Objective:This study aimed to assess the prevalence of gestational diabetes mellitus (GDM) in women without a prior GDM diagnosis who presented with third-trimester sonographic findings of estimated fetal weight (EFW) >90%, abdominal circumference (AC) >95%, or polyhydramnios. Study Design:Between 2018 and 2023, a perinatal diabetes registry tracked pregnant patients >28 weeks of gestation with sonographic findings of EFW >90%, AC >95%, or polyhydramnios (Amniotic Fluid Index [AFI] >25 cm), but no prior GDM diagnosis. These patients underwent a third-trimester 3-hour glucose tolerance test (GTT) or glucose panel. The primary outcome was a new diagnosis of GDM; secondary outcomes included delivery mode, live birth, shoulder dystocia, respiratory distress syndrome (RDS), preeclampsia, neonatal hypoglycemia, and neonatal intensive care unit (NICU) admission. Results:Of 723 patients, 169 (23.4%) were newly diagnosed with GDM. Among those with specific sonographic findings, GDM was identified in 25.4% (EFW >90%), 24.4% (AC >95%), and 21.2% (polyhydramnios). GDM was diagnosed in 19.5% with one sonographic finding, 25.5% with two, and 26.9% with all three. New third-trimester GDM was significantly associated with increased neonatal hypoglycemia (30.4%; p < 0.001), RDS (10.8%; p = 0.037), and NICU admission (13.4%; p = 0.036). Conclusion:Up to one in four women with third-trimester findings of EFW >90%, AC >95%, or polyhydramnios-despite a prior negative screen-were newly diagnosed with GDM. These cases were also linked to higher neonatal morbidity. Targeted third-trimester GDM screening in patients with these sonographic markers may help identify at-risk pregnancies and improve perinatal outcomes. Key Points:· High rate of missed GDM: Nearly 25% with U.S. findings had late GDM diagnosis.. · Cumulative risk: GDM risk rises with more U.S. findings.. · Neonatal morbidity risk: Later diagnosis linked to higher neonatal risks.. · Clinical implications: Consider later GDM screen if U.S. markers are seen..

Purpose Since discovering that intravenous (IV) fluid infusion rate of 250 mL/hr during labor decreases incidence of cesarean delivery and decreases time in labor when compared to infusion rate of 125 mL/hr, patients and midwives have expressed concern that increased fluid rates may lead to increased birth weights. Thus, our objectives were to determine the impact, if any, of increased IV fluid infusion rates on birth weight. Methods This was a meta-analysis of all randomized controlled trials (RCTs) of low-risk, nulliparous women with gestations ≥ 36 weeks comparing IV fluid rates of 125 vs. 250 mL/hr. We conducted a comprehensive literature search to identify studies published since the meta-analysis by Ehsanipoor et al. (2017) that assessed the impact of IV fluid rate on birth weight. For our analysis, we included the articles published since 2017 as well as articles from the original meta-analysis that included birth weight (6/7 studies). Results Eight trials, with an overall low risk of bias, including 1727 women were analyzed. 913 were in the 125 ml/hr group and 876 were in the 250 ml/hr group. The vast majority of the included trials used Ringer’s solution or normal saline. Overall, there was no significant difference in birth weights between the two treatment groups (mean difference –22.69 g; 95 % CI −75.52 to + 27.14). Conclusions We conclude that in addition to the previously demonstrated decreased incidence of cesarean delivery and length of labor demonstrated in Ehsanipoor et al. afforded by increased rate of IV fluid intake, there is no significant impact on birth weight.

Background: We describe a case of primary herpes simplex virus (HSV) infection imitating preterm prelabor rupture of membranes (PPROM) and review the intricacies of establishing the diagnosis. Case presentation: At 18 weeks of gestation, a patient was referred for suspected PPROM following leakage of fluid and a positive nitrazine test. The patient had a swollen inguinal lymph node, intermittent fevers, transaminitis, labial lesions, and cervical ulceration with vaginal discharge. Amniotic fluid volume was normal. An HSV PCR test was positive. Intravenous acyclovir followed by oral valacyclovir resulted in resolution of symptoms. Conclusion: Discharge from HSV cervicitis can present as nitrazine-positive pooling, imitating PPROM. A high index of suspicion is warranted, especially when the amniotic fluid volume is normal and arborization is not seen on microscopic exam.

