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Anti-N-methyl-D-aspartate receptor encephalitis in pregnancy can lead to NMDA receptor antibodies in the fetal circulation. Pregnancy interruption through early delivery with or without oophorectomy may accelerate maternal recovery.

OBJECTIVE Early initiation of low-dose aspirin (LDA) may reduce preeclampsia risk. We sought to determine whether LDA was beneficial when initiated <17w0d, within a trial of high-risk women enrolled <26w0d. STUDY DESIGN Secondary analysis of the Maternal-Fetal Medicine Units High-Risk Aspirin study, including women enrolled <17w0d, randomized to LDA (60 mg day−1) or placebo with chronic hypertension (CHTN, n = 186), diabetes (n = 191) or prior preeclampsia (n = 146). The primary outcome was preeclampsia at any time in pregnancy, secondary outcomes were early preeclampsia (<34w0d), late preeclampsia (⩾34w), small for gestational age (SGA; neonatal birthweight <10th %) and composite (early preeclampsia or SGA). Outcomes were compared by exact X2-tests. RESULTS Baseline characteristics were similar between treatment groups. Aspirin was associated with a lower rate of late-onset preeclampsia ⩾ 34w (17.36% vs 24.42%, P = 0.047), with a 41% reduction in women with CHTN (18.28% vs 31.18%, P = 0.041). There were no other significant differences in the outcome. CONCLUSION Aspirin initiated <17w0d reduced the risk for late-onset preeclampsia by 29% supporting the practice of early initiation of aspirin in high-risk women.

Soft tissue measurements of the fetal thigh at 28 weeks correlated better with neonatal percent body fat than currently used sonographic measurements. After validation in a larger cohort, our models may be useful for prenatal intervention strategies aimed at the prevention of excess fetal fat accretion and, potentially, optimization of long-term metabolic health.

OBJECTIVE We aimed to determine if a threshold number of forceps deliveries in residency predicts use of forceps in independent practice. STUDY DESIGN We surveyed Obstetrics and Gynecology residency graduates of two academic programs from 2008-12 regarding the use of operative vaginal delivery in practice. At these programs, residents are trained in both forceps and vacuums. Individual case log data were obtained with the number of forceps deliveries performed by each respondent during residency. Respondents were grouped as currently using any forceps or vacuums alone. A logistic regression model estimated the probability of forceps use, predicted by the number of residency forceps deliveries. From the resulting receiver operating characteristic curve we assessed sensitivity, specificity, positive predictive value and area under the curve. RESULTS The response rate was 85% (n=58); 90% (n=52) practice obstetrics. Seventy-nine percent (n=41) use forceps in practice. The mean number of forceps performed during residency was 22.3 ± 1.3 (mean ± standard error) in the any forceps group and 18.5 ± 2.1 in the vacuums only group (p=0.14). While the model performed only moderately (area under the curve 0.61, 0.42–0.81), more than 13 residency forceps deliveries corresponded to a 95% sensitivity (95% CI, 84–99) and a positive predictive value of 83% (95% CI, 69–92) for using forceps in practice. The specificity of this threshold is 27% (95% CI, 6–61). CONCLUSION While exceeding 13 forceps deliveries made it highly likely that obstetricians would use them in practice, further study is necessary to set goals for a number of resident forceps deliveries that translate into use in practice.

OBJECTIVE To characterize the risks of CIN3 and cancer in women age 21–24 with human papillomavirus (HPV)-positive atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) screening results in routine clinical practice. MATERIALS AND METHODS Quality assurance databases containing records of screening test and histology results from the Northern California Kaiser Permanente Medical Care Program Regional Lab were reviewed. Numbers of LSIL and HPV-positive ASC-US results and associated cancers and CIN3 in women age 21–24 during 2003–2007 were tabulated and the corresponding risks calculated overall and by year of age. RESULTS During the 5 year period 2003 to 2007, 1620 HPV-positive ASC-US and 2,175 LSIL were diagnosed in women age 21–24, for which corresponding histology is available. No invasive cancers were detected in association with LSIL and HPV-positive ASC-US screening results in this age group during this time period. The risk of cancer was therefore 0% (95%CI = 0.00%–0.10%). The risk of CIN3 associated with an HPV-positive ASC-US was 2.90% (95%CI = 2.14%–3.84%), with LSIL was 2.44% (95%CI = 1.83%–3.18%), and for the two combined the risk was 2.64% (95%CI = 2.15%–3.20%) CONCLUSION The risk of CIN3 and cancer is low enough that management of women age 21–24 with ASC-US and LSIL smears without immediate colposcopy should be considered, as is currently recommended for women age 20 and under.

