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In this single-center trial comparing chlorhexidine–alcohol with iodine–alcohol for skin antisepsis before cesarean delivery, the use of chlorhexidine–alcohol resulted in a risk of surgical-site infection that was significantly lower than that associated with iodine–alcohol. Cesarean delivery is the most common major surgical procedure among women in the United States. 1 In 2013, more than 32.7% (1.3 million) of the 3.9 million births were by cesarean section. 2 Surgical-site infections complicate 2 to 5% of all surgical procedures and 5 to 12% of cesarean deliveries. 3 – 6 Infection occurring after delivery places an extra burden on the new mother and may impair mother–infant bonding and breast-feeding. The average attributable hospital cost per surgical-site infection after cesarean delivery is estimated to be $3,529. 7 The skin is a major source of pathogens that cause surgical-site infections. Therefore, preoperative skin antisepsis . . .

Optimal management of pregnancies at 39 weeks gestational age is unknown. Therefore, we sought to perform a comparative effectiveness analysis of elective induction of labor (eIOL) at 39 weeks among nulliparous women with non-anomalous singleton, vertex fetuses as compared to expectant management (EM) which included IOL for medical or obstetric indications or at 41 weeks in undelivered mothers. A Monte Carlo micro-simulation model was constructed modeling two mutually exclusive health states: eIOL at 39 weeks, or EM with IOL for standard medical or obstetrical indications or at 41 weeks if undelivered. Health state distribution probabilities included maternal and perinatal outcomes and were informed by a review of the literature and data derived from the Consortium of Safe Labor. Analyses investigating preferences for maternal versus infant health were performed using weighted utilities. Primary outcome was determining which management strategy posed less maternal and neonatal risk. Secondary outcomes were rates of cesarean deliveries, maternal morbidity and mortality, stillbirth, neonatal morbidity and mortality, and preferences regarding the importance of maternal and perinatal health. A management strategy of eIOL at 39 weeks resulted in less maternal and neonatal risk as compared to EM with IOL at 41 weeks among undelivered patients. Cesarean section rates were higher in the EM arm (35.9% versus 13.9%, p<0.01). When analysis was performed only on patients with an unfavorable cervix, 39 week eIOL still resulted in fewer cesarean deliveries as compared to EM (8.0% versus 26.1%, p<0.01). There was no statistical difference in maternal mortality (eIOL 0% versus EM 0.01%, p = 0.32) but there was an increase in maternal morbidity among the EM arm (21.2% versus 16.5, p<0.01). There were more stillbirths (0.13% versus 0%, p<0.0003), neonatal deaths (0.25% versus 0.12%, p< 0.03), and neonatal morbidity (12.1% versus 9.4%, p<0.01) in the EM arm as compared to the eIOL arm. Preference modeling revealed that 39 week eIOL was favored over EM. Mathematical modeling revealed that eIOL at 39 weeks resulted in lower population risks as compared to EM with induction of labor at 41 weeks. Specifically, eIOL at 39 weeks resulted in a lower cesarean section rate, lower rates of maternal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal morbidity.

To generate a clinical prediction tool for stillbirth that combines maternal risk factors to provide an evidence based approach for the identification of women who will benefit most from antenatal testing for stillbirth prevention. Retrospective cohort study. Midwestern United States quaternary referral center. Singleton pregnancies undergoing second trimester anatomic survey from 1999-2009. Pregnancies with incomplete follow-up were excluded. Candidate predictors were identified from the literature and univariate analysis. Backward stepwise logistic regression with statistical comparison of model discrimination, calibration and clinical performance was used to generate final models for the prediction of stillbirth. Internal validation was performed using bootstrapping with 1,000 repetitions. A stillbirth risk calculator and stillbirth risk score were developed for the prediction of stillbirth at or beyond 32 weeks excluding fetal anomalies and aneuploidy. Statistical and clinical cut-points were identified and the tools compared using the Integrated Discrimination Improvement. Antepartum stillbirth. 64,173 women met inclusion criteria. The final stillbirth risk calculator and score included maternal age, black race, nulliparity, body mass index, smoking, chronic hypertension and pre-gestational diabetes. The stillbirth calculator and simple risk score demonstrated modest discrimination but clinically significant performance with no difference in overall performance between the tools [(AUC 0.66 95% CI 0.60-0.72) and (AUC 0.64 95% CI 0.58-0.70), (p = 0.25)]. A stillbirth risk score was developed incorporating maternal risk factors easily ascertained during prenatal care to determine an individual woman's risk for stillbirth and provide an evidenced based approach to the initiation of antenatal testing for the prediction and prevention of stillbirth.

