Objective This study evaluates penicillin allergy during pregnancy to estimate the proportion that could benefit from penicillin allergy testing. Study Design Retrospective cohort study of women with penicillin allergy that delivered from January 1, 2018 to December 31, 2018. Results Among 6,321 deliveries, 446 (7%) were identified with penicillin allergy. Nine percent (41/446) had no documentation of allergy severity. Allergies associated with intolerance, low, moderate, or high risk of anaphylaxis were reported in 6% (25/446), 40% (177/446), 32% (142/446), and 14% (61/446), respectively. Nearly 74% (330/446) received an antibiotic either antepartum, at delivery, or within 6 weeks of postpartum. The majority of women, 81% (360/446) (i.e., undocumented reactions, low, or moderate risk of anaphylaxis) would have been eligible for penicillin allergy testing. Greater appropriate utilization of antibiotics occurred in women with a high 80% (39/49) or moderate risk of anaphylaxis 70% (79/112) versus low risk of anaphylaxis 55% (64/117), history of intolerance 40% (8/20), or undocumented reaction 19% (6/32), p ≤ 0.01. Conclusion Most women who report a penicillin allergy during pregnancy would be candidates for penicillin allergy testing. With the high rate of antibiotic interventions in pregnant women who report a penicillin allergy, consideration should be given for penicillin allergy assessment.

IMPORTANCE:The management of lymphoma diagnosed during pregnancy is controversial and has been guided largely by findings from case reports and small series.OBJECTIVE:To determine maternal and fetal outcomes of women diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) during pregnancy.DESIGN, SETTING, AND PARTICIPANTS:This retrospective analysis studied a cohort of 39 pregnant women diagnosed with HL and NHL (31 HL and 8 NHL) at a single specialized cancer institution between January 1991 and December 2014.MAIN OUTCOMES AND MEASURES:We examined data on disease and treatment characteristics, as well as maternal and fetal complications and outcomes. The Kaplan-Meier method was used to compare progression free survival (PFS) and overall survival (OS) according to receipt of antenatal therapy and other clinical factors. Univariate and multivariate analyses were performed by using Cox proportional hazard regression models to identify potential associations between clinical and treatment factors and survival.RESULTS:The median (range) age of the 39 women in the patient cohort was 28 (19-38) years; 32 women (82%) had stage I or II disease at diagnosis, and 13 had bulky disease. Three women electively terminated the pregnancy to allow immediate systemic therapy; of the remaining 36 women, 24 received antenatal therapy (doxorubicin based combination chemotherapy in 20 of 24 patients), and 12 deferred therapy until after delivery. Four women experienced miscarriage, all of whom had received antenatal systemic therapy and 2 during the first trimester. Delivery occurred at a median (range) of 37 (32-42) weeks and was no different based on receipt of antenatal (median [range], 37 [33-42] weeks) vs postnatal (median [range], 37 [32-42] weeks) therapy (P = .21). No gross fetal malformations or anomalies were detected. At a median (range) follow-up time of 67.9 (8.8-277.5) months since the diagnosis of lymphoma, 5-year rates of PFS and OS were 74.7% and 82.4%, respectively; these rates did not differ according to timing of therapy. On univariate analysis, bulky disease (>10 cm), extranodal nonbone marrow involvement, and poor performance status (Eastern Cooperative Oncology Group score, ≥2) predicted increased risk of disease progression. On multivariate analysis, extranodal nonbone marrow disease and performance status remained significant for both PFS and OS.CONCLUSIONS AND RELEVANCE:Systemic therapy given for lymphoma after the first trimester of pregnancy is likely safe and results in acceptable maternal and fetal outcomes.

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.

OBJECTIVE:Cesarean is the single most common operation in United States and has reached epidemic proportions in recent decades. Our objective was to study the effect of nonclinical parameters on primary cesarean rates in a large contemporary population.STUDY DESIGN:We designed a retrospective multicenter study using data obtained from electronic medical records from 19 U.S. hospitals between 2005 and 2007 (Consortium on Safe Labor Database), which included 145,764 term, singleton, nonanomalous, vertex, live births that included labor. The impact of nonclinical parameters (patient and provider characteristics, time of delivery, institutional policies, and insurance type) was investigated using modified Poisson regression methodology and classification and regression tree analysis.RESULTS:There were 125,517 vaginal and 20,247 cesarean deliveries. Using the multivariable model, the nonclinical parameters with statistical significance for primary cesarean were delivery during evening hours, a male provider, public insurance, and nonwhite race (p < 0.001).CONCLUSIONS:Cesarean rates are associated with several nonclinical factors. Further investigation into these factors might help to develop strategies to reduce their influence and hence the rates of cesarean.

