Objective Our objective was to determine whether objectively measured sleep-disordered breathing (SDB) during pregnancy is associated with an increased risk of adverse neonatal outcomes in a cohort of nulliparous individuals. Study Design Secondary analysis of the nuMom2b sleep disordered breathing substudy was performed. Individuals underwent in-home sleep studies for SDB assessment in early (6–15 weeks' gestation) and mid-pregnancy (22–31 weeks' gestation). SDB was defined as an apnea-hypopnea index ≥5 events/h at either time point. The primary outcome was a composite outcome of respiratory distress syndrome, transient tachypnea of the newborn, or receipt of respiratory support, treated hyperbilirubinemia or hypoglycemia, large-for-gestational age, seizures treated with medications or confirmed by electroencephalography, confirmed sepsis, or neonatal death. Individuals were categorized into (1) early pregnancy SDB (6–15 weeks' gestation), (2) new onset mid-pregnancy SDB (22–31 weeks' gestation), and (3) no SDB. Log-binomial regression was used to calculate adjusted risk ratios (RR) and 95% confidence intervals (CIs) representing the association. Results Among 2,106 participants, 3% (n = 75) had early pregnancy SDB and 5.7% (n = 119) developed new-onset mid-pregnancy SDB. The incidence of the primary outcome was higher in the offspring of individuals with early (29.3%) and new onset mid-pregnancy SDB (30.3%) compared with individuals with no SDB (17.8%). After adjustment for maternal age, chronic hypertension, pregestational diabetes, and body mass index, new onset mid-pregnancy SDB conferred increased risk (RR = 1.43, 95% CI: 1.05, 1.94), where there was no longer statistically significant association between early pregnancy SDB and the primary outcome. Conclusion New onset, mid-pregnancy SDB is independently associated with neonatal morbidity. Key Points

Rationale: Knowledge gaps exist regarding health implications of sleep-disordered breathing (SDB) identified in pregnancy and/or after delivery. Objectives: To determine whether SDB in pregnancy and/or after delivery is associated with hypertension (HTN) and metabolic syndrome (MS). Methods: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be Heart Health Study) (N = 4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n = 1,964) and a repeat SDB assessment after delivery (n = 1,222). Two SDB definitions were considered: 1) apnea-hypopnea index (AHI) >= 5 and 2) oxygen desaturation index (ODI) >= 5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRRs). Measurements and Main Results: The aRR for MS given an AHI >= 5 during pregnancy was 1.44 (95% confidence interval [CI], 1.08-1.93), but no association with HTN was found. ODI >= 5 in pregnancy was associated with both an increased risk for HTN (aRR, 2.02; 95% CI, 1.30-3.14) and MS (aRR, 1.53; 95% CI, 1.19-1.97). Participants with an AHI >= 5 in pregnancy that persisted after delivery were at higher risk for both HTN (aRR, 3.77; 95% CI, 1.84-7.73) and MS (aRR, 2.46; 95% CI, 1.59-3.76). Similar associations were observed for persistent ODI >= 5 after delivery. Conclusions: An AHI >= 5 in pregnancy was associated with an increased risk of MS. An ODI >= 5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI during pregnancy and at 2-7 years after delivery were at the highest risk for HTN and MS.

