Objectives To assess the precision magnetic resonance imaging (MRI) in the neonate and determine if there is an early maternal influence on the pattern of neonatal fat deposition in the offspring of mothers with gestational diabetes (GDM) and obesity compared with the offspring of normal weight women. Study design 25 neonates, born to normal weight mothers (n=13) and to obese mothers with GDM (n=12), underwent MRI for measurement of subcutaneous and intra-abdominal fat and magnetic resonance spectroscopy for the measurement of intrahepatocellular (IHCL) fat at 1-3 weeks of age. Results Infants born to obese/GDM mothers had a mean 68% increase in IHCL compared with infants born to normal weight mothers. For all infants, IHCL correlated with maternal pre-pregnancy BMI but not with subcutaneous adiposity. Conclusion Deposition of liver fat in the neonate correlates highly with maternal BMI. This finding may have implications for understanding the developmental origins of childhood NAFLD.

In our population, of all the factors assessed, only tobacco use and preceding high-grade Pap tests were associated with positive margins at time of LEEP. This information may be helpful in preprocedural planning to optimize treatment.

IMPORTANCEWomen with an early nonviable pregnancy of unknown location are at high risk of ectopic pregnancy and its inherent morbidity and mortality. Successful and timely resolution of the gestation, while minimizing unscheduled interventions, are important priorities.OBJECTIVE To determine if active management is more effective in achieving pregnancy resolution than expectant management and whether the use of empirical methotrexate is noninferior to uterine evacuation followed by methotrexate if needed. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial recruited 255 hemodynamically stable women with a diagnosed persisting pregnancy of unknown location between July 25, 2014, and June 4, 2019, in 12 medical centers in the United States (final follow up, August 19, 2019).INTERVENTIONS Eligible patients were randomized in a 1:1:1 ratio to expectant management (n = 86), active management with uterine evacuation followed by methotrexate if needed (n = 87), or active management with empirical methotrexate using a 2-dose protocol (n = 82). MAIN OUTCOMES AND MEASURESThe primary outcome was successful resolution of the pregnancy without change from initial strategy. The primary hypothesis tested for superiority of the active groups combined vs expectant management, and a secondary hypothesis tested for noninferiority of empirical methotrexate compared with uterine evacuation with methotrexate as needed using a noninferiority margin of −12%. RESULTS Among 255 patients who were randomized (median age, 31 years; interquartile range, 27-36 years), 253 (99.2%) completed the trial. Ninety-nine patients (39%) declined their randomized allocation (26.7% declined expectant management, 48.3% declined uterine evacuation, and 41.5% declined empirical methotrexate) and crossed over to a different group. Compared with patients randomized to receive expectant management (n = 86), women randomized to receive active management (n = 169) were significantly more likely to experience successful pregnancy resolution without change in their initial management strategy (51.5% vs 36.0%; difference, 15.4% [95% CI, 2.8% to 28.1%]; rate ratio, 1.43 [95% CI, 1.04 to 1.96]). Among active management strategies, empirical methotrexate was noninferior to uterine evacuation followed by methotrexate if needed with regard to successful pregnancy resolution without change in management strategy (54.9% vs 48.3%; difference, 6.6% [1-sided 97.5% CI, −8.4% to ϱ]). The most common adverse event was vaginal bleeding for all of the 3 management groups (44.2%-52.9%).CONCLUSIONS AND RELEVANCE Among patients with a persisting pregnancy of unknown location, patients randomized to receive active management, compared with those randomized to receive expectant management, more frequently achieved successful pregnancy resolution without change from the initial management strategy. The substantial crossover between groups should be considered when interpreting the results.

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.