1099 Background: Increasing data are available regarding treating women diagnosed with breast cancer during pregnancy with chemotherapy in the second and third trimesters. Previous studies have demonstrated similar outcomes for pregnant and non-pregnant patients who receive standard therapies. However, there are limited data regarding potential health concerns for the children exposed to chemotherapy in utero. METHODS Between 1989-2010, 81 pts were treated with FAC during pregnancy in a prospective registry trial at our institution using a standardized chemotherapy regimen of 5-fluorouracil, doxorubin and cyclophosphamide (FAC) given during the second and third trimesters. Other standard systemic therapies were given after delivery. Outcomes of the women have been previously reported. Delivery records were obtained and IRB-approved health surveys sent to the parents or guardians of the children. Questions encompassed delivery, puberty and all health concerns. RESULTS Thus far, 41 of the surveys have been returned (51%). Median age of the children is 4 years (range <1-21 years). Mean weight at delivery was 3.09 kg (range 2.27 - 3.7 kg). Sixteen (39%) were delivered by c-section. During the delivery hospitalization 7 children (17%) required extra oxygen, 2 (4.8%) had hypoglycemia, and 2 (4.8%) had jaundice. Of the entire cohort (n=81) 1 child was born with Down's syndrome, 1 with clubfoot and 1 with ureteral reflux (hydronephrosis). Three parents described some childhood language delay. There have been no reported significant delay in puberty and no children have had children of their own to date. Other reported health problems include 15 (36.6%) children with reports of allergies and/or eczema, 2 with asthma, 1 with arthritis-like symptoms, 1 with migraine headaches and 1 with a history of absence seizures. Survey data for the entire cohort will be updated at the time of presentation. CONCLUSIONS Children exposed to chemotherapy in utero, overall appear to be doing well with no significant trend in increased medical problems, with the biggest long term health concern being allergies/eczema. Continued long-term follow-up of this and other cohorts is needed to provide more information to parents and pediatricians.

OBJECTIVE:To determine the validity of a novel Group B Streptococcus (GBS) diagnostic assay for the detection of GBS in antepartum patients.STUDY DESIGN:Women were screened for GBS colonization at 35 to 37 weeks of gestation. Three vaginal-rectal swabs were collected per patient; two were processed by traditional culture (commercial laboratory versus in-house culture), and the third was processed by an immunoblot-based test, in which a sample is placed over an antibody-coated nitrocellulose membrane, and after a six-hour culture, bound GBS is detected with a secondary antibody.RESULTS:356 patients were evaluated. Commercial processing revealed a GBS prevalence rate of 85/356 (23.6%). In-house culture provided a prevalence rate of 105/356 (29.5%). When the accelerated GBS test result was compared to the in-house GBS culture, it demonstrated a sensitivity of 97.1% and a specificity of 88.4%. Interobserver reliability for the novel GBS test was 88.2%.CONCLUSIONS:The accelerated GBS test provides a high level of validity for the detection of GBS colonization in antepartum patients within 6.5 hours and demonstrates a substantial agreement between observers.

To determine the validity of a novel Group B streptococcus (GBS) diagnostic assay for the detection of GBS in antepartum patients. Women were screened for GBS colonization at 35 to 37 weeks gestation. Three vaginal-rectal swabs were collected per patient; two were processed by traditional culture (commercial laboratory versus in-house culture), the third was processed by a novel diagnostic assay. 356 patients were evaluated. Commercial processing revealed a GBS prevalence rate of 85/356 (23.6%). In-house culture provided a prevalence rate of 105/356 (29.5%). When the rapid GBS result was compared to the in-house GBS culture, it demonstrated a sensitivity of 97.1% and a specificity of 88.4%. Inter-observer reliability for the novel GBS test was 88.2%. The rapid GBS test provides a high level of validity for the detection of GBS colonization in antepartum patients within 6.5 hours, and demonstrates substantial agreement between observers.

