Objectives To assess the association between aspirin and glycemic control in diabetic, pregnant patients, and the risk for aspirin resistance in those with poor glycemic control across gestation taking low-dose aspirin (LDA) for pre-eclampsia (PEC) prevention. Study Design We performed a secondary analysis of samples collected during the Maternal-Fetal Medicine Units trial of LDA for PEC prevention. A subset of insulin-controlled diabetic patient samples on placebo or 60 mg aspirin daily were evaluated. Glycosylated hemoglobin was measured at randomization, mid-second trimester, and third trimester time points. Thromboxane B (2) (TXB (2) ) measurements were previously assessed as part of the original study. Primary outcome was the effect of LDA on glycosylated hemoglobin levels compared with placebo across gestation. Results Levels of glycosylated hemoglobin increased across gestation in the placebo group (2,067.7 [interquartile range, IQR: 1,624.6-2,713.5 mu g/mL] vs. 2,461.9 [1,767.0-3,209.9 mu g/mL] vs. 3,244.3 [2,691.5-4,187.0 mu g/mL]; p < 0.01) compared with no difference in levels of glycosylated hemoglobin across gestation in the LDA group (2,186.4 [IQR: 1,462.3-3,097.7 mu g/mL] vs. 2,337.1 [1,327.7-5,932.6 mu g/mL] vs. 2,532.9 [1,804.9-5,511.8 mu g/mL]; p = 0.78). Higher levels of glycosylated hemoglobin were associated with increased TXB (2) levels prior to randomization ( r = 0.67, p < 0.05). Incomplete TXB (2) was higher in pregnancies with increasing levels of glycosylated hemoglobin compared with those with decreasing levels of glycosylated hemoglobin across gestation (69.2 vs. 18.1%, p = 0.02). Conclusion LDA exposure may be beneficial to glycemic control in this patient population. Additionally, poor glycemic control is associated with a higher level of TXB (2) in diabetic pregnant patients on LDA. Higher doses of aspirin may be required in these patients to prevent development of PEC.

Background: Pulmonary hypertension (PH) due to left heart disease (World Health Organization (WHO) Group 2 PH) is the largest PH subgroup, however most reports of PH in pregnancy focus on patients with pulmonary arterial hypertension (WHO Group 1 PH). We evaluated pregnancy outcomes across WHO PH subgroups. Methods: We performed a retrospective single center cohort study of maternal and fetal outcomes in pregnant women with PH (2004-2018). Results: We analyzed outcomes of 70 pregnancies in 70 women with PH (30 +/- 6 years-old), classified as WHO Group 1 PH (12 (17%)), Group 2 PH (45 (64%)), Group 3 PH (4 (6%)) and Group 5 PH (9 (13%)). Although no peripartum death occurred, 3 (4.3%) women with WHO Group 2 PH had late mortality (7 +/- 4 months postpartum). Additionally, 33 major adverse cardiac events occurred in 26 (37%) women, preterm birth occurred in 32 (49%), and post-partum hemorrhage in 10 (14%), such that only 24 (37%) women completed a viable pregnancy free of an adverse cardiac, obstetric or fetal/neonatal event. Major adverse cardiac events were predominantly due to heart failure (24 (73%)), occurring only in WHO Groups 1 and 2 PH (3 (25%) women vs. 17 (38%), p = 0.07), and significantly associated with pre-eclampsia, left ventricular ejection fraction <= 45%, maternal diabetes, and systemic hypertension. Conclusions: WHO Group 2 PH carries similar risk for maternal cardiovascular events when compared to women with WHO Group 1 PH. Further studies evaluating maternal risk in this cohort are needed.

