Abstract Background: During the SARS-CoV-2 pandemic, pregnancy outcomes remain in question with relationship to individuals who tested positive for COVID-19. There is a plethora of evidence that pregnant people who become infected with the SARS-CoV-2 virus may be at increased risk for perinatal loss. These losses are believed to be due to the destruction of the placenta, which then deprives the fetus of oxygen. Objective: This study aimed to compare placental findings and fetal outcomes between two 18-month periods, pre-COVID-19 and COVID-19, and to determine if there was an increase in abnormal placental findings and fetal complications during the COVID-19 period. The study hypothesized that pregnant individuals with COVID-19 positivity would have a higher risk of intrauterine fetal demise and FGR due to placental injury caused by the virus. Study Design: The placental findings and fetal outcomes of 34,102 deliveries were retrospectively compared between two equal seasonal 18-month timeframes. The COVID-19 period was April 1, 2020, to September 30, 2021. The pre-COVID-19 period was April 1, 2018, to September 30, 2019, with a wash-out period of October 1, 2019, to March 31, 2020. Chi-squared statistical tests with odds ratios and 95% confidence intervals were used to contrast three placental findings and two fetal outcomes. Results: The study found a significant increase in chorangiosis, chorioamnionitis, villitis, and FGR during the COVID-19 period compared to the pre-COVID-19 period. Additionally, there was a higher incidence of chorangiosis, chorioamnionitis, villitis, and marginally higher FGR in placentae from mothers with a history of COVID-19 infection compared to those without a positive test. There was no significant increase in intrauterine fetal demise among COVID-19-positive mothers. Conclusion: The study concludes that antenatal testing is not warranted solely for positive COVID-19 infection without other comorbidities present because there was no significant increase in intrauterine fetal demise. However, the study found a rise in FGR among pregnant individuals with a positive COVID-19 test. We agree with the Society for Maternal-Fetal Medicine's recommendations that a repeat fetal growth ultrasound should be conducted four weeks after a positive COVID-19 test. We acknowledge that chorangiosis can occur due to other maternal comorbidities. In the absence of data regarding maternal demographics, we cannot conclude whether chorangiosis occurred due to COVID-19 or other conditions.

BACKGROUND: Despite expectant management, preeclampsia remote from term usually results in preterm delivery. Antithrombin, which displays antiinflammatory and anticoagulant properties, may have a therapeutic role in treating preterm preeclampsia, a disorder characterized by endothelial dysfunction, inflammation, and activation of the coagulation system. OBJECTIVE: This randomized, placebo-controlled clinical trial aimed to evaluate whether intravenous recombinant human antithrombin could prolong gestation and therefore improve maternal and fetal outcomes. STUDY DESIGN: We performed a double-blind, placebo-controlled trial at 23 hospitals. Women were eligible if they had a singleton pregnancy, early-onset or superimposed preeclampsia at 23 0/7 to 30 0/7 weeks' gestation, and planned expectant management. In addition to standard therapy, patients were randomized to receive either recombinant human antithrombin 250 mg loading dose followed by a continuous infusion of 2000 mg per 24 hours or an identical saline infusion until delivery. The primary outcome was days gained from randomization until delivery. The secondary outcome was composite neonatal morbidity score. A total of 120 women were randomized. RESULTS: There was no difference in median gestational age at enrollment (27.3 weeks' gestation for the recombinant human antithrombin group [range, 23.1-30.0] and 27.6 weeks' gestation for the placebo group [range, 23.0-30.0]; P=.67). There were no differences in median increase in days gained (5.0 in the recombinant human antithrombin group [range, 0-75] and 6.0 for the placebo group [range, 0-85]; P=.95). There were no differences between groups in composite neonatal morbidity scores or in maternal complications. No safety issues related to recombinant human antithrombin were noted in this study, despite the achievement of supraphysiological antithrombin concentrations. CONCLUSION: The administration of recombinant human antithrombin in preterm preeclampsia neither prolonged pregnancy nor improved neonatal or maternal outcomes.