We determined if a new method of rapidly growing GBS in 6 hours could also determine antibiotic sensitivities in a shorter period compared to standard cultures. Women were screened between 35 to 37 weeks gestation. Vaginal-rectal swabs were collected in Stuarts transport medium. Swabs were then inoculated on a nitrocellulose membrane (NCM) that had been coated previously with polyclonal rabbit antibody against GBS in the presence or absence of clindamycin. At six hours, the NCM was removed from the sheep blood agar medium, and horseradish-peroxidase conjugate polyclonal antibody against GBS was added. An additional swab from each patient was cultured by traditional methods for 48-72 hours and those positive for GBS were then tested for resistance/sensitivity to clindamycin. A final control consisted of sending a separate swab from each patient to a commercial lab. 124 patient samples were screened, of which 33 were positive for GBS by the rapid test (97.0% concordance with traditional culture). Of these 33 positive samples, 10 were resistant to clindamycin, which agreed 100% with traditional culture. Results of the both the rapid and traditional culture showed 100% concordance with sensitivity or resistance to clindamycin when compared with commercial lab results. This new NCM assay offers a rapid and unique method for both detection and determination of antibiotic sensitivities for GBS; thus improving the targeting of antibiotic prophylaxis for GBS colonization.

Abstract 3670 Background: Diagnosis of cancer during pregnancy is emotionally stressful for the patient and her family and presents challenges for the medical team including how to best minimize risk of adverse fetal events while still ensuring the best disease outcome for the woman. Cancer is diagnosed during 0.1% of pregnancies with lymphoma being the 4th most common cancer effecting 1 in 6000 pregnancies (Brenner, B et al, The Lancet, 2012 & Pereg, D et al, Haematologica, 2007). This prevalence is anticipated to grow given the shift towards increasing average age at time of pregnancy. The overall rarity of this presentation and the variance of the histological diagnoses have prevented the conduction of large prospective clinical trials, and thus no stringent management algorithms exist. Methods: From 2005 women with a diagnosis of lymphoma during pregnancy were consented and enrolled into this IRB-approved prospective database trial. Patients received multidisciplinary care including counseling and co-management with our maternal-fetal medicine and reproductive medicine collaborators. Results: A total of 19 patients (pts) were consented with full treatment (tx) and fetal outcome data available for 16. The median age of the women was 30 (20–38) years with a slightly lower median age for the classical Hodgkin lymphoma (HL) pts of 28.5 (20–35) years. Ten pts had HL (6 early stage [ES], 2 advanced stage [AS], 2 relapsed), while the remaining 9 had NHL (3 [2 ES, 1 AS] diffuse large B-cell lymphoma [DLBCL], 1 ES anaplastic lymphoma kinase [ALK]-positive LBCL, 1 primary CNS DLBCL, 1 AS follicular lymphoma [FL] with transformation to DLBCL, 1 ES FL, 1 AS MALT, and 1 ALK+ anaplastic LCL). Fifteen pts had diagnoses made of initial or relapsed disease during pregnancy at a median of 18 (3–34) weeks (wks) gestation with 33% during 1st trimester, 54% during 2nd trimester, and 13% during 3rd trimester. Four pts with chronic oligomenorrhea with baseline negative serum pregnancy tests became pregnant while on tx (ABVD, rituximab plus gemcitabine, R-CHOP, and maintenance rituximab) with fetal loss in all 4 with spontaneous abortions from wk 8 to 26 and an elective abortion at wk 6. Four pts of the 15 pts deferred start of tx until after delivery (ES HL and ES primary mediastinal DLBCL pts, a relapsed HL pt, and a ES FL grade 3B pt diagnosed respectively at wks gestation of 31, 34, 14, and 27) and the 3 pts for whom outcome data is available have durable complete remissions (CRs) at a median of 25 (5–52) months (mos) of follow-up with babies born at a median of 35 (31–37) wks at a median birth weight of 2381 (1814–3004) grams with 75% being above the 50% weight percentile. Ten pts started tx while pregnant (80% during 2nd/3rd trimester) at a median of 18 (11–29) wks (ABVD/AVD in 5, R-CHOP/AVD in 1, R-CHOP in 2, HCVAD in 1, and DeAngelis regimen in 1) with all but 1 pt having MRIs and ultrasounds for staging. Seven of these pts delivered babies at a median of 37 (33–39) weeks with 57% delivered at term, a median birth weight of 2948 (2494–3061) grams with 50% being above the 50% weight percentile, and no fetal malformations. At a median of 20.5 (8–53) mos of follow-up 60% of the pts who received tx while pregnant are free of progression while 2 HL pts (1 ES HL pt 22 months after delivery) died from disease progression and 2 pts are on active treatment for relapsed disease (HL and ALK+ LBCL). Three pts experienced fetal loss including a AS HL pt with SVC syndrome necessitating intubation with prolonged ICU care (spontaneous abortion at 23 wks), a AS HL pt who started ABVD at 14 wks of gestation (stillbirth of twins at 26 wks), and the pt with CNS DLBCL who initiated the DeAngelis regimen with high dose methotrexate at 13 wks (elective abortion at 19 wks). Conclusions: Given the rarity of the diagnosis of lymphoma during pregnancy our series to our knowledge represents one of the largest single center prospective clinical studies. Our data highlight that ABVD, R-CHOP, and HCVAD can be given with excellent outcomes for pt and fetus at a preferred start of 2nd trimester or later, although 1 pt with symptomatic HL did start ABVD early at 11 wks of gestation with preservation of positive outcomes. These findings also emphasize the importance of co-management through all the steps of treatment with a maternal-fetal medicine colleague. Furthermore, we show the need to counsel oligomenorrheic pts on the risk of still becoming pregnant and perform assessments to rule-out pregnancy beyond the baseline pre-tx visit. Disclosures: Fanale:Millennium: Research Funding; MedImmune: Research Funding; Novartis: Honoraria, Research Funding, Travel Expenses, Travel Expenses Other; Genentech: Research Funding; Celgene: Membership on an entity9s Board of Directors or advisory committees, Research Funding, Travel Expenses, Travel Expenses Other; Seattle Genetics: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees, Research Funding, Travel Expenses Other; Onyx: Research Funding; Allos: Membership on an entity9s Board of Directors or advisory committees. Lai:Celgene: Membership on an entity9s Board of Directors or advisory committees. Younes:Seattle Genetics, Inc.: Consultancy, Research Funding; Millennium: Honoraria; Novartis: Honoraria, Research Funding; Celgene: Honoraria; Affimed: Research Funding; Gilead: Research Funding; Johnson & Johnson: Research Funding.