PROBLEM:Limited data exists on the temporal trend of the Sars-CoV-2 immunologic response and duration of protection following natural infection. We sought to investigate the presence and duration of Sars-CoV-2 serum antibodies in obstetrical healthcare workers (HCW) on serial assessments over a 6-month period, and to assess rates of vaccine acceptance and reported vaccine side effects among this cohort. METHOD OF STUDY:A prospective cohort study of a convenience sample of obstetrical HCWs at a tertiary hospital. Serum Sars-CoV-2 antibodies for Immunoglobulin G (IgG) and Immunoglobulin M (IgM) were measured longitudinally at four intervals: baseline, 4 weeks, 12 weeks, and 6 months. Participants completed voluntary surveys on COVID19 testing, high-risk exposures, vaccine acceptance, and vaccine side effects. RESULTS:One hundred twenty-six of 150 (84%) HCWs who volunteered for participation completed all four blood draws. Prevalence of seropositive HCWs based on positive Sars-CoV-2 IgG antibodies increased from 2% at baseline to 31% at 12 weeks but declined to 21% by 6 months. Forty-two percent (19/43) of the participants considered seropositive for Sars-CoV-2 IgG antibodies at any of the initial three blood draws converted to seronegative status at the 6-month follow-up. Eighty-seven percent (72/83) of participants who responded to a follow-up survey were willing to accept the COVID19 vaccine. Rates of acceptance did not differ by participant antibody status. Those that experienced symptoms with the first injection were more likely to have positive Sars-CoV-2 IgG antibodies (36.8% vs. 9.6%, p = .01). CONCLUSION:Sars-CoV-2 IgG antibodies wane over time and may not provide prolonged and robust immune protection. This underscores the importance of vaccination and continued research in this area while the COVID19 pandemic continues.

Pregnancies with hypertensive diseases of pregnancy (HDP) often require induction of labor to minimize maternal and fetal risks. There is no superior method of labor induction and rates of cesarean delivery (CD) range from 15-60% in this population. Nitric oxide donors decrease maternal blood pressure and soften the cervix without inducing uterine contractions. We hypothesized that addition of vaginal isosorbide mononitrate (IMN) to vaginal misoprostol for labor induction may decrease the rate of CD and need for intrapartum emergent antihypertensive therapy in pregnancies complicated by HDP. This was a double-blind, placebo-controlled, randomized trial of women with singleton pregnancy ≥24 weeks gestation with an induction of labor for HDP between 11/2017-2/2020. Participants were eligible if Bishop score less than 6 and cervical dilation ≤2cm. They received up to 3 doses of 40mg IMN and 25mcg vaginal misoprostol in addition to standard interventions for induction - foley and oxytocin. Primary outcome was rate of cesarean delivery. Secondary outcomes included indication for CD, length of labor, use of intrapartum emergent antihypertensives, and maternal and neonatal morbidities. A sample size of 176 women was needed to detect at least a 20% difference in the primary outcome (Power 0.8). 89 women were randomized to the IMN group and 87 to the placebo group. GA at delivery were similar between groups (37 [34-38] vs 37 [35-38]). CD rates were similar with between both (32.6% vs 25.3%; RR, 1.29; 95% CI, 0.81 to 2.06; P=0.39). Neither length of labor nor use of intrapartum emergent antihypertensives was significantly different. Maternal headache was more common in IMN group than placebo group (47.2% vs 27.0%; RR, 1.52; 95% CI, 1.04 to 2.23; P=0.04), whereas clinical chorioamnionitis was less common in the IMN group (0% vs 8%; P=0.02). Adding vaginal IMN to vaginal misoprostol for labor induction in pregnancies complicated by HDP did not result in fewer CD.