OBJECTIVE: To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting. DATA SOURCES: PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied. METHODS OF STUDY SELECTION: Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included. TABULATION, INTEGRATION, AND RESULTS: Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference −7.24 hours, 95% CI −11.03 to −3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59–0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths. CONCLUSION: Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery by more than 7 hours and a significant 24% decreased risk of cesarean delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019140503.

Objective To evaluate maternal and neonatal outcomes of low-risk singleton pregnancies, without underlying maternal medical conditions or genetic and fetal anomalies associated with fetal growth restriction, that were diagnosed with fetal growth restriction (FGR) (EFW < 10th %) in the mid-second trimester (between 17 and 22 weeks and 6 days' gestation). Methods A retrospective cohort study of all women who underwent a routine fetal anatomy ultrasound between 17 and 22 weeks and 6 days' gestation at a community-based academic hospital was performed to identify subjects with an EFW <10th%. Pregnancies with inadequate dating, multiple gestations, preexisting maternal vascular disease (chronic hypertension and pregestational diabetes), lethal fetal anomalies, and abnormal prenatal genetic screening were excluded. Descriptive statistics were computed to describe the study population. Subjects were stratified into two groups, estimated fetal weight (EFW) <5th% and EFW 5th-9th%. The primary outcome was a small for gestational age neonate (SGA) at delivery. Secondary outcomes included a composite adverse neonatal outcome, perinatal death, hypertensive disorders of pregnancy, medically indicated delivery, and mode of delivery. A comparison of the two groups, EFW <5th% and EFW 5th-9th %, was performed. Continuous variables were compared utilizing Wilcoxon Rank Sum tests and categorical variables were compared using Fisher's exact test or Chi-squared tests, and a dichotomous composite variable for adverse neonatal outcomes was also calculated. Results In total, 3,868 unique patient records were screened. Thirty-two patient records (0.8% of the total screened records) were eligible for inclusion. The primary outcome, SGA at delivery, occurred in 13/32 (41%) of the subjects. The secondary outcomes of the composite neonatal morbidity occurred in 9/32 (28%), hypertensive disorders of pregnancy in 10/32 (31%), and medically indicated delivery at <28 weeks gestation in 7/32 (22%) of the subjects. When comparing EFW <5th% and EFW 5th-9th%, EFW <5th% had a larger percentage of SGA newborns (66% vs. 25%, p = .02, OR = 8.0 95% CI 1.5-42.5). EFW <5th% was also significantly associated with a greater composite adverse neonatal outcome when compared to EFW 5th-9th% (54% vs. 10%, p = .015). The subgroup with an EFW <5th% also had higher rates of adverse outcomes including preeclampsia (42% vs. 10%, p = .073), abnormal umbilical artery Doppler studies (50% vs. 15%, p = .049), and medically indicated delivery <28 weeks (42% vs. 10%, p = .07). Conclusions Early onset FGR is a associated with high rates of SGA at delivery, as well as several adverse maternal and neonatal outcomes which include hypertensive disorders of pregnancy, a greater composite neonatal morbidity, perinatal death, and medically indicated preterm delivery. EFW <5th% was associated with worse outcomes when compared to those with an EFW 5th%-9th%.

BACKGROUND:Patients with a serologic weak D phenotype may demonstrate variable RhD expression. We present a case in which clinical management would have been simplified if RHD genotyping had been performed previously.CASE:A 33-year-old patient, G11P4155, presented with an incomplete miscarriage and was transfused RhD-positive packed red blood cells after typing RhD-positive. The patient had been historically typed RhD-negative by a different testing methodology. Indirect antiglobulin testing was performed, which revealed a serologic weak D phenotype. The patient was given 9,600 micrograms of Rh immune globulin. Molecular testing revealed a partial D antigen, which was originally thought to be at risk for alloimmunization; however, this has since been disproven.CONCLUSION:Although not yet universal practice, prenatal RHD genotyping for partial D antigen could have prevented the characterization of this patient as RhD-positive at the time of transfusion.