Objective This multicenter randomized controlled trial compared cervical pessary (CP) versus expectant management (EM) in women with placenta previa between 22.0 and 32.0 in prolonging gestation until ≥ 36.0 weeks' gestation. Study Design This study took place from November 2016 to June 2018. Women were randomized to receive either the Bioteque CP or EM. The pessary was removed at ≥ 36.0 weeks unless indicated. The primary outcome was gestational age (GA) at delivery, with secondary outcomes including need for transfusion, number and duration of antepartum admissions, type of delivery, and neonatal outcomes. A total of 140 patients were needed to show a 3-week prolongation of pregnancy in the pessary group; however, the trial was stopped early due to budgetary issues. Results Of the 33 eligible women, 17 were enrolled. Although not statistically significant, the mean GA at delivery in the CP group was greater than women in the EM group (36.5 ± 1.23 vs. 36.0 ± 2.0; p = 0.1673). The number and duration of antepartum admissions was greater in the EM group (2.7 ± 0.58 vs. 16.0 ± 22.76 days; p = 0.1264) as well. Conclusion Although the study was underpowered to determine the primary outcome, safety and feasibility of CP in pregnancies complicated with previa were demonstrated.

OBJECTIVE: Preterm rupture of membranes (PROM) is associated with an increased risk of preterm birth and neonatal morbidity. Prophylactic 17-hydroxyprogesterone caproate (17OHP-C) reduces the risk of preterm birth in some women who are at risk for preterm birth. We sought to test whether 17OHP-C would prolong pregnancy or improve perinatal outcome when given to mothers with preterm rupture of the membranes.STUDY DESIGN: This is a multicenter, double-blind, placebocontrolled, randomized clinical trial. The study included singleton pregnancies with gestational ages from 23(0/7) to 30(6/7) weeks at enrollment, documented PROM, and no contraindication to expectant management. Consenting women were assigned randomly to receive weekly intramuscular injections of 17OHP-C (250 mg) or placebo. The primary outcome was continuation of pregnancy until a favorable gestational age, which was defined as either 34(0/7) weeks of gestation or documentation of fetal lung maturity at 32(0/7) to 33(6/7) weeks of gestation. The 2 prespecified secondary outcomes were interval from randomization to delivery and composite adverse perinatal outcome. The planned sample size was 222 total women.RESULTS: From October 2011 to April 2014, 152 women were enrolled; 74 women were allocated randomly to 17OHP-C, and 78 were allocated randomly to placebo. The trial was stopped when results of a planned interim analysis suggested that continuation was futile. The primary outcome was achieved in 3% of the 17OHP-C group and 8% of the placebo group (P = .18). There was no significant between-group difference in the prespecified secondary outcomes, randomization-to-delivery interval (17.1 +/- 16.1 vs 17.0 +/- 15.8 days, respectively; P = .76) or composite adverse perinatal outcome (63% vs 61%, respectively; P = .93). No significant differences were found in other outcomes, which included rates of chorioamnionitis, postpartum endometritis, cesarean delivery, individual components of the composite outcome, or prolonged neonatal length of stay.CONCLUSION: Compared with placebo, weekly 17OHP-C injections did not prolong pregnancy or reduce perinatal morbidity in patients with PROM in this trial.