BACKGROUND: Pregnancies complicated by hypertensive disease of pregnancy often require labor induction. Rates of cesarean delivery range from 15% to 60% in this population. Nitric oxide deficiency has been shown to underlay the pathophysiology of preeclampsia, and nitric oxide promotes cervical ripening. OBJECTIVE: We hypothesized that addition of vaginal isosorbide mononitrate for labor induction could decrease the rate of cesarean delivery in pregnancies with hypertensive disease of pregnancy. STUDY DESIGN: This study was a double-blind, placebo-controlled, randomized trial of patients with singleton pregnancy at >= 24 weeks' gestation undergoing labor induction for hypertensive diseases of pregnancy between November 2017 and February 2020. Participants were eligible if their Bishop score was <6 and if their cervical dilation was <= 2 cm. In addition, participants received up to 3 doses of 40 mg isosorbide mononitrate in addition to misoprostol for labor induction. Labor management was per healthcare provider preference. The primary outcome was rate of cesarean delivery. Secondary outcomes included the length of labor and frequency of intrapartum adverse events, including the use of intrapartum antihypertensive agents. RESULTS: 89 women were randomized to the isosorbide mononitrate group, and 87 women were randomized to the placebo group. Cesarean delivery rates were similar in both groups (32.6% vs 25.3%; relative risk, 1.29; 95% confidence interval, 0.81-2.06; P=.39). Maternal headache was increased in patients exposed to isosorbide mononitrate (42.7% vs 31%; relative risk, 1.52; 95% confidence interval, 1.04-2.23; P=.04). Clinical chorioamnionitis was increased in the placebo group (0% vs 8%; P=.02). Secondary outcomes were similar between groups. CONCLUSION: The addition of vaginal isosorbide mononitrate for labor induction in pregnancies complicated by hypertensive disease of pregnancy did not result in fewer cesarean deliveries.

Objective: To investigate the association between meconium-stained amniotic fluid (MSAF) and postcesarean surgical site infections. Methods: This was a secondary analysis of the Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry. Women with a singleton pregnancy attempting labor or induction of labor, who ultimately had a cesarean delivery, were included in the study. Pregnancies complicated by MSAF (n = 4262) and those who did not have MSAF (n = 13,850) were compared. The primary outcome was the incidence of SSI. Results: A total of 18,112 patients were included in the study. 4262 (38%) had meconium-stained amniotic fluid. After accounting for potential confounders in a multivariable logistic regression, meconium-stained amniotic fluid was associated with an increased risk of postoperative surgical site infection (odds ratio 1.16, 95% CI 1.03-1.30). Conclusions: Meconium-stained amniotic fluid may be associated with an increased risk of postoperative surgical site infection.

INTRODUCTION:The use of echocardiography to evaluate the probability for pulmonary hypertension (PH) in pregnant women has not been reported or correlated with outcomes. We hypothesized that in women with elevated right ventricular systolic pressure (RVSP) on echocardiography first identified during pregnancy, those with low probability for PH would have fewer major adverse cardiac events (MACE).METHODS:We performed a retrospective cohort study of pregnant women with RVSP >35 mm Hg on echocardiogram first identified during pregnancy. Women were classified as intermediate-high probability for PH (HP) or low probability for PH (LP) based on simplified European Society of Cardiology echocardiographic criteria. Maternal cardiac, obstetric, and fetal outcomes were assessed.RESULTS:A total of 77 women met inclusion criteria (mean age 30 ± 5 years), with 45 (58%) classified as HP and 32 (42%) as LP. There were 21 (27%) women who experienced MACE, more commonly in the HP cohort (HP 18 (40%) women vs. LP 3 (9%) women, P = .01). The echocardiographic criteria for intermediate-high probability of PH identified women at risk for MACE with 85% sensitivity and 52% specificity. The negative predictive value for MACE in women meeting low echocardiographic probability for PH criteria was 91%.CONCLUSIONS:In women with elevated RVSP on echocardiography first identified during pregnancy, those with low echocardiographic PH probability are at significantly lower risk for MACE during pregnancy, though the risk is not eliminated. This may be useful to risk stratify pregnant women with suspected PH, guiding tertiary care referral and invasive catheterization.