To evaluate the difference in time from hospital admission to delivery when undergoing inpatient versus outpatient cervical ripening with a transcervical Foley catheter. This was a randomized controlled trial of patients with singleton pregnancies, Bishop Score ≤ 6 and at least 37 weeks' gestation, undergoing labor induction at Sinai Hospital of Baltimore and Thomas Jefferson University Hospital. Patients were randomized to outpatient or inpatient cervical ripening with a Foley catheter. Inpatients received concurrent oxytocin. Outpatients returned 12 hours after Foley placement, and on arrival oxytocin was initiated if the balloon was still in place. Foleys were removed if in place after 12-18 hours, and labor induction initiated with oxytocin as needed. The primary outcome was the difference in time from admission to delivery. A maternal satisfaction survey was also administered. Unpaired t-tests, chi-square tests, and Fisher's exact test were performed to estimate differences in outcomes between the inpatient and outpatient arms of the study. Enrollment commenced January 2016 and continued until November 2020, after randomizing 30 patients (n=15 per group). The study was terminated prematurely due to low enrollment and temporary suspension during COVID-19. There was no significant difference in time from admission to delivery between outpatient and inpatient groups (14.5 ± 6.1 versus 18.9 ± 8.2 hours, P=.11). The total induction time was shorter for the inpatient group (24.9 ± 6.8 versus 17.3 ± 9.4 hours, P=.02). There were no differences in other maternal or neonatal outcomes (P>.05). Maternal satisfaction was similar between groups on a 1-10 scale (8.6 ± 1.7 versus 8.9 ± 1.0, P=.53), and all patients felt safe. No difference in the primary outcome of time from admission to delivery was noted between inpatient and outpatient cervical ripening with a Foley catheter; however, this may be a result of inadequate power related to early termination. Consistent with past studies, outpatient balloon cervical ripening appears to be safe, and overall satisfaction was high.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To evaluate the difference in time on Labor and Delivery with outpatient versus inpatient cervical ripening with a balloon catheter in low-risk women. This is an updated systematic review and meta-analysis including only randomized controlled trials (RCTs). Electronic databases were searched for eligible articles. Those not comparing balloon use in both arms of the RCT were excluded. The reference lists of identified articles were examined to identify additional studies. Authors were contacted for unpublished data. The primary outcome was the difference in time on labor and delivery. Secondary outcomes included duration of oxytocin use, delivery outcomes and neonatal outcomes. The meta-analysis was performed using the effects measure of mean difference with a 95% confidence interval (CI), and the random effects model of DerSimonian and Laird to calculate risk ratio (RR) with 95% CI. Five RCTs, including 544 women, met inclusion criteria. The mean difference in time on Labor and Delivery when comparing the outpatient to inpatient groups was -6.92 hours (95% CI -11.05, -2.78). There was no difference in duration of oxytocin use among four studies (mean difference 0.04 hours, 95% CI -2.54, 2.61). Data on route of delivery was available for all five RCTs. The outpatient group was less likely to deliver via cesarean (RR 0.69, 95% CI 0.52-0.92). There was no difference in risk of postpartum hemorrhage, chorioamnionitis or endometritis. There was no difference in neonatal outcomes, including intensive care unit admission or 5-minute Apgar score less than seven. Outpatient cervical ripening with a balloon catheter in low-risk women is associated with a decreased amount of time spent on Labor and Delivery. Additionally, it is associated with a decreased risk of cesarean delivery. Outpatient cervical ripening with a balloon catheter would likely translate into decreased hospital costs and improved patient outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To evaluate maternal and neonatal outcomes of low-risk singleton pregnancies with estimated fetal weight (EFW) > 95th% during routine mid-second trimester ultrasound (between 17 and 22 weeks and 6 days’ gestation). A retrospective cohort study of all women who underwent a routine fetal anatomy ultrasound between 17 and 22 weeks and 6 days’ gestation at an urban community-based hospital from January 2016 to May 2019 was performed. The primary outcome was large for gestational age neonate at term. Secondary outcomes were abnormal glucose testing, gestational diabetes, cesarean delivery, shoulder dystocia, and obstetric anal sphincter injuries. Descriptive statistics were computed to describe the study population. Continuous outcomes were compared between EFW >95th% and EFW=50th% groups utilizing Wilcoxon Rank Sum tests and categorical variables were compared using Fisher’s exact test or Chi-squared tests. A logistic regression analysis was performed to estimate these associations while adjusting for potential confounders. In total, 3,868 unique patient charts were identified. 49 (1.3%) had an EFW >95th % and 54 (1.4%) had an EFW=50th% and were eligible for review and subsequent analysis. When compared to EFW=50th%, the group with an EFW >95th% was more likely to have large for gestational age (LGA) newborns at term (41% vs. 4%, OR=18 95% CI 3.9-82). These findings were robust to adjustment for potential confounders (age, race, obesity, mode of delivery, etc.) in logistic regression modeling. There were no statistically significant differences amongst the two groups for the secondary outcomes. Estimated fetal weight >95th% at the time of routine ultrasound between 17 and 22 weeks and 6 days’ gestation is associated with large for gestational age neonates at term.There were no statistically significant findings for the secondary outcomes. Such gestations with EFW >95th% during the mid-second trimester may benefit from additional ultrasonography growth assessment at later gestational ages; however, early glucose tolerance testing does not appear indicated.