Postpartum hypertensive disease is the leading cause of postpartum readmission, and predicting which patients will be readmitted is challenging. We sought to estimate risk factors for postpartum readmission for hypertensive disease. A case-control study of postpartum readmissions for hypertensive disease from 2016 to 2018. Cases were all patients readmitted for hypertensive disease within 6 weeks of delivery. Cases were matched 1:2 to controls who delivered within 2 days in the same institution, but were not readmitted. Multivariable logistic regression was used to estimate independent predictors of readmission. Area under the receiver operating characteristics curve (AUC) was used to estimate overall prediction accuracy. Of a total of 362 patients, 121 were cases of readmission for postpartum hypertensive disease and 241 were matched controls who were not readmitted. Several patient and obstetric characteristics were significantly different between cases and controls. In multivariable analysis, black race, tobacco use, preterm delivery (<37 weeks), preeclampsia or gestational hypertension (but not chronic hypertension) and peak postpartum systolic (but not diastolic) blood pressure before discharge were independent predictors of readmission (Table). Taken together, these factors predicted readmission for hypertensive disease with relatively high accuracy (AUC=0.81) (Figure). Patient and obstetric factors predict postpartum readmission with relatively high accuracy. These factors may be useful for identifying patients who may need longer stay prior to discharge, closer outpatient surveillance, or additional interventions postpartum to reduce readmission.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: This study compared differences in buprenorphine doses needed to treat opioid use disorder in pregnant women with and without mood disorders and to compare the development of neonatal abstinence syndrome in infants delivered to mothers treated with buprenorphine in patients with history of mood disorders versus those without mood disorder. Methods: This retrospective cohort study included women with opioid use disorder prescribed buprenorphine who had at least one outpatient visit at with the Indiana University Department of Maternal Fetal Medicine during pregnancy and delivered within the Indiana University Health system. Charts were reviewed for maternal demographics, medical history and medication use, and neonatal outcomes. Cases included those patients with history of mood disorder including depression, anxiety, or post-traumatic stress disorder based on initial appointment intake forms. Starting and maximum doses of buprenorphine during pregnancy were recorded. Outcomes were compared using Student’s t-tests and Analysis of Variance models for continuous variables and chi-square tests for categorical variables. All analytic assumptions were verified, with non-parametric tests being performed where necessary. Results: A total of 266 women were treated with opioids, of which 171 were diagnosed with a mood disorder: 148 depression, 130 anxiety, and 19 post-traumatic stress disorder. Over 40% of the patients had a history of dual diagnoses. Patients with a history of depression or anxiety required a higher dose of buprenorphine during pregnancy (p=0.0217, p=0.0165) compared to those without a history of mood disorder. There was no significant difference in the doses in patients with post-traumatic stress disorder versus controls. In those with a diagnosis of mood disorder, there was no difference in buprenorphine dose between women on medication versus those not on medication for depression, anxiety, and Post Traumatic Stress Disorder. There was no statistical difference between patients with or without mood disorder and the development of neonatal abstinence syndrome. For those that developed neonatal abstinence syndrome, infants whose mothers had anxiety or post-traumatic stress disorder required 2-6 extra days of morphine treatment compared to those infants of mothers without mood disorder (p=0.0088, p=0.0291), no difference seen for depression or a combination of mood disorders. Development of neonatal abstinence syndrome or length of treatment did not vary if the mother was on medication for treatment of her mood disorder. Conclusion: Pregnant women with a mood disorder require higher doses of buprenorphine compared to patients without a mood disorder. In women with mood disorders, there was no difference in buprenorphine dose in women treated with medication compared to those not taking medication for mood disorders. While, there was no difference in the incidence of neonatal abstinence syndrome in infants whose mothers also had a mood disorder, infants born of women with anxiety or post-traumatic stress disorder had longer stays at the Neonatal Intensive Care Unit as they needed 2-6 extra days of morphine treatment. These findings may help guide provider counseling of these women in discussion of post-delivery expectations.

OBJECTIVE:To determine the utility of fetal echocardiography in diagnosing cardiac defects in fetuses with a single umbilical artery (SUA).METHODS:A retrospective cohort study of prenatally diagnosed SUA was conducted over a 10-year period at a single institution. Cardiac anatomy on detailed anatomical survey was compared with fetal echocardiogram for fetuses with prenatally diagnosed SUA. A diagnostic meta-analysis of studies comparing fetal anatomical survey to fetal echocardiogram in fetuses with SUA between 2010 to 2019 was also performed.RESULTS:Three hundred and twenty fetuses with SUA were identified, 113 of which had completed both ultrasound and echocardiography. There were 36 cases of cardiac defects on prenatal echocardiogram and all had abnormal anatomical ultrasounds. There were zero cases of abnormal cardiac exams (0%) when the cardiac views on anatomical survey were normal. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound were 100%, 77%, 73% and 100%, respectively. A summary ROC curve demonstrated a high predictive value of routine anatomic survey for cardiac defects (AUC: 0.99).CONCLUSION:Anatomic survey is highly predictive in the detection of cardiac defects in fetuses with SUA. Fetal echocardiogram is unnecessary in SUA when cardiac views are normal on ultrasound.

