Faculty Bibliography

Objective: To compare the efficacy of Shirodkar to McDonald cerclage in patients with singleton pregnancies undergoing an ultrasound-indicated cerclage. Methods: Historical cohort of all patients with singleton pregnancies undergoing cerclage for the indication of a short cervix on ultrasound (ultrasound indicated) at one institution in 2005-2010. We compared outcomes based on cerclage type, Shirodkar or McDonald. Outcome measures were gestational age (GA) at delivery, delivery >/=35 weeks, >/=32 weeks, and PPROM. Multivariable regression analysis was performed to control for significant variables. Results: Seventy-four patients with singleton pregnancies underwent an ultrasound-indicated cerclage in the study period (47 Shirodkar, 27 McDonald). Shirodkar was associated with later GA at delivery (mean GA at delivery 36.98 +/- 3.39 vs. 33.34 +/- 6.37 weeks, p = 0.006), a higher likelihood of delivering >/=35 weeks (83 vs. 55.6%, p = 0.011) and >/=32 weeks (91.5 vs. 59.3%, p = 0.001), and a lower likelihood of preterm premature rupture of membrane (PPROM) (13.0 vs. 46.2%, p = 0.002). On adjusted analysis controlling for differing baseline characteristics, Shirodkar remained significantly associated with an increased incidence of delivery >/=32 weeks (odds ratio [OR]: 5.180, 95% CI: 1.024-26.205). Conclusion: Compared to the McDonald technique, the Shirodkar technique was more effective in prolonging pregnancy in patients with singleton pregnancies undergoing ultrasound-indicated cerclage. A prospective trial is needed to compare these two techniques.

Objective: To assess the diagnostic accuracy of vaginal fetal fibronectin (fFN) sampling for predicting preterm birth in asymptomatic women carrying triplet gestations. Methods: An historical cohort of patients carrying triplet gestations between 1998 and 2010 was identified from a single practice by chart review. All patients were screened with fFN testing at 2-3 week intervals from 22 weeks to 32 weeks of gestation. Outcomes evaluated were spontaneous preterm birth prior to 28, 30, and 32 weeks' gestation and delivery within 2 and 3 weeks of testing. Results: There were 56 pregnancies that met criteria for inclusion. For delivery prior to 30 weeks' gestation, the test had a sensitivity of 75%, a specificity of 85.4%, a positive predictive value of 46.2%, a negative predictive value of 95.3%, positive likelihood ratio of 5.13, and a negative likelihood ratio of 0.29 (p < 0.0001). For delivery within 3 weeks of a single fFN assessment, the test had a sensitivity of 53.3%, a specificity of 95.8%, a positive predictive value of 53.3%, a negative predictive value of 95.8%, positive likelihood ratio of 12.7 and negative likelihood ratio of 0.48 (p < 0.0001). Conclusion: Fetal fibronectin testing provides moderate to high prediction of spontaneous preterm birth in triplet gestations.

OBJECTIVE: : To estimate the likelihood of cesarean delivery and length of labor in twin pregnancies undergoing induction of labor as compared with singleton pregnancies. METHODS: : This was a retrospective cohort study of 100 patients with twin pregnancy in one maternal-fetal medicine practice undergoing induction of labor from 2005 to 2012. The control group was 100 randomly selected patients in the same practice with a singleton pregnancy undergoing induction of labor over the same time period. The primary outcome was mode of delivery (vaginal or cesarean). RESULTS: : The likelihood of cesarean delivery did not differ between the groups (19% in twins compared with 21% in singletons, P=.724) nor did the time from induction to vaginal delivery (median and interquartile time 9.7 [5.5-12.5] hours in twins compared with 10.4 [6.6, 14.1] hours in singletons, P=.255). Results were not different when we looked at nulliparous patients only or multiparous patients only. On adjusted analysis of risk factors for cesarean delivery in patients undergoing induction, twin pregnancy was not independently associated with cesarean delivery. CONCLUSION: : Patients with twin pregnancies undergoing induction of labor have a similar risk of cesarean delivery and a similar length of labor as patients with singleton pregnancies undergoing induction of labor. LEVEL OF EVIDENCE: : II.

