Objective The American College of Obstetricians and Gynecologists recommends speculum exams rather than digital exams for cervical evaluation in preterm prelabor rupture of membranes (PPROM). However, making management decisions based on speculum exams has challenges. This study aims to investigate OB/GYN clinicians’ self-reported adherence to and comfort with these recommendations. Methods We conducted a web-based survey distributed via email to labor and delivery clinicians at nine hospitals in 2024. The survey inquired about respondents’ management of a hypothetical patient admitted with stable PPROM who now requires cervical evaluation due to symptoms like contractions. We used descriptive statistics to compare practices across different hospital settings, provider types, and levels of training. Results Sixty respondents completed the survey. Most respondents “always” (58%) or “often” (30%) attempt speculum exam before resorting to digital exam. However, 30% of respondents reported needing to perform a digital exam after a speculum exam more than half of the time, primarily due to inability to visualize the cervix or patient instability. When asked about their confidence in decisions made post-exams, 37% of respondents expressed high confidence after speculum exams, whereas 85% reported high confidence after digital exams. Respondents reported that they believe patients experience more discomfort with speculum exams. Discussion This survey indicates that while providers attempt to follow recommendations for speculum exams in PPROM, they often find this exam type insufficient and resort to using both speculum and digital exams. Confidence in clinical decision making was cited as a significant barrier to adhering to the guidelines

BACKGROUND:Stage 1 hypertension, defined by the American Heart Association as a systolic blood pressure of 130 to 139 mm Hg and/or a diastolic blood pressure of 80 to 89 mm Hg, is associated with an increased risk of developing hypertensive disorders of pregnancy. However, the postpartum implications of this diagnosis remain unknown. OBJECTIVE:This study aimed to evaluate whether stage 1 hypertension before 20 weeks of gestation is associated with persistent antihypertensive medication use at 6 weeks after delivery. STUDY DESIGN:This was a secondary analysis of a retrospective cohort study of all patients who delivered singleton pregnancies after 20 weeks of gestation at a tertiary care center between January 1, 2014, and June 8, 2016. Patients with a diagnosis of chronic hypertension, defined as a maximum blood pressure of ≥140/90 mm Hg before 20 weeks of gestation, and those without 6-week postpartum data were excluded. The primary outcome was antihypertensive medication use at 6 weeks after delivery, which was compared between patients with stage 1 hypertension before 20 weeks of gestation and those with normal blood pressure before 20 weeks of gestation. The secondary outcomes included the development of a hypertensive disorder of pregnancy, antihypertensive medication use at delivery discharge, postpartum readmission for hypertensive disorders of pregnancy, and blood pressure values at 6 weeks after delivery. Multivariate logistic regression was used to adjust for potential cofounders. A sensitivity analysis compared the primary outcome between the groups only among those with hypertensive disorders of pregnancy. RESULTS:Of note, 465 patients (23.1%) met the criteria for stage 1 hypertension before 20 weeks of gestation. The remaining 1546 patients in the cohort were normotensive before 20 weeks of gestation, with a maximum blood pressure of <130/80 mm Hg. Compared with the group with normal blood pressure, the group with stage 1 hypertension had a higher mean age (28.2±5.7 vs 29.1±5.6 years, respectively; P=.002) and higher rates of obesity (25.0% vs 52.0%, respectively; P<.001) and pregestational diabetes mellitus (2.4% vs 5.2%, respectively; P=.002). In addition, patients with stage 1 hypertension were more likely to have a hypertensive disorder of pregnancy in the current pregnancy than those with normal blood pressure (43.0% vs 23.8%, respectively; P<.001). Patients with stage 1 hypertension were significantly more likely to require antihypertensive medication use at 6 weeks after delivery than those with normal blood pressure (8.8% vs 2.9%, respectively; aOR, 2.23 [95% CI, 1.41-3.54]), even when the analysis was restricted to those diagnosed with a hypertensive disorder of pregnancy (P=.02). In addition, patients with stage 1 hypertension were more likely to be readmitted after delivery for a hypertensive disorder of pregnancy than those with normal blood pressure (3.9% vs 1.5%; aOR, 2.11 [95% CI, 1.10-4.06]). CONCLUSION:Stage 1 hypertension before 20 weeks of gestation is a risk factor for hypertensive disorders of pregnancy, persistent antihypertensive medication use at 6 weeks after delivery, and postpartum readmission for hypertension, suggesting that close postpartum surveillance is needed in this patient population. El resumen está disponible en Español al final del artículo.

