Objective: Estimated fetal weight, large for gestational age (eLGA) (≥90th percentile) may be associated with failed trial of labor after Cesarean (TOLAC), like fetal macrosomia. The aim of this study was to evaluate obstetrical outcome and safety of TOLAC, for women with eLGA. Design: A retrospective cohort study. Setting: a single large tertiary care center. Population or Sample: all women with singleton pregnancy, gestational age ≥ 37weeks, admitted for TOLAC between 2012 and 2017. Methods: Women with eLGA were compared to women with EFW < 90th percentile. Main outcome measures: the rate of successful vaginal delivery, adverse obstetrical outcomes. Results: 1949 women met inclusion criteria, including78 (4%) eLGA and 1871 (96%) controls. Study group were older (35 vs. 33 year; p=0.004), with higher Body Mass Index (30.9 vs. 27.5 kg/m2; p=0.001) and higher gravidity (4 vs. 3; p=0.001) compared to the controls. Median fetal weight was [3887g (IQR 3718-4073) vs. 3275g (IQR 2995-3545); p=0.001 in the study vs. controls respectively]. 55 (70.5%) women in the study group had successful vaginal delivery compared to 1506 (80.5%) women in the control (p= 0.03). The rate of obstetrical complications, including: scar dehiscence, uterine rupture, 3rd /4th degree perineal tear or shoulder dystocia were comparable. The rate of post-partum hemorrhage was increased in the study group compared to controls (7.7% vs.1.7%; p=0.001). Conclusion: TOLAC for eLGA fetuses can be considered as safe, however, lower successful VBAC rates and increased PPH rate may be expected.

Objective To determine the accuracy of intrapartum fetal heart rate (FHR) abnormalities as defined by National Institute of Health and Care Excellence guidelines for the prediction of moderate-severe hypoxic-ischemic neonatal encephalopathy (HIE). Design Case-control study Setting Rotunda Hospital, Dublin, Ireland. Population or Sample Eligible babies were born between September 2006 and November 2017 at ≥35+0 weeks’ gestational age. Cases were eligible babies with moderate-severe HIE. Controls were eligible babies born before and after each case with normal Apgar scores. Methods Blinded manual marking of FHR trace features followed by automated categorisation of each 15-minute segment. Main Exposure Measures FHR pattern features: baseline, variability, accelerations, early, variable, deep/prolonged variable, late or prolonged decelerations, bradycardia, sinusoidal pattern FHR pattern categories: normal, suspicious, or pathological Results Adequate FHR traces results were available in 52 of 88 cases and 118 of 176 controls. The FHR pattern feature with the largest area under the receiving operator characteristic curve (AUROCC) was the maximum number of consecutive segments with the baseline >160bpm (0.71 [95% confidence interval {CI}: 0.62-0.80]). The FHR category variable with the highest AUROCC was the number of suspicious segments (0.76 [95% CI: 0.67-0.84]). A multivariate model incorporating the number of segments and the percentage of segments classed suspicious/pathological achieved an AUROCC of 0.782 (95% CI: 0.704-0.861). Conclusions The power of FHR analysis to predict HIE is hampered by poor sensitivity for the rarity of the outcome. When analysing a suspicious FHR trace, it is beneficial to consider the overall duration of the suspicious patterns

Abstract Objective To study the impacts of obstetric complications and anxiety among pregnant women in non-epizootic area which are caused by COVID-19. Design Retrospective cohort. Setting China. Population or sample the women who delivered in the third trimester of pregnancy in Qingdao Municipal hospital for the year the months March and April, 2019 and 2020. Method This paper is based on the clinical data from This paper makes a detailed analysis of the problems that can arise because of special circumstances related with delivery history, personal physical symptoms, anxiety index, adverse complications as well as neonatal birth weight. Result Comparing with the same period between 2019 and 2020, maternal age(32.12±5.32vs31.01±4.21, P<0.05) and the ratio of macrosomia(12.10%vs2.53%)are increasing steadily. Meanwhile, times of prenatal visits (10.49±2.15vs10.89±1.81, P<0.05) and score of PHQ-9（1.46±2.09vs4.96±1.38, P<0.05）are to fall significantly。 Conclusion It is helpful to relieve the negative emotion of fear and anxiousness for the pregnant women if they can be encouraged and soothed by social support. The leading cause why regular checkups are decreasing is due to the fear of the epidemic and the transport restrictions, which, in return, may result in a lack of effective management in fetal weight. The COVID-19 had no giant effect on the third trimester of pregnant women. Government as well as obstetric practitioners should strengthen the education of fetal weight management during the pregnancy. Keywords Pregnancy; COVID-19; obstetric complications; anxiety Tweetable abstract The COVID-19 had no giant effect on the third trimester of pregnant women in the non-epizootic area China.