Introduction: Pulmonary hypertension (PH) diagnosed by elevated right ventricular systolic pressure (RVSP) is present in 6-11% of patients with sickle cell disease (SCD) and is associated with increased mortality. PH, independent of SCD, is associated with increased maternal mortality. While there are reports of adverse outcomes during pregnancy in patients with SCD, pregnancy outcomes of patients with SCD and PH have not been well studied. Methods: Using our institutional electronic data warehouse we searched for pregnant women who had an echocardiogram between November 1, 2011 and April 30, 2018, and met criteria for pulmonary hypertension with report of either RVSP > 35 mmHg or tricuspid regurgitant (TR) velocity of more than 2.8 m/s. We assessed maternal and fetal outcomes in this group of patients. Results: We identified 136 women with elevated RVSP, of which 7 (5%) had SCD (mean maternal age 29 ± 3 years, mean RVSP 47 ± 11 mmHg, mean TR velocity 3.1 ± 0.4 m/s). RVSP was known to be elevated before pregnancy in 5 (71%). There were no maternal deaths during pregnancy or up to 1-year post-partum. Thromboembolic complications occurred in 3 (43%); including 1 deep vein thrombosis with presumed pulmonary embolism (PE) at 20 weeks gestational age (GA), 1 catheter associated right atrial thrombus at 22 weeks GA, and 1 PE at 16 weeks GA. There were no heart failure complications. Cesarean section occurred in 5 (71%), all for obstetric indications. There were no fetal or neonatal deaths. Pre-eclampsia occurred in 2 (28%). The average gestational age was 35 ± 4 weeks. Preterm birth and low birth weight occurred in 3 (43%) patients. Conclusion: In conclusion, there was no maternal mortality or heart failure in pregnant women with SCD and elevated RVSP at our high-volume center, however 3 of 7 patients (43%) had thromboembolic complications. Further studies of women with PH and SCD are needed to assess the thromboembolic risk during pregnancy.

Isolated fetal ventriculomegaly (VM) is often an incidental benign finding on antenatal ultrasound (US), although it can be associated with genetic, structural, and neurocognitive disorders. The literature suggests that over 40% of mild VM will resolve in utero. The aim of this study is to evaluate the fetal and neonatal outcomes of persistent versus resolved VM on serial ultrasound. A retrospective cohort study of women who were diagnosed with isolated VM at a tertiary referral center between 1/1/2011 and 7/1/2019. Patients were excluded if other structural anomalies were identified on US. Patients were divided into 2 groups based on whether the diagnosed VM resolved on serial prenatal US. Data was compared using Chi-squared, Fisher’s exact and Student’s t-test as appropriate. 51 patients were included in the study: 24 in the resolved VM group, and 27 in the persistent VM group. Women in both groups had similar age and incidence of aneuploidy screening. Women in the resolved VM group were more likely to be diagnosed earlier, carry a male fetus, and have mild VM. They were less likely to have an amniocentesis and have a child with neurodevelopmental delay. They were also less likely to have additional structural neurological anomalies and more likely to have a fetus with a genetic/chromosomal anomaly, although these differences were not statistically significant. Fetuses with resolved ventriculomegaly remain at an increased risk of having genetic/chromosomal anomalies, as well as childhood neurodevelopmental delay. This should be part of the counseling of these at-risk patients.

Objective Isolated fetal ventriculomegaly is often an incidental finding on antenatal ultrasound. It is benign in up to 90% of cases, although it can be associated with genetic, structural, and neurocognitive disorders. The literature suggests that over 40% of isolated mild ventriculomegaly will resolve in utero, but it is unclear if resolution decreases the associated risks.The aim of this study is to compare the fetal and neonatal genetic outcomes of ventriculomegaly that persists or resolves on subsequent ultrasound. Study Design This is a retrospective cohort study of women diagnosed with isolated ventriculomegaly via fetal ultrasound at a tertiary referral center between 2011 and 2019. Patients were excluded if other structural anomalies were identified on ultrasound. Results A total of 49 patients were included in the study, 19 in the resolved ventriculomegaly group and 30 in the persistent ventriculomegaly group. Women in the resolved ventriculomegaly group were more likely to be diagnosed earlier (24 vs. 28 weeks, p = 0.007). Additionally, they were more likely to have mild ventriculomegaly (63 vs. 84%, p = 0.15), and less likely to have structural neurological abnormalities diagnosed on postnatal imaging (5 vs. 17%, p = 0.384), although these were not statistically significant. Aneuploidy risk for resolved compared with persistent ventriculomegaly was similar (5 vs. 7%, p = 0.999). Conclusion This study suggests that resolution of isolated ventriculomegaly in utero may not eliminate the risk of genetic or chromosomal abnormalities in this population and may warrant inclusion as part of the counselling of these at-risk patients. Larger prospective studies are needed to confirm these findings. Key Points