OBJECTIVE: The decision of whether to retain or remove a previously placed cervical cerclage in women who subsequently rupture fetal membranes in a premature gestation is controversial and all studies to date are retrospective. We performed a multicenter randomized controlled trial of removal vs retention of cerclage in these patients to determine whether leaving the cerclage in place prolonged gestation and/or increased the risk of maternal or fetal infection.STUDY DESIGN: A prospective randomized multicenter trial of 27 hospitals was performed. Patients included were those with cerclage placement at <= 23 weeks 6 days in singleton or twin pregnancies, with subsequent spontaneous rupture of membranes between 22 weeks 0 days and 32 weeks 6 days. Patientswere randomized to retention or removal of cerclage. Patients were then expectantly managed and delivered only for evidence of labor, chorioamnionitis, fetal distress, or other medical or obstetrical indications. Management after 34 weeks was at the clinician's discretion.RESULTS: The initial sample size calculation determined that a total of 142 patients should be included but after a second interim analysis, futility calculations determined that the conditional power for showing statistical significance after randomizing 142 patients for the primary outcome of prolonging pregnancy was 22.8%. Thus the study was terminated after a total of 56 subjects were randomized with complete data available for analysis, 32 to removal and 24 to retention of cerclage. There was no statistical significance in primary outcome of prolonging pregnancy by 1 week comparing the 2 groups (removal 18/32, 56.3%; retention 11/24, 45.8%) P = .59; or chorioamnionitis (removal 8/32, 25.0%; retention 10/24, 41.7%) P = .25, respectively. There was no statistical difference in composite neonatal outcomes (removal 16/33, 50%; retention 17/30, 56%), fetal/neonatal death (removal 4/33, 12%; retention 5/30, 16%); or gestational age at delivery (removal mean 200 days; retention mean 198 days).CONCLUSION: Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage. These findings may not have met statistical significance if the original sample size of 142 was obtained, however they provide valuable data suggesting that there may be no advantage to retaining a cerclage after preterm premature rupture of membranes and a possibility of increased infection with cerclage retention.

17-hydroxyprogesterone caproate (17OHPC) reduces the risk of recurrent preterm birth in women with prior preterm birth. We sought to test whether 17OHPC treatment prolongs pregnancy or reduces perinatal morbidity in women with preterm rupture of membranes (PROM). Previous studies of 17OHPC after PROM were small and had limited statistical power. We conducted a double-blind, placebo-controlled, multicenter randomized trial. Inclusion criteria were: maternal age ≥ 18 years, singleton pregnancy, gestational age 230/7-306/7 weeks, confirmed PROM, and no contraindications to expectant management. Consenting women were randomized to receive weekly intramuscular injections of either 17OHPC (Makena, 250 mg) or placebo. Prophylactic antibiotics and antenatal corticosteroids were used. The primary outcome was defined as: successful prolongation of pregnancy until 34 weeks, or until 32 weeks with documented fetal lung maturity. A total sample size of 222 was planned, but the trial was stopped when a planned interim analysis determined that continuation was futile. From October, 2012 through May, 2014, 152 women were enrolled at mean gestational age 27±2.4 wks, 74 randomized to 17OHPC and 78 to placebo. One subject from each group was lost-to-follow-up. As shown in the Table, there was no significant difference between the two groups for the primary outcome and no significant differences in gestational age at delivery, latency to delivery, or perinatal morbidity and mortality. Weekly 17OHPC (250 mg/week) given to women with PROM did not prolong pregnancy or improve perinatal outcome.

To evaluate the effectiveness and barriers for the use of 17-P for prevention of recurrent PTB in the context of routine care in a large urban medical center. In this observational cohort study, 224 women with prior SPTB who were enrolled prospectively in an urban high-risk clinic: 122 (54%) were offered and accepted 17-P, and 102 (46%) did not receive 17-P, (36 refused 17-P, and 66 were not eligible because they presented at > 26 weeks to our clinic). Maternal demographics, risk factors for SPTD, and effects of 17-P prophylaxis on birth outcomes were evaluated. Logistic regression was used to evaluate the benefits of 17-P after adjusting for the effects for maternal demographics and risk factors for SPTB. Maternal socio-demographics and clinical characteristics of study patients, and delivery outcomes are shown in the Table. Among women who received 17-P, mean initiation of therapy was 20.4 3.4 wks and mean number of injections was 12.1 6.3. Those who received 17-P were more likely to have a prior SPTB 26 wk factors for not receiving medications included not being offered by medical providers, no to minimal complications with previous PTD, and financial reasons. Rates of total PTB and SPTB were similar among those who received and did not receive 17-P (Table).Tabled 1 In this high-risk urban clinic population, there was a high percentage of STPB among those who received 17-P in the routine obstetric setting, and among those who did not receive it. In addition, 46% of eligible patients were not offered or did not receive 17-P. Finally, these date are important in calculations of cost benefit analysis for using progesterone to prevent preterm birth.

