Baha M. Sibai

Background: Preterm birth is associated with an increased rate of serious maternal complication compared with those who deliver at term. However, data are limited on risk factors for maternal morbidity and mortality specifically in the setting of preterm birth. Improved understanding of risk factors for morbidity in patients with preterm birth can help optimize interventions to best support patients experiencing preterm birth. Objective: To assess associations between obstetric factors and maternal morbidities and mortality among patients who gave birth less than 35 weeks’ gestation. Study design: This is a secondary analysis of a multicenter registry of gravidas carrying singletons or twins who gave birth at 16 0/7 to 34 6/7 weeks’ gestation January through August 2019. The primary outcome was a maternal morbidity and mortality composite (blood transfusion, postpartum hemorrhage, maternal sepsis, stroke, thromboembolism, intensive care unit admission, or death) during the delivery hospitalization. Factors were compared between those with and without the composite outcome to identify statistically significant variables. Those factors were then used to create a parsimonious multivariable logistic regression model with adjusted odds ratio (aOR) and 95% confidence intervals (CIs) using a backward strategy. We estimated area under the curve to quantify the predictive ability of these factors for the primary outcome. Results: The analysis was based on 6660 patients, of whom 15.1% experienced the primary composite outcome. Factors associated with increased odds of the outcome included increasing maternal age, use of assisted reproductive technology, twin gestation, preeclampsia, placental abruption and cesarean delivery—aOR ranged from 1.02 [1.01–1.04] for maternal age (continuous) to 2.55 [2.08–3.14] for abruption. In contrast, nulliparity, gestational diabetes, preterm prelabor rupture of membranes (PPROM), and later birth gestational age were associated with decreased odds of the primary outcome—aOR ranging from 0.96 [0.95–0.98] for gestational age (continuous) to 0.54 [0.44–0.66] for PPROM. The model with these factors had low to moderate predictive ability (AUC 0.68 [0.66–0.69]). Conclusion: Among individuals who experienced preterm birth before 35 weeks, multiple factors were associated with maternal morbidity and mortality. The factors together modestly discriminate maternal morbidity or mortality.

Objectives: We aimed to evaluate a quantitative method for analyzing vascularization in the anterior fornix/cervix (AFC) region in women at risk of placenta accreta spectrum (PAS). The primary aim was to evaluate the association between quantitative vascularization (QV) and severity of PAS (determined by histopathology) and to estimate the optimal QV cut‐off value to predict PAS. A secondary aim was to evaluate the association of QV with severe intraoperative blood loss (IOBL). Methods: This was a prospective study including patients with anterior placenta previa referred for suspected PAS at the University of Texas Health Science Center at Houston, TX, USA, between December 2021 and June 2025. Transvaginal ultrasound with color Doppler (with standardized settings) was performed to visualize the cervix and the lower uterine segment in the midsagittal plane. The prenatal diagnosis of high risk for PAS was based on ultrasound features including loss of the uteroplacental interface, the presence of placental lacunae, increased vascularization and abnormal bladder wall. For QV assessment, a videoclip was acquired, in which the AFC region was defined and post‐processing analysis was used to estimate the percentage of color pixels within the AFC region in each frame. The mean value across all frames was defined as the QV value. QV values were not provided to clinicians and were not used for clinical decisions. Associations between QV and PAS, depth of implantation, IOBL and units of blood products transfused were evaluated, as well as the ability of QV to discriminate between patients with and those without PAS. Results: A total of 117 patients were included. PAS was confirmed histopathologically in 89 (76.1%) patients (placenta accreta, n = 11; placenta increta, n = 55; placenta percreta, n = 23). A reliable estimation of IOBL was obtained in 109 patients and severe IOBL (> 1500 mL) occurred in 53 (48.6%) of these cases. The area under the receiver‐operating‐characteristics curve, demonstrating the ability of QV to discriminate between cases with and those without confirmed PAS, was 0.821 (95% CI, 0.739–0.886). The optimal QV cut‐off value was 8.5%, yielding a sensitivity of 70.5% (95% CI, 59.8–79.7%), specificity of 89.7% (95% CI, 68.3–96.1%), positive predictive value of 93.9% (95% CI, 86.1–97.5%) and negative predictive value of 50.0% (95% CI, 40.3–57.8%). QV ≥ 8.5% was associated with increased odds of PAS (odds ratio (OR), 14.9 (95% CI, 4.7–47.0); P < 0.0001), placenta percreta (OR, 55.5 (95% CI, 10.1–305.7); P < 0.0001), severe IOBL (OR, 3.9 (95% CI, 1.8–8.7); P = 0.0009) and the need for ≥ 4 units of blood products during delivery (OR, 4.6 (95% CI, 2.0–10.4); P = 0.0002). Conclusion: QV ≥ 8.5% of the AVC region identifies patients at increased risk for PAS and for severe IOBL. Although the negative predictive value was limited, QV assessment of the AFC region may provide valuable information to support clinical management and surgical planning in PAS. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