Introduction Although fetal brain injury due to COL4A1 gene mutation is well documented, fetal central nervous system (CNS) and placental histopathology lack description. We report CNS and placental pathology in fetal cases with symptomatic COL4A1 mutation. Methods We retrieved four autopsy cases of COL4A1 related disease, confirmed by genetic sequencing after fetal brain injury was detected. Results One case was a midgestation fetus with residua of ventricular zone hemorrhage and normal placental villi. Three cases were 30-32 week gestation fetuses: two demonstrated CNS small vessel thrombosis, with CNS injury. Both demonstrated high grade placental fetal vascular malperfusion (FVM). One additionally showed villous dysmorphism, the other demonstrated mild villous immaturity. The fetus whose placenta demonstrated high grade FVM was growth restricted. A fourth fetus demonstrated schizencephaly with a CNS arteriopathy with smooth muscle cell degeneration and cerebral infarcts; the placenta demonstrated severe villous dysmorphism and low grade FVM. Discussion These cases confirm that small vessel disease is important in producing intracranial pathology in COL4A1mutation. We report an arteriopathy distinct from microvascular thrombosis and demonstrate that placental pathology is common in fetal COL4A1 related disease. This tentatively suggests that placental pathology may contribute to CNS abnormalities by affecting circulatory sufficiency.

Comparison of Two Timing Strategies for Third-Trimester Sonographybstetricians regularly use fetal weight estimates in delivery management, particularly in women with diabetes. Larger fetuses are at increased risk for perinatal complications such as shoulder dystocia and birth injury 1 due to both a larger size and relative body-to-head disproportion (which is more common in patients with diabetes). For this reason, patients with diabetes who Gaea S. Moore, MD, Annalisa L. Post, MD, Nancy A. West, PhD, Jan E. Hart, MSPH, Anne M. Lynch, MB, BCh, BAO, MSPH Received April 17, 2014, Objectives-The gestation-adjusted projection method extrapolates birth weight using third-trimester sonography. This technique is shown to be more accurate for sonographic examinations from 34 weeks to 36 weeks 6 days than 37 weeks to 38 weeks 6 days. Our objective was to determine whether even earlier sonographic examinations (31 weeks-33 weeks 6 days) further improves birth weight prediction in patients with diabetes.Methods-We conducted a retrospective cohort analysis of 388 pregnant women with pregestational or gestational diabetes who delivered at 37 weeks or later and had a sonographic examination performed between 31 weeks and 36 weeks 6 days. Sonographic examinations were categorized as "early" if performed at 31 weeks to 33 weeks 6 days or "late" if performed at 34 weeks to 36 weeks 6 days. We estimated birth weight using the gestation-adjusted projection method, compared errors in prediction of birth weight using the t test and Mann-Whitney U test, and performed a 2-sample test of proportions to compare prediction of macrosomia (birth weight >4000 g).Results-The early and late groups had similar mean gestational ages at birth (38 weeks 4 days versus 38 weeks 5 days; P = .13) and rates of macrosomia (10.7% versus 12.4%; P = .63). The early group had a greater mean absolute error (336 versus 297 g; P = .03) and percent error (9.9% versus 7.9%; P = .01) in birth weight prediction but a lower mean birth weight (3303 versus 3426 g; P = .02). Sensitivity for prediction of macrosomia was 19% in the early group versus 45% in the late group (P = .07), whereas specificity was similar (98% versus 96%; P = .27).Conclusions-Using the gestation-adjusted projection method in our patients with diabetes, we found that sonographic examinations performed at 34 weeks to 36 weeks 6 days better predicted birth weight than those performed at 31 weeks to 33 weeks 6 days.