We compared the rates of abnormal 1-hour glucose challenge tests (GCT) and gestational diabetes (GDM) between women receiving 17 alpha-hydroxyprogesterone caproate (17-P) and women who did not receive 17-P to determine if the effect varies based on the number of doses received or in a group of high-risk obese women. We performed a secondary analysis of a prospective cohort study where women with a history of a previous preterm delivery in the antecedent pregnancy followed at a high-risk clinic were offered 17-P. GCT was performed after the initiation of 17-P, and doses given prior to testing were recorded. Rates of abnormal GCT and GDM were compared between those receiving 17-P (n = 67) and controls (n = 140). Mean glucose values (112.4 versus 111.3, p = 0.8), rate of abnormal GCT (23.9% versus 20%, adjusted odds ratio 1.45, 95% confidence interval 0.7 to 3.0), and rate of GDM (6% versus 8.6%, adjusted odds ratio 1.21, 95% confidence interval 0.3 to 4.5) were similar between groups. In this prospective study, 17-P administration to women at risk of recurrent preterm delivery did not significantly affect glucose tolerance.

Premature delivery (PTD), defined as birth prior to 37 weeks’ gestation, remains one of the major problems that lead to perinatal morbidity and mortality in the developed countries (Goldenberg et al., 2008). It affects approximately 12.7% of all deliveries in the United States and 4.4 – 8.2% in many other developed countries such as Australia, New Zealand, Sweden, Canada and Japan (Hamilton et al., 2006; Jenkins et al., 2006; Morken et al., 2005; Health Canada 2003). One third of these occur before 34 weeks’ gestation (Amon, 1999; Behrman & Butler et al., 2007). In the United States, the preterm birth (PTB) rate has increased more than 30% since 1984 and equates to nearly 500,000 PTBs each year (March of Dimes, 2007). This prematurity rate has been increasing probably as a result of delayed child bearing, increased frequency of multifetal pregnancies from assisted reproductive technology (Tough et al., 2002; Reynolds et al.,2003), general non-interventional approach at or beyond 34 weeks’ gestation and the increase in labor inductions and cesarean deliveries including those medically indicated (Damus et al., 2008). Prematurity causes an estimated 60-80% of all neonatal deaths of non-anomalous infants in developed countries (Guyer et al., 1997). Neonatal mortality is directly correlated with gestational age (GA) at delivery. For example, the mortality rate for infants born at less than 32 weeks’ gestation is almost 70 times the rate of a term infant, and for infants born less than 37 weeks’ gestation it is 15 times the term infant rate (2.6/1000 live births)(March of Dimes Birth Defects Foundation, 2005). Reported neonatal morbidity is also a major concern, especially for infants born at less than 32 weeks’ gestation. Neonatal complications include intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), jaundice and anemia (Behrman and Butler et al., 2007). Economically, care for these infants is responsible for an estimated $51,600 investment per child in neonatal care, contributing more than $26 billion to annual healthcare costs in the US (Behrman and Butler et al., 2007). Among the infants who survive, 10% -15% are burdened with significant handicaps, such as cerebral palsy, mental retardation, retinopathy, or hearing impairment (Gluckman & Hanson, 2004). More importantly, low birth weight (LBW) infants who are spared significant neonatal morbidity are at higher risk for cardiovascular disease (myocardial infarction, stroke, and hypertension) and diabetes as adults (Gluckman & Hanson, 2004). Therefore, greater attention should be focused on very PTBs < 32 weeks’ gestation, because, although this group represents only 1-2% of all deliveries, it accounts for about 60% of perinatal mortality