Having lived through the havoc of COVID-19 in a hospital situated in one of the hardest hit zip codes in the United States, the thought that another wave could loom in the fall is bracing. Obstetricians at our institution have cared for well over 200 COVID-19-infected pregnant women, and are acutely aware of the herculean effort it took to reorganize the service to accommodate the needs of women infected with this new pathogen.1 Many institutions, including ours, modified the frequency of prenatal visits, among other measures, to minimize in-person contacts, in an effort to reduce the likelihood of viral spread. However, it is those changes, along with our prior experience of treating women unimmunized against influenza that leads to our concern that a singular focus on COVID-19 could leave pregnant women at risk from a more familiar threat.While COVID-19 is a threat to the health of individuals and society, its effect on pregnancy is less clear. Thus far, few COVID-19-infected pregnant women have required ICU care, and to date three maternal deaths has been reported in the United States.2-4 The toll of influenza in pregnancy is more clearly documented and is more severe.5Now that the first wave is ebbing in New York, we are seeing fewer and fewer cases but still diagnose about 15 infections per week in our hospital. That pattern is the converse of what is being seen in large swaths of the country. Despite the higher prevalence seen earlier in the epidemic in New York, and the fact that many of those women needed respiratory support, only two women in our hospital required admission to the intensive care unit (ICU), and only one needed ventilator support. Mercifully, none died. During the preceding influenza season, whose end overlapped with the start of the COVID-19 pandemic, we treated six women with influenza who required admission to the ICU, only one of whom had been vaccinated against influenza. As opposed to our COVID-19 cases (putting aside the more rigorous application of social distancing), there were clearly missed opportunities to have prevented some of the morbid events caused by influenza.Admittedly, the higher admission rate to the ICU may be misleading. It is certainly possible that criteria for admission to ICUs, like almost all other aspects of care, evolved during the COVID-19 crisis. There was such a rapid and dramatic increase in the need for ICU beds in our hospital (from a baseline of 40 mid-March, 2020 to a peak of 140 mid-April; 2020, internal data) that more stringent criteria for admission may have been applied and some of our COVID-19 patients that were cared for on the wards, may have been cared for in an ICU in less harrowing times. But even given that possibility, the fact that a similar number of women were extremely ill with influenza raises grave concerns going forward.In the first instance, co-infection with COVID-19 and influenza, as well as other viruses, has been reported.6 Co-infection events will make diagnosis of either entity more difficult, and could potentially increase morbidity. Thus, both because of the risks of co-infection, and the known risks of influenza in pregnancy, providers can’t afford to take their “eye off the ball,” and become less vigilant about vaccinating patients, even if some of the new protocols for fewer visits or telehealth visits remain in place. With fewer visits comes the risk of missing both the vaccination “window” and the opportunity to incorporate vaccination as an essential component of health maintenance. In addition, obstetricians’ performance as vaccinators has been less than ideal as only approximately half of pregnant women get influenza vaccines.7In addition to vaccination, obstetricians must remain vigilant in order to prevent progression of disease among those who get infected. Oseltamivir provides the opportunity for secondary prevention.8 It has been shown to reduce maternal ICU admission and mortality.9 Yet, as with vaccination, even before the COVID-19 epidemic, it was underutilized.10Beyond committing to better use of medical interventions for influenza, obstetricians have to assure that just because they have lived through COVID-19, and the world’s attention remains fixed on COVID-19, they don’t become so COVID-19-focused, that they fail to include influenza in the differential diagnosis of women reporting respiratory symptoms in the fall. Every fever and ache will not be COVID-19. If we delay consideration of the diagnosis of influenza, we will lose the opportunity to use Oseltamivir before the window of eligibility closes. In the post-pandemic world, it will be hard to avoid cognitive biases, such as the availability heuristic (a strategy for making judgments about likelihood of occurrence based on the salience of the information) and confirmation bias (the tendency to gather evidence that confirms preexisting expectations, typically by emphasizing or pursuing supporting evidence while dismissing or failing to seek contradictory evidence). These can result in physicians being hammers and every respiratory symptom, a COVID-19 nail; especially when rapid COVID-19 tests are not uniformly available and don’t yet have uniformly high quality. This is the reverse of one of the most cited examples of the availability heuristic, “In influenza season, it is tempting to consider all patients with fever and myalgias as having influenza.”11 An enhanced situational awareness, i.e., recognizing the influence of recent diagnoses on your diagnostic proclivities, will become an ever more crucial antidote to the hard earned reflex response to fevers and aches that developed during the first wave of COVID-19.We know from history that influenza recurs both in epidemic and pandemic forms, and that an initial wave can be a “herald wave” for the following one.12 Hence, it is our responsibility not to let the current COVID pandemic prevent us from properly dealing with the possibility of overlapping epidemics (seasonal influenza and COVID) in the fall. Vaccination, rapid recourse to antivirals (e.g., Oseltamivir), and community mitigation measures will be more important than ever. COVID-19 can kill, but so can influenza, and if we do our jobs, we can reduce that toll.

Hysteromyoma is a common benign tumor in females. While pregnancy with submucous hysteromyoma is rare in the clinical setting, it often results in abdominal pain, red degeneration, abortion, placental abruption, premature rupture of membranes, premature delivery, fetal malformation, postpartum hemorrhage, and endometritis because of the tumor location, which in turn increases the incidence of cesarean section and hysterectomy. Submucosal myomectomy is not recommended during pregnancy because of the risk of miscarriage, bleeding, and premature delivery. Moreover, whether submucous myoma should be removed during cesarean section remains controversial. Thus, this study aims to review the diagnosis and treatment of pregnancy with submucous myoma.

