24 weeks' gestation. Notably, 12 patients (4.0%) had unintended loss of 1 fetus before 24 weeks' gestation in the ongoing pregnancy cohort, and 12 patients (4.0%) had unintended loss of both fetuses before 24 weeks' gestation. Moreover, 5 patients (1.7%) in the ongoing pregnancy group had intrauterine fetal demise at >24 weeks' gestation and 10 patients (3.3%) electively terminated both fetuses. There was no significant difference in loss rates between the 2 groups.

CONCLUSION

In this study of monochorionic diamniotic twins, patients who elected to undergo multifetal pregnancy reduction had significantly lower rates of preterm birth at <37 weeks and a lower trend of preterm birth at <36 weeks' gestation without an increased risk of pregnancy loss. Median gestational age at delivery was significantly higher in the elective multifetal pregnancy reduction group (38 weeks) than in the ongoing pregnancy group (35.9 weeks). Further research is needed to clarify if multifetal pregnancy reduction improves long-term outcomes.

Subchorionic Hematomas and Adverse Pregnancy Outcomes among Twin Pregnancies

OBJECTIVE

This study estimates the association of a first trimester finding of subchorionic hematoma (SCH) with third trimester adverse pregnancy outcomes in women with twin pregnancies.

STUDY DESIGN

Retrospective cohort study of twin pregnancies prior to 14 weeks at a single institution from 2005 to 2019, all of whom had a first trimester ultrasound. We excluded monoamniotic twins, fetal anomalies, history of fetal reduction or spontaneous reduction, and twin-to-twin transfusion syndrome. Ultrasound data were reviewed, and we compared pregnancy outcomes after 24 weeks in women with and without a SCH at their initial ultrasound 6^0/7 to 13^6/7 weeks. Regression analysis was used to control for any differences in baseline characteristics.

RESULTS

A total of 760 women with twin pregnancies met inclusion criteria for the study, 68 (8.9%) of whom had a SCH. Women with SCH were more likely to have vaginal bleeding and had their initial ultrasound at earlier gestational ages. On univariate analysis, SCH was not significantly associated with gestational age at delivery, preterm birth, birthweight of either twin, low birthweight percentiles of either twin, fetal demise, or preeclampsia. SCH was associated with placental abruption on univariate analysis, but not after controlling for vaginal bleeding and gestational age at the time of the initial ultrasound (adjusted odds ratio: 2.00, 95% confidence interval: 0.63-6.42). Among women with SCH, SCH size was not associated with adverse pregnancy outcomes.

CONCLUSION

In women with twin pregnancies, the finding of a first trimester SCH is not associated with adverse pregnancy outcomes >24 weeks.

The Association between Placental Histopathology, Fetal Growth Restriction, and Preeclampsia in Twin Pregnancies

OBJECTIVE

This study aims to estimate the association between abnormal placental histopathology, fetal growth restriction (FGR), and preeclampsia (PEC) in twin pregnancies.

STUDY DESIGN

Retrospective cohort study of women with diamniotic twin pregnancies with live births at ≥24 weeks of gestation and available placental pathology. Findings were compared between women with and without FGR, which was defined as a birthweight <10th percentile, using singleton and twin growth curves, and those with and without PEC. The primary study outcome was a composite of abnormal placental histopathology. Chi-square, Fisher's exact, and Student's t-tests were used for analysis.

RESULTS

Among 859 patients with diamniotic twins, 806 (93.8%) had placental pathology. A total of 422 (52.4%) women had at least one twin with FGR, using a singleton growth curve. FGR affected 136 (16.9%) pregnancies when a twin growth curve was applied. There was no significant difference in composite outcome between groups, using either growth curve (45.5 vs. 44.8%, p = 0.84; adjusted odds ratio (aOR): 1.06, 95% CI: 0.79-1.40 and 52.2 vs. 43.7%, p = 0.07; aOR: 1.44, 95% CI: 0.90-2.10). A total of 122 of 789 (15.5%) patients developed PEC. There was no significant difference in composite outcome between patients with and without PEC (41.8 vs. 45.4%, p = 0.46; aOR: 0.79, 95% CI: 0.53-1.18).

CONCLUSION

In twin pregnancies, FGR and PEC are not associated with abnormal placental histopathology. This suggests that the pathologic placental manifestations of these conditions may differ in twins and include factors other than those commonly described in singletons.

The Association between Gestational Weight Gain in Each Trimester and Pregnancy Outcomes in Twin Pregnancies

OBJECTIVE

Adequate maternal weight gain in twin pregnancies is associated with improved outcomes such as increased fetal growth and decreased incidence of preterm birth. However, it remains unclear when gestational weight gain has the greatest influence on pregnancy outcomes. Our objective was to identify at which time in a twin pregnancy does inadequate maternal weight gain have the greatest association with adverse pregnancy outcomes.

STUDY DESIGN

This is a retrospective cohort study of women with twin pregnancies and normal prepregnancy body mass index (BMI, 18.5-24.9 kg/m²) who delivered at ≥24 weeks' gestation by a single maternal-fetal medicine practice between 2005 and 2017. Baseline characteristics and pregnancy outcomes were compared between women with and without adequate average gestational weight gain (weight gain per week based on the 2009 Institute of Medicine recommendations). This analysis was performed for weight gain over the entire pregnancy, as well as from 0 to 16, 16 to 24, and 24 weeks to delivery. Multivariable regression analysis was performed to control for potential confounding variables.