INTRODUCTION: The purpose of this study is to compare differences in buprenorphine doses needed to treat Opiate Use Disorder (OUD) in patients with and without mood disorders. METHODS: This is a retrospective cohort study of pregnant women treated at Indiana University with OUD. IRB approval was obtained from Indiana University School of Medicine. Charts were obtained via prescription medication search. Patients were included if they had at least one outpatient visit with our center during pregnancy and delivered within the Indiana University Health system. Charts were reviewed for maternal demographics, medical history, prescription use, and delivery data. RESULTS: 266 patients were treated and 171 patients had a mood disorder: 148 with depression, 130 with anxiety, and 19 with post-traumatic stress disorder (PTSD). Over 40% of the patients had a history of dual diagnoses. Patients with a history of depression or anxiety required a higher dose of buprenorphine during pregnancy (p=0.0217, p=0.0165) compared to those without a history of mood disorder. There was no significant difference in dose in those with PTSD versus those without mood disorder. In those with a diagnosis of mood disorder, there was no difference in buprenorphine dose between women on medication versus those not on medication for depression, anxiety, and PTSD. CONCLUSION: Patients with a mood disorder require higher doses of buprenorphine compared to patients without a mood disorder. Treatment of depression, anxiety or PTSD did not show a difference in buprenorphine dose versus no treatment when a mood disorder was diagnosed.

Background: Maternal sleep position on the back or right side has been associated with adverse pregnancy outcomes, leading to recommendations to always sleep on the left side and maternal anxiety about sleep. However, available data are from case-control studies, which are subject to recall bias. Our objective was to examine the relationship between prospectively assessed sleep position and subsequent adverse pregnancy outcomes. Methods: This was a secondary analysis of a prospective observational multicenter cohort study of nulliparous women with singleton gestations. Participants prospectively completed in-depth sleep questionnaires between 6+0 and 13+6 week's gestation (V1) and 22+0 and 29+6 week's gestation (V3). At each visit, women were asked in what position they went to sleep last night and on average during the past week. A subset of women also underwent level 3 home sleep tests using the Embletta Gold device. The primary outcome was a composite of adverse pregnancy outcomes including stillbirth, small for gestational age fetus (SGA), and gestational hypertensive disorders. Results: 8,706 (of 10,038 total) women had data from at least one sleep questionnaire and for pregnancy outcomes, and they comprised the population for this analysis. There was no association between reported non-left lateral or supine sleep during the last week at V1 or V3 and the composite or any individual outcome, except for an apparent protective effect for stillbirth at V3. Women with objectively measured supine sleep position for > 50% of the time were no more likely than those in the supine position ≤ 50% of the time to have the composite adverse outcome. Conclusions: Going to sleep in the supine or right lateral position, as self reported prior to the development of pregnancy outcome and objectively assessed through 30 weeks gestation was not associated with an increased risk of stillbirth, SGA fetus or gestational hypertensive disorders. Trial Registration: clinicaltrials.gov (NCT01322529)Funding Statement: This study is supported by grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD063036, RTI International; U10 HD063072, Case Western Reserve University; U10 HD063047, Columbia University; U10 HD063037, Indiana University; U10 HD063041, University of Pittsburgh; U10 HD063020, Northwestern University; U10 HD063046, University of California Irvine; U10 HD063048, University of Pennsylvania; and U10 HD063053, University of Utah. In addition, support was provided by respective Clinical and Translational Science Institutes to Indiana University (UL1TR001108) and University of California Irvine (UL1TR000153).Declaration of Interests: No conflicts of interest to declare or report.Ethics Approval Statement: The study was approved by the Institutional Review Boards at each clinical site and the Data Coordinating Center, and all participants gave written informed consent.