Objective: To establish a prediction model of clinical outcomes in women with placenta accreta spectrum (PAS) Design: Retrospective cohort study Setting: International multicenter study (PAS-ID); 11 centers from 9 countries Population: Women who were diagnosed with PAS and were managed in recruiting centers between January 1st, 2010 and December 31st, 2019. Methods: Data were collected using a standardized sheet, which included baseline information, medical and obstetric history, diagnosis, disease characteristics, management, and outcomes. Analysis of association between these variables and primary outcome was first conducted using conventional logistic regression. Data were reanalyzed using machine learning (ML) models, and 2 models were created to predict outcomes using antepartum and perioperative features. Main Outcome Measures: Massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, triggering massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Other outcomes include prolonged hospitalization > 7 days and admission to intensive care unit (ICU). Results: 727 women with PAS were included. Area under curve (AUC) for ML antepartum prediction model was 0.84, 0.81, and 0.82 for massive blood loss, prolonged hospitalization, and admission to ICU, respectively. Significant contributors to this model were parity, placental site, method of diagnosis and antepartum hemoglobin. Combing baseline and perioperative variables, ML model performed at 0.86, 0.90, and 0.86 for study outcomes, respectively. This model was most contributed by ethnicity, pelvic invasion, and uterine incision. Conclusions: ML models may be used to calculate individualized risk of morbidity in women with PAS, which may assist to outline management plan in priori

Objective: To elucidate the correlation between sleep disturbances and blood pressure during pregnancy in women with no pre-existing hypertension. Design: Prospective cohort study. Setting: Outpatient specialist clinics at KK Women’s and Children’s Hospital, Singapore. Population: Women with viable singleton pregnancies confirmed by ultrasonography at less than 14 weeks of amenorrhea at first visit. Methods: 926 subjects were recruited for this study in the outpatient specialist clinics at KK Women’s and Children’s Hospital, Singapore, between September 1, 2010, and August 31, 2014. They were followed up throughout pregnancy with sleep quality, blood pressure and uterine artery doppler assessed at each visit. Main outcome measures: sleep quality, blood pressure and uterine artery doppler. Results: Sleep progressively worsened as pregnancy advances. Shorter sleep duration and poorer sleep efficiency were associated with higher blood pressure, especially in the first trimester. Mixed model analysis demonstrated overall positive correlation between sleep quality represented by Pittsburgh Sleep Quality Index (PSQI) score and diastolic blood pressure (DBP) (p<0.001) and mean arterial pressure (MAP) (p=0.005) during pregnancy after considering all trimesters. Sleep duration was found to be negatively correlated with both systolic blood pressure (SBP) (p=0.029) and DBP (p=0.002) while sleep efficiency is negatively correlated with DBP (p=0.002) only. Overall poor sleep during pregnancy was also found to be correlated to higher uterine artery pulsatility index. Conclusion: Our prospective study demonstrated that sleep quality is significantly correlated with blood pressure during pregnancy with most prominent effect in the first trimester.

Measurement of maternal serum soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), and the ratio between the two, has been shown to predict preeclampsia. In women with suspected preeclampsia, an sFlt-1: PlGF ratio below 38 rules out the need for delivery in the subsequent week with a negative predictive value of 99.3% (95% CI 97.9 to 99.9%) (Zeisler H et al. , N Engl J Med 2016;374:13-22). This test may be of particular benefit for women at low risk of developing the disease in the short term, as it may reduce unnecessary follow-up, investigations and admissions (Cerdeira ASet al. , Hypertension 2019;74:983–990).But do these biomarkers have a potential use in women after preeclampsia is diagnosed? This has not been studied extensively. In this issue of BJOG, Peguero and colleagues report the results of a study in which the changes in sFlt-1 and PlGF levels were examined in 63 women with early-onset preeclampsia from diagnosis to delivery (Peguero A et al. , BJOG 2020). Whilst no association between the change in PlGF levels and the development of adverse outcomes was evident, changes in sFlt-1 levels were significantly more pronounced in women who later developed complications and negatively associated with interval to delivery. This change (i.e., the delta sFlt-1) also outperformed a previously published risk score and the use of sFlt-1 at admission only.Because prevention is better than cure, identifying high-risk women early and modifying their risk is desirable. Prediction of preeclampsia can now be achieved at 11 to 14 weeks of gestational age by calculation of individual patient risk. The risk calculation is based on a combined screening test that incorporates maternal characteristics, medical history and biomarkers (mean arterial pressure, uterine artery Doppler and PlGF) alongside first trimester combined screening for fetal aneuploidy. This test is particularly accurate for predicting early-onset preeclampsia, identifying nine out of ten of these severe cases (O’Gorman N et al. , Am J Obstet Gynecol. 2016;214(1):103 e1- e12). More importantly, when this high-risk group is given prophylaxis using aspirin 150 mg from the first trimester to 36 weeks, the rate of preeclampsia before 37 and before 32 weeks is reduced by more than 60% and 90%, respectively (Rolnik DL et al. , N Engl J Med. 2017;377(7):613-22). A recent implementation study demonstrated that early screening is not only feasible in a public health care setting, but is also associated with a significant reduction in the rate of preterm preeclampsia and nearly total physician compliance of aspirin use (29% with usual care versus 99% when combined screening is used) (Guy GP et al. , BJOG 2020).Nevertheless, not all women will undergo such early screening, and not all cases will be avoided by aspirin: some women will still develop preeclampsia, and early-onset disease will remain a significant cause of morbidity and mortality, disproportionally driving the disease burden. Hence, the findings of Peguero and colleagues are important and suggest that serial sFlt-1 measurements following a diagnosis of early-onset preeclampsia can still allow risk stratification – identifying women at lower risk of complications who may be eligible for expectant management, and those at higher risk who require prompt administration of steroids and timely transfer to tertiary health care facilities.No disclosures: Completed disclosure of interest forms are available to view online as supporting information.