Among several interleukin (IL)-6 family members, only IL-6 and IL-11 require a gp130 protein homodimer for intracellular signaling due to lack of intracellular signaling domain in the IL-6 receptor (IL-6R) and IL-11R. We previously reported enhanced decidual IL-6 and IL-11 levels at the maternal-fetal interface with significantly higher peri-membranous IL-6 immunostaining in adjacent interstitial trophoblasts in preeclampsia (PE) vs. gestational age (GA)-matched controls. This led us to hypothesize that competitive binding of these cytokines to the gp130 impairs extravillous trophoblast (EVT) differentiation, proliferation and/or invasion. Using global microarray analysis, the current study identified inhibition of interferon-stimulated gene 15 ( ISG15 ) as the only gene affected by both IL-6 plus IL-11 vs. control or IL-6 or IL-11 treatment of primary human cytotrophoblast cultures. ISG15 immunostaining was specific to EVTs among other trophoblast types in the first and third trimester placental specimens, and significantly lower ISG15 levels were observed in EVT from PE vs. GA-matched control placentae ( p = 0.006). Induction of primary trophoblastic stem cell cultures toward EVT linage increased ISG15 mRNA levels by 7.8-fold ( p = 0.004). ISG15 silencing in HTR8/SVneo cultures, a first trimester EVT cell line, inhibited invasion, proliferation, expression of ITGB1 (a cell migration receptor) and filamentous actin while increasing expression of ITGB4 (a receptor for hemi-desmosomal adhesion). Moreover, ISG15 silencing further enhanced levels of IL-1β-induced pro-inflammatory cytokines ( CXCL8 , IL-6 and CCL2 ) in HTR8/SVneo cells. Collectively, these results indicate that ISG15 acts as a critical regulator of EVT morphology and function and that diminished ISG15 expression is associated with PE, potentially mediating reduced interstitial trophoblast invasion and enhancing local inflammation at the maternal-fetal interface. Thus, agents inducing ISG15 expression may provide a novel therapeutic approach in PE.

Objective. To test the hypothesis that maternal obesity is an independent risk factor for rectovaginal group B streptococcus (GBS) colonization at term. Study Design. Retrospective cohort study of consecutive women with singleton term pregnancies admitted in labor at Barnes-Jewish Hospital (2004–2008). Maternal BMI ≥ 30 Kg/m2 (obese) or <30 Kg/m2 (nonobese) defined the two comparison groups. The outcome of interest was GBS colonization from a positive culture. Baseline characteristics were compared using Student’s t-test and Chi-squared or Fisher’s exact test. The association between obesity and GBS colonization was assessed using univariable and multivariable analyses. Results. Of the 10,564 women eligible, 7,711 met inclusion criteria. The prevalence of GBS colonization in the entire cohort was relatively high (25.8%). Obese gravidas were significantly more likely to be colonized by GBS when compared with nonobese gravidas (28.4% versus 22.2%, P<0.001). Obese gravidas were still 35% more likely than nonobese women to test positive for GBS after adjusting for race, parity, smoking, and diabetes (adjusted OR 1.35 [95% CI 1.21–1.50]). Conclusion. Maternal obesity is a significant risk factor for GBS colonization at term. Further research is needed to evaluate the impact of this finding on risk-based management strategies.

Understanding the timing of fetal brain vulnerability to inflammatory changes in pregnancy complications is crucial for predicting neurodevelopmental risks. Beyond the placenta, the developing brain’s vascular system is believed to form a secondary defense, the blood–brain barrier (BBB), which restricts harmful substances that could disrupt neurodevelopment. However, the precise timing and mechanisms underlying BBB development are poorly understood. In this study, we examined the spatiotemporal expression of key BBB components and fetal brain vascularization in mice from gestational days (GD) 10 to 18. Fetal brain sections were immunostained to identify BBB components, including CD31, Factor VIII, NG2, and claudin-5. Our results showed that endothelial precursor cells form the primitive vascular network in a caudal-to-rostral gradient by GD10, with pericyte recruitment stabilizing vessels by GD12 in a lateral-to-medial gradient that aligns with neurogenesis, despite some regional exceptions. However, Factor VIII was not detected until GD15, and claudin-5 until GD18, suggesting a significant delay in endothelial maturation and tight junction formation. These findings highlight the critical timing of structural developments in the fetal brain vasculature and its vulnerability to placental diseases, laying the groundwork for future research on the impact of placental disorders on fetal brain development and potential therapeutic interventions.