RESULTS

A total of 609 women with twin pregnancies and normal prepregnancy BMI were included, of whom 386 (63.4%) had adequate average gestational weight gain over the entire pregnancy and 223 (36.6%) did not. Inadequate average gestational weight gain between 0 and 16 weeks' gestation was associated with a higher incidence of birthweight less than the 10th percentile for gestational age (adjusted odds ratio [aOR]: 1.67; 95% confidence interval [CI]: 1.11-2.51) and less than the 5th percentile for gestational age (aOR: 2.10; 95% CI: 1.29-3.40). Inadequate gestational weight gain between 16 and 24 weeks was associated with lower birthweight of the larger twin (β: -0.09; p = 0.04). Inadequate weight gain from 24 weeks to delivery was associated with spontaneous preterm birth <37 weeks' gestation (aOR: 1.67; 95% CI: 1.13-2.47), <34 weeks' gestation (aOR: 4.32; 95% CI: 2.45-7.63), <32 weeks' gestation (aOR: 9.07; 95% CI: 3.66-22.48), and a lower incidence of preeclampsia (aOR: 0.31; 95% CI: 0.16-0.63).

CONCLUSION

In twin pregnancies, gestational weight gain between 0 and 16 weeks as well as between 16 and 24 weeks is most associated with fetal growth, whereas gestational weight gain after 24 weeks is most associated with preterm birth. This may help elucidate the mechanism of action of the impact of gestational weight gain in twin pregnancies.

The association between sonographic cervical length components and preterm birth in women with ultrasound- or exam-indicated cerclage

OBJECTIVE

To evaluate which parameters of a sonographic cervical length measurement are associated with preterm birth in women with ultrasound- or exam-indicated cerclage.

METHODS

This was a retrospective cohort study of women with singleton pregnancies who underwent ultrasound- or exam-indicated Shirodkar cerclage by a single maternal-fetal medicine practice between 2011 and 2019. All patients underwent sonographic cervical length measurement 2-3 weeks after cerclage placement, and then every 2-4 weeks up to 32 weeks. The images from the first and second post-cerclage cervical lengths were reviewed. Total cervical length, upper cervical length (from the internal cervical os to the cerclage), and lower cervical length (from the cerclage to the external os) were measured. The primary outcome for this study was gestational age at delivery.

RESULTS

A total of 114 women with cerclage were included (85 (74.6%) ultrasound-indicated and 29 (25.4%) exam-indicated). The first and second total cervical lengths correlated with gestational age at delivery (r = 0.26, p=.005; r = 0.33, p<.001, respectively), and the change from first to second was inversely correlated with gestational age at delivery (r = -0.20, p=.032). The first and second upper cervical lengths also correlated with gestational age at delivery (r = 0.22, p = .019; r = 0.33, p<.001, respectively), and the change from first to second upper cervical length was inversely correlated with gestational age at delivery (r= -0.20, r = 0.029). Neither the first nor the second lower cervical lengths were significantly associated with gestational age at delivery. On regression analysis, total cervical length and upper cervical length were not independently associated with gestational age at delivery (p = .108 and p=.806, respectively, for the first scan; p = .153 and p=.166, respectively, for the second scan).

CONCLUSIONS

Postcerclage total cervical length and upper cervical length are both associated with gestational age at delivery and risk of preterm birth, but not independently. After ultrasound- or exam-indicated cerclage, sonographic monitoring of either the total cervical length or the upper cervical length might be predictive of gestational age at delivery and the risk of preterm birth.

Stratified risk of pregnancy loss for women with a viable singleton pregnancy in the first trimester

OBJECTIVE

Calculate the risk of miscarriage in women with a viable (defined as presence of fetal heart rate on ultrasound) first trimester singleton pregnancy and to create a model for stratified risk-assessment for pregnancy loss based on significant risk factors.

STUDY DESIGN

Retrospective cohort study of unselected women with singleton pregnancies in a large obstetrical practice who presented for prenatal care prior to 14 weeks over a three-year period. All women underwent a formal first-trimester ultrasound, and we only included women with viable pregnancies with fetal heart activity seen on that ultrasound. Our primary outcome was pregnancy loss prior to 20 weeks. Statistical modeling was used to create a risk-assessment tool from adjusted likelihood ratios of pregnancy loss based on risk factors independently associated with this outcome.

RESULTS

From January 2015-December 2017, 2,446 women met the inclusion criteria for the study and 132 (5.4%) had a pregnancy loss <20 weeks. On regression analysis, the independent risk factors for pregnancy loss were earlier gestational age (aOR 0.72, 95% CI 0.65-0.80) and increasing number of prior miscarriages (aOR 1.56, 95% CI 1.32-1.83). Using these risk factors, we calculated the stratified risk of pregnancy loss, which ranged from 0.8% in women at 13 weeks of gestation with no prior miscarriages to 33.7% in women at six weeks of gestation with three or more prior miscarriages.

CONCLUSION

In first trimester singleton pregnancies, the overall risk of pregnancy loss <20 weeks after confirmation of fetal heart activity is 5.4%, but can be stratified for each woman and ranges from 0.8% to 33.7% based on the gestational age and number of prior pregnancy losses.

Predictors of Early Preterm Birth Despite Vaginal Progesterone Therapy in Singletons with Short Cervix

OBJECTIVE

This study aimed to identify the incidence of and risk factors for early preterm birth (PTB) (delivery <34 weeks) in women without prior PTB and current short cervix (≤20 mm) prescribed vaginal progesterone.

STUDY DESIGN

Retrospective cohort study of singletons without prior PTB diagnosed with short cervix (≤20 mm) between 18^0/7 and 23^6/7 weeks. Women who accepted vaginal progesterone and had delivery outcomes available were included. Demographic/obstetric history, cervical length, and pregnancy characteristics compared between women with early PTB versus delivery ≥34 weeks. Multiple logistic regression analysis used to identify predictors; odds ratio for significant factors used to generate a risk score. Risk score and risk of early PTB assessed with receiver operating characteristic curve (ROCC). Perinatal outcomes compared by risk score.