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which has developed into a global pandemic with vast social, economic, and health consequences. High transmissibility in asymptomatic individuals makes controlling viral spread difficult and poses unprecedented challenges to healthcare systems. At the onset of the pandemic in the United States, 19% of reportable cases were healthcare workers (HCWs) with the majority reporting exposure within the workplace.1CDC COVID-19 Response TeamCharacteristics of health care personnel with COVID-19—United States, February 12-April 9, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 477-481Crossref PubMed Scopus (563) Google Scholar Although hospital protocols have morphed with increasing available data, there continues to be a variation in screening, testing, and personal protective equipment (PPE) use across the country. Obstetrical units are an underestimated hotspot in the pandemic, owing to an asymptomatic population, high patient turnover, integrated workstations, and frequent emergencies requiring response from multiple disciplines and expedient transfer to onsite surgical suites. These factors underscore current advocacy from professional obstetrical and anesthesia societies for universal PPE in obstetrical units and the use of N95 masks during vaginal deliveries of infected patients because of suspected aerosolization during this procedure.2American College of Obstetricians and GynecologistsACOG urges action on testing and PPE for labor and delivery. 2020.https://www.acog.org/en/News/News%20Articles/2020/04/ACOG%20Urges%20Action%20on%20Testing%20and%20PPE%20for%20Labor%20and%20DeliveryDate accessed: May 3, 2020Google Scholar,3Society for MFM and Society for Obstetric and Anesthesia and PerinatologyLabor and delivery COVID-19 considerations. 2020.https://s3.amazonaws.com/cdn.smfm.org/media/2327/SMFM-SOAP_COVID_LD_Considerations_-_revision_4-14-20_-_changes_highlighted.pdfDate accessed: May 3, 2020Google Scholar Therefore, we investigated the exposure and seroconversion to SARS-CoV-2 among obstetrical HCWs in a tertiary care center. This prospective cohort study investigated SARS-CoV-2 antibody levels in obstetrical HCWs at a tertiary hospital with approximately 5500 deliveries per year. The study included HCWs employed in the inpatient obstetrical unit. Written consent was obtained, and blood samples were obtained at 2 time points 4 weeks apart, with baseline collection beginning March 25, 2020, and follow-up on April 23, 2020. Data regarding the demographics, symptoms, previous nasopharyngeal polymerase chain reaction (PCR) results for SARS-CoV-2, and the timing of high-risk exposures were collected through a voluntary written survey. Immunoglobulin M (IgM) and Immunoglobulin G (IgG) levels in the serum were measured from whole blood samples of all study participants at the 2 time points using a validated SARS-CoV-2 enzyme-linked immunosorbent assay (ELISA) per manufacture's protocol (Novel Coronavirus COVID-19 IgG ELISA Kit; Epitope Diagnostics Inc, San Diego, CA).4Epitope Diagnostics, Inc. COVID-19, Diagnostic immunoassay solutions for coronavirus detection. 2020.https://eaglebio.com/wp-content/uploads/data-pdf/EagleBio-COVID-19-ELISA-Assay-04.15.20.pdfDate accessed: May 18, 2020Google Scholar The optical density ratio for positive IgM was >0.201 (negative cutoff value of <0.179) and positive IgG was >0.439 (negative cutoff value of <0.359). The minimal detectable concentration for IgM and IgG was 5 IU/mL. The inter- and intra-assay coefficients of variation were <15% and <20%, respectively. Participants were considered to have seroconverted if they had a positive result for IgM or IgG. Specimen collection began in accordance with institutional biorepository (Institutional Review Board [IRB] study #2013H0404), and specimen and data analysis continued with additional institutional approval (IRB study #2020H0133). Of note, an outbreak of SARS-CoV-2 among obstetrical HCWs in our inpatient unit occurred between baseline and follow-up blood collection, with the first positive case on March 26, 2020. Mandatory employee temperature and symptom screening began on March 27, 2020, and universal masking was enforced on April 1, 2020. A total of 110 obstetrical HCWs completed the survey and blood collection at the 2 time points. All participants were female with a median age of 34 years (interquartile range, 28.8–45.0) and predominantly white (86%). Most participants were registered nurses (68.2%), followed by obstetrical and anesthesia physicians (24.5%). At the time of the follow-up collection, 90 participants (82%) reported exposure to SARS-CoV-2; 66 (60%) reported 1 or more COVID-19 symptoms; 52 (47%) had nasopharyngeal PCR testing, of which 15 (29%) received a positive result for the virus (Figure and Supplemental Table). At baseline, 3 (2.7%) of the participants had positive antibodies, whereas 22 (20%) had positive antibodies at the time of the follow-up collection. A total of 14 (93%) of the participants who received a positive result for SARS-CoV-2 by nasopharyngeal PCR seroconverted. Notably, 3 (8.1%) participants who received a negative result for nasopharyngeal PCR had positive antibodies. An additional 2 participants had positive IgM and IgG antibodies on baseline sample and an IgG that persisted at 4 weeks; both were asymptomatic and did not undergo nasopharyngeal PCR testing. Furthermore, 3 participants without any nasopharyngeal PCR testing seroconverted to IgM only at 4 weeks. In total, 5 participants (4.5%) who reported being asymptomatic seroconverted at either of the 2 time points (Figure and Supplemental Figure). Reported symptoms in this cohort varied from headache (77.3%) as the most common to chest pain (18.2%) as the least. However, the most predictive symptoms for any positive SARS-CoV-2 test result (PCR or antibody) were loss of taste and loss of smell, both independently with a positive predictive value, sensitivity, and specificity of 87.5%, 60.9%, and 97.7%, respectively. Limited data are available on antibody testing for SARS-CoV-2 and our study presents seroconversion rates in high-risk HCWs after a contained outbreak within our unit. About 20% of our participants received a positive result for SARS-CoV-2 antibodies, and all but 1 participant that received a positive result for COVID-19 based on PCR had evidence of seroconversion (93%). Of further interest, antibody testing was positive in 3 participants who received negative PCR test results and 5 participants who reported no symptoms at all. In addition, our study evaluated a broad range of associated symptoms and found a loss of taste and smell to be the most predictive, which is a finding similar to other published reports.5Tostmann A. Bradley J. Bousema T. et al.Strong associations and moderate predictive value of early symptoms for SARS-CoV-2 test positivity among healthcare workers, the Netherlands, March 2020.Euro Surveill. 2020; 25: 2000508Crossref Scopus (166) Google Scholar