Maternal sleep position on the back or right side has been associated with adverse pregnancy outcomes (APOs), leading to recommendations to always sleep on the left side and maternal anxiety about sleep. However, available data are from case-control studies, which are subject to recall bias. Our purpose was to examine the relationship between prospectively assessed sleep position and subsequent APOs. Secondary analyses of the nuMoM2b and sleep sub-study observational cohort were performed. Nulliparous women prospectively completed in-depth sleep questionnaires between 6+0 and 13+6 week's gestation (V1) and 22+0 and 29+6 week's gestation (V3). At each visit, women were asked in what position they went to sleep last night and on average during the past week. At V1, they were also asked in what position they went to sleep prior to pregnancy. Adjusted ORs and 95% CIs were calculated using regression models to relate sleep position at V1 and V3 to APO (a composite of stillbirth, SGA birth weight, and gestational hypertensive disorders). Adjustment covariates included age, BMI and chronic hypertension in early pregnancy; V3 analyses were also adjusted for rate of weight gain from early to mid-pregnancy. 8,706 (of 10,038 total) women had data from at least one sleep questionnaire and for pregnancy outcomes, and they comprised the population for this analysis. There was no association between reported non-left lateral sleep during the last week at V1 or V3 and the APO composite or any individual outcome, except for an apparent protective effect for stillbirth at V3 (table). The same was true for position going to sleep last night and prior to pregnancy. In addition, women who reported going to sleep slept in the supine position were not more likely to experience the composite or any individual outcome compared to the left lateral position. Going to sleep in the supine or right lateral position, as reported prior to the development of pregnancy outcome, was not associated with an increased risk of a composite APO including stillbirth, SGA fetus or gestational hypertensive disorders. These data do not support recommendations for women to avoid going to sleep in the supine or right lateral position.

INTRODUCTION: Gastroschisis is an abdominal wall defect and it is often difficult to accurately measure the abdominal circumference. The purpose of this study is to compare formulas for estimating fetal weight by ultrasound in these infants. METHODS: A retrospective cohort analysis of singleton deliveries complicated by Gastroschisis. Exclusions included fetuses with additional anomalies, fetuses born at < 28 weeks, and those without available delivery data. Biometric measurements (BPD, AC, HC and FL) and estimated fetal weight were extracted from ultrasound reports. The EFW was adjusted based on a correction factor for weight gain in the third trimester. Maternal and fetal charts were reviewed for gestational age at time of delivery and birth weight. RESULTS: 148 cases of Gastroschisis were identified. 39 were excluded based on unavailable delivery data, additional fetal anomalies, termination, and stillbirths. A total of 41 charts were reviewed with an ultrasound within 14 days of delivery (1-7 days n= 29, 8-14 days n=11). Median birth weight for those infants born within 1-7 days and 8-14 days of delivery was 2250g and 2487g. Average gestational age at time of delivery was 35 weeks 5 days and 35 weeks 6 days for those with an ultrasound between 1-7 days and 8-14 days. Average Pearson Correlation Coefficient was 0.803 (range 0.776-0.832) with the highest correlation found using Hadlock IV, JSUM, and Hadlock II. Percentage of error noted similar findings. CONCLUSION: As seen in other studies comparing EFW in pregnancies complicated by Gastroschisis, we noted underestimation of weight in both pregnancies with ultrasounds.

Sleep-disordered breathing (SDB) refers to a group of disorders characterized by abnormal respiratory patterns or abnormal gas exchange during sleep. The most common type of SDB, especially among young obese women, is obstructive sleep apnea. SDB has clearly been linked to poor sleep and impaired daytime function, but there are also data linking SDB to other health outcomes, principally cardiovascular and metabolic disease. SDB symptoms are common in pregnancy, and pregnancy itself has been associated with an increase in the prevalence of SDB symptoms. Although a link between SDB and adverse pregnancy outcomes appears to be biologically plausible, data exploring this relationship are only now emerging, and large prospective studies in which the authors use objective measures of sleep are lacking. Until we know more about the epidemiology and the impact of SDB in pregnancy, screening efforts for SDB in pregnancy should be focused on identifying very symptomatic patients because treatment of these individuals often leads to improved sleep quality and daytime functioning.

Abstract Purpose: The purpose of this study is to evaluate the incidence of maternal cell contamination (MCC) in the first few milliliters of amniotic fluid withdrawn during amniocentesis. Methods: A prospective observational study was performed. The initial 2–3 ml of amniotic fluid withdrawn during amniocentesis was divided into direct analysis (uncultured) and cultured samples. A matching maternal buccal swab was obtained for MCC testing. MCC was determined by short-tandem repeat analysis. The primary outcome was measurement of clinically significant contamination (MCC >5%). Secondary outcomes included the determination of risk factors associated with MCC >5%. Outcomes were assessed by fisher’s exact, independent t-test, binary logistic regression, and ANOVA. Results: Direct analysis measured clinically significant contamination (MCC > 5%) in 26% of specimens, while any amount of MCC was present in 68% of specimens. Cultured specimens had MCC > 5% in 2%, and any amount of MCC in 24%. Only blood-tinged fluid was associated with an increased risk for MCC > 5%. Larger volumes of the discard sample were not associated with increased incidence of MCC greater than 5%. Conclusion: A significant amount of MCC is present with direct analysis of the initial few milliliters of amniotic fluid withdrawn and is not influenced by the volume of the discard sample. Our results suggest that the first few milliliters of amniotic fluid be removed and discarded when direct analysis is utilized for prenatal genetic testing.