RESULTS

Among 109 patients included, 29 (27%) had a spontaneous PTB <34 weeks. In univariate analysis, only gestational age at ultrasound, presence funneling, and mean cervical length were significantly different between those with and without early sPTB. With multiple logistic regression analysis, only gestational age at diagnosis (odds ratio [OR]: 0.66; 95% confidence interval [CI]: 0.46-0.96; p = 0.028) and index cervical length (OR: 0.84; 95% CI: 0.76-0.93; p = 0.001) remained significantly associated with early PTB. ROCC for the risk score incorporating cervical length and gestational age was predictive of early PTB with an AUC of 0.76 (95% CI: 0.67-0.86; p < 0.001). A high-risk score was predictive of early PTB with a sensitivity of 79%, specificity of 75%, positive predictive value of 54%, and negative predictive value of 91%. Women with a high-risk score had worse perinatal outcomes compared with those with low-risk score.

CONCLUSION

A total of 27% of patients with short cervix prescribed vaginal progesterone will have a sPTB < 34 weeks. Patients at high risk for early PTB despite vaginal progesterone therapy may be identified using gestational age and cervical length at diagnosis of short cervix. Given the narrow window for intervention after diagnosis of short cervix, this has important implications for clinical care.

Induction of Labor versus Cesarean Delivery in Twin Pregnancies

OBJECTIVE

This study was aimed to compare maternal and neonatal outcomes between women with twin pregnancies who underwent induction of labor with those women who had planned Cesarean delivery (CD).

STUDY DESIGN

This is a retrospective cohort study of women with twin pregnancies ≥ 24 weeks with an indication for delivery but not in labor. Two groups were examined, women who underwent induction and women who underwent planned CD. Maternal and neonatal outcomes were compared between groups both for deliveries at gestational age ≥ 37 weeks and < 37 weeks.

RESULTS

A total of 453 patients were included. Overall, 212 (46.8%) women underwent induction and 241 (53.2%) underwent planned CD. Women who underwent induction of labor had a high rate of VD, both in the term and preterm groups (69.8 and 73.6%, respectively). Women who underwent induction of labor had reduced maternal length of stay, neonatal length of stay, and blood loss, without any increase in adverse outcomes. Neonatal ventilation of either twin delivered < 37 weeks was higher in the CD compared with induction group (27.5 vs. 9.4%, p < 0.01), but this was not significant on adjusted odds ratio analysis (aOR = 0.71, 95% CI: 0.19-2.66).

CONCLUSION

Labor induction in twin gestations have improved maternal outcomes and similar neonatal outcomes compared with planned CD.

A Case Report to Assess Passive Immunity in a COVID Positive Pregnant Patient

INTRODUCTION

Data regarding transplacental passage of maternal coronavirus disease 2019 (COVID-19) antibodies and potential immunity in the newborn is limited.

CASE REPORT

We present a 25-year-old multigravida with known red blood cell isoimmunization, who was found to be COVID-19 positive at 27 weeks of gestation while undergoing serial periumbilical blood sampling and intrauterine transfusions. Maternal COVID-19 antibody was detected 2 weeks after positive molecular testing. Antibodies were never detected on cord blood samples from two intrauterine fetal cord blood samples as well as neonatal cord blood at the time of delivery.

CONCLUSION

This case demonstrates a lack of passive immunity of COVID-19 antibodies from a positive pregnant woman to her fetus, neither in utero nor at the time of birth. Further studies are needed to understand if passage of antibodies can occur and if that can confer passive immunity in the newborn.

KEY POINTS

· Passive immunity should not be assumed in COVID-19 infection in pregnancy.. · Isoimmunization may impair passive immunity of certain antibodies.. · Vaccination to or maternal infection of COVID-19 may not be protective for the fetus..

COVID-19 in Pregnant Women: Case Series from One Large New York City Obstetrical Practice

OBJECTIVE

This study aimed to report a case series of pregnant women in New York City with confirmed or presumed coronavirus disease (COVID-19) infection.

STUDY DESIGN

Beginning March 22, 2020, all pregnant women from one large obstetrical practice in New York City were contacted regularly to inquire about symptoms of COVID-19 (fever, cough, shortness of breath, malaise, anosmia), or sick contacts. A running log was kept of these patients, as well as all patients who underwent COVID-19 testing. For this report, we included every patient with suspected COVID-19 infection, which was defined as at least two symptoms, or a positive COVID-19 nasopharyngeal polymerase chain reaction test.

RESULTS

From March 22, 2020 until April 30, 2020, 757 pregnant women in our practice were evaluated and 92 had known or suspected COVID-19 (12.2%, 95% confidence interval [CI]: 10.0-14.7%). Of these 92 women, 33 (36%) had positive COVID-19 test results. Only one woman required hospital admission for 5 days due to COVID-19 (1.1%, 95% CI: 0.2-5.9%). One other woman received home oxygen. No women required mechanical ventilation and there were no maternal deaths. One woman had an unexplained fetal demise at 14 weeks' gestation around the time of her COVID-19 symptoms. Twenty one of the 92 women have delivered, and all were uncomplicated.

CONCLUSIONS

Among 92 women with confirmed or presumed COVID-19, the overall morbidity was low. These preliminary results are encouraging for pregnant women during the COVID-19 pandemic.