Objective: To analyse the proportion of RhD negative women where routine antenatal anti-D prophylaxis (RAADP) in gestational week (gw) 28 is not detectable at delivery and to investigate if a strategy with RAADP administered in gw 28 and 38 result in efficient protection at term, postterm and postdelivery. Design: A retrospective database analysis and a prospective interventional study. Setting: Antenatal centers in the Stockholm region. Sample: RhD negative women carrying an RHD positive fetus, 4280 cases evaluated retrospectively, 39 cases included prospectively. Methods: In a retrospective analysis, RhD negative women with a negative antibody screen at delivery was determined. In 39 pregnancies, quantification of anti-D was analysed before a second dose anti-D was administered in gw 38, and then weekly up to 43 weeks post gestation. Main outcome measures: The proportion of women with non-detectable anti-D at term. The concentration of anti-D measured weekly at term, postterm and postdelivery. Results: In 20,5% (856/4280, retrospective analysis) and 44% (17/39, prospective study) RAADP in gw 28 was below screening detection level, 10 IU/L at term and in 18% (7/39, prospective study) below 1 IU/L in the quantification assay. Anti-D prophylaxis administered in gw 38 showed stable protective levels of anti-D up to 30 days postdelivery, with concentration at delivery 60+34 IU/L (mean+SD). Conclusion: At least one third of the RhD negative women have non-detectable levels of RAADP given at gw 28, at term and postterm. A second dose of RAADP at gw 38 improves the protection.

In November 2019, section 4.6 of the ondansetron Summary of Product Characteristics (SmPC) was revised by the European Medicines Agency (EMA). It explicitly states, “ondansetron should not be used during the first trimester of pregnancy” (Ondansetron, SmPC[cited 2020 July 08]. Available from: https://www.medicines.org.uk/emc/). Ondansetron is an effective antiemetic drug commonly prescribed as a second-line treatment for severe Nausea and Vomiting of Pregnancy (NVP) (Fiaschi L et al,BJOG 2019;126:1201–11; Oliviera L et al. Obstet Gynecol2014;124:735-42). We do not believe that the underlying evidence supports a strong regulatory discouragement.Tightening of the SmPC on the use during pregnancy follows EMA assessment of two large pharmacoepidemiological studies, each comprising more than 80,000 first trimester pregnancy exposed liveborn children.In a methodologically meticulous pharmacoepidemiological study, Huybrechts et al. studied malformation outcomes among 88,000 liveborn children exposed to ondansetron in the first trimester. Comparing to 1,727,000 unexposed liveborn, they used comprehensive propensity score adjustments for their inferential analysis. Adjusted relative risks were 1.01 (95% CI 0.98-1.05) for any malformation, 0.99 (95% CI 0.93-1.06) for cardiac malformations and 1.24 (95% CI 1.03-1.48) for oral clefts (Huybrechts et al. JAMA 2018;320:2429–37).Subject to substantial academic controversy, Zambelli-Weiner et al. reported data on 82,000 liveborn children exposed to ondansetron in the first trimester (Zambelli-Weiner et al. Reprod Toxicol2019;83:14–20). Overall, they reported a small excess risk of cardiac malformations with an adjusted odds-ratio (aOR) of 1.04 (95% CI 1.00-1.08) and a weak association with orofacial clefts, aOR 1.12 (95% CI: 0.95-1.33). When restricting exposure to about 5,500 women who were administered ondansetron in a hospital setting, the vast majority of which comprised a single intravenous dose, aOR was 1.43 (95% CI 1.28-1.61) for cardiac malformations and 1.30 (95% CI: 0.75-2.25) for orofacial clefts. This study is substantially flawed and we argue it should not be considered when weighing the totality of evidence on the safety of ondansetron in pregnancy due to: 1) strong selection bias 2) poor external validity (the cardiac malformation rate of 3.7% was extraordinarily high among 780,000 unexposed controls) 3) inadequate adjustment for confounders and covariates and, importantly, 4) serious conflict of interest (Schachtman Law. Re: Zambelli-Weiner [cited 2020 July 8]. Available from: http://schachtmanlaw.com/litigation-science-in-re-zambelli-weiner/ )In summary, robust clinical data suggest 1) no overall increased risk of major malformations 2) no increased risk of cardiac malformations 3) a small excess risk of oral clefts corresponding to three additional cases of oral cleft for every 10,000 liveborn children exposed to ondansetron in the first trimester of pregnancy (figure 1).NVP causes significant physical and psychological morbidity to the degree that some women contemplate termination of pregnancy. Denying such patients effective and low-risk treatment is inappropriate. We are confident that women suffering from severe NVP can comprehend the small excess risk of oral clefts in making an informed decision. The statement “ondansetron should never be used in pregnancy” is: 1) misconceived 2) insufficiently substantiated by evidence and 3) not in the best interest of pregnant women.