BACKGROUND: Trophoblastic invasion of the uterine spiral arteries substantially increases compliance to accommodate increased blood flow to the placenta. Failure of this process impedes uterine artery blood flow, and this may be detected by uterine artery Doppler flow studies. However, the clinical utility of uterine artery Doppler flow studies in the prediction of adverse pregnancy outcomes in a general population remains largely unknown. OBJECTIVE: We sought to determine the utility of early second-trimester uterine artery Doppler studies as a predictor of small-for-gestational-age neonates. STUDY DESIGN: Nulliparous women with a viable singleton pregnancy were recruited during their first trimester into an observational prospective cohort study at 8 institutions across the United States. Participants were seen at 3 study visits during pregnancy and again at delivery. Three indices of uterine artery Doppler flow (resistance index, pulsatility index, and diastolic notching) were measured in the right and left uterine arteries between 16 weeks 0 days' and 22 weeks 6 days' gestation. Test characteristics for varying thresholds in the prediction of small for gestational age (defined as birthweight <5th percentile for gestational age [Alexander growth curve]) were evaluated. RESULTS: Uterine artery Doppler indices, birthweight, and gestational age at birth were available for 8024 women. Birthweight <5th percentile for gestational age occurred in 358 (4.5%) births. Typical thresholds for the uterine artery Doppler indices were all associated with birthweight <5th percentile for gestational age (P < .0001 for each), but the positive predictive values for these cutoffs were all <15% and areas under receiver operating characteristic curves ranged from 0.50-0.60. Across the continuous scales for these measures, the areas under receiver operating characteristic curves ranged from 0.56-0.62. Incorporating maternal age, early pregnancy body mass index, race/ethnicity, smoking status prior to pregnancy, chronic hypertension, and pregestational diabetes in the prediction model resulted in only modest improvements in the areas under receiver operating characteristic curves ranging from 0.63-0.66. CONCLUSION: In this large prospective cohort, early second-trimester uterine artery Doppler studies were not a clinically useful test for predicting small-for-gestational-age babies.

OBJECTIVE:To assess the utility of cervical funnel volume as a predictor of cerclage failure. METHODS:We performed a retrospective cohort study of pregnant women with a McDonald cerclage and sonographic evidence of cervical funneling between 1/2008 and 2/2014. Funnel volume (FV) was calculated and used as a correction factor for cervical length (CL) or cerclage height (CH). Receiver operating characteristic (ROC) curves were used to compare the predictive value of CL, CL:FV, CH and CH:FV for cerclage failure at <28 or <34 weeks. CL:FV was further stratified to the <5th, <10th and >10th percentiles and analyzed for prediction of preterm delivery. RESULTS:Subjects with cerclage failure (n = 30) delivered at a mean gestational age of 29.8 +/- 5.3 weeks compared to 38.1+/- 1.39 weeks in those without failure (n = 27; p < 0.001). ROC curves demonstrated CL:FV was the best predictor of delivery <28 weeks (AUC 0.80), while CL was the best predictor of delivery <34 weeks (AUC 0.76). Stratification of CL:FV into <5th versus >10th percentile groups was predictive of early preterm delivery (25.1 weeks versus 34 weeks, p = 0.01). CONCLUSIONS:Volumetric assessment of cervical funneling may improve prediction of cerclage failure in the mid-trimester.

Background: The cause of primary immunodeficiency has expanded to nearly 200 distinct disorders. An improved understanding of these disorders has resulted in decreased morbidity and mortality with reciprocal improved life expectancy. Obstetricians should have knowledge of primary immunodeficiency, as more women with these disorders will reach reproductive age. Case: 21-year-old G1P0 with purine nucleoside phosphorylase (PNP) deficiency delivered a viable infant vaginally at 37 weeks. Although the patient's diagnosis and pregnancy placed her at increased risk for infection, she remained asymptomatic and infection-free throughout pregnancy. Conclusion: The management of pregnancy complicated by PNP deficiency requires strict immune surveillance and regimented immunoglobulin replacement.

