Covid-19 CasesTo rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a series of case reports that offer important teaching points or novel findings. The case reports should be viewed as observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports are evaluated by in-house editors, with peer review reserved for key points as needed.

Objective-We sought to determine predictors of adverse neonatal outcomes in women with intrahepatic cholestasis of pregnancy (ICP).Study Design-This study was a multicenter retrospective cohort study of all women diagnosed with ICP across 5 hospital facilities from January 2009 through December 2014. Obstetric and neonatal complications were evaluated according to total bile acid (TBA) level. Multivariable logistic regression models were developed to evaluate predictors of composite neonatal outcome (neonatal intensive care unit admission, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, transient tachypnea of the newborn, mechanical ventilation use, oxygen by nasal cannula, pneumonia, and stillbirth). Predictors including TBA level, hepatic transaminase level, gestational age at diagnosis, underlying liver disease, and use of ursodeoxycholic acid were evaluated.Results-Of 233 women with ICP, 152 women had TBA levels 10-39.9 μmol/L, 55 had TBA 40-99.9 μmol/L, and 26 had TBA ≥100 μmol/L. There was no difference in maternal age, ethnicity, or prepregnancy body mass index according to TBA level. Increasing TBA level was associated with higher hepatic transaminase and total bilirubin level (P < .05). TBA levels ≥100 μmol/L were associated with increased risk of stillbirth (P< .01). Increasing TBA level was also associated with earlier gestational age at diagnosis (P< .01) and ursodeoxycholic acid use (P = . 02). After adjusting for confounders, no predictors were associated with composite neonatal morbidity. TBA 40-99.9 μmol/L and TBA ≥100 μmol/L were associated with increased risk of meconium-stained amniotic fluid (adjusted odds ratio, 3.55; 95% confidence interval, 1. 45-8.68 and adjusted odds ratio, 4.55; 95% confidence interval, 1.47-14.08, respectively).Corresponding author: Tetsuya Kawakita, MD. tetsuya.x.kawakita@gunet.georgetown.edu. The authors report no conflict of interest.Presented at the 35th annual meeting of the Society for Maternal-Fetal Medicine, San Diego, CA, Feb. 2-7, 2015. Conclusion-In women with ICP, TBA level ≥100 μmol/L was associated with increased risk of stillbirth. TBA ≥40 μmol/L was associated with increased risk of meconium-stained amniotic fluid. HHS Public AccessKeywords bile acid; intrahepatic cholestasis of pregnancy; neonatal outcome; ursodeoxycholic acid Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease in pregnancy characterized by pruritus, elevated total serum bile acids, and elevated liver enzymes. ICP is associated with increased risk of preterm birth (19-60%), meconium passage <37 weeks (17.9%), intrapartum nonreassuring fetal heart tracing (22-41%), respiratory distress syndrome (RDS) (29%), and stillbirth (0.75-7%). 1-4 Based on high rates of stillbirth and neonatal morbidity, early delivery is often advocated to reduce the risk of term stillbirth. In the absence of evidence-based guidelines for optimal timing of delivery, induction of labor at 36-37 weeks of gestation or after documenting fetal lung maturity is freque...