6116 Background: Parenthood after cancer is a critical concern for many cancer patients (pts). Pregnancy (prg) during cancer is an emotional time for about 1/1000 pregnant women. No randomized controlled studies exist examining the impact of cancer treatment (tx) on the developing fetus nor on the woman with cancer. Methods: From 2002-2011, women presenting for cancer tx during prg were approached for this IRB-approved prospective database study. All pts provided written consent. Results: To date 143 pts are evaluable. The median age at diagnosis was 32.1 years and median gestational age (GA) at enrollment was 18.2 weeks. 95/143 (66.4%) are White, 19 (13.3%) are African American, 17 (11.9%) are Hispanic and 12 (8.4%) are Asian/Other. Primary cancers included breast (n=59, 41.3%), hematologic (n=29, 20.3%), melanoma (n=13, 9%), GYN (n=11, 8%), GI (n=8, 5.6%), head/neck (n=7, 6%) and other (n=16, 11%) (brain=4, GU=1, thyroid=3, head/neck=7, thoracic=1, sarcoma=6, unknown primary=1). 111/143 (77.6%) of prgs resulted in live births. Median birth weight was 6.5 lbs. Median follow-up time for pts was 32.3 months. To date, 3/19 pts who terminated prgs have died (1.6%). Most terminations occurred in the 1st trimester. To date, 79 pts (55.2%) are NED and 23 pts have died; of these 19 (1.7%) had live births. No major malformations were observed in the 74/143 (52%) of pts who received chemotherapy (CTx) during pregnancy. 57% received FAC/FEC; other regimens included ABVD (n=5), cytarabine (n=5), CHOP/R-CHOP, and platinum-based regimens. Median GA at the start of CTx was 19.7 wks. Median number of CTx cycles during prg was 4. Other pts underwent surgery (n=32), no tx (n=14), deferred tx until after delivery (n=17), radiation (2), transplant (3), other (1). Conclusions: Cancer diagnosis during prg is compatible with successful tx and prg outcome. Cancer tx during the 2nd and 3rd trimester can be safely given and in our pts did not result in adverse prg outcomes. Tx during the 1st trimester is usually not recommended. Thus cancer pts in their 1st trimester need to be extensively counseled about their disease as well as about the risks to the prg. In our pts continuation or termination of prg were not associated with an increased risk of death.