ObjectiveStudies have demonstrated that sleep restriction adversely affects appetite regulating hormones, insulin sensitivity, inflammation and autonomic function. However, data regarding the clinical consequences of short sleep durations during pregnancy are limited. Our objective was to determine whether insufficient sleep is associated with increased risks of gestational hypertension (GHTN), preeclampsia (PE), and/or gestational diabetes mellitus (GDM).Study DesignWomen enrolled in a multi-center prospective cohort study of adverse pregnancy outcomes in nulliparous women with a singleton gestation were recruited at the 2nd study visit (16 0/7-21 6/7 weeks’) to wear an actigraph (ActiWatch, Phillips Respironics) to record objective sleep activity for 7 consecutive days. Women with pregestational diabetes and chronic hypertension were excluded. Short sleep duration (SSD) was defined as average sleep of < 7 hours per night.ResultsActigraphy and outcome data were obtained for 760 women. Median sleep duration was 7.4 (IQR 1.0) hours, and 28% of women had SSD, averaged over the 7 days. 5.1% of women developed GHTN, 5.1% developed PE and 4.1% developed GDM. Outcome rates stratified by SSD status are shown in the Table. SSD was associated with an increased rate of GDM even after adjusting for age and BMI (aOR 2.12, 95% CI 1.02-4.41), but was not associated with GHTN and/or PE.ConclusionSSD during pregnancy, a potentially modifiable factor, is associated with the development of GDM after controlling for maternal age and BMI. Further research can establish if screening for sleep disturbances and education to modify sleep patterns in women with SSD can lessen the risk of GDM. ObjectiveStudies have demonstrated that sleep restriction adversely affects appetite regulating hormones, insulin sensitivity, inflammation and autonomic function. However, data regarding the clinical consequences of short sleep durations during pregnancy are limited. Our objective was to determine whether insufficient sleep is associated with increased risks of gestational hypertension (GHTN), preeclampsia (PE), and/or gestational diabetes mellitus (GDM). Studies have demonstrated that sleep restriction adversely affects appetite regulating hormones, insulin sensitivity, inflammation and autonomic function. However, data regarding the clinical consequences of short sleep durations during pregnancy are limited. Our objective was to determine whether insufficient sleep is associated with increased risks of gestational hypertension (GHTN), preeclampsia (PE), and/or gestational diabetes mellitus (GDM). Study DesignWomen enrolled in a multi-center prospective cohort study of adverse pregnancy outcomes in nulliparous women with a singleton gestation were recruited at the 2nd study visit (16 0/7-21 6/7 weeks’) to wear an actigraph (ActiWatch, Phillips Respironics) to record objective sleep activity for 7 consecutive days. Women with pregestational diabetes and chronic hypertension were excluded. Short sleep duration (SSD) was defined as average sleep of < 7 hours per night. Women enrolled in a multi-center prospective cohort study of adverse pregnancy outcomes in nulliparous women with a singleton gestation were recruited at the 2nd study visit (16 0/7-21 6/7 weeks’) to wear an actigraph (ActiWatch, Phillips Respironics) to record objective sleep activity for 7 consecutive days. Women with pregestational diabetes and chronic hypertension were excluded. Short sleep duration (SSD) was defined as average sleep of < 7 hours per night. ResultsActigraphy and outcome data were obtained for 760 women. Median sleep duration was 7.4 (IQR 1.0) hours, and 28% of women had SSD, averaged over the 7 days. 5.1% of women developed GHTN, 5.1% developed PE and 4.1% developed GDM. Outcome rates stratified by SSD status are shown in the Table. SSD was associated with an increased rate of GDM even after adjusting for age and BMI (aOR 2.12, 95% CI 1.02-4.41), but was not associated with GHTN and/or PE. Actigraphy and outcome data were obtained for 760 women. Median sleep duration was 7.4 (IQR 1.0) hours, and 28% of women had SSD, averaged over the 7 days. 5.1% of women developed GHTN, 5.1% developed PE and 4.1% developed GDM. Outcome rates stratified by SSD status are shown in the Table. SSD was associated with an increased rate of GDM even after adjusting for age and BMI (aOR 2.12, 95% CI 1.02-4.41), but was not associated with GHTN and/or PE. ConclusionSSD during pregnancy, a potentially modifiable factor, is associated with the development of GDM after controlling for maternal age and BMI. Further research can establish if screening for sleep disturbances and education to modify sleep patterns in women with SSD can lessen the risk of GDM. SSD during pregnancy, a potentially modifiable factor, is associated with the development of GDM after controlling for maternal age and BMI. Further research can establish if screening for sleep disturbances and education to modify sleep patterns in women with SSD can lessen the risk of GDM.