Objective To evaluate maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor. Methods Retrospective study of 2,518 women carrying singleton fetuses at ≥37 weeks gestation who underwent attempted forceps-assisted delivery, attempted vacuum-assisted vaginal delivery, or cesarean delivery from a low station in the second stage of labor. Primary outcomes were stratified by parity and included a maternal adverse outcome composite (postpartum hemorrhage, transfusion, endometritis, peripartum hysterectomy, or intensive care unit {ICU} admission) and a neonatal adverse outcome composite (5 minute Apgar<4, respiratory morbidity, neonatal intensive care unit {NICU} admission, shoulder dystocia, birth trauma, or sepsis). Results In nulliparous patients the maternal adverse composite was not significantly different between women who underwent attempted forceps (12.1% vs.10.8%,aOR 0.77,95%CI 0.40–1.34) or vacuum (8.3% vs. 10.8%,aOR 0.68,95%CI 0.40–1.16) delivery compared to cesarean delivery. Among parous women, the maternal adverse composite was not significantly different with attempted forceps (10.7% vs. 12.5%,aOR 0.40,95%CI 0.09–1.71) or vacuum (11.3% vs. 12.5%,aOR 0.44,95%CI 0.11–1.72) compared to cesarean delivery. Compared to infants delivered by cesarean, the neonatal adverse composite was significantly lower among infants born to nulliparous women who underwent attempted forceps (9.4% vs. 16.7%,aOR 0.44,95%CI 0.27–0.72) but not among those who underwent vacuum delivery (11.9% vs. 16.7%,aOR 0.68,95%CI 0.44–1.04). Among parous women, the neonatal adverse composite was not significantly different after attempted forceps (4.1% vs 12.5%,aOR 0.28,95%CI 0.06–1.35) or vacuum (12.5% vs. 12.5%,aOR 1.03,95%CI 0.28–3.87) compared to cesarean delivery. Conclusion A trial of forceps delivery from a low station compared to cesarean delivery was associated with decreased neonatal morbidity among infants born to nulliparous women.

ObjectiveThe relationship between placental and fetal brain growth is poorly understood, and difficult to assess. The objective of this study was to interrogate placental and fetal brain growth in healthy pregnancies and those complicated by fetal growth restriction (FGR).Study DesignIn a prospective, observational study, pregnant women with normal pregnancies or pregnancies complicated by FGR underwent fetal MR imaging. Placental, global and regional brain volumes were calculated.Results114 women (79 controls and 35 FGR) underwent MR imaging (median GA 30 weeks, range 18 –39). All measured volumes increased exponentially with advancing GA. Placental, total brain, cerebral and cerebellar volumes were smaller in FGR compared to controls (p<0.05). Increasing placental volume was associated with increasing cerebral and cerebellar volumes (p<0.05).ConclusionQuantitative fetal MRI can accurately detect decreased placental and brain volumes in pregnancies with FGR and may provide insight into the timing and mechanisms of brain injury in FGR.

Background Obesity is a known risk factor for cesarean delivery. Limited data are available regarding the reasons for the increased rate of primary cesarean in obese women. It is important to identify the factors leading to an increased risk of cesarean to identify opportunities to reduce the primary cesarean rate. Objective We evaluated indications for primary cesarean across body mass index kg/m2 classes to identify the factors contributing to the increase rate of cesarean among obese women. Study design In the Consortium of Safe Labor study between 2002 and 2008, we calculated indications for primary cesarean including failure to progress or cephalopelvic disproportion, non-reassuring fetal heart tracing, malpresentation, elective, hypertensive disease, multiple gestation, placenta previa or vasa previa, failed induction, human immunodeficiency virus or active herpes simplex virus, history of uterine scar, fetal indication, placental abruption, chorioamnionitis, macrosomia, and failed operative delivery. For women with primary cesarean for failure to progress or cephalopelvic disproportion, dilation at the last recorded cervical examination was evaluated. Women were categorized according to body mass index on admission: normal weight (18.5-24.9), overweight (25.0-29.9), obese class I (30.0-34.9), II (35.0-39.9), and III (≥40). Cochran-Armitage Trend Test and Chi-square tests were performed. Results Of 66,502 nulliparous and 76,961 multiparous women in the study population, 19,431 nulliparous (29.2%) and 7,329 multiparous women (9.5%) underwent primary cesarean. Regardless of parity, malpresentation, failure to progress or cephalopelvic disproportion, and non-reassuring fetal heart tracing were the common indications for primary cesarean. Regardless of parity, the rates of primary cesarean for failure to progress or cephalopelvic disproportion increased with increasing body mass index (normal weight, class I, II and III obesity in nulliparous: 33.2%, 41.6%, 46.4%, 47.4%, and 48.9% [P<.01] and multiparous women: 14.5%, 20.3%, 22.8%, 27.2%, and 25.3% [P<.01]), whereas the rates for malpresentation decreased (normal weight, class I, II and III obesity in nulliparous: 23.7%, 17.2%, 14.6%, 12.0%, and 9.1% [P<.01] and multiparous women: 35.6%, 30.6%, 26.5%, 24.3%, and 22.9% [P<.01]). Rates of primary cesarean for non-reassuring fetal heart tracing were not statistically different for nulliparous (P>.05) or multiparous women (P>.05). Among nulliparous women who had a primary cesarean for failure to progress or cephalopelvic disproportion, rates of cesarean prior to active labor (6 cm) increased as body mass index increased, accounting for 39.3% of women with class I, 47.1% of women with class II and 56.8% of women with class III obesity compared to 35.2% for normal weight women (P<.01). Conclusion Similar to normal weight women, the indication of cesarean for failure to progress or cephalopelvic disproportion was the major factor contributing to the increase in primary cesarean in obese women, but was even m...