KEY POINTS

· Coronavirus disease (COVID-19) is prevalent in New York City.. · In this case series, COVID-19 in pregnant women had a very low morbidity and no mortality.. · This preliminary data is reassuring for pregnant women at risk of COVID-19..

The Association between Glucose Levels and Adverse Pregnancy Outcomes in Nondiabetic Twin Pregnancies

Objective  The aim of this study is to determine if hyperglycemia in twin pregnancies without gestational diabetes mellitus (GDM) is associated with an increased risk of adverse pregnancy outcomes. Study Design  Retrospective cohort study of twin pregnancies in a single Maternal-Fetal Medicine practice between 2005 and 2019 who underwent two-step GDM screening at 24 to 28 weeks. We excluded women with pregestational or gestational diabetes. We examined the association between maternal glycemia and adverse pregnancy outcomes. Glycemia was defined as the 1-hour GCT in all women, and each of the four values of the 3-hour OGTT in women who failed the GCT (≥130 mg/dL). Primary outcomes were preeclampsia, cesarean delivery, and neonatal hypoglycemia in either twin. Statistical tests used included Pearson's correlation, Student's t -test, Mann-Whitney U test, Chi-square test for trend, and logistic regression. Results  A total of 847 women underwent a GCT and 246 women underwent an OGTT. Increasing maternal glucose levels had no positive association with adverse outcomes. Women with preeclampsia, cesarean delivery, and neonatal hypoglycemia did not have higher mean GCT or OGTT values than women without these outcomes. There was no increased risk of adverse outcomes with increasing quartiles of the GCT or OGTT values. Conclusion  In women with twin pregnancies without GDM, elevated maternal glucose levels are not associated with preeclampsia, cesarean delivery, or neonatal hypoglycemia. The altered physiology of twin gestations may modify the effect of maternal hyperglycemia on perinatal outcomes as compared with singleton pregnancies. Current approaches to screening for and treating GDM during pregnancy might not adequately account for these unique considerations among twins.

The international prevalence of antidepressant use before, during, and after pregnancy: A systematic review and meta-analysis of timing, type of prescriptions and geographical variability

BACKGROUND

Antidepressant use during pregnancy has increased over the last decades, while safety has been under debate. Our aim was to measure the international prevalence of antidepressant use before, during, and after pregnancy and examine timing, type of prescriptions and geographic variability.

METHODS

We searched Embase, Medline Ovid, Web of Science, Cochrane Central and Google Scholar from their inception until February 19, 2019. We determined pooled prevalence estimates of antidepressants before, during, and after pregnancy, as well as stratified according to substantive variables.

RESULTS

We identified 40 cohorts from 15 countries, together reporting on 14,072,251 pregnancies. Included studies had a low risk of bias, often reporting on large representative cohorts. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly used antidepressants during pregnancy, with an international prevalence estimate of 3.0% (95%CI 2.3;3.7). While Europe and Australasia had pooled prevalence estimates of 1.6% and 1.3% respectively, Northern America had a prevalence estimate of 5.5% (Q-value = 126.19; df = 2; p-value<0.01). Highest SSRI prevalence rates were found for sertraline (1.10%), followed by citalopram and fluoxetine (0.77% and 0.76% respectively) (Q-value = 121.25; df = 5; p-value<0.01). Qualitative analysis indicated an increase in antidepressant use over subsequent calendar years.

LIMITATIONS

Substantial heterogeneity remained unaccounted for throughout the analyses, even after accounting for hypothetical contributors.

CONCLUSIONS

This meta-analysis revealed substantial regional differences in antidepressant use around pregnancy, which could be due to variability in prescription behavior, healthcare seeking behavior and organization of healthcare. There is an urgent need for evidence on effectiveness, benefit, and harm of antidepressants during pregnancy to guide clinical practice.

Serial Cervical Length Evaluation in Low-Risk Women with Shortened Cervical Lengths in the Midtrimester: How Many Will Dilate Prior to 24 Weeks?

OBJECTIVE

To determine what proportion of women with a short cervical length (CL) without a history of spontaneous preterm birth (SPTB) will ultimately be dilated at <24 weeks.

STUDY DESIGN

This is a retrospective cohort study of women with singleton pregnancies with a short CL (≤25 mm) between 16 and 22 weeks' gestational age (GA). We excluded women with a history of SPTB. We examined the progression of women with short CL based on the CL measurement and GA at diagnosis. The primary outcome was cervical dilation or spontaneous delivery <24 weeks.

RESULTS

A total of 163 women were included, of whom 27 (16.6%) were ultimately dilated and 4 (2.5%) had pregnancy loss by 24 weeks. The median GA at diagnosis of short CL was 19^5/7 (range: 15-22) weeks. Women with a CL <15 mm were more likely to have cervical dilation or loss prior to 24 weeks than women whose CL was 15 to 25 mm (42.5 vs. 11.9%, <0.001, adjusted odds ratio: 3.72, 95% confidence interval: 1.52-9.09). GA at diagnosis was not associated with risk of progression.

CONCLUSION

In women with a short CL without a history of SPTB, the risk of dilation or pregnancy loss <24 weeks is significant, approaching 50% for women with a CL <15 mm.

Frequency of spontaneous resolution of vasa previa with advancing gestational age

BACKGROUND

Vasa previa is a serious obstetric complication that can result in fetal hemorrhage and death on spontaneous labor. Suggested management for vasa previa is elective hospitalization and cesarean delivery before spontaneous labor. There is little reported evidence of the rate of vasa previa resolution over the course of gestation. Identification of the resolution rate and of factors predictive of resolution potentially could improve clinical management and patient counseling.

OBJECTIVE

The purpose of this study was to identify the resolution rate of vasa previa across gestation and to determine clinical and sonographic factors that are associated with vasa previa resolution.