OBJECTIVE:The objective of the Sleep Disordered Breathing substudy of the Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be (nuMoM2b) is to determine whether sleep disordered breathing during pregnancy is a risk factor for adverse pregnancy outcomes. STUDY DESIGN:NuMoM2b is a prospective cohort study of 10,037 nulliparous women with singleton gestations that was conducted across 8 sites with a central Data Coordinating and Analysis Center. The Sleep Disordered Breathing substudy recruited 3702 women from the cohort to undergo objective, overnight in-home assessments of sleep disordered breathing. A standardized level 3 home sleep test was performed between 6(0)-15(0) weeks' gestation (visit 1) and again between 22(0)-31(0) weeks' gestation (visit 3). Scoring of tests was conducted by a central Sleep Reading Center. Participants and their health care providers were notified if test results met "urgent referral" criteria that were based on threshold levels of apnea hypopnea indices, oxygen saturation levels, or electrocardiogram abnormalities but were not notified of test results otherwise. The primary pregnancy outcomes to be analyzed in relation to maternal sleep disordered breathing are preeclampsia, gestational hypertension, gestational diabetes mellitus, fetal growth restriction, and preterm birth. RESULTS:Objective data were obtained at visit 1 on 3261 women, which was 88.1% of the studies that were attempted and at visit 3 on 2511 women, which was 87.6% of the studies that were attempted. Basic characteristics of the substudy cohort are reported in this methods article. CONCLUSION:The substudy was designed to address important questions regarding the relationship of sleep-disordered breathing on the risk of preeclampsia and other outcomes of relevance to maternal and child health.