Intrauterine vacuum-induced hemorrhage control may provide an effective treatment option for postpartum hemorrhage that has the potential to prevent severe maternal morbidity and mortality.

Background Data on complications associated with classical cesarean delivery are conflicting. In extremely preterm cesarean delivery (22 0/7–27 6/7 weeks’ gestation), the lower uterine segment is thicker. It is plausible that the rates of maternal complications may not differ between classical and low transverse cesarean. Objective To compare maternal outcomes associated with classical comparing with low transverse cesarean after stratifying by gestation (23 0/7–27 6/7 and 28 0/7–31 6/7 weeks’ gestation). Study design We conducted a multi-hospital retrospective cohort study of women undergoing cesarean delivery at 23 0/7–31 6/7 weeks’ gestation between 2005 and 2014. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and Intensive Care Unit admission) was compared between classical and low transverse cesarean. Outcomes were calculated using multivariable logistic regression models yielding adjusted odds ratios with 95% confidence intervals and adjusted p-values controlling for maternal characteristics, emergency cesarean delivery, and comorbidities. Analyses were stratified by gestational age categories (23 0/7–27 6/7 and 28 0/7–31 6/7 weeks’ gestation). Results Of 902 women, 221(64%) and 91 (16%) underwent classical cesarean between 23 0/7 and 27 6/7 and between 28 0/7 and 31 6/7 weeks’ gestation, respectively. There was no increase in maternal complications for classical cesarean compared to low transverse cesarean between 23 0/7 and 27 6/7 weeks’ gestation. However, between 28 0/7 and 31 6/7 weeks’ gestation, classical cesarean was associated with increased risks of the composite maternal outcome (adjusted odds ratio=1.95; 95% confidence interval=1.10–3.45), transfusion (adjusted odds ratio=2.42; 95% confidence interval=1.06–5.52), endometritis (adjusted odds ratio=3.23; 95% confidence interval=1.02–10.21), and Intensive Care Unit admission (adjusted odds ratio=5.05; 95% confidence interval=1.37–18.52) compared to low transverse cesarean. Conclusion Classical cesarean delivery compared with low transverse was associated with higher maternal complication rates between 28 0/7 and 31 6/7 weeks, but not between 23 0/7 and 27 6/7 weeks’ gestation.

Purpose-To measure the stiffness of the placenta in healthy and preeclamptic patients in the second and third trimesters of pregnancy using ultrasound shear-wave elastography (SWE). We also aimed to evaluate the effect of age, gestational age, gravidity, parity and body mass index (BMI) on placental stiffness and a possible correlation of stiffness with perinatal outcomes.Methods-In a case-control study, we recruited a total of 47 singleton pregnancies in the second and third trimesters of which 24 were healthy and 23 were diagnosed with preeclampsia. In vivo placental stiffness was measured once at the time of recruitment for each patient. Pregnancies with posterior placentas, multiple gestation, gestational hypertension, chronic hypertension, diabetes, autoimmune disease, fetal growth restriction and congenital anomalies were excluded.