OBJECTIVE:Our objective was to determine if oxytocin discontinuation in the active phase of labor impacts the rate of cesarean delivery compared to continuation of oxytocin. DATA SOURCES:This study was a systematic review and meta-analysis of randomized controlled trials. A research librarian performed a database search using a combination of standardized terms and keywords related to oxytocin discontinuation and stages of labor from database inception until February 2024. This protocol was registered in The International Prospective Register of Systematic Reviews (PROSPERO). STUDY ELIGIBILITY CRITERIA:Randomized controlled trials of pregnant patients who received oxytocin for induction or augmentation of labor, whose outcomes compared discontinuation and continuation of oxytocin in active labor, were included. We defined "active phase of labor" as defined by each trial. Nonrandomized trials, quasi-randomized trials, and animal models were excluded. The primary outcome was the rate of cesarean delivery. Secondary maternal outcomes included postpartum hemorrhage, total blood loss, and infectious outcomes. Secondary neonatal outcomes included Apgar score at 5 minutes <7, umbilical arterial pH <7.10, neonatal therapeutic hypothermia, neonatal intensive care unit admission, neonatal resuscitation at birth, and neonatal death. STUDY APPRAISAL AND SYNTHESIS METHODS:The risk of bias in each study was assessed using the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Heterogeneity was measured using Higgins I2. Meta-analysis was performed in Review Manager 5.4.1 and StataSE 16 to determine summary treatment effects in terms of relative risk or mean difference with 95% confidence intervals. The adherence of each included trial to the trustworthiness criteria outlined by the OBGYN Editors' Integrity Group was assessed, and a leave-1-out analysis was performed to evaluate the effect of studies with concerns regarding trustworthiness. RESULTS:Fifteen randomized controlled trials, including 5734 patients, were ultimately included in the meta-analysis. The rate of cesarean delivery, reported in 13 studies, was lower with discontinuation of oxytocin in the active phase of labor (relative risk=0.80; 95% confidence interval, 0.66-0.97; 95% prediction interval, 0.38-1.22). Discontinuation of oxytocin was also associated with a lower risk of uterine tachysystole (relative risk=0.45; 95% confidence interval, 0.34-0.60; I2, 26%), and nonreassuring fetal heart rate tracing (relative risk=0.64; 95% confidence interval, 0.49-0.82; I2, 41%). Discontinuation of oxytocin increased the duration of active labor by an average of 30 minutes and second stage of labor by an average of 6 minutes. CONCLUSION:Although associated with an extension of labor by half an hour, discontinuation of oxytocin in the active phase of labor was associated with a 20% decreased risk of cesarean delivery and a lower risk of uterine tachysystole and nonreassuring fetal heart rate tracing. While the pooled analysis suggests a beneficial effect, this finding is dependent on the inclusion of studies with concerns regarding trustworthiness.