Objective: Recommending using lymphopenia and neutrophil/lymphocyte ratio(NLR) as a severity marker rather than diagnostic marker for pregnant patients with COVID-19. Design: retrospective study. Setting :Birmingham city hospital, Birmingham, United Kingdom maternity unit admissions to delivery suite between 10 March 2020 and 31 May 2020. Population: We reviewed all patients who tested positive for COVID-19 and were pregnant. Methods: We looked at the white blood cell counts of all the patients and their outcomes. We specifically looked at lymphocyte count as well as neutrophil count and calculated the neutrophil lymphocyte ratio(NLR) for every case in our series. Main Outcome Measures: Only 15.3% of pregnant patients who tested positive for COVID-19 had lymphopenia and raised NLR in contrast with up to 90% in non-pregnant population. Results: Our results  indicate that out of 13 patients who tested positive, for COVID-19, only 2 915.3% had lymphopenia and raised NLR more than 8. Conclusions: There are very conflicting results for normal values of white blood cells and lymphocytes in pregnancy. In our study Lymphopenia and raised NLR do not seem to be common findings in confirmed pregnant cases of COVID-19 but can help determine morbidity as patients that had lymphopenia and raised NLR displayed severe symptoms, were more unwell and needed high dependency unit admission.

Objective To evaluate the Australian Capital Territory (ACT) Preterm Birth (PTB) Prevention Initiative and its effects on preterm and early term birth rates at the main tertiary hospital after 16 months of implementation. Design: A non-randomised before and after study, where the intervention was a multifaceted PTB prevention initiative. Setting: The main tertiary referral hospital in the ACT. Population: Women who birthed at the main tertiary hospital in the ACT in the pre and post intervention period. Methods: The PTB prevention initiative was implemented in 2019. Rates of early birth were assessed using run charts of bimonthly preterm and early term rates from 2014-2020. Main Outcomes measured: The main outcomes measured were rates of preterm and early term births before and after implementation of the PTB prevention initiative. Results: At the main tertiary hospital in the ACT, the rate of PTB was significantly reduced by 10% after 16 months of implementation of the initiative, corresponding to 45 averted or delayed PTBs. The number of iatrogenic early term births with no medical indication (NMI) was significantly reduced by 34.5% and resulted in 77 averted or delayed early term births. Conclusions: The multifaceted PTB prevention initiative safely lowered the rates of early birth in the ACT context. These results highlight the importance of prioritising early birth prevention, education, research and expanding the PTB Prevention Initiative nationwide.

Uterine rupture is the feared complication when a uterus scarred by a caesarean section (CS) is labouring. The increased awareness of uterine rupture and its dramatic consequences of perinatal asphyxia has lead to guidelines dictating safe circumstances when undertaking a trial of labour after caesarean section (TOLAC). This complication occurs in an estimated 35 per 10 000 women with a previous CS undergoing labour (INOSS study of uterine rupture, BJOG 2019;126:370–381), but is extremely rare before the onset of labour and in the unscarred uterus. Our knowledge of prelabour uterine ruptures is confined merely to a small number of published case reports and case series in the literature.In this issue of BJOG, Al-Zirqi and colleagues present the results of a retrospective population-based study during 41 years (1967-2008) in Norway describing the characteristics and outcomes of complete uterine rupture before the onset of labour in 8 unscarrred and 22 scarred uteri, besides another 45 partial ruptures in scarred uteri (BJOG 2020 xxxx). The authors point out that complete ruptures before onset of labour are absolutely rare, but result in a higher number of perinatal deaths. In the unscarred uterus, complete ruptures before onset of labour were related to trauma (n=3), abnormal invasive placenta (n=2) and congenital uterine malformations (n=2) and were unavoidable in most cases. In the scarred uterus, complete ruptures before onset of labour were related to abnormally invasive placenta (n=4), previous complete uterine rupture (n=3) and scars outside the lower uterine segment (n=17). These scars were caused by classical CS (n=9), myomectomy (n=5), tubo-uterine surgery (n=3), uterine septal operation (n=1) and perforation during endometrial ablations (n=3). Classical CS by vertical incision has become rare, while laparoscopic and hysteroscopic uterine surgery increase in frequency. A systematic review by Gambacorti-Passerini et al. (Acta Obstetricia et Gynecologica Scandinavica 2016;95:724-734) revealed that the majority of uterine ruptures after prior myomectomy occurred before 36 weeks and before labour (5/330, 1.5%), while only 0.47% (2/426) in women undergoing a trial of labour after myomectomy (TOLAM). The researchers could not reveal any riskfactor (surgical approach, type of myoma, type of hemostasis, suture layers) keeping the risk of uterine rupture following prior myomectomy largely unpredictable. Only case reports and small case series report on uterine ruptures following operative hysteroscopy or tubo-uterine surgery, where perforation is considered a risk factor (Sentilhes et al. Gynecol Obstet Fertil 2006;34(11):1064-70), similar to the 3 cases of endometrial ablation with perforation in the study of Al-Zirqi et al. More large scale studies like this retrospective analysis are needed to understand to what extent uterine surgical procedures contribute to uterine ruptures, during or before onset of labour. In this regard, we expect a report of the International Network of Obstetric Survey Systems (INOSS) who analysed complete uterine ruptures in 10 countries, including 215 uterine ruptures before onset of labour.This study advocates a higher level of alertness for uterine rupture when taking care for women with congenital uterine abnormalities, with suspected AIP and with prior uterine surgery.No disclosures: A completed disclosure of interest form is available to view online as supporting information.

