OBJECTIVE Delayed cord clamping has been shown to decrease the need for transfusion in preterm neonates, but may delay resuscitation. The aim of this study was to determine whether umbilical cord milking compared with immediate cord clamping in extremely preterm deliveries reduces the need for neonatal red blood cell transfusion. STUDY DESIGN Women admitted to a tertiary care center and expected to deliver between 24 to 28 completed weeks of gestation were randomized to cord milking before clamping or immediate cord clamping. The primary outcome was the risk of neonatal transfusion, reported as risk ratio (RR) and 95% confidence interval (CI). RESULT Of 113 women who were enrolled and randomized, 56 were assigned to cord milking with 36 remaining eligible and completing the study and 57 were assigned to the control group with 39 remaining eligible and completing the study. Albeit not statistically significant, neonates in the cord milking group were less likely to require transfusion compared with those in the control group (RR: 0.86; 95% CI: 0.73 to 1.0). Neonates whose cords were milked had higher hematocrits at birth (P = 0.004) and were less likely to develop an intraventricular hemorrhage (P = 0.0195). CONCLUSION Milking the umbilical cord of a preterm neonate is an easy intervention with the potential to improve perinatal outcomes. Our results suggest that milking of the cord increases the neonate’s initial hematocrit and may lessen the need for transfusion in the neonatal period. The observed reduction in the incidence of intraventricular hemorrhage may have important long-term implications that warrant further study.

To evaluate whether angiogenic factor levels correlate with preeclampsia-related adverse maternal and perinatal outcomes in women with twin pregnancy, we studied 79 women with suspected preeclampsia in the 3rd trimester. Anti-angiogenic soluble fms-like tyrosine kinase 1 (sFlt1) and pro-angiogenic placental growth factor (PlGF) were measured at presentation on an automated platform. An adverse outcome was defined as hemolysis elevated liver enzymes and low platelets syndrome; disseminated intravascular coagulation; abruption; pulmonary edema; cerebral hemorrhage; maternal, fetal and neonatal death; eclampsia; acute renal failure; small for gestational age; and indicated delivery. All outcomes were ascertained 2 weeks after initial evaluation. Comparing the 52 (65.8%) women who experienced an adverse outcome to the 27 (34.2%) women without an adverse outcome, the median sFlt1 was elevated [11461.5 pg/ml (8794.0–14847.5) versus 7495.0 pg/ml (3498.0–10482.0, P=0.0004], PlGF was reduced [162.5 pg/ml (98.0–226.5) versus 224.0 pg/ml (156.0–449.0), P=0.005] and sFlt1/PlGF ratio was elevated [74.2 (43.5–110.5) versus 36.2 (7.1–71.3), P=0.0005]. Among those presenting <34 weeks (n=40), the difference in sFlt1/PlGF ratio was more striking [97.7 (76.6–178.1) versus 31.7 (6.5–48.7); P=0.001]. Addition of sFlt1/PlGF to the highest systolic blood pressure and proteinuria improved prediction of adverse outcomes. We conclude that in women with twin pregnancy and suspected preeclampsia, the sFlt1/PlGF ratio at the time of initial evaluation is associated with subsequent adverse maternal and perinatal outcomes. These findings are similar to singleton pregnancies and may implicate common pathogenic pathways.