OBJECTIVE:We aimed to determine if postpartum administration of loop diuretic therapy among patients at risk of or diagnosed with a hypertensive disorder of pregnancy impacts the rate of hospital readmission compared to typical care. DATA SOURCES:This study was a systematic review and meta-analysis of randomized controlled trials (RCTs). A research librarian performed a database search using a combination of standardized terms and keywords related to postpartum hypertension and loop diuretics from database inception until February 2025. This study was registered in PROSPERO (registration number CRD42024546708). STUDY ELIGIBILITY CRITERIA:RCTs that compared outcomes between administration of loop diuretic therapy and routine care among postpartum patients at risk of or diagnosed with a hypertensive disorder of pregnancy were included. Inclusion criteria and diagnosis of hypertensive disorder of pregnancy were defined per each trial's protocol. Nonrandomized trials, quasi-randomized trials, and animal models were excluded. All titles and abstracts obtained through the search were independently assessed by two reviewers using the screening tool in Covidence, and full-text articles were reviewed. A total of 10 articles met inclusion criteria and were included in the systematic review and meta-analysis. STUDY APPRAISAL AND SYNTHESIS METHODS:Two independent investigators independently abstracted data using a standardized template created in Covidence. The primary outcome was the rate of hospital readmission. Secondary maternal outcomes included readmission for hypertension, mean postpartum blood pressure, and severe maternal morbidity. The risk of bias in each study was assessed using the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Heterogeneity was measured using Higgins I2. Meta-analysis was performed in Review Manager 5.4.1 to produce summary treatment effects in terms of relative risk (RR) or mean difference with 95% confidence intervals (CIs). RESULTS:Ten RCTs, including 1401 patients, were included in the meta-analysis. The rate of hospital readmission, reported in 3 studies, did not differ between administration of loop diuretic therapy and routine care (RR=2.00; 95% CI, 0.71-5.67). The rate of readmission for hypertension also did not differ between groups (3 studies, RR=0.69; 95% CI, 0.35-1.36). Additional antihypertensive requirements were lower in patients who received diuretics (6 studies, RR=0.47; 95% CI, 0.26-0.85). There were no differences in any other secondary maternal outcomes, including discharge on antihypertensives (8 studies, RR=1.00; 95% CI, 0.91-1.11), hospital length of stay (6 studies, mean difference=0.15; 95% CI, -0.18 to 0.48), or severe maternal morbidity. CONCLUSION:There is insufficient evidence to support routine prophylactic administration of loop diuretic therapy in the postpartum period to prevent hospital readmission associated with hypertensive disorders of pregnancy. Additional antihypertensive requirements were lower with diuretic use. Additional large trials are needed. El resumen está disponible en Español al final del artículo.

A prolonged latent phase (PLP) is associated with maternal/neonatal morbidity. Although ACOG recommends against cesarean for PLP, the rising rate of patients undergoing induction of labor (IOL) demands identification of meaningful latent phase timepoints that can guide counseling/management. We aim to define the optimal latent phase length during IOL using maternal, neonatal, and cesarean risks. This was a secondary analysis of the Consortium for Safe Labor study, a multicenter retrospective study of consecutive births at 19 hospitals from 2002-2008. We included singleton, cephalic gestations at ≥ 37 weeks who underwent IOL and completed the latent phase. Pregnancies with prior uterine incisions, major congenital anomalies, and incomplete labor curve information were excluded. Composite maternal and neonatal morbidities (see figure) and likelihood of vaginal delivery (VD) were analyzed at each four-hour interval of latent phase past 12 hours. Results were stratified by parity. Multivariable logistic regression was used to determine adjusted odds ratios for cumulative risk. 13,161 patients were included with 6128 (47%) nulliparas and 7033(53%) multiparas. The composite maternal and neonatal morbidities were seen in 13% and 8% of patients, respectively. Among nulliparas undergoing IOL, cumulative risks of maternal and neonatal morbidity consistently increased after 16 and 20 hours, respectively. Although the odds of a VD decreased consistently with each time extension past 12 hours, the absolute chance of VD remained high at 74% even at >24 hours of latent phase for nulliparas. Among multiparas undergoing IOL, the odds of neonatal morbidity increased at 12 hours but then remained stable, whereas maternal morbidity did not increase with time. The odds of VD decreased at each time point after 12 hours, but VD rates remained >78% at >24 hours for multiparas. In nulliparous patients undergoing IOL, 20 hours of latent labor is a reasonable timepoint to engage in shared decision-making about increased risks of maternal and neonatal morbidity and chances of VD.