17 alpha hydroxyprogesterone caproate is a synthetic form of the natural progestin 17-alpha hydroxyprogesterone that is US FDA approved for the prevention of recurrent spontaneous preterm birth in women with a history of a prior singleton preterm birth. For women with a history of a prior spontaneous preterm birth between 20 weeks and 36 weeks and 6 days of gestation, the use of 17-alpha hydroxyprogesterone caproate has been shown to reduce the risk of recurrent preterm birth by more than 30%. This medication is the only drug currently FDA approved for the prevention of preterm birth, and it is the first drug the FDA has approved for use exclusively during pregnancy in approximately 15 years

OBJECTIVES: The purpose of this study was to estimate the association between second-trimester estimated fetal weight and fetal growth restriction in twin pregnancies. METHODS: A historical cohort of 306 twin pregnancies from a single center was analyzed. Estimated fetal weight and discordance at 18 to 24 weeks were calculated. Patients with a fetus whose second-trimester estimated fetal weight was below the 10th percentile were compared to patients with both fetuses at or above the 10th percentile. Also, patients with second-trimester discordance of 15% or greater were compared to patients with discordance of less than 15%. RESULTS: Second-trimester discordance was significantly smaller than birth weight discordance (mean discordance +/- SD, 7.41% +/- 6.06% versus 11.43% +/- 9.6%, respectively; P < .001). Patients with second-trimester discordance of 15% or greater were significantly more likely to deliver a twin with a birth weight below the 10th percentile for gestational age (67.7% versus 44.1%; P = .012) and below the 5th percentile for gestational age (41.9% versus 22.8%; P = .019). Patients with a second-trimester estimated fetal weight below the 10th percentile were significantly more likely to deliver a twin with a birth weight below the 10th percentile for gestational age (65.5% versus 44.5%; P = .031) and below the 5th percentile for gestational age (55.2% versus 21.5%; P < .001). CONCLUSIONS: In twin pregnancies, second-trimester estimated fetal weight below the 10th percentile and discordance of 15% or greater are associated with fetal growth restriction.

OBJECTIVE: To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM). METHODS: Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI >/= 30 kg/m(2)) and non-obese (pre-pregnancy BMI < 30 kg/m(2)) women and for women across five increasing pre-pregnancy BMI categories. RESULTS: A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes. CONCLUSION: In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

We sought to estimate the association of several maternal risk factors with intrauterine growth restriction (IUGR) in twin pregnancies. This is a case-control study of 313 patients with twin pregnancies delivered greater than 24 weeks between June 2005 and January 2010. We used three definitions of IUGR: (1) either twin with a birth weight < 10th percentile for gestational age; (2) either twin with a birth weight < 5th percentile for gestational age; and (3) birth-weight discordance >/= 20%. Using each definition of IUGR, we estimated the association between IUGR and maternal age, weight, monochorionicity, in vitro fertilization, pregnancy reduction, thrombophilia, hypertension, and diabetes. Overall, 47% of patients delivered at least one twin with a birth weight <10th percentile, 27% of patients delivered at least one twin with a birth weight <5th percentile, and 16% of patients had birth-weight discordance of >/=20%. Using any of these three definitions for IUGR in twin pregnancies, there was no significant association between IUGR and any of the risk factors examined. This remained true when we excluded all patients who delivered <34 weeks. IUGR is very common in twin pregnancies. However, in twin pregnancies, IUGR cannot be predicted by maternal risk factors.

We evaluated the added benefit of a comprehensive counseling protocol for first-trimester aneuploidy risk assessment. We performed a prospective cohort study surveying patients referred for first-trimester aneuploidy risk assessment. We compared responses between women who underwent serum testing done in advance of their ultrasound such that their final risk assessment was given to them the same day as their ultrasound (comprehensive) versus women who underwent serum testing the same day as their ultrasound and who therefore received their final risk assessment later (standard). Response rate was 94.8%. The comprehensive group was significantly more likely to receive counseling in accordance with recommended American College of Obstetricians and Gynecologists (ACOG) guidelines, had significantly greater reduction in anxiety and increased satisfaction, and was more likely to report an increased understanding of their results. The comprehensive group scored significantly higher on test-style questions about aneuploidy risk assessment. Comprehensive aneuploidy risk assessment counseling including same-day results is associated with increased patient understanding and satisfaction, decreased anxiety, and increased adherence to ACOG guidelines.

The objective of this study is to evaluate neonatal and maternal outcomes of multiple gestations undergoing delayed-interval delivery at a single institution. A 10-year retrospective review of medical records of patients followed by a Maternal-Fetal Medicine practice in a university-based setting was performed. Patients met criteria for inclusion if a single fetus was delivered spontaneously between 16 and 28 weeks of gestation and a planned attempt was made to prolong the gestation for the remaining fetus(es). Nineteen pregnancies met criteria for inclusion. The median gestational age at delivery of the first fetus was 20 (2)/ (7) weeks and the last fetus was 25 (1)/ (7) weeks. The median latency was 16 days (range 0 to 152 days). Three patients (15.8%) delivered within 24 hours. There was a 15.8% survival rate for the firstborn fetus and a 53.8% survival rate for all retained fetuses ( P = 0.01). There was a 31.6% incidence of serious maternal morbidity related to the procedure. One patient required a postpartum hysterectomy due to massive hemorrhage and uterine atony. Delayed-interval delivery is associated with a higher neonatal survival rate when retained fetuses are compared with firstborn fetuses. However, the procedure is associated with a significant risk of serious maternal morbidity