STUDY DESIGN

We conducted a retrospective cohort study of all women who were diagnosed with vasa previa in a single ultrasound unit between 2005 and 2018. Vasa previa was defined as a fetal vessel within 2 cm of the internal cervical os on transvaginal sonography. The primary outcome was vasa previa resolution, defined as migration of the vasa previa to >2 cm away from the internal os.

RESULTS

One hundred women with vasa previa that had been diagnosed at a mean gestational age of 22.8±4.9 weeks were included. Thirty-nine women (39.0%; 95% confidence interval, 30-49%) had resolution of vasa previa at a mean gestational age of 28.6-4.7 weeks. Factors that were associated with vasa previa resolution were an earlier gestational age at diagnosis (adjusted odds ratio, 6.10; 95% confidence interval,1.92-19.40), vasa previa did not cover the internal os at diagnosis (adjusted odds ratio, 8.29; 95% confidence interval, 2.79-24.62), and vasa previa was not the result of a resolved placenta previa (adjusted odds ratio, 2.85; 95% confidence interval, 1.01--8.03). One woman with a dichorionic twin pregnancy and vasa previa resolution (at 31 weeks gestation; fetal vessels located 2.8 cm from the internal os) presented at 33 weeks with massive bleeding and fetal death of twin A. It was unclear whether the death was related to vasa previa or placental abruption.

CONCLUSION

Thirty-nine percent of vasa previas in our population resolved over the course of pregnancy. Earlier gestational age at diagnosis, vasa previa not covering the internal os, and not having a resolved placenta previa all are associated independently with an increased likelihood of vasa previa resolution. Women with vasa previa should be observed serially to assess for vasa previa resolution, because many will resolve in the third trimester.

Two decades of interventions in New York State to reduce maternal mortality: a systematic review

Objective: To perform a systematic review of interventions to reduce maternal mortality in New York.Study design: We conducted a systematic review of literature published between 2000 and January 2019 reporting interventions to reduce maternal mortality in New York using PubMed and search terms: pregnancy-related death or maternal mortality OR maternal death AND New York. Eight hundred and ninety-three articles were reviewed by title, content, and focus on New York interventions or policies. Ten met inclusion criteria. A second review of the Safe Motherhood Initiative (SMI) identified an additional six articles.Results: Nine articles described hospital-based initiatives; one described a community-based initiative. No prospective randomized controlled trials in a nonsimulated setting were identified. Several articles described SMI bundles; one tested simulated checklist implementation. Three presented results of bundle implementation but did not significantly impact measured maternal mortality and/or morbidity. The single community-based initiative provided doulas to low-income women, yielding significantly lower rates of preterm birth and low birthweight, but no difference in cesarean deliveries compared to other women in the community.Conclusion: Current hospital-based interventions have not reduced maternal mortality in New York. The single community-based intervention identified reduced adverse birth outcomes. Continued concern about maternal mortality in New York suggests community-based approaches should be considered to affect change in conjunction with longer term hospital-based interventions.

The effect of microbiome exposure at birth on pediatric outcomes using a twin cohort discordant for microbiome exposure at birth

Objective: Microbiome exposure at birth has been associated with long-term pediatric outcomes. However, it is difficult to determine if differences in outcomes are truly due to microbiome exposure at birth or other exposures after birth and in early infancy. Using a twin cohort, we sought to determine the association between length of exposure to the maternal vaginal-fecal microbiome and long-term pediatric health outcomes by comparing outcomes between presenting and nonpresenting twins born to women who labored.Methods: We performed a mail-based survey study of women in a single maternal-fetal medicine practice who delivered twin pregnancies ≥24 weeks. The survey study was sent to women when twins were between 2 and 10 years old to assess the long-term health outcomes, including any medical diagnoses or problems with grown and development. For this study, we included all women who labored, and we compared health outcomes for the presenting versus nonpresenting twin with the primary outcome being the development of asthma/reactive airway disease and allergies. The length of exposure to the maternal vaginal-fecal microbiome was measured using the time from rupture of membranes (ROM) to delivery of each twin. Chi-square and Student's t-test were used.Results: Two hundred fifty-seven sets of twins were eligible for analyses. The presenting twin had a longer time of ROM than the nonpresenting twin (617 ± 2408 min versus 2 ± 5 minutes, p < .001). There were no significant differences between health outcomes for the presenting versus nonpresenting twin in the overall cohort, including the development of asthma/reactive airway disease (9.3 versus 10.1%, p = .77) or allergies (12.5 versus 7.8%, p = .08). There were no differences in any outcomes when comparing the presenting versus nonpresenting twin for those twins delivered vaginally or by cesarean delivery.Conclusion: In twins born to women who labored and either delivered vaginally or via cesarean section, delivery order was not associated with any significant increase in defined adverse pediatric outcomes, including the development of asthma or allergies. Using twins as a model for microbiome exposure may help to elucidate the role of the maternal vaginal-fecal microbiome on long-term pediatric health outcomes.

Change in cervical length and spontaneous preterm birth in nulliparous women with a history of loop electrosurgical excision procedure

BACKGROUND

Prior studies have shown an association between history of loop electrode procedures (LEEP) and spontaneous preterm delivery (SPTD) independent of mid-trimester cervical length. These studies suggest that there may be other factors beyond an individual cervical length, which contribute to identifying at-risk pregnancies.

OBJECTIVE

The objective of this study is to determine the association between change in cervical length and SPTD in women with a history of LEEP.