Obesity in women of reproductive age is increasing. Gynecologic laparoscopy in the morbidly obese pregnant patient presents challenges, and is not often attempted. Herein is reported a successful case using a modified Foley lap-lift technique, which improved visualization and facilitated mechanical ventilation.

This article reviews the essential criteria for inductions of labor, weighing both the advantages and disadvantages of labor induction, and the various mechanical and pharmacologic agents available for cervical ripening. At the end of this article, one should be able to counsel women about the potential risks and benefit of labor induction and understand the neonatal consequences of elective induction of labor before 39 weeks of gestation. This article also discusses the different mechanical and pharmacologic agents available for cervical ripening.

Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.

1106 Background: In women with pregnancy associated breast cancer (PABC), fetal exposure to chemotherapy during the second / third trimester has not been linked to considerable neonatal adverse outcome. Breast cancer resistance protein (BCRP) is a member of the ATP-binding cassette (ABCG2) efflux transporter family localized in the placenta. BCRP has been implicated in preventing passage of chemotherapy across the placenta. Our study examines if exposure to chemotherapy regimens including adriamycin, a known substrate of the transporter, changes placental immunostaining for BCRP. Methods: 13 placentas from women with (PABC) who received 5-fluorouracil, adriamycin and cyclophosphamide (FAC), were collected. Controls matched for gestational age were identified at a 1:1 ratio. Immunohistochemistry was performed using the BXP-21 monoclonal antibody (Santa Cruz Biotechnology, Inc) specific to the BCRP protein. Staining intensity was quantified in 10 chorionic villi per slide using the Image Pro (Version 7.0) software. All measurements were standardized and taken using a grey value scale (gvs) according to the software specifications. Samples were run in triplicate. Investigators were blinded to case/control status. Analysis was performed (STATA statistical software package, version 10.0). Kruskal-Wallis rank test was utilized for comparison between case and control groups. Results: Median density for case samples was 107.13 (IQR 101.1 – 118.7) gvs compared to 78.97 (IQR 77.09 – 87.9) gvs for controls. Kruskal-Wallis rank test was significant ( p = 0.0001), with cases scoring significantly higher than controls. Within the chemotherapy group, there was not a significant difference in density between those cases receiving ≤ 4 cycles of FAC (n=7) and those receiving ≥5 cycles (n = 6), p = 0.78. Conclusions: Administration of FAC during pregnancy appears to increase placental BCRP immunostaining. The observed increase in BCRP may account for diminished transfer of chemotherapy agents to the fetus, therefore limiting exposure. This novel finding could have implications in treating women with PABC.

OBJECTIVE: To characterize potentially modifiable risk factors for third- or fourth-degree perineal lacerations and cervical lacerations in a contemporary U.S. obstetric practice.METHODS: The Consortium on Safe Labor collected electronic medical records from 19 hospitals within 12 institutions (228,668 deliveries from 2002 to 2008). Information on patient characteristics, prenatal complications, labor and delivery data, and maternal and neonatal outcomes were collected. Only women with successful vaginal deliveries of cephalic singletons at 34 weeks of gestation or later were included; we excluded data from sites lacking information about lacerations at delivery and deliveries complicated by shoulder dystocia; 87,267 and 71,170 women were analyzed for third-or fourth-degree and cervical lacerations, respectively. Multivariable logistic regressions were used to adjust for other factors.RESULTS: Third-or fourth-degree lacerations occurred in 2,516 women (2,223 nulliparous [5.8%], 293 [0.6%] multiparous) and cervical lacerations occurred in 536 women (324 nulliparous [1.1%], 212 multiparous [0.5%]). Risks for third-or fourth-degree lacerations included nulliparity (7.2-fold risk), being Asian or Pacific Islander, increasing birth weight, operative vaginal delivery, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations. Risk factors for cervical lacerations included young maternal age, vacuum vaginal delivery, and oxytocin use among multiparous women, and cerclage regardless of parity.CONCLUSION: Our large cohort of women with severe obstetric lacerations reflects contemporary obstetric practices. Nulliparity and episiotomy use are important risk factors for third-or fourth-degree lacerations. Cerclage increases the risk for cervical lacerations. Many identified risk factors may not be modifiable. (Obstet Gynecol 2011;117:627-35) DOI:10.1097/AOG.0b013e31820afaf2