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Introduction: We aim to evaluate uterine artery (UtA) Doppler velocimetry in patients at risk of placenta accreta spectrum (PAS). Methods: Prospective cohort of patients referred to an academic referral center for suspected PAS. The left and right UtA were evaluated, and mean peak systolic velocity (PSV), end‐diastolic velocity (EDV), and pulsatility index (PI) were obtained and converted to gestational age (GA)‐adjusted z ‐scores. Differences in UtA Doppler indices between patients with and without PAS, and among varying degrees of placental implantation depth, were analyzed. The predictive performance of UtA Doppler velocimetry to diagnose PAS and intraoperative bleeding (IOBL) >1500 mL was calculated. A sub‐analysis of patients with and without placenta previa was conducted. Results: A total of 177 patients were included, and PAS was confirmed in 61.0% (108/177). In the complete study group, patients with PAS had significantly lower UtA‐PI and higher UtA‐PSV and UtA‐EDV ( p < 0.05) than patients without PAS. We found the following associations with PAS: UtA‐PSV ≥90th percentile for GA demonstrated an odds ratio (OR) of 4.9 (95% confidence interval [CI], 2.31–10.39; p < 0.0001); UtA‐EDV ≥90th percentile for GA demonstrated an OR of 3.49 (95% CI, 1.71–7.14; p = 0.0006); and UtA‐PI ≤25th percentile for GA demonstrated an OR of 0.71 (95% CI, 0.23–2.23; p = 0.2). The predictive performance of UtA velocities improved when analyzing only patients without placenta previa. There were no significant differences in UtA Doppler indices related to the placental implantation depth. Patients with severe IOBL (>1500 mL, n = 86) had significantly higher UtA‐PSV ( p = 0.004) and UtA‐EDV ( p = 0.0001), but no differences in UtA‐PI than those without severe IOBL ( n = 79). The association between UtA‐PSV ≥90th percentile for GA and severe IOBL demonstrated an OR of 3.67 (95% CI, 1.86–7.23; p = 0.002); UtA‐EDV ≥90th percentile for GA demonstrated an OR of 3.34 (95% CI, 1.68–6.64; p = 0.0006). The association between increased UtA velocities and severe IOBL was similar regardless of the presence of placenta previa. Conclusions: Patients with PAS showed lower UtA‐PI and higher UtA‐PSV and UtA‐EDV than those without PAS. The predictive performance of UtA Doppler velocimetry for PAS seems to improve in patients without placenta previa. Patients who experienced severe IOBL exhibited significantly higher UtA‐PSV and UtA‐EDV than those without severe IOBL.

Background: Expectant management of early‐onset preeclampsia with severe features (N = 325; 87.8%; 95% CI, 84.1–91.0). For 40 patients (10.8%; 95% CI, 7.8–14.4), blood test abnormalities were detected after decision for delivery was made. The median number of blood tests per patient was 10 (IQR 6–14), and blood testing charge per patient was $5030 (IQR 3018–7042). The total charge for blood testing was $2.176 million over the study period. Conclusion: Among 370 patients with early‐onset preeclampsia with severe features managed expectantly, only 1% of the cohort had blood test abnormalities as the sole indication for delivery. All other patients were delivered either because of maternal‐fetal indications or developed blood test abnormalities occurring in association with other indications for delivery. Finally, serial blood testing in this setting resulted in total charges of $2.176 million over 9 years. Based on this large cohort, there is a need to reconsider the frequency of blood testing in the absence of new‐onset symptoms or worsening severe features.