BACKGROUND: Both short and long interpregnancy intervals are associated with adverse pregnancy outcomes; however, the impact of interpregnancy intervals on labor progression is unknown. OBJECTIVE: We examined the impact of interpregnancy intervals on the labor curve, hypothesizing that those with a longer interpregnancy intervals would have slower labor progression. STUDY DESIGN: This is a retrospective cohort study of patients with a history of one prior vaginal delivery admitted for induction of labor or spontaneous labor with a singleton gestation >= 37 weeks at an academic medical center between 2004 and 2015. Repeated measures regression was used to construct labor curves, which were compared between patients with short interpregnancy intervals, defined as <3 years since the last delivery, and long interpregnancy intervals, defined as >3 years since the last delivery. We chose this interval as it approximates the median birth interval in the United States. Interval-censored regression was used to estimate the median duration of labor after 4 centimeters of dilation, stratified by type of labor (spontaneous vs induced). Multivariate analysis was used to adjust for potential confounders. RESULTS: Of the 1331 patients who were included in the analysis, 544 (41%) had a long interpregnancy interval. Among the entire cohort, there were no significant differences in first or second-stage progression between short and long interpregnancy interval groups. In the stratified analysis, first-stage progression varied between groups on the basis of labor type: long interpregnancy interval was associated with a slower active phase among those being induced and a quicker active phase among those in spontaneous labor. The second-stage duration was similar between cohorts regardless of labor type. CONCLUSION: Multiparas with an interpregnancy interval >3 years may have a slower active phase than those with a shorter interpregnancy interval when undergoing induction of labor. Inter- pregnancy interval does not demonstrate an effect on the length of the second stage.

Venous thromboembolism (VTE), a largely preventable condition, accounts for almost 15% of maternal mortalities. The physiologic changes of pregnancy, including quantitative changes in coagulation factors and compression of vasculature by the gravid uterus, cause an increase in risk of VTE, including deep vein thromboembolism (DVT), pulmonary embolism, and stroke (CVA). Long term antepartum admission for preeclampsia, preterm prelabor rupture of membranes (PPROM) or other high-risk pregnancy needs present additional risk factors for VTE due to the patient's medical condition and their inpatient status. Given the near-universal support for anticoagulation in patients with a history of venous thromboembolism or high-risk thrombophilia, we will focus this work on patients generally considered low or moderate risk. As outpatients, we do not recommend anticoagulation for this lower risk population. However, with the increase in risk factors for VTE with prolonged admission, it is our general practice to discuss the risks, benefits, and alternatives of chemical VTE prophylaxis 72 hours after admission and recommend administration to all patients unless they have active vaginal bleeding or are at risk for imminent delivery. Here, we will argue why this strategy of universal VTE prophylaxis during antepartum admission with unfractionated heparin (UFH) or low-molecular weight heparin (LMWH) is ultimately in the best interest of patient safety.

We sought to assess the impact of a prolonged latent phase (PLP) on maternal and neonatal morbidity.This is a secondary analysis of a prospective cohort study conducted 2010 to 2015 that included all term gravidas who reached active labor (6 cm). Primary outcomes were composite maternal morbidity (maternal fever, postpartum hemorrhage, transfusion, endometritis, and severe perineal lacerations) and composite neonatal morbidity (respiratory distress syndrome, mechanical ventilation, birth injury, seizures, hypoxic ischemic encephalopathy, therapeutic hypothermia, or umbilical artery pH ≤ 7.1). Outcomes were compared between patients with and without PLP, defined as ≥90th percentile of labor duration between admission and active phase. Results were stratified by induction of labor (IOL) versus spontaneous labor. A stratified analysis was performed by mode of delivery. Multivariable logistic regression was used to adjust for confounders.In this cohort of 6,509 patients, 51% underwent IOL. A total of 650 patients had a PLP with a median length of 8.5 hours in spontaneous labor and 18.8 hours in IOL. Among patients with PLP, there was a significant increase in composite maternal morbidity with both IOL (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.01, 1.84) and spontaneous labor (aOR: 1.49, 95% CI: 1.09, 2.04) and an increase in composite neonatal morbidity with spontaneous labor only (aOR: 1.57, 95% CI: 1.01, 2.45). Cesarean delivery occurred more often in PLP group (14.0 vs. 25.1%). Among patients who underwent cesarean delivery, PLP remained associated with increased odds of maternal morbidity compared with those with normal latent phase.PLP at or above the 90th percentile in patients who reach active labor is associated with increased risk of maternal morbidity that is not mediated by cesarean delivery. PLP in spontaneous labor is associated with increased neonatal morbidity. These data suggest that further research is needed to establish latent phase cut-offs that may be incorporated into labor management guidelines. · Latent labor ≥90th percentile is associated with increased maternal morbidity in induced and spontaneous labor.. · Latent labor ≥90th percentile in spontaneous but not induced labor is associated with increased neonatal morbidity.. · Cesarean delivery alone does not explain this increased maternal morbidity..