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Objective To assess intralevator Botulinum toxin type A (Botox) injections for refractory myofascial pelvic pain with short tight pelvic floor. Methods Retrospective cohort study of all women with intralevator Botox injection (100-300 Units) from 2005 through 2010 for refractory myofascial pelvic pain. Primary outcomes were self-reported pain on palpation and symptom improvement. Secondary outcomes included post-injection complications and repeat injection. Pain was assessed during digital palpation of the pelvic floor muscles using a scale of 0-10, with 10 being the worst possible pain. Follow-up occurred at <6 weeks post-injection and again at ≥ 6 weeks. Data are presented as median (interquartile range) or proportion. Results Thirty-one patients met eligibility criteria; 2 were lost to follow up and excluded. Median age was 55.0 years (38.0-62.0). Before Botox injection, median pain score was 9.5 (8.0-10.0). Twenty-nine patients (93.5%) returned for the first follow-up visit; 79.3% reported improvement in pain, while 20.7% reported no improvement. Median pain with levator palpation was significantly lower than before injection (P<0.0001). Eighteen women (58.0%) had a second follow-up visit with a median pain score that remained lower than before injection (P<0.0001). Fifteen (51.7%) women elected to have repeat Botox injection; the median time to repeat injection was 4.0 (3.0-7.0) months. Three (10.3%) women developed de-novo urinary retention, 2 (6.9%) reported fecal incontinence and 3 (10.3%) reported constipation and/or rectal pain; all side effects resolved spontaneously. Conclusions Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few, self-limiting adverse effects.

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Objective The incidence of placenta accreta spectrum (PAS) has been increasing in the United States. In addition, there has also been an increase in the utilization of in vitro fertilization (IVF). The IVF pregnancies confer an increased risk of adverse obstetric and neonatal outcomes, but there is limited data on whether IVF is associated with PAS. The aim of this study is to assess the association between IVF and the risk of PAS. Study Design This was a retrospective cohort study of deliveries from January 1, 2013 to August 1, 2018 at a tertiary hospital in the Massachusetts. IVF pregnancies were compared with non-IVF pregnancies, and PAS diagnosis was confirmed by histopathology reports. Hospital administrative data and medical record review were used, and supplemented with data from birth certificates from the Massachusetts Department of Public Health. Results We identified 28,344 pregnancies that met inclusion criteria, of which 1,418 (5.0%) were IVF pregnancies. The overall incidence of PAS was 0.4% (2.2% in the IVF group and 0.3% in the non-IVF group). Women who underwent IVF had 5.5 times the risk of PAS (95% confidence interval [CI]: 3.4–8.7) compared with women in the non-IVF group, adjusted for maternal age, nulliparity, and year of delivery (Table 5). Compared with women in the non-IVF group, the IVF group had fewer prior cesarean deliveries (22.6 vs. 64.2%) and a lower prevalence of placenta previa (19.4 vs. 44.4%). Conclusion Women with an IVF pregnancy carry an increased risk of PAS compared with non-IVF. Among women who underwent IVF, there was a lower prevalence of prior cesarean deliveries and placenta previa. Future work is needed to identify the mechanism of association for this increased risk as well as a reliable tool for antenatal detection in this cohort of women. Key Points

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Introduction and hypothesis Many providers recommend concurrent estrogen therapy with pessary use to limit complications; however, limited data exist to support this practice. We hypothesized that vaginal estrogen supplementation decreases incidence of pessary-related complications and discontinuation. Methods We performed a retrospective cohort study of women who underwent a pessary fitting from 1 January 2007 through 1 September 2013 at one institution; participants were identified by billing code and were eligible if they were post-menopausal and had at least 3 months of pessary use and 6 months of follow-up. All tests were two sided, and P values < 0.05 were considered statistically significant. Results Data from 199 women were included; 134 used vaginal estrogen and 65 did not. Women who used vaginal estrogen had a longer median follow-up time (29.5 months) compared with women who did not (15.4 months) and were more likely to have at least one pessary check (98.5 % vs 86.2 %, P < 0.001). Those in the estrogen group were less likely to discontinue using their pessary (30.6 % vs 58.5 %, P < 0.001) and less likely to develop increased vaginal discharge than women who did not [hazard ratio (HR) 0.31, 95 % confidence interval (CI) 0.17–0.58]. Vaginal estrogen was not protective against erosions (HR 0.93, 95 % CI 0.54–1.6) or vaginal bleeding (HR 0.78, 95 % CI 0.36–1.7). Conclusions Women who used vaginal estrogen exhibited a higher incidence of continued pessary use and lower incidence of increased vaginal discharge than women who did not.