To evaluate the association between single nucleotide polymorphisms (SNPs) in the progesterone receptor gene (PGR, 11q22-23) and responsiveness to 17-P treatment for the prevention of recurrent preterm birth among women with prior spontaneous pre-term birth (SPTB). 213 women (110 African American and 103 Caucasian) with prior SPTB were geneotyped and prospectively categorized into 2 groups; 17-P treatment (n=114), and no treatment (n=99). Tagging SNPs (tagSNPs) spanning the PGR gene (MAF ≥ 0.05, pairwise LD r2 ≥ 0.8) were selected using the Caucasian and Yoruban HapMapII database. Forty-one tagSNPs, from the union of Caucasian and Yoruban, were genotyped using the SNPlex platform. Four additional SNPs (rs471767, rs1893505, rs1942836, rs1042839 on PGR were selected from literature and genotyped using the TaqMan assays. Allelic associations were tested in those with PTB vs others and total PTB vs others, for all 213 women and for those receiving 17-P only (n = 114). Analysis was performed using the Gen ABEL package in R. Analysis was performed separately for Caucasians and African Americans. For all women (n=113), of 90 association tests (45 SNPs x 2 groups), 3 associations (rs618972 in STPB versus others, rs555653 and rs 11224592 om TPB versus full-term) were nominally significant (p < 0.05) in Caucasians compared to none in Africal Americans. In the 17-P treated group (n=114), significant SNPs associations with SPTB are listed in the Table. However, the associations became non-significant after multiple test corrections.Tabled 1 Common tagSNPs on PGR were marginally associated with pre-term delivery in women that received 17-P treatment. Although the associations did not hold after multiple test corrections, the trend was stronger in African American compared to Caucasians.

OBJECTIVE: The objective of the study was to assess cerclage to prevent recurrent preterm birth in women with short cervix.STUDY DESIGN: Women with prior spontaneous preterm birth less than 34 weeks were screened for short cervix and randomly assigned to cerclage if cervical length was less than 25 mm.RESULTS: Of 1014 women screened, 302 were randomized; 42% of women not assigned and 32% of those assigned to cerclage delivered less than 35 weeks (P = .09). In planned analyses, birth less than 24 weeks (P = .03) and perinatal mortality (P = .046) were less frequent in the cerclage group. There was a significant interaction between cervical length and cerclage. Birth less than 35 weeks (P = .006) was reduced in the less than 15 mm stratum with a null effect in the 15-24 mm stratum.CONCLUSION: In women with a prior spontaneous preterm birth less than 34 weeks and cervical length less than 25 mm, cerclage reduced previable birth and perinatal mortality but did not prevent birth less than 35 weeks, unless cervical length was less than 15 mm.

We sought to determine the risk of preterm (< 32 weeks) delivery as it relates to cervical dilatation at presentation of an initial preterm labor admission episode. We retrospectively reviewed the records of all patients presenting with preterm contractions at 22 to 32 weeks' gestation. Multiple regression was used to analyze the relationship between the interval from initial preterm labor admission episode to delivery and cervical dilatation at presentation. Logistic regression analysis was used to identify variables associated with preterm birth. Mean gestational age on admission for preterm labor episode was 28.1 +/- 2.9 weeks. With a cervical dilatation of 0 to 1 cm, 6% of the women delivered within 48 hours, 20% delivered at < 32 weeks, and 38% delivered at < 35 weeks. With cervical dilatation of 6 to 10 cm, 89% delivered in < 24 hours, 11% between 24 and 48 hours, 94% delivered at < 32 weeks, and 100% delivered at < 35 weeks. Time from admission for initial preterm labor episode to delivery was inversely associated with cervical dilatation. Variables associated with preterm birth at < 32 weeks' gestation were cervical dilatation ( P < 0.0001), gestational age ( P < 0.0001), and effacement ( P < 0.0001) at presentation. In women who experience preterm contractions, cervical dilatation on admission is inversely related to interval to delivery. However, women with cervical dilatation of 0 to 1 cm are still at significant risk for preterm delivery: 19/94 (20%) at < 32 weeks' gestation and 40/104 (38%) at < 35 weeks' gestation.