Introduction: Pregnancy is contraindicated in women with pulmonary hypertension (PH), yet many still decide to pursue pregnancy. Hypothesis: We hypothesized improved maternal mortality with PH at our center’s cardio-obstetrics program and sought to identify factors to estimate the risk of major adverse cardiac events (MACE). Methods: Pregnant women with right ventricular systolic pressure (RVSP) ≥35 mmHg or tricuspid regurgitant velocity > 2.8 m/s on transthoracic echocardiogram (TTE) were identified. Women with intermediate to high probability PH by ESC criteria (TTE or catheterization, n = 70) were classified using the 6 th World Society of PH definitions. Results: In 70 women with PH (30 ± 6 years-old, RVSP 52 ± 16 mmHg) there were 12 (17%) with WHO Group 1 PH, 45 (64%) with Group 2 PH, 4 (6%) with Group 3 PH and 9 (13%) with Group 5 PH (Figure A). Baseline characteristics were similar except: Group 1 PH had 83% on prostacyclin (PC) therapy, higher RVSP (78 ± 20 mmHg vs. Groups 2 (46 ± 9), 3 (44 ± 2 mmHg) and 5 PH (48 ± 10mmHg), p<0.01), and compared to Group 2 PH, more Group 1 PH women were diagnosed pre-pregnancy (9 (75%) vs. 12 (27%), p = 0.01) and had cardio-obstetrics care (10 (83%) vs. 16 (36%), p < 0.01) (Figure B - E). There were no peripartum deaths, however 3 (4.3%) women with Group 2 PH had late mortality (7 ± 4 months post-partum). MACE occurred in 24 (34%) women and was more likely in those with: NYHA FC ≥ 2 (95% CI 4.7-57, p < 0.01), pre-eclampsia (95% CI 1.2-13, p = 0.03), RVSP >50 mmHg (95% CI 1.3-10, p = 0.02) and LVEF <50% (95% CI 1.1-8.8, p = 0.04) (Figure F). Preterm birth occurred in 32 (49%) pregnancies, with no neonatal mortality. Conclusion: To conclude, in a large single center cohort we report 100% 1-year survival in Groups 1, 3, and 5 PH, with most Group 1 PH patients on PC therapy and under cardio-obstetrics care. We identify Group 2 PH as an under-recognized group for adverse outcomes in pregnancy, with NYHA FC, pre-eclampsia, RVSP >50 mmHg and LVEF <50% associated with increased MACE.