STUDY DESIGN

This is a retrospective cohort study of singleton nulliparous women with a history of LEEP who received serial cervical length measurements at a single institution between 2012 and 2016. Women with serial cervical lengths and available outcome data were included. The cervical length at different gestational ages and the rate of change in length were compared with the risk for SPTD <37 weeks using Student's t-test.

RESULTS

One-hundred-thirty subjects met the inclusion criteria for the study. The mean cervical length (35.3 versus 39.8 mm, p = .042 at 16 weeks; 32.2 versus 37.8 mm, p < .01 at 20 weeks; 29.9 versus 35.6 mm, p = .027 at 24 weeks; 21.6 versus 33.4 mm, p < .01 at 28 weeks) was significantly different between women who had an SPTD <37 weeks compared to women who did not. The average rate of change in transvaginal cervical length between 16 to 28 weeks was significantly different between women who had an SPTD <37 weeks compared to women who did not (-1.4 versus 0.4 mm/week, p < .01).

CONCLUSION

Women with a history of LEEP who had an SPTD <37 weeks had a shorter cervical length at 16, 20, 24, and 28 weeks' gestation and a higher rate of change in cervical length between 16 and 28 weeks than women without a history of SPTD. Our findings support the concept of the preterm birth syndrome as an evolving biophysical process rather than a distinct event, suggesting improved prediction in the setting of prior history of a LEEP with serial imaging.

Weight gain and pregnancy outcomes in overweight or obese women with twin gestations

BACKGROUND

While adequate weight gain in twin pregnancies with normal prepregnancy BMI has been associated with improved pregnancy outcomes, it remains unclear whether adequate weight gain in patients with overweight or obese prepregnancy BMI is associated with similarly improved pregnancy outcomes, and whether this comes at the expense of maternal health risks such as increased risk for gestational diabetes or hypertension.

OBJECTIVE

To estimate the association between adherence to weight gain recommendations and pregnancy outcomes in overweight and obese women with twin pregnancies.

METHODS

This is a retrospective cohort study of women with overweight (BMI 25.0-29.9 kg/m²) and obese prepregnancy BMI (≥30.0 kg/m²) and twin pregnancies delivered >24 weeks by a single MFM practice between 2005 and 2017. Baseline characteristics, weight gain patterns, and pregnancy outcomes were compared between women who met or exceeded, and who did not meet gestational weight gain requirements, as recommended by the Institute of Medicine (IOM) in 2009. Since total weight gain is also dependent on gestational age at delivery, we used weight gain per week to define adequate weight gain for overweight (0.85 lb/week) and obese (0.68 lb/week) women.

RESULTS

A total of 252 overweight and obese women with twin pregnancies met inclusion criteria, 171 (67.9%) of whom met or exceeded weight gain requirements and 81 (32.1%) of whom did not. There were no differences in baseline clinical and demographic characteristics between the two groups. Women with inadequate weight gain had significantly less weight gain in each trimester, as well as less total weight gain for the whole pregnancy. Women with inadequate average gestational weight gain had significantly lower birthweights of the larger twin (2440 versus 2675 g, p = .001) and the smaller twin (2212 versus 2398 g, p = .005), higher incidence of spontaneous preterm birth <37 weeks (33.3 versus 21.1%, p = .03), higher incidence of premature rupture of membranes (24.7 versus 11.7%, p = .008), and greater likelihood of any twin birthweight < 10th percentile for gestational age (51.9 versus 35.5%, p = .01). There were no differences in the likelihood of cesarean delivery, preeclampsia, or gestational diabetes between the two groups. These results did not differ after excluding the 24 women in the cohort with excessive weight gain.

CONCLUSIONS

For overweight and obese women with twin gestations, meeting the IOM recommendations for weight gain in pregnancy is associated with improved pregnancy outcomes. CondensationWomen with overweight or obese prepregnancy BMI in twin gestations who gain the recommended amount of weight in pregnancy have improved pregnancy outcomes.

The Association between Solo versus Group Obstetrical Practice Model and Delivery Outcomes

OBJECTIVE

To determine if women under the care of obstetricians in solo practice have different delivery outcomes from women in a group practice.

STUDY DESIGN

This is a retrospective cohort of live, term, singleton, vertex (LTSV) deliveries at one hospital from 2011 to 2015. We compared outcomes between women whose obstetrician was in solo practice with women in a group practice model.

RESULTS

There were 18,214 LTSV deliveries by private obstetricians. Solo obstetricians were more likely to deliver at night (41.0 vs. 37.5%, p = 0.002) and less likely to induce labor (22.6 vs. 30.6%, p < 0.001). Solo obstetricians had a significantly higher rate of cesarean delivery (35.7 vs. 27.2%, adjusted odds ratio, aOR: 1.53, 95% confidence interval, CI [1.32, 1.78]), but also had a significantly lower rate of shoulder dystocia (0.4 vs. 1.4, aOR: 0.42, 95% CI [0.19, 0.89]), third or fourth degree lacerations (1.6 vs. 2.4%, aOR: 0.56, 95% CI [0.35, 0.914]), and neonatal intensive care unit admission rates (3.2 vs. 6.2%, aOR: 0.57, 95% CI [0.42, 0.77]).

CONCLUSION

In a large, tertiary care hospital, solo obstetricians have similar neonatal outcomes as group obstetricians. Their higher cesarean delivery rate is balanced by fewer shoulder dystocias and third/fourth degree lacerations, indicating a more conservative approach to labor management. Patient outcomes should not be a reason to discourage a solo practice model.

The Association between Intended Mode of Delivery and Maternal Morbidity in Twin Pregnancies

OBJECTIVE

To compare maternal morbidity between women undergoing delivery of twins who intend to labor with those women who do not intend to labor.