Preterm birth occurs in approximately 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality (). Prelabor rupture of membranes (PROM) that occurs preterm complicates approximately 2-3% of all pregnancies in the United States, representing a significant proportion of preterm births, whereas term PROM occurs in approximately 8% of pregnancies (). The optimal approach to assessment and treatment of women with term and preterm PROM remains challenging. Management decisions depend on gestational age and evaluation of the relative risks of delivery versus the risks (eg, infection, abruptio placentae, and umbilical cord accident) of expectant management when pregnancy is allowed to progress to a later gestational age. The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented. This Practice Bulletin is updated to include information about diagnosis of PROM, expectant management of PROM at term, and timing of delivery for patients with preterm PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation.

Health care costs are an important consideration in the decision of hysterectomy routes and robotic surgery is often critiqued for its high cost. We sought to compare the cost of robotic-assisted hysterectomies performed after initial acquisition of the robotic surgical system to cases performed after 5 years of experience. The first 20 patients at a community teaching hospital who underwent robotic-assisted hysterectomy for endometrial cancer by a single gynecologic oncology surgeon were designated Group 1 and 20 patients undergoing robotic hysterectomies 5 years later for the same indication were designated Group 2. Direct hospital costs were divided into operative and non-operative costs. Mean operating room cost and cost of anesthesia per minute for Group 1 were adjusted to Group 2 mean costs. Supply costs were adjusted using the 2015 Consumer Price Index. Baseline characteristics of the groups were comparable. After 5 years of experience, there was a 15.5% [95% CI (−$2865, −$407), p = 0.01] reduction in mean total costs (Group 1 = $10,543, Group 2 = $8907) and a 14.3% [95% CI (−$2378, −$390), p ≤ 0.01] reduction in mean operative costs (Group 1 = $9688, Group 2 = $8304). Significant reductions in procedure time, operating room time, operating room cost, and cost of anesthesia were seen from Group 1 to Group 2. There were no differences in mean non-operative costs, estimated blood loss, cost of supplies or surgeon cost. Experience with robotic-assisted hysterectomies is associated with reduction in costs, which is primarily a result of reduced operative times. This is an important factor when considering costs related to robotic surgery.

INTRODUCTION: To create and implement a venous thromboembolism (VTE) calculator for post-cesarean section patients at a community hospital, and analyze its association with subsequent rates of pharmacologic thromboprophylaxis use. METHODS: A risk calculator was developed, with points weighted based on the severity of the risk factor. Use of a paper form of the calculator was initiated in May 2015 (phase 1), and of an electronic form in August 2016 (phase 2). Data from 50 subjects each prior to the intervention (phase 0), during phase 1, and during phase 2 were collected (total n=150). Rates of pharmacologic thromboprophylaxis were compared with risk categories using Fisher exact test. Logistic regression models of these associations adjusting for key covariates (age, body mass index greater than 40, chorioamnionitis) were also constructed. RESULTS: There was a statistically significant increase in the use of pharmacologic prophylaxis after the intervention (phase 1 and 2), when compared to phase 0 (p=0.02). There was also a statistically significant decrease in high risk patients not receiving prophylaxis (p <0.0001). The association between phase and use of prophylaxis remained statistically significant after adjustment for covariates. CONCLUSION: Use of our calculator has led to a significant increase in prescription of pharmacologic thromboprophylaxis, particularly in moderate and high risk patients. To our knowledge, there have been no thromboembolic events since the start of the intervention.