Background: Preeclampsia (PE) is a pregnancy-specific vascular endothelial disorder characterized by multiorgan system involvement. This includes the maternal kidneys, with changes such as continuous vasospasm of renal arteries and reduced renal blood flow. However, it is unclear whether similar renal vascular changes are seen in the fetus. This study sought to compare renal artery impedance in fetuses of women with and without PE. Methods: This was a prospective Doppler assessment study of the fetal renal artery impedance in 48 singleton fetuses. The group with PE consisted of 24 appropriately grown fetuses in pregnancy complicated by both mild and severe PE and a control group of 24 uncomplicated pregnancies. Doppler studies included renal artery systolic/diastolic (S/D) ratio, pulsatility index (PI), resistance index (RI), and identification of end-diastolic blood flow. Results: Fetuses of mothers with PE were more likely to have a lower renal artery Doppler S/D ratio (7.85 [6.4-10.2] vs. 10.8 [7.75-22.5], P=0.03) and lower RI (0.875 [0.8420.898] vs. 0.905 [0.872-0.957], P= 0.03). However, there was no statistically significant difference in PI. There was also no difference in the incidence of absent end-diastolic flow. Conclusion: This study suggests that PE results in changes in blood flow to the renal arteries of the fetus. This may be associated with long-term adverse health effects later in adulthood.

The current standard is that hospitals should have the ability to initiate an emergent cesarean within 30 minutes (min), but there is a paucity of evidence to support this threshold. Our objectives were to: 1) examine the relationship between decision-to-incision (DI) interval in emergent cesareans on adverse neonatal outcomes; and 2) explore cut-points for DI time intervals which maximize sensitivity to adverse neonatal outcomes. This retrospective cohort study included all women delivered by emergent cesarean delivery at ≥24 weeks' gestation over 2 years at a single institution with in-house obstetric and anesthesia staff. Women with a multifetal pregnancy or a fetus with a major anomaly were excluded. During the study, the designation of a cesarean as emergent was documented in the medical record at the time of surgery and a decision time for all emergent cesarean deliveries was recorded. Adverse neonatal outcome was defined as ≥1 of the following: umbilical artery pH <7.0, 5-min APGAR <5, intrapartum stillbirth, or neonatal death. The sensitivity and specificity was estimated for a range of cut-points for DI time interval. The variability of sensitivities at these cut-points was illustrated through bias corrected (BCa) confidence intervals. The estimated effect of DI time on adverse neonatal outcomes was estimated through generalized marginal models, weighted by the stabilized inverse probability weight for each determined optimal cut-point. Of 169 emergency cesareans, 14.8% (n=25) of infants had an adverse neonatal outcome. Only 4% (n=7) patients had a DI interval ≥30 min. Using bootstrap re-sampling, the optimal cut-off to ensure sensitivity above 80% for DI interval was determined to be ≥7 min (n=118 women). The sensitivity of a DI interval ≥7 min for the adverse neonatal outcome was 88% (90% BCa CI: 0.80, 0.96). DI interval ≥7 min was associated with an increased risk of adverse neonatal outcome, when adjusted for confounders (aRR: 2.7, 95% CI: 0.78, 9.23); however this estimate had high variability. The optimal DI time interval appears shorter than the current standard of 30 min. Nevertheless, factors other than DI interval may also influence on the risk of adverse neonatal outcomes in the setting of an emergency cesarean.