STUDY DESIGN

This was a retrospective cohort study of women undergoing delivery of twins in a single maternal-fetal medicine practice between January 2005 and February 2018. We identified women with a twin delivery at gestational age ≥24 weeks and determined if they intended or did not intend to labor. Maternal outcomes were compared between the groups.

RESULTS

A total of 788 patients were included, of whom 404 (51.3%) intended to labor and 384 (48.7%) did not intend to labor. Women who intended to labor had a high rate of vaginal delivery (VD; 79.7%). Overall, 45 (5.7%) women required blood transfusion; this was not significantly different between the groups (6.2 vs. 5.2%, p = 0.54). Women who intended to labor had a shorter hospital stay and lower blood loss. There were no significant differences for all other maternal outcomes.

CONCLUSION

In patients undergoing twin delivery, women who intend to labor have similar maternal morbidity compared with women who do not intend to labor. This supports current guidelines recommending providers offer a trial of VD for twin pregnancies.

Pregnancy outcomes in viable pregnancies with a septate uterus compared with viable pregnancies after hysteroscopic uterine septum resection

BACKGROUND

Septate uterus is one of the more common Müllerian anomalies and is the anomaly most amenable to surgical correction. It is currently uncertain if hysteroscopic septum resection reduces the incidence of adverse pregnancy outcomes.

OBJECTIVE

The purpose of this study was to compare pregnancy outcomes in women who had reached at least 20 weeks gestation with those women with a uterine septum and those women who had undergone septum resection before pregnancy.

STUDY DESIGN

Retrospective cohort study of women with a history of uterine septum who were cared for by a large maternal-fetal medicine practice from 2005-2018. We included women with singleton pregnancies at >20 weeks gestation. Baseline characteristics and pregnancy outcomes were compared between women with a history of a hysteroscopic uterine septum resection and women with an unresected septum. Regression analysis was performed to control for differences in baseline characteristics. The analysis was repeated in nulliparous women only.

RESULTS

A total of 109 women (163 pregnancies) were included. In the entire population, pregnancy outcomes did not differ between the groups, aside from a higher rate of cesarean delivery in the resected septum group. In the 63 nulliparous women, septum resection was associated with later gestational ages at delivery (39.1 vs 37 weeks; P=.030), decreased preterm birth <37 weeks gestation (4.5% vs 31.6%; adjusted odds ratio, 0.154; 95% confidence interval, 0.027-0.877), and an increased incidence of cesarean delivery in women who attempted vaginal delivery (30.6% vs 0%; P=.012). There was no difference in the rates of small for gestational age, preeclampsia, blood transfusion, retained placenta, or morbidly adherent placenta.

CONCLUSION

In nulliparous women with viable pregnancies, hysteroscopic resection of a uterine septum is associated with a decreased incidence of preterm birth and an increased incidence of cesarean delivery. These findings need to be confirmed in a well-designed randomized trial before uterine septum resection is recommended routinely.

The association between high-normal blood pressure and the development of preeclampsia in twin pregnancies

Objective: We sought to determine if women with twin pregnancies and blood pressure (BP) above the 95th percentile but within normal ranges (i.e. less than 140 systolic and 90 diastolic) are at increased risk of hypertensive disorders of pregnancy.Methods: Retrospective cohort study of all women with twin pregnancies being cared for by a single Maternal Fetal Medicine practice between 2012 and 2018. We identified all women who had a systolic blood pressure (SBP) or diastolic blood pressure (DBP) above the 95th percentile but less than 140 systolic and 90 diastolic at any point during pregnancy. Based on prior publications, the 95th percentile was defined as: a SBP 121-139 mmHg up to 30 weeks or 131-139 mmHg after 30 weeks, a DBP 81-89 mmHg up to 34 weeks or 85-89 mmHg after 34 weeks. We excluded women diagnosed with chronic hypertension either before or during pregnancy. The primary outcome was the development of preeclampsia. Chi-square and logistic regression were used.Results: A total of 457 patients met the inclusion criteria, of whom 109 (23.9%) had either a systolic or diastolic BP above the 95th percentile (but normal) at any time during pregnancy. These women were significantly more likely to develop preeclampsia (30.3 versus 12.6%, p < .001, aOR 2.32 (1.31, 4.09)) and gestational hypertension without preeclampsia (16.5 versus 4.6%, p < .001, aOR 4.27 (2.01, 9.07)).Conclusions: In women with twin pregnancies, a high-normal systolic or diastolic BP (above 120 systolic or 80 diastolic prior to 30 weeks, or above 130 systolic or 84 diastolic after 30 weeks) is associated with a significantly increased risk of gestational hypertension and preeclampsia.

Time to Delivery after Scheduled Shirodkar Cerclage Removal in Singleton Gestations based on the Original Indication for Cerclage Placement

OBJECTIVE

To estimate the time to delivery after elective cerclage removal and evaluate whether there is a difference based on the indication for cerclage placement.

STUDY DESIGN

This was a retrospective cohort of singleton pregnancies that underwent Shirodkar cerclage placement at a single maternal-fetal medicine practice between June 2005 and June 2017. We included all scheduled elective cerclage removals >36 weeks. The primary outcome was latency to delivery. We further compared time to delivery based on the original indication for cerclage. Data were analyzed using the one-way analysis of variance and chi-square test.

RESULTS

A total of 143 patients met the inclusion criteria. Of these, 40.6% were history indicated, 51.0% ultrasound indicated, and 8.4% exam indicated. The mean time from removal to delivery was 13.3 ± 8.4 days; 12.6% (18/136) of patients delivered within 24 hours of removal. When stratified by indication for cerclage, there were no significant differences for all delivery outcomes. Delaying cerclage removal to >37 weeks resulted in a statistically significantly later gestational age at delivery compared with removal between 36 and 36^6/7 weeks (39.0 vs. 38.3 weeks, p = 0.001).