Preeclampsia is a leading cause of maternal death during pregnancy, and the role of circadian rhythms in predicting preeclampsia is not well understood. We aimed to determine whether glucose circadian rhythm disruption is associated with preeclampsia and can be used to predict this disorder. We analyzed a dataset of 92 pregnant individuals recruited with Continuous Glucose Monitoring (CGM). To study rhythmicity, we performed a cosinor analysis using the packages cosinor and cosinor2, and we calculated the non-parametric circadian rhythm variables using the nparACT package in R. Furthermore, we performed multiple-component cosinor analysis to detect internal oscillations and identify glucose postprandial peaks using the package CosinorPy in Python. Seventy-one participants (20 women with preeclampsia) had sufficient data for studying glucose circadian rhythmicity and performing all the chronobiological analyses. All the participants exhibited a significant circadian rhythm in their glucose oscillation. We developed a model including the time difference between the first postprandial peak and the last one, L5 start-time, and age that was predictive for preeclampsia. Patients diagnosed with preeclampsia from this model had a reduced amplitude and less robust glucose rhythmicity. We conclude that identifying abnormal glucose circadian rhythm during pregnancy may help to anticipate pregnancy-related disorders like preeclampsia.

Background: To examine the incidence of overt hypothyroidism 1 and 5 years after pregnancies where screening before 21 weeks identified subclinical hypothyroidism (SH) or hypothyroxinemia (HT). Methods: Secondary analysis of two multicenter treatment trials for either SH or HT diagnosed between 8 and 20 weeks gestation. Current analyses focus only on individuals randomized to the placebo groups in the two parallel studies. SH was diagnosed with thyrotropin (TSH) ≥4.0 mU/L and normal free T4 (fT4) (0.86–1.9 ng/dL). HT was diagnosed with normal TSH (0.08–3.99 mU/L) but fT4 p < 0.001) and year 5 (15.6% vs. 2.6%, p < 0.001) for participants with SH compared with those with HT. This progression was more common in individuals with TSH values >10 mIU/mL. Baseline TPO level >50 IU/mL in participants with SH was associated with higher rates of hypothyroidism at year 1 (26.7% vs. 6.5%, odds ratio [OR] = 5.3 [confidence interval (CI) 2.6–10.7]) and year 5 (30.5% vs. 7.5%, OR = 5.4 [CI: 2.8–10.6]) compared with those with TPO levels ≤50 IU/mL. For participants with HT, no differences in overt hypothyroidism were seen at 1 year related to baseline TPO level >50 IU/mL (1/10 (10%) vs. 6/218 (2.8%), OR = 3.9 [CI: 0.43–36.1]), but more participants with TPO levels >50 IU/mL developed hypothyroidism by year 5 (2/10 (20%) vs. 4/218 (1.8%), OR = 13.4 [CI: 2.1–84.1]). Conclusion: SH is associated with higher rates of overt hypothyroidism or thyroid replacement therapy within 5 years of delivery than is HT when these conditions are diagnosed in the first half of pregnancy.

Uterine leiomyomas are common benign smooth muscle tumors that often occur during the reproductive years. Although many cases may not result in significant complications, negative pregnancy outcomes have been associated with the size and location of the fibroids. Degeneration of fibroids can occur as early as the late first trimester when they undergo significant volumetric growth, contributing to pain during pregnancy. While myomectomy is typically avoided during pregnancy, conservative management with anti-inflammatory medications may be effective. Surgical removal or preterm delivery may be necessary if symptoms persist. Abdominal compartment syndrome (ACS) is a rare condition characterized by sustained elevated intra-abdominal pressure leading to organ failure. Although ACS resulting from large-volume leiomyomas in the postpartum period has not been previously described, we present a case of a 25-year-old patient with massive uterine fibroids who required indicated preterm delivery via primary cesarean section at 25 weeks gestation. Her postpartum course was complicated by ACS, requiring emergent surgical decompression. When a large fibroid burden is present during pregnancy or in the postpartum period, ACS should be considered in the differential diagnosis. Early diagnosis and timely surgical decompression are necessary to prevent organ dysfunction and worsening maternal outcomes.

To the Editor We would like to underscore a few concerns about the recent study¹ of aspirin discontinuation at 24 to 28 weeks’ gestation in pregnancies at high risk of preterm preeclampsia. First, this study highlighted the need for discussion around the optimal usage of biomarker tests in preeclampsia risk assessment. Of 13 983 pregnancies screened using a first-trimester algorithm, the authors identified 1984 at risk of preterm preeclampsia. Of these, only 7 (0.4%) had an abnormal ratio of soluble fms-like tyrosine kinase–1 to placental growth factor (sFlt-1:PlGF) at 24 to 28 weeks, indicating an overall low-risk population. One could argue that the risk was modified by aspirin use, but the mechanism by which aspirin reduces preeclampsia risk is not known. Our limited knowledge is illustrated by the higher frequency of term preeclampsia and gestational hypertension in the control group despite longer aspirin therapy. Nevertheless, we believe that the use of biomarker-based screening to “rule in” then “rule out” the same patient at different time points in gestation is confusing and contradictory.