OBJECTIVE: This study aimed to evaluate if induction of labor (IOL) is associated with an increased risk of severe perineal laceration. DATA SOURCES: A systematic search was conducted in MEDLINE, Ovid, Scopus, ClinicalTrials. gov, Cochrane Central Register of Controlled Trials, and CINHAL using a combination of keywords and text words related to "induction of labor, " "severe perineal laceration, " "third-degree laceration, " "fourth-degree laceration, " and "OASIS " from inception of each database until January 2023. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials (RCTs) comparing IOL to expectant management of a singleton, cephalic pregnancy at term gestation that reported rates of severe perineal laceration. STUDY APPRAISAL AND SYNTHESIS AND METHODS: The primary outcome of interest was severe perineal laceration, de fined as 3rd- or 4th-degree perineal lacerations. We conducted meta-analyses using the random effects model of DerSimonian and Laird to determine the relative risks (RR) or mean differences with 95% con fidence intervals (CIs). Bias was assessed using guidelines established by Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: A total of 11,187 unique records were screened and ultimately eight RCTs were included, involving 13,297 patients. There was no statistically signi ficant difference in the incidence of severe perineal lacerations between the IOL and expectant management groups (209/6655 [3.1%] vs 202/6641 [3.0%]; RR 1.03, 95% CI 0.85, 1.26). There was a statistically signi ficant decrease in the rate of cesarean birth (1090/6655 [16.4%] vs 1230/6641 [18.5%], RR 0.89, 95% CI 0.82, 0.95) and fetal macrosomia (734/2696 [27.2%] vs 964/ 2703 [35.7%]; RR 0.67: 95% CI 0.50, 0.90) in the IOL group. CONCLUSION: There is no signi ficant difference in the risk of severe perineal lacerations between IOL and expectant management in this meta-analysis of RCTs. Furthermore, there is a lower rate of cesarean births in the IOL group, indicating more successful vaginal deliveries with similar rates of severe perineal lacerations. Patients should be counseled that in addition to the known bene fits of induction, there is no increased risk of severe perineal lacerations.

The American College of Obstetricians and Gynecologists recommends speculum exams, rather than digital exams, for evaluation of the cervix after preterm prelabor rupture of membranes (PPROM). However, in clinical practice, digital exams may be necessary. We examined whether increasing numbers of digital exams were associated with adverse outcomes in PPROM.This was a single-center retrospective cohort study of patients admitted between 2019 and 2021 with PPROM at 24 to 34 weeks of gestation. The primary outcome was intra-amniotic infection and inflammation (triple I), compared between patients who had ≤1 or ≥2 digital exams during expectant management of PPROM. Secondary outcomes included latency, antepartum events, and other maternal and neonatal morbidities. Groups were compared using univariate analysis and Cox proportional hazards model to account for time between admission and delivery and potential confounders.Of 125 patients included in the analysis, 46 (36.8%) had ≤ 1 and 79 (63.2%) had ≥2 digital exams. There was no significant difference in triple I between groups (adjusted hazard ratio [aHR]: 1.03, 95% confidence interval [CI]: 0.47, 2.26). There were no significant differences in composite maternal or neonatal morbidities or latency from admission to delivery between groups (8 days [interquartile range (IQR): 3, 14] vs. 6 days [IQR: 3, 12]). There was a higher rate of spontaneous labor as the indication for delivery in the group with ≥2 exams (aHR: 2.07, 95% CI: 1.04, 4.11).In this retrospective cohort study, ≥2 digital exams during expectant management of PPROM was not associated with change in infectious morbidity or pregnancy latency. There was an increase in spontaneous labor in the group with more digital exams; this may be due to confounding by indication, as patients who are in prodromal labor are more likely to receive digital exams. These results suggest equipoise in exam type in the management of PPROM. · We compared patients with ≤1 or ≥2 digital exams during latency with PPROM.. · There was no difference in rate of triple I with increased number of digital exams.. · There was no difference in latency or other neonatal or maternal morbidities.. · There was an increase in labor as indication for delivery with more digital exams..