CONCLUSION

The mean time from elective Shirodkar cerclage removal to delivery is 13 days with only 12.6% of patients delivering within 24 hours of removal.

Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series

The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.

Weight gain and pregnancy outcomes in underweight women with twin gestations

Background: Adherence to minimum weight gain recommendations in twin pregnancies as defined by the Institute of Medicine (IOM) guidelines is associated with improved pregnancy outcomes; however, these recommendations have yet to be made for underweight women (BMI < 18.5 kg/m²).Objective: To determine if existing pregnancy weight gain recommendations in twin gestations apply to women with underweight prepregnancy body mass index (BMI), and if these women have similar pregnancy outcomes to women with normal prepregnancy BMI.Methods: This is a retrospective cohort study of women with underweight (BMI < 18.5 kg/m²) and normal prepregnancy BMI (18.5-24.9 kg/m²) and twin pregnancies delivered > 24 weeks by a single Maternal Fetal Medicine (MFM) practice between 2005-2017. Weight gain patterns and pregnancy outcomes were compared between women with underweight prepregnancy BMI and normal prepregnancy BMI. The primary outcomes of the study were gestational age at delivery and intrauterine growth restriction.Results: A total of 664 women met inclusion criteria during the study period, 55 (8.3%) of whom had an underweight prepregnancy BMI, and 609 (91.7%) of whom had a normal prepregnancy BMI. There were no differences in baseline clinical and demographic characteristics between the groups, nor any differences in overall weight gain or weight gain patterns between the two groups. There were no significant differences between the groups in birthweight of the larger twin (2415 versus 2489 g, p = .26) or the smaller twin (2150 versus 2190 g, p = .55), gestational age at delivery (35.8 versus 35.8 weeks, p = .96), incidence of preterm birth < 34 weeks (16.4 versus 16.3%, p = .98), spontaneous preterm birth < 34 weeks (9.1 versus 11.7%, p = .57), or the incidence of either twin with a birthweight < 10% for gestational age (60.0 versus 56.0%, p = .57) or < 5% for gestational age (36.4 versus 30.9%, p = .40).Conclusions: Women with underweight prepregnancy BMI who gain equal weight to women with normal prepregnancy BMI have similar pregnancy outcomes. The recommendations for adequate weight gain in women with underweight prepregnancy BMI should therefore not exceed those for women with normal prepregnancy BMI.

Cervical length, cervical dilation, and gestational age at cerclage placement and the risk of preterm birth in women undergoing ultrasound or exam indicated Shirodkar cerclage

Background: Preterm birth is a major cause of neonatal morbidity and mortality in the USA. In many patients at risk for preterm birth, cervical length (CL) screening is used to guide decisions regarding cerclage placement. Quality evidence shows that cerclage prolongs pregnancy in high-risk women with a short CL in women with a history of preterm birth and in women with painless cervical dilation in the second trimester, though the degree of cervical shortening, dilation, or gestational age at cerclage placement are not consistently associated with the subsequent rate of preterm birth. Our objective was to determine if cervical length (CL), cervical dilation or gestational age (GA) at the time of cerclage placement are associated with preterm birth among women undergoing ultrasound-indicated or exam-indicated cerclage.Study design: This was a retrospective cohort study of all patients with a singleton pregnancy who underwent ultrasound-indicated or exam-indicated Shirodkar cerclage placement at a single maternal-fetal medicine practice in New York City between November 2005 and May 2017. All patients included in the study had previously undergone CL screening for an increased risk of preterm birth (for example, prior spontaneous preterm birth or mid-trimester loss, prior cervical excision). The cervical length or dilation and GA at the time of cerclage placement were collected, as were demographic and obstetric outcome data for the current pregnancy. The primary outcome was delivery <36 or ≥36 weeks. Planned subgroup analyses of the primary outcome were performed based on CL at the time of ultrasound-indicated cerclage (0-9 mm, 10-19 mm, ≥20 mm), cervical dilation at the time of physical exam-indicated cerclage (<2 cm vs. ≥2 cm), and gestational age at cerclage placement (<20 weeks vs. ≥20 weeks). Data were analyzed using the Student's t-test and chi-square test for trend.Results: There were 123 and 39 patients in the ultrasound- and exam-indicated cerclage groups, respectively. Twenty six (21.2%) patients in the ultrasound-indicated subgroup and 24 patients (61.5%) in the exam-indicated subgroup delivered <36 weeks. CL (16.4 versus 17.6 mm, p = .28) and GA (19.7 versus 20.0 weeks, p = .58) at the time of ultrasound-indicated cerclage placement were not significantly different in patients who delivered <36 and ≥36 weeks' gestation, respectively. Women with cervical dilation ≥2 cm prior to exam-indicated cerclage placement were significantly more likely to deliver <36 weeks when compared to women with cervical dilation <2 cm (77.8 versus 47.6%, p = .05); however, there were no significant differences in rates of preterm birth <28 and <32 weeks between these two groups (38.9 versus 23.8%, p = .31 and 50.0% versus 28.6%, p = .17, respectively).Conclusions: Cervical length and GA at the time of ultrasound-indicated Shirodkar cerclage placement do not appear to impact the likelihood of preterm birth <36 weeks, while cervical dilation ≥2 cm at the time of exam-indicated Shirodkar cerclage is associated with an increased rate of preterm birth <36 weeks, but not earlier gestational ages at delivery.