Dr. Pierce-Williams is Resident Physician, and Dr. Ehsanipoor is Assistant Professor, Department of Obstetrics and Gynecology, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave, Baltimore, MD 21215; E-mail: [email protected]. From the Editors: Early-onset preeclampsia with severe features is associated with significant morbidity and mortality. Weighing the risks and benefits of expectant management is a clinical challenge that we highlight in reissuing this previously published article. CME credit is available.The authors, faculty, and staff in a position to control the content of this CME activity, and their spouses/life partners (if any), have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This activity expires on September 29, 2020.

Introduction. The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine have emphasized the need to promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate. Material and methods. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, Embase, Web of Science, and the Cochrane Library for randomized controlled trials. We included all randomized controlled trials comparing intravenous fluid rates of 250 vs. 125 mL/h in nulliparous women in spontaneous labor at term with singleton pregnancies at >= 36 weeks. Studies were included regardless of the type of intravenous fluids used and regardless of whether oral intake was restricted during labor. Studies including multiparous women or women whose labor was induced were excluded. The primary outcome was the incidence of cesarean delivery. We planned to assess a subgroup analysis according to type of fluids used and according to restriction of oral fluid intake. Results. Seven trials including 1215 nulliparous women in spontaneous labor at term were analyzed; 593 (48.8%) in the 250 mL/h group, and 622 (51.2%) in the 125 mL/h group. Five studies used lactated Ringer's solution, one used normal saline in dextrose water, and in one study it was unclear which intravenous fluid was used. Women who received intravenous fluids at 250 mL/h had a significantly lower incidence of cesarean delivery for any indication (12.5 vs. 18.1%; RR 0.70, 95% CI 0.53-0.92; seven studies, 1215 participants; I-2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI 0.38-0.97; five studies, 1093 participants; I-2 = 18%), a significantly shorter mean duration of labor of about one hour (mean difference -64.38 min, 95% CI -121.88 to -6.88; six studies, 1155 participants; I-2 = 83%) and a significantly shorter mean length of second stage of labor (mean difference -2.80 min, 95% CI -4.49 to -1.10; 899 participants; I-2 = 22%) compared with those who received intravenous fluid at 125 mL/h. No differences were found in the other secondary outcomes. There were no maternal or perinatal deaths and only one woman, in the 125 mL/h group, developed pulmonary edema. The findings persisted regardless of the type of intravenous fluid used. No significant reduction in the incidence of cesarean delivery was demonstrated in women with unrestricted oral intake; however, this was limited to only two studies evaluating 254 women. Conclusions. Our findings provide evidence that the duration of labor in low-risk nulliparous women may be shortened by a policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h. A rate of 250 mL/h seems to be associated with a reduction in the incidence of cesarean delivery compared to 125 mL/h. The number needed to treat to prevent one cesarean delivery is 18 women. Our data support increased hydration among nulliparous women in labor when oral intake is restricted.Further study is needed regarding risks and benefits of increased hydration among women with unrestricted oral intake, those undergoing induction of labor, and those with medical comorbidities.

OBJECTIVES:To investigate whether there is an association between congenital heart disease (CHD) and placental abnormalities. METHODS:We conducted a case-control study that included cases of infants with CHD who underwent cardiac surgery within 6 months of life at the Johns Hopkins Medical Center from 2000 to 2013, and gestational age-matched normal pregnancy controls (200 neonates per group). RESULTS:Overall, abnormal placental cord insertion (ie, eccentric, marginal, or velamentous) was associated with CHD (odds ratio, 2.33-3.76). The main cardiac defects associated with abnormal cord insertion were conotruncal defects (relative risk, 3.08; 95% confidence interval [CI], 1.48-6.40; P = .003), left heart disease (relative risk, 2.40; 95% CI, 1.32-4.37; P = .004), and right heart disease (relative risk, 2.22; 95% CI, 1.21-4.07; P = .010). The Placenta-to-birth weight ratio was not associated with CHD. Intrauterine growth restriction was associated with CHD (odds ratio, 3.00; 95% CI, 1.41-6.39; P = .004). CONCLUSIONS:Abnormal cord insertion, as well as intrauterine growth restriction, was determined to be correlated with the presence of CHD. On the basis of our results, we conclude that cord insertion should be evaluated at routine obstetric sonography, and further fetal heart evaluation is warranted if abnormal cord insertion is detected.