Objective: To evaluate the maternal and neonatal outcomes of parturients attempting trial of labor (TOL) after two previous cesarean deliveries (CD) Design: A retrospective computerized database cohort study. Setting: A single tertiary center between 2005 and 2019. Population: Parturients attempting TOL after two CD were compared to parturients opting for elective third repeat CD. TOL after two CD was allowed only for those who met all the criteria of our departments’ protocol. Methods: A univariate analysis was conducted and was followed by a multivariate analysis. Main outcome measures: A composite of adverse maternal and neonatal outcomes. Results: A total of 2719 eligible births following two CD were identified, of which 485 (17.8%) had attempted TOL. Overall, successful vaginal delivery rate following two CDs was 86.2%. Uterine rupture rates were higher among those attempting TOL (0.6% vs 0.1% p=0.04). However, rates of hysterectomy, re-laparotomy, blood product infusion and intensive care unit admission did not differ significantly between the groups. Neonatal outcomes following elective repeat CD were less favorable (specifically, neonatal intensive care unit admission and composite adverse neonatal outcome). Nonetheless, when controlling for potential confounders, an independent association between composite adverse neonatal outcome and an elective repeat CD was not demonstrated. In a subgroup analysis, diabetes mellitus and hypertensive disorders of pregnancy were found independently associated with failed TOLAC. Conclusion: When following a strict protocol, TOL after two CD is a reasonable alternative and associated with favorable maternal and neonatal outcomes

Background: Post-traumatic stress disorder (PTSD) affects approximately 3% of women in the postnatal period, but less is known about risk factors for PTSD than for other postnatal mental illnesses. Objectives: To analyse literature surrounding the impact of mode of birth on postnatal PTSD. Search Strategy: Five databases were systematically searched (1990-2019). Selection Criteria: Studies investigating the link between mode of birth and postnatal PTSD in high income countries. Data Collection and Analysis: Quantitative and qualitative data were collected and synthesised. Meta-analysis was performed with four of the studies, and the rest were analysed narratively. Main Results: Twelve quantitative and two qualitative studies were included in the review. Most found a significant relationship between mode of birth and maternal PTSD symptoms. Meta-analysis found caesarean section was more associated with PTSD than vaginal delivery (VD) (p=0.005), emergency caesarean section (EmCS) more than elective caesarean section (ElCS) (p<0.001), instrumental vaginal delivery (IVD) more than spontaneous vaginal delivery (SVD) (p<0.001) and EmCS more than VD (P<0.001). Women who developed PTSD after EmCS felt less in control and less supported than those who did not develop it after the same procedure. Request for repeat ElCS appeared more common among women with pre-existing postnatal PTSD, but this may subsequently leave them feeling dissatisfied and their fears of childbirth unresolved. Conclusions: Modes of birth involving emergency intervention may be risk factors for the development of postnatal PTSD. Ensuring that women feel supported and in control during emergency obstetric interventions may mediate against this risk.

Objective: To determine the contribution that pre-labor cesarean (cesarean performed without attempting vaginal birth) makes to all cesarean births, and to cesarean births within subgroups of the pregnant population. Design: Retrospective cohort study. Setting: 15 hospitals in the Pacific Northwest of the United States. Population: Births at 23+0-42+6 weeks’ gestation between January 1, 2017 and March 31, 2018. Methods: Review of clinical data abstracted from medical records. Main Outcome Measures: The contribution of pre-labor cesarean to all cesareans and to primary cesareans. The indications for pre-labor primary cesarean in singleton term cephalic pregnancies. Results: Of 32756 births in the study population, 10290 (31.4%) were cesarean births. Pre-labor cesareans represented: 63.7% of all cesareans; 32.4% of cesareans in nulliparas; 58.7% of cesareans in multiparas with no history of cesarean; and 20.0% of all births. Pre-labor cesareans constituted 68.3% (2418/3542) of cesareans in singleton term cephalic multiparas with one previous cesarean, 89.4% (356/398) of cesareans in multiple pregnancies, and 53.2% (216/406) of cesareans in twin pregnancies where Baby A was cephalic. In singleton term cephalic pregnancies with no previous cesarean 18.3% (674/3682) of cesareans were pre-labor and suspected macrosomia (28.9%) and maternal request (18.1%), jointly accounted for 47.0% of indications for these surgeries. Conclusions: Cesarean without attempting vaginal birth is a major contributor to both primary and repeat cesarean birth rates. Greater tracking of the rate and indications for these cesarean births may be important in the effort to understand and potentially reduce the primary cesarean birth rate.

Objective: To quantify the incidence, risk and associated factors that contribute to the development of Surgical Site Infection (SSI) in emergency Caesarean Section (CS). Design: A retrospective case-control study. Setting: An acute District General Hospital in England. Sample: 206 patients (101 SSI patients and 105 non-SSI patients) who had emergency CS between January-December 2017. Methods: Grade of surgeon, smoking status, pre-operative vaginal swab, diabetes status, age, body mass index (BMI), membrane rupture to delivery interval and length of surgery were recorded. Risk factors significantly associated with SSI were identified using simple and multiple logistic regression procedures. Results: BMI (kg/m2) was significantly associated with SSI occurrence and age (odds ratio (OR) 1.17; 95% confidence interval (CI) 1.11 to 1.24; p<0.001). Substantive non-significant associations were recorded between SSI, patient age and vaginal swab. Conclusion: This study identified BMI as the only significant risk factor from a range of patient-level factors for the development of an SSI in emergency CS, possibly due to the impact of excessive adipose tissue on the body’s immune system and reduced effectiveness of antibiotics. The importance of appropriate wound management including frequent wound cleaning, appropriate dressings and dressing change and education is highlighted. Improved guidelines and strategies for managing at-risk patients would enable clinicians to manage emergency CS patients better and reduce the risk of SSI development. Diabetes status, patient age and pre-op vaginal swab were not significantly associated with SSI in emergency CS. Future research on larger samples should be conducted to validate these findings.