Contractions are produced through a complex interplay of hormonal, mechanical, and electrical factors. In labor, contractions are measured using the Montevideo unit. Clinical considerations in labor wherein contraction assessment becomes paramount include the care of women whose labor is complicated by abnormal progress or tachysystole. In an era of obstetrics in which the high cesarean rate is a major issue of concern, there remain many questions as to how to best incorporate contraction monitoring into practice in order to optimize care. Technological advancement has led to the development on new modalities that can be used to study contraction physiology, and there may be an opportunity in the future to apply these methods for use in the clinical setting. This article also makes a case for the need to reevaluate the current measures of uterine contractile activity and the definition of contraction adequacy using updated definitions of normal labor progress.

Objective This study aimed to determine if intrapartum placement of an intrauterine pressure catheter (IUPC) is associated with an increased rate of surgical site infections in women undergoing a cesarean delivery. Study Design This was a secondary analysis of the prospective observational Maternal-Fetal Medicine Units Network Vaginal Birth after Cesarean Registry. We compared patients with and without IUPC use. A multivariable logistic regression was performed to evaluate for an association between IUPC use and postcesarean surgical site infections. Results The study included 16,887 women: 7,441 with IUPC use and 9,446 without IUPC use. After adjustment for potential cofounders, IUPC use was associated with an increased risk of postcesarean infections compared with those without IUPC use (adjusted odds ratio: 1.28; 95% confidence interval: 1.10-1.50; p = 0.002). Conclusion IUPC use is associated with an increased risk of postcesarean surgical site infections. This supports the judicious use of IUPC for limited clinical indications and provides a potential area of focus for reduction in postcesarean infections.

INTRODUCTION: Surgical site infection (SSI) rates are increasingly being linked to payment incentives for hospitals and represent an important clinical quality indicator of care. Clinical interventions aimed to significantly reduce cost and morbidity can be designed through identification of key predisposing obstetrical risk factors for SSI. Studies conducted in a limited number of subjects suggest an association between IUPC and post-partum endomyometritis. Our objective was to examine the relationship between intra-partum use of IUPC and risk of post-cesarean SSI. METHODS: We performed a secondary analysis using data from Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry (1999-2002). Patients included in this analysis had a singleton viable pregnancy and a cesarean delivery following labor for recognized obstetrical indication from 24 to 42 weeks gestational age (GA). A multivariable logistic regression model was used to control for GA, race, BMI at delivery, smoking, limited prenatal care, length of labor, length of membrane rupture, PPROM, pre-gestational diabetes, hypertensive diseases, physical health status assessed using American Society of Anesthesiologists established categories, and maternal clinical chorioamnionitis. RESULTS: 25,986 women were included in this analysis. The rate of SSI was 12.9% (1,542 of 11,941) in the patients with IUPC and 7.8% (1,099 of 14,045) in the patients without IUPC (P= < 0.001). The adjusted Odds Ratio for SSI among patients who had IUPC was 1.40, (95% CI=1.26-1.57, P= < 0.001). CONCLUSION: We present compelling data that in laboring women undergoing cesarean delivery, the use of IUPC is an independent risk factor for post-cesarean SSI.