OBJECTIVE: To assess the efficacy of obstetric maneuvers for resolving shoulder dystocia and the effect that these maneuvers have on neonatal injury when shoulder dystocia occurs.METHODS: Using an electronic database encompassing 206,969 deliveries, we identified all women with a vertex fetus beyond 34 0/7 weeks of gestation who incurred a shoulder dystocia during the process of delivery. Women whose fetuses had a congenital anomaly and women with an antepartum stillbirth were excluded. Medical records of all cases were reviewed by trained abstractors. Cases involving neonatal injury (defined as brachial plexus injury, clavicular or humerus fracture, or hypoxic-ischemic encephalopathy or intrapartum neonatal death attributed to the shoulder dystocia) were compared with those without injury.RESULTS: Among 132,098 women who delivered a term cephalic liveborn fetus vaginally, 2,018 incurred a shoulder dystocia (1.5%), and 101 (5.2%) of these incurred a neonatal injury. Delivery of the posterior shoulder was associated with the highest rate of delivery when compared with other maneuvers (84.4% compared with 24.3-72.0% for other maneuvers; P<.005 to P<.001) and similar rates of neonatal injury (8.4% compared with 6.1-14.0%; P=.23 to P=.7). The total number of maneuvers performed significantly correlated with the rate of neonatal injury (P<.001).CONCLUSION: Delivery of the posterior shoulder should be considered following the McRoberts maneuver and suprapubic pressure in the management of shoulder dystocia. The need for additional maneuvers was associated with higher rates of neonatal injury. (Obstet Gynecol 2011;117:1272-8) DOI: 10.1097/AOG.0b013e31821a12c9

Shoulder dystocia (SD) remains a major cause of maternal and neonatal morbidity whose accurate prediction remains elusive. We sought to determine if accurate prediction of SD could be derived through multivariable modeling. Using the Consortium on Safe Labor database(derived from electronic medical records of 12 US medical centers), we identified women with a singleton vertex pregnancy who delivered vaginally >34 weeks. All women who incurred a SD during the course of their delivery had their charts retrospectively abstracted. Neonatal injury was defined as brachial plexus injury, fracture of the clavicle or humerus, hypoxic ischemic encephalopathy and/or intrapartum death attributable to SD. Previously reported risk factors for SD were incorporated into two multivariable models( Model 1: SD vs. No SD; Model 2: SD with Neonatal Injury vs No SD + SD without injury) and those with the greatest predictive value were retained. A total of 143,606 women met the inclusion criteria of whom 2269(1.6%) incurred a SD. Among SD cases, 135(5.9%) had a neonatal injury. Preexisting diabetes(OR 1.67), BMI(OR 1.02/kg/m2), epidural anesthesia(OR 1.17), gestational age(OR 0.94/week), birthweight(OR1.003/gm), parity(OR 0.96/per prior birth), operative vaginal delivery(OR 1.67), and public insurance(OR 1.61) were all statistically associated with SD(Model 1). This model provided a sensitivity of 66% and a specificity of 83% with a number needed to treat (NNT) of 17.4 per case of SD(C = 0.83). Model 2(SD with Neonatal inury) was statistically associated with preexisting diabetes(OR 2.60), BMI(OR 1.08/kg/m2), birthweight(OR 1.003/gm), parity(OR 0.72/prior birth), and operative vaginal delivery(OR 2.10). This model provided a sensitivity of 70%, a specificity of 87% with a NNT of 200.5 per case of SD with neonatal injury(C=0.79). Multivariable modelling may provide more accurate identification of SD. Despite improved prediction, the number of cesarean deliveries required to prevent one case of neonatal injury (200.5) is high, likely making it medically and financially prohibitive.

We describe obstetric outcomes in a group of patients with prior cesarean delivery (CD) presenting with an intrauterine fetal demise (IUFD). A secondary analysis of an observational study of women with prior CD was performed. All antepartum singleton pregnancies with a prior CD and IUFD >= 20 weeks' gestation or 500 g were evaluated. Two hundred nine patients met inclusion criteria for analysis. The mean gestational age +/- standard deviation at delivery was 31.3 +/- 6.5 weeks. The trial of labor rate was 75.6% (158/209), and the vaginal birth after cesarean (VBAC) success rate was 86.7%. Labor induction or augmentation occurred in 83.3% of attempted VBAC. Uterine rupture occurred in five women (2.4%), and in 3.4% of those being induced but none of these required hysterectomy. Women with a history of previous CD and an IUFD often undergo trial of labor with a high VBAC success rate. Uterine rupture complicates 2.4% of such cases.