A document by Yunhai Chuai, written on Authorea.

Objective: To describe opioid prescribing patterns following cesarean section before and after the New York State Department of Health (NYSDOH) mandated the Opioid Prescriber Training Program. Design: This is a retrospective cohort study. Setting: A single hospital institution in New York City, United States. Sample: 1,494 women hospitalized for cesarean section between July 2016 and August 2018. Methods: Chart review of patient records. Main Outcome Measures: Primary outcome was total amount of narcotic prescribed before and after the Opioid Prescriber Training. Secondary outcomes included outpatient opioid prescription habits by provider level, as well as outpatient opioid prescription patterns related to the amount of inpatient narcotic use, and patient, surgical, and hospital-specific factors. Results: There was a significant difference in narcotics prescribed before and after the training. The median dose of narcotic prescribed pre and post intervention was 150 morphine milligram equivalents (MME) which is equal to 20 pills of 5 mg of oxycodone. Pre-training, 41.1% of prescriptions amounted to >150 MME, compared with 21.3% post-training (p-value for association < 0.001). Post-training, all provider levels had reduced narcotic prescriptions in the category of >150 MME. Neither inpatient opioid use, patient demographic, surgical nor hospital factors affected opioid prescriber patterns. Conclusion: This suggests the NYSDOH mandated opioid training course had an effect on opioid prescribing patterns with the greatest impact noted in residents. Funding: None. Keywords: discharge prescriptions, obstetric narcotics, opioid training, post-cesarean narcotics.

Risk assessment to target aspirin is accurate but not universalLow dose aspirin, for the prevention of early onset pre-eclampsia is an established antenatal intervention; it is safe, effective, cheap and accessible in many health care settings.Optimal implementation strategies including dose, timing and screening are currently debated. The evidence supports starting aspirin early (before 16 weeks), prescribe at night, give up to 150mg and continue until at least 36 weeks gestation ((Poon et al. Int J Gynaecol Obstet. 2019 May;145 Suppl 1(Suppl 1):1-33). From the women’s perspective, many may not be happy to routinely medicate an apparently normal pregnancy, to prevent an unknown or unfamiliar disease.Despite campaigns by APEC and others, too many women only hear of pre-eclampsia when it affects them. Generally, as perceived risks escalate the acceptance of taking aspirin is greater which improves compliance by both physicians prescribing, and by pregnant women. Any strategy that allows targeting of aspirin is likely to prevent unnecessary treatment and would be welcomed. It should be noted that the MBRAACE Report (Knight et al. University of Oxford 2019. ISBN: 978-0-9956854-8-2) called for a national patient direction for midwives to prescribe aspirin which has not yet happened.This current analysis compared two such strategies to target antenatal aspirin NICE guidance uses history to establish risk (Guy et al. BJOG 2020 xxxx). It is relatively simple, requiring either a combination of minor risk factors or a single major risk factor to dictate the need for aspirin. The FMF algorithm uses a combination of tests, including scans, blood pressure and blood markers to dictate risk; this requires skill and more resource which may not be consistently available in lower income settings.When compared in a real-world setting, in a London teaching hospital, the FMF algorithm had a screen positive rate that was half that of NICE, while aspirin was given to far more high-risk women. The FMF algorithm was changed to suit local circumstances, including details of the tests used (PAPPA, rather than PLGF) and thresholds adopted for treatment, but the real-world findings are impressive.The dosage of aspirin was higher in the FMF group, (150mg vs 75mg) which could explain some of the additional clinical benefit. Aspirin has recently been shown to impact on preterm birth when given routinely to all women who have never given birth in a low resource setting. In these settings, the cost and practicalities of implementing the algorithm maybe prohibitive. However, elements of the algorithm such as blood pressure measurement are simple and potentially more generalisable.It is exciting we have an intervention that can impact on one of the world’s most significant pregnancy disorders; but if resources allow, we clearly now have the tools to predict risk and improve outcomes. The challenge is how to deliver this to the global south, where most of pre-eclampsia occurs.At Action on Pre-Eclampsia, in the UK, we will continue to push for easy availability of aspirin. This paper is a welcome piece of the jigsaw and we hope it offers further tools in the armoury to defeat pre-eclampsia.No disclosures: Completed disclosure of interest forms are available to view online as supporting information.

Objective: To identify pregnancies at risk for adverse outcomes in the late preterm (LP) period, we investigated how gestational age (GA) at delivery, circumstances at parturition, and specific prenatal risk factors may affect neonatal outcomes. Study design: Prospective, area-based cohort study of neonatal morbidity and mortality among singleton infants born between 34+0 and 36+6 weeks, at 21 L&D units in Emilia Romagna county, Italy, during 2013-15. The primary neonatal outcome was a composite of Apgar 5’ ≤ 3, umbilical-cord-blood arterial pH < 7.0, RDS, TTN, hypoglycemia, sepsis, confirmed seizures, stroke, IVH, cardiopulmonary resuscitation, invasive respiratory support and hospitalization ≥ 5 days. Multivariate logistic regression models were used to respectively investigate the effects on study outcomes of 1) GA at delivery and circumstances at parturition 2) GA at delivery and prenatal risk factors, after controlling for confounding Results: Among 1867 births, 302, 504 and 1061 infants were born at 34, 35 and 36 weeks, respectively. There were no neonatal deaths. When studying circumstances at parturition, an increased risk of composite neonatal outcome was observed among 34 weeks births, 35 weeks deliveries, and indicated deliveries. When studying prenatal risk factors, neonatal morbidity was associated with delivery 34 weeks, birth at 35 weeks, pregestational diabetes, pPROM, maternal BMI, bleeding and polyhidramnios; instead, preeclampsia had a protective effect. Conclusion: LP with indicated deliveries at 34 or 35 weeks, or with specific prenatal risk factors have worse neonatal outcome when compared to 36. Such differences should be considered when counseling patients and planning interventions.