OBJECTIVE: The objective of the study was to evaluate the indications for late preterm birth and compare outcomes by gestational age among late preterm (34-36 weeks) and term (>= 37 weeks) neonates at our institution.STUDY DESIGN: This was a retrospective analysis of delivery indications and short-term neonatal outcomes in women who delivered at the University Hospital between January 1, 2005 and Dec. 31, 2006. Data were analyzed using chi(2), Student's t-test, analysis of variance, and post hoc Tukey tests.RESULTS: One hundred forty-nine late preterm (n = 49 for 34, n = 50 for 35, n = 50 for 36 weeks) and 150 term infants (n = 50 for 37, n = 50 for 38, n = 50 for 39 weeks or longer) were evaluated. Differences among groups (ie, 34 vs 35 vs 36 vs 37, etc) as well as combinations of differences between 2 groups (ie, 34-36 weeks vs >= 37 or >= 38 weeks) were analyzed. Spontaneous labor and/or rupture of membranes were the most common indications for late preterm delivery (92%). Compared with term, late preterm infants had longer hospital stays (5 days vs 2.4 days; P < .001) and higher rates of neonatal intensive care unit (NICU) admissions (56% vs 4%; P < .001), feeding problems (36% vs 5%; P < .001), hyperbilirubinemia (25% vs 3%; P < .001), and respiratory complications (20% vs 5%; P < .001). Neonatal complications were minimal at 38 weeks or longer.CONCLUSION: Rates of neonatal intensive care unit admission, length of stay, and neonatal morbidities are significantly higher in late preterm as compared with term births.

Objectives To determine whether progesterone supplementation alters cervical shortening in women at increased risk for preterm birth.Methods We performed a planned secondary analysis from a large, multinational preterm birth prevention trial of daily intravaginal progesterone gel, 90 mg, compared with placebo in women with a history of spontaneous preterm birth or premature cervical shortening. Transvaginal cervical length measurements were obtained in all randomized patients at baseline (18 + 0 to 22 + 6 weeks' gestation) and at 28 weeks' gestation. For this secondary analysis, the difference in cervical length between these time points was compared for the study population with a history of spontaneous preterm birth and for a population with premature cervical shortening (<= 30 mm) at randomization. Differences between groups in cervical length for the 28-week examination were analyzed using ANCOVA, including adjustment for relevant clinical parameters and maternal characteristics.Results Data were analyzed from 547 randomized patients with a history of preterm birth. The progesterone-treated patients had significantly less cervical shortening than the placebo group (difference 1.6 (95% CI, 0.3-3.0) mm; P = 0.02, ANCOVA). In the population of 104 subjects with premature cervical shortening at randomization, the cervical length also differed significantly on multivariable analysis, with the treatment group preserving more cervical length than the placebo group (difference 3.3 (95% CI, 0.3-6.2) mm; P = 0.03, ANCOVA), with adjustment for differences in cervical length at screening. A significant difference was also observed between groups for categorical outcomes including the frequency of cervical length progression to <= 25 mm and a >= 50%, reduction in cervical length from baseline in this subpopulation.Conclusions Intravaginal progesterone enhances preservation of cervical length in women at high risk for preterm birth. Copyright (C) 2009 ISUOG. Published by John Wiley & Sons, Ltd.

OBJECTIVE:The aim of this study was to identify changes in protein expression in normal pregnancy compared with preterm labor by using 3 proteomic methods.STUDY DESIGN:Serum was collected from 25 nonpregnant (n = 5) and pregnant women at 24-40 weeks' gestation (n = 20) who had preterm labor resulting in preterm delivery (n = 5), preterm labor with term delivery (n = 5), term labor resulting in delivery (n = 5), or at term with contractions (n = 5). Undepleted serum was used for surface-enhanced laser desorption ionization and immune-depleted serum for matrix-assisted laser desorption ionization and 2-dimensional electrophoresis.RESULTS:Surface-enhanced laser desorption ionization identified significantly different peaks between preterm labor resulting in preterm delivery vs term labor resulting in delivery and preterm labor resulting in preterm delivery vs preterm labor with term delivery using 4 surfaces. In preterm labor resulting in preterm delivery vs preterm labor with term delivery, a peak of 7783.2 m/z was significantly up-regulated and at 3164 m/z down-regulated on 3 surfaces. By using 2-dimensional electrophoresis, protein 5364 was significantly different between preterm labor resulting in preterm delivery and term labor resulting in delivery. In preterm labor resulting in preterm delivery, 6 proteins showed decreasing trend and 1 showed increasing trend vs preterm labor with term delivery. Matrix-assisted laser desorption ionization showed a striking difference at 55,000 m/z between preterm labor resulting in preterm delivery and term labor resulting in delivery.CONCLUSION:Surface-enhanced laser desorption ionization identified 2 proteins fulfilling the criteria of putative biomarkers. Biomarker identification may aid in identifying women with preterm labor who will deliver preterm.