The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine have emphasized the need to promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, Embase, Web of Science, and the Cochrane Library for randomized controlled trials. We included all randomized controlled trials comparing intravenous fluid rates of 250 vs. 125 mL/h in nulliparous women in spontaneous labor at term with singleton pregnancies at ≥36 weeks. Studies were included regardless of the type of intravenous fluids used and regardless of whether oral intake was restricted during labor. Studies including multiparous women or women whose labor was induced were excluded. The primary outcome was the incidence of cesarean delivery. We planned to assess a subgroup analysis according to type of fluids used and according to restriction of oral fluid intake. Seven trials including 1215 nulliparous women in spontaneous labor at term were analyzed; 593 (48.8%) in the 250 mL/h group, and 622 (51.2%) in the 125 mL/h group. Five studies used lactated Ringer's solution, one used normal saline in dextrose water, and in one study it was unclear which intravenous fluid was used. Women who received intravenous fluids at 250 mL/h had a significantly lower incidence of cesarean delivery for any indication (12.5 vs. 18.1%; RR 0.70, 95% CI 0.53–0.92; seven studies, 1215 participants; I 2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI 0.38–0.97; five studies, 1093 participants; I 2 = 18%), a significantly shorter mean duration of labor of about one hour (mean difference −64.38 min, 95% CI −121.88 to −6.88; six studies, 1155 participants; I 2 = 83%) and a significantly shorter mean length of second stage of labor (mean difference −2.80 min, 95% CI −4.49 to −1.10; 899 participants; I 2 = 22%) compared with those who received intravenous fluid at 125 mL/h. No differences were found in the other secondary outcomes. There were no maternal or perinatal deaths and only one woman, in the 125 mL/h group, developed pulmonary edema. The findings persisted regardless of the type of intravenous fluid used. No significant reduction in the incidence of cesarean delivery was demonstrated in women with unrestricted oral intake; however, this was limited to only two studies evaluating 254 women. Our findings provide evidence that the duration of labor in low-risk nulliparous women may be shortened by a policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h. A rate of 250 mL/h seems to be associated with a reduction in the incidence of cesarean delivery compared to 125 mL/h. The number needed to treat to prevent one cesarean delivery is 18 women. Our data support increased hydration among nulliparous women in labor when oral intake is restricted. Further study is needed regarding risks and benefits of increased hydration among women with unrestricted oral intake, those undergoing induction of labor, and those with medical comorbidities.

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm premature rupture of membranes (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

INTRODUCTION: Robotic surgery is criticized for its cost. Most studies evaluating costs are limited to the initial robotic cases performed. We sought to determine if costs decrease with an increase in experience. METHODS: In this retrospective cohort study at a community teaching hospital, the total cost of the first 20 robotic-assisted hysterectomies performed for endometrial cancer by a single surgeon (Group 1) were compared to 20 comparable cases by the same surgeon five years later (Group 2). Data was abstracted from charts and accounting records using direct costs to the hospital. To adjust for inflation, mean operating room and anesthesia costs per minute for Group 1 were adjusted to the mean costs per minute for Group 2. The cost of supplies for Group 1 was adjusted from the 2010 to the 2015 Consumer Price Index. RESULTS: Age, BMI, and uterine weight were comparable between the groups. Mean total cost decreased (Group 1=$10,584±1475; Group 2=$8,907±2,284; P=.009) and mean total operative costs decreased (Group 1=$9,729±1284; Group 2=$8,304±1788; P=.007) over the 5 year period. Significant reductions in operating room cost, anesthesia cost, procedure time, and operating room time were seen. However, non-operative costs, cost of supplies, surgeon's charge, and estimated blood loss were similar between the two groups. CONCLUSION: Experience over 5 years with robotic-assisted hysterectomies is associated with a significant reduction in cost. This cost reduction is primarily attributable to shorter procedure time and operation room time.