Both short and long interpregnancy intervals (IPI) are associated with adverse outcomes, however the impact of IPI on labor progression is unknown. We examined the impact of IPI on the labor curve, hypothesizing that those with a longer IPI would have a slower labor progression. This is a retrospective cohort study of multiparous patients with a history of one prior vaginal delivery admitted for induction of labor or spontaneous labor with a singleton gestation ≥37 weeks at a single academic medical center between 2004 and 2015. Repeated measures regression was used to construct labor curves which were compared between patients with a short IPI, defined as < 3 years since last delivery, and long IPI, defined as ≥3 years since last delivery. We chose this interval as it closely approximates the median birth interval in the USA. Interval-censored regression was used to estimate median duration of labor after 4-cm dilation stratified by type of labor (spontaneous versus induced). Multivariate analysis was used to adjust for potential confounders. Of the 1331 patients who were included in the analysis, 544 (41%) had a long IPI. Among the entire cohort, there were no significant differences in first stage progression between short and long IPI groups. The second stage was significantly shorter in patients with long IPI compared to those with short IPI (Table). In the stratified analysis, first stage progression varied between labor type. Long IPI was associated with a slower active phase among those being induced and quicker active phase among those in spontaneous labor (Figure). Second stage duration remained significantly shorter in the long IPI group regardless of labor type. The effect of IPI on first stage progression varies based on induction versus spontaneous labor. Regardless, a long IPI is consistently associated with a shorter second stage of labor, potentially secondary to improved physical fitness or muscle recovery with a longer IPI.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Purpose of ReviewThis review aims to summarize the current evidence regarding maternal oxygen supplementation for Category II fetal heart tracings (FHT) in labor. We aim to evaluate the theoretical rationale for oxygen administration, the clinical efficacy of supplemental oxygen, and the potential risks.Recent FindingsMaternal oxygen supplementation is an intrauterine resuscitation technique rooted in the theoretic rationale that hyperoxygenating the mother results in increased oxygen transfer to the fetus. However, recent data suggest otherwise. Randomized controlled trials on the efficacy of oxygen supplementation in labor suggest no improvement in umbilical cord gases or other adverse maternal and neonatal outcomes compared to room air. Two meta-analyses demonstrated that oxygen supplementation is not associated with an improvement in umbilical artery pH or reduction in cesarean delivery. Although we lack data on definitive clinical neonatal outcomes with this practice, there is some suggestion of adverse neonatal outcomes with excess in utero oxygen exposure, including lower umbilical artery pH.SummaryDespite historic data suggesting the benefit of maternal oxygen supplementation in increasing fetal oxygenation, recent randomized trials and meta-analyses have demonstrated a lack of efficacy of this practice and some suggestion of harm. This has led to conflicting national guidelines. Further research is needed on short- and long-term neonatal clinical outcomes following prolonged intrauterine oxygen exposure.

To describe outcomes of screening echocardiograms (echos) in a high-risk pregnant population. This is a retrospective cohort study of screening echos based on risk factors identified by the California Perinatal Quality Care Collaborative of all Maternal-Fetal Medicine (MFM) consultations at one tertiary care center. Echo was recommended if patients had a history of cardiac disease and no echo in the last year or ≥ four of the following risk factors: age ≥ 40, BMI > 35, substance use disorder, pregestational diabetes, chronic hypertension, or Black race. Echo results and patient outcomes were compared between history and risk-based screening using Fisher's Exact Test and Student T-test. From 1/1/2020 until 5/21/21, maternal echos were recommended in 56 of 1430 (4%) MFM consults and 82% were completed. In patients with a cardiac history, all revealed abnormalities, with 5 (19%) affecting peripartum management and 10 (37%) recommending long-term follow-up. In the risk factor group, none of the echos affected intrapartum management and 2 (11%) were recommended for long term follow-up. 27 patients had an outpatient cardiology consult. Peripartum, two patients who developed pulmonary edema and one developed supraventricular tachycardia. Two patients had a planned delivery in the cardiac ICU. There were no unplanned ICU transfers, intubations, cardiac arrests, or maternal deaths. In patients with a cardiac history, 19% of screening maternal echos provided clinical information that affected peripartum management. Risk factor-based screening did not yield clinically useful results in this small cohort study. Larger studies are needed to better assess optimal screening strategies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