OBJECTIVE: To evaluate subsequent pregnancy outcome and impact of gestational age at onset of HELLP on long-term prognosis after HELLP over an average follow-up of 5 yearsSTUDY DESIGN: One hundred twenty-eight patients with a history of HELLP filled out questionnaires and sent their medical records. Hemolysis, elevated liver enzymes, and low platelets data were stratified according to gestational age at onset of HELLP <= 28 weeks and >28 weeks.RESULTS: Fifty-three patients had subsequent pregnancies with 24% complicated by HELLP and 28% by preeclampsia. During follow-up, 33% of the patients had new onset hypertension develop, 32% had depression develop, 26% had anxiety develop, and 2.4% required dialysis. There was no significant difference in long-term outcome between comparison groups.CONCLUSION: Patients with a history of HELLP are at increased risk for preeclampsia and HELLP as well as long-term morbidities as depression and chronic hypertension. Gestational age at the onset of HELLP could be a predictor for long-term outcome.

OBJECTIVE:We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis.STUDY DESIGN:Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment.RESULTS:There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each.CONCLUSION:TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Two previous retrospective studies reported an increased rate of gestational diabetes (GDM) in patients receiving IM 17-hydroxyprogesterone caproate (17P) for prevention of recurrent preterm delivery (PTD). Our objective is to determine whether the rates of abnormal glucose challenge test (GCT 135mg/dL) and GDM are increased in women receiving 17P early in pregnancy for prevention of PTD. A prospective cohort study of patients with a history of previous PTD in the antecedent pregnancy followed in a high-risk pregnancy clinic were offered IM 17P weekly until 36 completed weeks. Patients had routine GCT as per protocol; those with a value 135mg/dL received OGTT. GDM was defined according to Carpenter/Coustan criteria. Results of GCT and rate of GDM were compared between those receiving 17P and those not receiving therapy. Sixty-five women received 17P and 85 did not (Table). Maternal age in years (26.7, 26.9), age >30 (31%, 23.6%), BMI (26.9, 29.0), history of gestational diabetes (12.7%, 11.6%), parity (4.5, 4.0) and maternal race (45% and 64% African American) were similar between 17P and no 17P groups. The 17P group received an average of 6.9 doses prior to GCT. The odds ratios were calculated using a multiple logistic regression analysis. Mean glucose values, rate of abnormal GCT and rate of GDM were similar between groups (Table).Tabled 117P N=65No 17P N=85OR (95%CI)Mean Plasma GCT (mg/dL)106.9 ± 35.7* not significant110.3± 32.0 * not significantGCT ≥135 mg/dL12 (18.5%)15 (17.6%)1.1 (0.5-2.4)GDM2 (3.1%)7 (8.2%)0.4 (0.07-1.8) Open table in a new tab Contrary to previous reports, we found in this prospective study that 17P administration to patients at risk of recurrent preterm delivery did not affect glucose tolerance.

Preterm birth is the leading cause of neonatal mortality and morbidity and long-term disability of non-anomalous infants. Previous studies have identified a prior early spontaneous preterm birth as the risk factor with the highest predictive value for recurrence. Two recent double blind randomized placebo controlled trials reported lower preterm birth rate with the use of either intramuscular 17 alpha-hydroxyprogesterone caproate (IM 17OHP-C) or intravaginal micronized progesterone suppositories in women at risk for preterm delivery. However, it is still unclear which high-risk women would truly benefit from this treatment in a general clinical setting and whether socio-cultural, racial and genetic differences play a role in patient’s response to supplemental progesterone. In addition the patient’s acceptance of such recommendation is also in question. More research is still required on identification of at risk group, the optimal gestational age at initiation, mode of administration, dose of progesterone and long-term safety.