Sonography is a fundamental tool in the management of pregnancies affected by maternal diabetes. Purposeful use of ultrasound in each trimester provides an invaluable amount of information about the developing fetus including gestational age and growth patterns, anatomical structure and function, assessment of fetal well-being, and prediction of adverse outcome. There are great ongoing research efforts in this field of prenatal diagnosis and management, yet even more are needed.

Objective: We investigated the association between number of prenatal visits (PNV) and pregnancy outcomes. Study Design: A retrospective cohort of 12 092 consecutive, uncomplicated term births was included. Exclusion criteria included unknown or third trimester pregnancy dating, pre-existing medical conditions and common pregnancy complications. Patients with ⩽10 PNV were compared with those with >10. The primary outcome was a neonatal composite including neonatal intensive-care unit admission, low APGAR score (<7), low umbilical cord pH (<7.10) and neonatal demise. Secondary outcomes included components of the composite as well as vaginal delivery, induction and cesarean delivery. Logistic regression was used to adjust for potential confounders. Result: Of 7256 patients in the cohort meeting inclusion criteria, 30% ( N =2163) had >10 PNV and the remaining 70% ( N =5093) had ⩽10, respectively. There was no difference in the neonatal composite between the two groups. However, women with>10 PNV were more likely to undergo induction of labor and cesarean delivery. Conclusion: Low-risk women with ⩾10 PNV had higher rates of pregnancy interventions without improvement in neonatal outcomes.

In a multinational survey of 122 medical facilities in nine Asian countries, the WHO analyzed data on 107,950 deliveries. Compared with spontaneous vaginal deliveries, any type of cesarean was associated with a 2.7-14.5-fold increase in the odds of the maternal mortality and morbidity index. Antepartum cesarean with indications and intrapartum cesarean demonstrated similar perinatal outcomes when compared with spontaneous vaginal delivery; patients who underwent an intrapartum cesarean without indication had a 2.1-fold increase in the odds of the perinatal mortality and morbidity index. Cesarean delivery decreased perinatal morbidity when performed for noncephalic presentation. Operative vaginal deliveries were also associated with a 2.1-fold increase in the odds of maternal morbidity or mortality with a concomitant 1.9-fold increase in the odds of perinatal morbidity and mortality.

OBJECTIVE: To develop a model for identifying women receiving cervical cerclage at risk for spontaneous preterm birth <32 weeks. STUDY DESIGN: Retrospective cohort study of high-risk patients based on past obstetric history. Our inclusion criteria involved all patients with singleton gestation who received cerclage between 10 and 24 weeks. They were evaluated for the risk factors associated with preterm birth <32 weeks. Risk factors evaluated include: indication for cerclage, gestational age at cerclage placement, cervical length prior to cerclage, timing of cerclage (emergency or elective) and route of cerclage (abdominal or vaginal). Univariable and multivariable analyses were used to determine the risk factors associated with preterm birth. A risk-scoring model was developed for the prediction of preterm birth <32 weeks in women receiving cerclage. RESULTS: We identified 256 women receiving cerclage that met our inclusion criteria. Preterm births <32 weeks occurred in 51 (20%). Multivariable analysis revealed a cervical length <25 mm, a history of cone biopsy and emergency cerclage to be significant risk factors associated with preterm birth <32 weeks. The sensitivity, specificity, positive and negative predictive values of the best model for predicting spontaneous preterm birth <32 weeks in women with cerclage are 80%; 96%; 82% and 95%, respectively. CONCLUSION: The presence of a short cervical length, a history of cone biopsy and emergency cerclage were associated with preterm birth <32 weeks. Our model had a high sensitivity for identifying women who may benefit from a closer surveillance.