(Am J Obstet Gynecol. 2021;224:510.e1–510.e12. doi: 10.1016/j.ajog.2020.11.022. Epub November 20, 2020) The global coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leads to mostly mild adverse outcomes. Due to the physiological changes during pregnancy, pregnant women are more susceptible to infection and respiratory issues. Thus, there is cause for concern that morbidity and mortality will increase for pregnant women with COVID-19 compared with nonpregnant women. This study aimed to better understand the course of COVID-19 comparing pregnant and nonpregnant women and analyzing severe and critical cases of each population.

INTRODUCTION: Adverse maternal outcomes from cardiac disease may be mitigated by pregnancy screening guidelines as proposed by the California Maternal Quality Care Collaborative. METHODS: Prior to guideline implementation (January 2020), provider discretion determined echocardiography recommendations. Post-guideline, echocardiography was recommended to pregnant women with ≥4 risk factors OR, history of cardiac disease. Risk factors included: age ≥40, BMI ≥35, Black race, chronic hypertension, prepregnancy diabetes, and substance use (opiates, cocaine, alcohol, or other substance). Underlying heart disease included history of endocarditis, congenital heart disease, cardiotoxic chemotherapy, or other cardiac disease. All outpatient maternal–fetal medicine consultations from December 2017 to August 2021 were reviewed, and patient demographics and echocardiography recommendations were recorded. RESULTS: Pre-guideline, 1,318 consultations (93 high-risk for cardiac disease) were completed. Post-guideline, 1,697 consultations (69 high-risk) were completed. Risk factors for the 162 high-risk patients included age (20.4%), race (60.5%), BMI (48.7%), diabetes (29.6%), hypertension (46.3%), opioids (5.6%), cocaine (1.2%), alcohol (1.2%), other substance use (5.6%), cardiotoxic chemotherapy (8.1%), endocarditis (3.1%), congenital heart disease (20.4%), and other cardiac disease (35.8%). Of the 162 high-risk patients, 100 (61.7%) received recommendations for echocardiography. Post-guideline, echocardiography was recommended for high-risk patients more often than pre-guideline (n=62 [89.9%] versus n=38 [40.9%], P <.001). When echocardiography was recommended, it was more likely to be completed (87.0%) than if not recommended (17.7%, P <.001). Delivery mode for 133 completed pregnancies was via cesarean delivery (51.9%), operative vaginal delivery (4.5%), and spontaneous vaginal delivery (43.6%). CONCLUSION: A standardized guideline prompted more recommendations for and subsequent completion of transthoracic echocardiography among pregnant patients at high risk for underlying cardiac disease.

To evaluate if manual rotation (MR) of occiput posterior (OP) or occiput transverse (OT) position during the second stage of labor increased the rate of spontaneous vaginal delivery (SVD). Searches of electronic databases were performed with the use of a combination of words related to "occiput posterior" and "manual rotation" from inception until July 2021. We included all randomized controlled trials evaluating MR of infants in the OP or OT position in labor. Authors of original studies were contacted for additional data. The primary outcome was the rate of SVD. Meta-analysis was performed using the random effects model of DerSimonian and Laird to produce relative risk (RR) or mean difference (MD) with 95% confidence interval (CI). A total of 643 records were screened. Six studies were included with 1,002 patients. All included studies compared rotation of OP (5 studies) or OT (2 studies) fetuses in the second stage to either no rotation or a sham rotation procedure. There was no difference in the rate of SVD with MR (RR 1.07, 95% CI 0.95, 1.20) nor in any other maternal or fetal outcomes. In a planned subgroup analysis of OP only, there was a 12.8-minute decrease in the length of the second stage in the MR group (MD -12.80, 95% CI -22.61, -2.99). There were no other significant differences in maternal or fetal outcomes in the OP subgroup and no differences in the OT subgroup. There was no difference in the rate of SVD with MR of OP or OT position in the second stage of labor compared to no MR. As there is no evidence of risk and a shorter second stage for MR performed for OP position, MR can be offered to patients in the second stage with OP position of the fetal head.