Yossi Bart

We sought to evaluate adverse neonatal respiratory outcomes among twin pregnancies who delivered between 32.0 and 36.6 weeks, comparing those with and without assisted reproductive technology (ART). This is a retrospective cohort study including patients who delivered from 2008 through 2011 at 25 hospitals of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network within the United States. Twin pregnancies that delivered at 32.0 to 36.6 weeks gestation were included with exclusion of fetal anomalies. The primary outcome was a composite of respiratory adverse outcomes in neonates (CRAO), including resuscitation at the first 24 hours of life, respiratory distress syndrome, bronchopulmonary dysplasia, and neonatal death. Poisson regression was used to calculate adjusted relative risk (aRR) with 95% confidence intervals (CI) and overlap weighting to address the cohort size imbalance. Overall, 1,268 patients (327 [25.8%] ART-conceived and 941 [74.2%] non-ART conceived pregnancies) met the inclusion criteria. Patients who underwent ART were older, had lower body mass index, less likely to smoke, less racially diverse, and had higher rates of private insurance and nulliparity in pregnancy. The CRAO did not differ between the ART group and controls (weighted aRR 0.61, 95% CI 0.27–1.34) following adjustment for maternal age, race/ethnicity, BMI, insurance, smoking, and nulliparity. A sensitivity analysis stratified by gestational age subgroups did not yield any differences between groups. Another sensitivity analysis on the receipt of antenatal corticosteroids showed no difference between groups as well; among the 706 (55.7%) patients who received a full course, ART was not associated with different CRAO rates compared with the control group (weighted aRR 1.03, 95% CI 0.24–4.43). In this study, there was no difference in the CRAO when comparing ART and non-ART groups among twin pregnancies that delivered between 32.0 and 36.6 weeks.

This study aimed to identify predictors for maternal morbidity among individuals categorized as low-risk for postpartum hemorrhage (PPH) according to American College of Obstetrics and Gynecology (ACOG) Practice Bulletin (no.: 183). A retrospective cohort study of all singleton births between March 2020 and February 2022 at a Level IV maternity center. Individuals deemed at medium- or high-risk for PPH according to the ACOG risk stratification and those with missing data were excluded from the main analysis. Individuals with the composite maternal hemorrhagic outcome (CMHO) were compared with those without. Variables previously associated with maternal morbidity yet absent from the ACOG stratification were examined as potential predictors of the CMHO. Possible predictors were identified using a multivariable logistic regression and further assessed with a receiver operating characteristic curve (ROC). Out of 8,623 deliveries, 3,472 (40.3%) met the inclusion criteria. Among them, 175 (5.0%) had a CMHO. Individuals with the composite outcome were older, had a higher body mass index, and had higher rates of Hispanic race/ethnicity, diabetes, postterm pregnancy, scheduled cesarean delivery, and neonatal birth weight ≥ 4,000 g. The combination of ≥ 2 risk factors among low-risk patients, present in 16%, was associated with a similar CMHO rate compared with those at medium PPH risk by the ACOG criteria. The combined presence of ≥ 4 factors was associated with a CMHO rate of 36% and yielded a 10.47 positive likelihood ratio (95% confidence interval [CI]: 3.55–30.90). The area under the curve for the ROC curve of the final model was 0.63 (95% CI: 0.62–0.65). Among low-risk PPH patients, several risk factors with low predictive value flagged roughly one out of six with morbidity similar to medium risk.

Objective This study aimed to compare maternal and neonatal outcomes between labor induction versus cesarean delivery (CD) without labor among nulliparous individuals with class III obesity (body mass index [BMI] ≥40 kg/m2). Study Design A retrospective cohort study of all nulliparous singleton deliveries at ≥37 weeks with a BMI of ≥40 kg/m2 at delivery between March 2020 and February 2022. We excluded individuals with spontaneous labor, fetal malformations, and stillbirths. The primary outcome was a composite of maternal mortality and morbidity, including infectious and hemorrhagic morbidity. The secondary outcome was a neonatal composite. A subgroup analysis evaluated patients with a BMI of ≥50 kg/m2. Another subgroup analysis compared outcomes between CD without labor and an indicated CD following induction. A multivariable logistic regression was applied. For adjustment, we used possible confounders identified in a univariate analysis. Results Among 8,623 consecutive deliveries during the study period, 308 (4%) met the inclusion criteria. Among them, 250 (81%) underwent labor induction, and 58 (19%) had a CD without labor. The most common indications for CD without labor were fetal malpresentation (26; 45%), suspected macrosomia (8; 14%), and previous myomectomy (5; 9%). Indicated CD occurred in 140 (56%) of the induced individuals, with the two leading indications being labor arrest (87; 62%) and non-reassuring fetal heart rate tracing (51; 36%). The rates of composite maternal morbidity (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [CI]: 0.64–7.13) and composite neonatal morbidity (aOR = 3.62, 95% CI: 0.42–31.19) did not differ following a CD without labor compared to labor induction. The subgroup analyses did not demonstrate different outcomes between groups. Conclusion Among nulliparous individuals with class III obesity at term who underwent induction, more than 50% had indicated CD; the rate of short-term maternal and neonatal morbidity, however, did not differ between labor induction and CD without labor. Key Points

Objective: To identify risk factors for readmission following methotrexate treatment for tubal pregnancy.Methods: A retrospective study undertaken in two tertiary medical centers, including all individuals with medically treated tubal pregnancy (N = 511), between December 2009 and June 2021. Individuals with and without readmission following methotrexate treatment were compared. The primary outcome was the readmission rate. Secondary outcomes included the rate of post‐discharge gynecological emergency department visits, tubal rupture rate, and the eventual need for surgical treatment.Results: Readmission following methotrexate treatment occurred in 224/511 patients (43.8%). Most readmissions were due to abdominal pain or suspicion of treatment failure. Readmitted individuals were more likely to have a history of pelvic inflammatory disease and pretreatment serum human chorionic gonadotropin (hCG) >2000 mIU/mL. Both factors remained significantly associated with higher readmission rates in a logistic regression analysis (adjusted odds ratio [OR] 6.28, 95% confidence interval [CI] 1.30–30.45, and adjusted OR 2.73, 95% CI 1.83–4.07, respectively) after adjustment for age, endometriosis, tubal pathology, abdominal pain, and presence of yolk sac or embryo at diagnosis. A dose‐dependent association was observed between pretreatment serum hCG levels and readmission rate (P < 0.001). Pretreatment hCG levels were also associated with tubal rupture and the eventual need for surgical treatment (P < 0.001 for both). A prediction model using hCG was not sufficiently accurate to predict readmission risk.Conclusion: Readmission following methotrexate treatment for tubal pregnancy was independently associated with previous pelvic inflammatory disease and pretreatment serum hCG levels. The latter was also associated with surgical intervention rate.