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recommends a delay in umbilical cord clamping in term neonates for at least 30 to 60 seconds after birth. Most literature supporting this practice is from low-risk vaginal deliveries. There are no published data specific to cesarean delivery. OBJECTIVE To compare maternal blood loss with immediate cord clamping vs delayed cord clamping in scheduled cesarean deliveries at term (Ն37 weeks). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial performed at 2 hospitals within a tertiary academic medical center in New York City from October 2017 to February 2018 (follow-up completed March 15, 2018). A total of 113 women undergoing scheduled cesarean delivery of term singleton gestations were included. INTERVENTIONS In the immediate cord clamping group (n = 56), cord clamping was within 15 seconds after birth. In the delayed cord clamping group (n = 57), cord clamping was at 60 seconds after birth. MAIN OUTCOMES AND MEASURES The primary outcome was change in maternal hemoglobin level from preoperative to postoperative day 1, which was used as a proxy for maternal blood loss. Secondary outcomes included neonatal hemoglobin level at 24 to 72 hours of life. RESULTS All of the 113 women who were randomized (mean [SD] age, 32.6 [5.2] years) completed the trial. The mean preoperative hemoglobin level was 12.0 g/dL in the delayed and 11.6 g/dL in the immediate cord clamping group. The mean postoperative day 1 hemoglobin level was 10.1 g/dL in the delayed group and 9.8 g/dL in the immediate group. There was no significant difference in the primary outcome, with a mean hemoglobin change of −1.90 g/dL (95% CI, −2.14 to −1.66) and −1.78 g/dL (95% CI, −2.03 to −1.54) in the delayed and immediate cord clamping groups, respectively (mean difference, 0.12 g/dL [95% CI, −0.22 to 0.46]; P = .49). Of 19 prespecified secondary outcomes analyzed, 15 showed no significant difference. The mean neonatal hemoglobin level, available for 90 neonates (79.6%), was significantly higher with delayed (18.1 g/dL [95% CI, 17.4 to 18.8]) compared with immediate (16.4 g/dL [95% CI, 15.9 to 17.0]) cord clamping (mean difference, 1.67 g/dL [95% CI, 0.75 to 2.59]; P < .001). There was 1 unplanned hysterectomy in each group. CONCLUSIONS AND RELEVANCE Among women undergoing scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in no significant difference in the change in maternal hemoglobin level at postoperative day 1.

has been reviewed by the Editorial Board and by special expert referees. The Editors are interested in potentially publishing your revised manuscript in a timely manner. In order to have this considered quickly, we need to have your revision documents submitted to us as soon as you are able. I am tentatively setting your due date to July 6, 2020, but please let me know if you need additional time. Please note that the Editors would like you to format the submission as a Research Letter. The formatting guidelines for this article type are as follows: The Research Letter is a concise, focused report of original research (including pre-clinical research, sub-analyses or updates of previously published research, small studies, or pilot studies). Length should not exceed 600 words (approximately 2 1/2 manuscript pages; see Table 1). Figures or tables are limited to two, total. Research Letters should be organized using the following headings: Introduction, Methods, Results and Discussion. An abstract should not be included. The standard revision letter text follows.

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reterm birth, which is defined as delivery before 37 weeks' gestation, is responsible for 35% of deaths in the first year of life and more than $26 billion in annual health care costs. 1 Current methods for identifying women at increased risk for preterm birth are inadequate. Although universal cervical length screening during the second-trimester anatomic survey may identify patients at risk for spontaneous preterm birth, many patients with normal second-trimester cervical length measurements will still have preterm birth. [2][3][4] Justin S. Brandt, MD, Jamie A. Bastek, MD, MSCE, Eileen Wang, MD, Stephanie Purisch, MD, Nadav Schwartz, MD Received July 2, 2015, ORIGINAL RESEARCHObjectives-Previous studies have demonstrated an association between adverse obstetric outcomes, such as preterm birth, and in utero inflammation. The fetal thymus, which can be visualized in the anterior mediastinum on obstetric sonography, may involute in response to such inflammation and thus may identify pregnancies at increased risk for these outcomes. We therefore sought to determine whether secondtrimester fetal thymus measurements are associated with preterm birth.Methods-Transabdominal fetal thymus measurements were prospectively obtained in singleton pregnancies at gestational ages of 18 weeks to 23 weeks 6 days during a 5-month period. The transverse and anterorposterior thymus diameters and the thymicthoracic ratio were measured. Delivery outcomes were collected from our clinical database. The primary outcome was preterm birth, which we defined as delivery between 24 weeks and 36 weeks 6 days. Small for gestational age (SGA) and pregnancyrelated hypertension, which are adverse obstetric outcomes that may also be associated with in utero inflammation, were included as secondary outcomes.Results-We included 520 patients with thymus measurements and obstetric outcome data. The prevalence of preterm birth was 12.3% (n = 64). None of the thymus measurements were associated with preterm birth. Similarly, there was no association between thymus measurements and SGA or pregnancy-related hypertension.Conclusions-Sonographic assessment of the second-trimester fetal thymus did not identify patients at increased risk for preterm birth, SGA, and pregnancy-related hypertension. Routine thymus measurements during the second-trimester anatomic scan are not clinically useful for prediction of preterm birth and other adverse outcomes.

BACKGROUND Preterm birth remains a significant cause of neonatal morbidity and mortality. Women with a prior preterm birth are at risk for recurrent preterm birth. Treatment with 17-alpha-hydroxyprogesterone caproate has become standard-of-care for women with prior preterm birth to help reduce this risk. Factors that affect a woman’s decision to use this medication are largely unknown. OBJECTIVE The objective of our study was to investigate patient level barriers to 17-alpha-hydroxyprogesterone caproate use. We studied a cohort of women eligible for 17-alpha-hydroxyprogesterone caproate with the hypothesis that 17-alpha-hydroxyprogesterone caproate is underutilized and certain patient characteristics, such as obstetrical history, influence its use. STUDY DESIGN A cross-sectional study of all women seen at a specialty prematurity clinic from 2009 to 2013 was performed. Women with a singleton pregnancy were included if they had a prior spontaneous preterm birth. Chi-squared tests were performed for univariate analyses. Multivariable logistic regression was used to control for confounders. RESULTS 243 women had 17-alpha-hydroxyprogesterone caproate recommended to them based on prior obstetrical history. There were 218 women with a pregnancy during our study period that were included in our analysis. 163 (74.7%) had documented 17-alpha-hydroxyprogesterone caproate use. Women were more likely to accept 17-alpha-hydroxyprogesterone caproate if they had a history of a second trimester loss only (OR 2.32, 1.17–4.58) or received recommendation for cerclage due to a short cervical length (OR 4.12, 1.55–10.99). Women with a prior full-term birth were less likely to accept 17-alpha-hydroxyprogesterone caproate (OR 0.48, 0.26–0.89), especially when the prior full-term birth was subsequent rather than prior to the preterm birth (OR 0.19, 0.08–0.47). Race, obesity, and insurance status did not impact 17-alpha-hydroxyprogesterone caproate use. There was no difference in the rate of spontaneous preterm birth between those who used and did not use 17-alpha-hydroxyprogesterone caproate (37.2 vs. 34.0%, p=0.7). CONCLUSION Past obstetric history impacted 17-alpha-hydroxyprogesterone caproate use. This study identifies biases regarding 17-alpha-hydroxyprogesterone caproate at the patient level and can be used to develop strategies to increase its use. However, the similarity in the spontaneous preterm birth rate between users and non-users highlights the importance of identifying specific populations where 17-alpha-hydroxyprogesterone caproate is and is not effective in preventing preterm birth.