Objective: Video-based teaching has been part of medical education for some time. We investigated if an additional 3D video to the curriculum leads to an improvement of long-term recall of knowledge regarding situation, procedure and organisation. Design quasi-experimental design Setting: Sequential gynaecology residency teaching groups had or had no access to a VR-video of a gentle caesarean section (CS). Sample: 41 medical students participated in the VR group and 48 in the conventional study group. Methods: After 6 weeks of residency, knowledge was assessed with an open and multiple choice questionnaire. Main outcome measures: General obstetric and specific CS related knowledge and happiness with the use of VR glasses Results: 3D video did not result in a difference in either specific or general knowledge retention between the VR group and the conventional study group. However 83.4% of the VR-group reported that more videos should be used in future to prepare for surgical procedures. In the VR group 56.7% reported side effects like nausea or dizziness. After adjustment for the number of attended CSs, students in the VR group stated less often (p=0.04) that they would have liked to attend more real-life CSs as compared to the conventional study group. Conclusion: Even though the use of VR did not increase knowledge, it did provide a partial alternative for attending a real CS. In case only few possibilities to attend a CS are available, VR might provide an alternative. Funding: Spaarne Gasthuis innovation fund

Objective To compare the effectiveness and safety of dexamethasone versus betamethasone for preterm birth (registered in PROSPERO CRD42017078006). Search strategy We searched in MEDLINE, EMBASE, Cochrane Library, LILACS, Clinical Trials.gov, International Clinical Trials Registry Platform, reference lists and contacted field experts. Selection criteria, data collection and analysis Randomized controlled trials comparing any corticosteroids against each other or against placebo. Three researchers independently selected, extracted data and assessed the risk of bias of the included studies by using EROS and COVIDENCE software. We performed a pairwise meta-analysis and Bayesian network meta-analysis. Main results We included 45 trials (11227 women, 11878 infants). There was no important difference between corticosteroids in neonatal death (odds ratio[OR] 1.05; 95% confidence interval 0.62-1.84; moderate-certainty evidence[CE]), neurodevelopmental disability (OR 1.03; 0.80-1.33; moderate-CE), intraventricular haemorrhage (OR 1.04; 0.56-1.78); low-CE) and birthweight (+5.29 gr; -49.79 to 58.97; high-CE). Compared with betamethasone, dexamethasone may reduce chorioamnionitis (OR 0.70; 0.45-1.06; moderate-CE), foetal death (OR 0.81; 0.24-2.41; low-CE) while may increase puerperal sepsis (OR 2.04; 0.72-6.06; low-CE) and respiratory distress syndrome (OR 1.34; 0.96-2.11; moderate-CE), however, the confidence interval indicates both beneficial and detrimental effects. Conclusions We found no important difference on neonatal death, neurodevelopmental disability, intraventricular haemorrhage and birthweight between corticosteroids. Compared with betamethasone, dexamethasone may reduce chorioamnionitis and foetal death, but may increase endometritis/puerperal sepsis and respiratory distress syndrome. Further research is warranted to improve the certainty of evidence. Keywords preterm birth, antenatal corticosteroids, dexamethasone, betamethasone, systematic review, network meta-analysis

Objective: This study aimed to clarify the effectiveness of cervical cerclage in preventing recurrent preterm births. Design: A retrospective study. Setting: The perinatal registration database of the Japan Society of Obstetrics and Gynecology Perinatal Center from 2014 to 2016. Population or Sample: For this study, 6,060 multiparous women with a history of preterm birth were reviewed. After excluding 17 subjects who had unknown indications for cervical cerclage, 6,043 subjects were included in this study. Methods and main outcome measures: The efficacies of elective, ultrasound-indicated, and emergency cerclage as preventive treatments for women with a history of preterm birth were evaluated by comparing the cerclage and non-cerclage cases. Prior to evaluation, a propensity score matching was performed for elective and ultrasound-indicated cerclage patients. Results: Elective cerclage did not reduce the risk of preterm birth in subsequent pregnancies for any of the pregnancy periods (p = 0.413). Similarly, ultrasound-indicated cerclage was ineffective (p = 1.000). In addition, for ultrasound-indicated cerclage, Kaplan-Meier survival curves showed that the risk of a subsequent preterm birth might increase at < 33 weeks of gestation. However, the hazard ratio could not be determined to be statistically significant using the log-rank test at < 28 weeks of gestation. In contrast, emergency cerclage significantly reduced the risk of subsequent preterm birth for all pregnancy periods (p < 0.001). Conclusions: Subsequent preterm births were effectively prevented only in emergency cerclage cases. For elective and ultrasound-indicated cerclage, statistically significant differences in subsequent preterm births were not evident.