BACKGROUND Preterm birth is the leading cause of death and disability in newborns worldwide. A wide variety of tocolytic agents have been utilized to delay birth for women in preterm labor. One of the earliest tocolytics utilized for this purpose was ethanol infusion, although this is not generally used in current practice due to safety concerns for both the mother and her baby. OBJECTIVES To determine the efficacy of ethanol in stopping preterm labor, preventing preterm birth, and the impact of ethanol on neonatal outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA We included randomized and quasi-randomized studies. Cluster-randomized trials and cross-over design trials were not eligible for inclusion. We only included studies published in abstract form if there was enough information on methods and relevant outcomes. Trials were included if they compared ethanol infusion to stop preterm labor versus placebo/control or versus other tocolytic drugs. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed studies for inclusion and risk of bias. At least two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS Twelve trials involving 1586 women met inclusion criteria for this review. One trial did not report on the outcomes of interest in this review.Risk of bias of included studies: The included studies generally were of low quality based on inadequate reporting of methodology. Only three trials had low risk of bias for random sequence generation and one had low risk of bias for allocation concealment and participant blinding. Most studies were either high risk of bias or uncertain in these key areas. Comparison 1: Ethanol versus placebo/control (two trials, 77 women) Compared to controls receiving pain medications and dextrose solution, ethanol did not improve any of the primary outcomes: birth < 48 hours after trial entry (one trial, 35 women; risk ratio (RR) 0.93, 95% confidence interval (CI) 0.43 to 2.00), or neonatal mortality (one trial, 35 women; RR 1.06, 95% CI 0.31 to 3.58). Serious maternal adverse events and perinatal mortality were not reported by either of the two trials in this comparison. Maternal adverse events (overall) were not reported but one trial (42 women) reported that there were no maternal adverse events that required stopping or changing drug) in either group. One trial did report delay until delivery but this outcome was reported as a median with no mention of the standard deviation (median 19 days in ethanol group versus "less than 1" day in the glucose/water group). There were no differences in any secondary outcomes reported: preterm birth < 34 weeks or < 37 weeks; serious infant outcome; fetal alcohol syndrome/fetal alcohol spectrum disorder; or small-for-gestational age. Comparison 2: Ethanol versus other tocolytic (betamimetics) (nine trials, 1438 women) Compared to betamimetics (the only tocolytic used as a comparator in these studies), ethanol was associated with no clear difference in the rate of birth < 48 hours after trial entry (two trials, 130 women; average RR 1.12, 95% CI 0.53 to 2.37, Tau² = 0.19, I² = 59%), similar rates of perinatal mortality (six trials, 698 women; RR1.20, 95% CI 0.78 to 1.84), higher rates of neonatal mortality (eight trials, 1238 women; RR 1.43, 95% CI 1.02 to 2.02), higher rates of preterm birth < 34 weeks (two trials, 599 women; RR 1.56, 95% CI 1.11 to 2.19), higher rates of neonatal respiratory distress syndrome (three trials, 823 women; RR 1.76, 95% CI 1.33 to 2.33), and higher rates of low birthweight babies < 2500 g (five trials, 834 women; RR 1.30, 95% CI 1.09 to 1.54). These outcomes are likely all related to the lower incidence of preterm birth seen with other tocolytics, which for all these comparisons were betamimetics. Serious maternal adverse events were not reported in any of the nine trial reports. However, ethanol had a trend towards a lower rate of maternal adverse events requiring stopping or changing the drug (three trials, 214 women; RR 0.25, 95% CI 0.06 to 0.97). There were no differences in other secondary outcomes of preterm birth < 37 weeks, number of days delivery was delayed, or overall maternal adverse events.Planned sensitivity analysis, excluding quasi-randomized trials did not substantially change the results of the primary outcome analyses with the exception of neonatal mortality which no longer showed a clear difference between the ethanol and other tocolytic groups (3 trials, 330 women; RR 1.49, 95% CI 0.82 to 2.72). AUTHORS' CONCLUSIONS This review is based on evidence from twelve studies which were mostly low quality. There is no evidence that to suggest that ethanol is an effective tocolytic compared to placebo. There is some evidence that ethanol may be better tolerated than other tocolytics (in this case betamimetics), but this result is based on few studies and small sample size and therefore should be interpreted with caution. Ethanol appears to be inferior to betamimetics for preventing preterm birth in threatened preterm labor.Ethanol is generally no longer used in current practice due to safety concerns for the mother and her baby. There is no need for new studies to evaluate the use of ethanol for preventing preterm birth in threatened preterm labour. However, it would be useful for long-term follow-up studies on the babies born to mothers from the existing studies in order to assess the risk of long-term neurodevelopmental status.

Stillbirth is a common complication of pregnancy, affecting one in every 160 women in the United States who are pregnant. Stillbirth has a significant adverse medical and psychological impact on families. Identifying the cause of stillbirth can yield recommendations for the management of future pregnancies, provide a risk of recurrence, and give families a sense of closure. The placental examination is one component of a comprehensive stillbirth investigation. A systematic approach to the examination of the placenta is presented, along with an explanation of critical findings that have been associated with stillbirth. A checklist for placental evaluation by the provider who attends the birth is provided, along with information on stillbirth assessment programs.

Pseudomonoamniotic gestations are increasingly recognized through sonographic surveillance of monochorionic twins, though etiologic factors remain undefined. We present a case of spontaneous pseudomonoamniotic twins and propose umbilical cord insertion proximity as a sonographic marker. Systematic review of the literature was performed and additional cases with similar findings were noted. Approximately 75% of reported cases (28/37) were deemed spontaneous and several included short inter-cord distances. Shunting of blood away from the membranes in the region between the cord insertions may be responsible for membrane rupture. Further investigation is needed into short inter-cord distance as a marker for monochorionic twins at risk to become a pseudomonoamniotic gestation.

Fetal seizures are relatively rare and most often associated with anomalies or adverse neonatal outcome. We describe a patient who presented in both her G1 and G2 pregnancies with fetal seizures. The second pregnancy was a twin gestation in which only one twin was affected. The fetal seizures were noted by the patient as "extreme rhythmic movement" and were observed on ultrasound. Both neonates were diagnosed with a seizure disorder within 1 day of life. Currently, the seizures are controlled by medication; however, both children have some developmental delay. Additionally, the patient and her partner are consanguineous, suggesting a likely genetic etiology. In utero diagnosis of fetal seizures warrants a multidisciplinary approach to attempt to further define prognosis and provide appropriate treatment and counseling.