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Every year, 1·1 million babies die from prematurity, and many survivors are disabled. Worldwide, 15 million babies are born preterm (<37 weeks' gestation), with two decades of increasing rates in almost all countries with reliable data. The understanding of drivers and potential benefit of preventive interventions for preterm births is poor. We examined trends and estimate the potential reduction in preterm births for countries with very high human development index (VHHDI) if present evidence-based interventions were widely implemented. This analysis is to inform a rate reduction target for Born Too Soon. Countries were assessed for inclusion based on availability and quality of preterm prevalence data (2000–10), and trend analyses with projections undertaken. We analysed drivers of rate increases in the USA, 1989–2004. For 39 countries with VHHDI with more than 10 000 births, we did country-by-country analyses based on target population, incremental coverage increase, and intervention efficacy. We estimated cost savings on the basis of reported costs for preterm care in the USA adjusted using World Bank purchasing power parity. From 2010, even if all countries with VHHDI achieved annual preterm birth rate reductions of the best performers for 1990–2010 (Estonia and Croatia), 2000–10 (Sweden and Netherlands), or 2005–10 (Lithuania, Estonia), rates would experience a relative reduction of less than 5% by 2015 on average across the 39 countries. Our analysis of preterm birth rise 1989–2004 in USA suggests half the change is unexplained, but important drivers include non-medically indicated labour induction and caesarean delivery and assisted reproductive technologies. For all 39 countries with VHHDI, five interventions modelling at high coverage predicted a 5% relative reduction of preterm birth rate from 9·59% to 9·07% of livebirths: smoking cessation (0·01 rate reduction), decreasing multiple embryo transfers during assisted reproductive technologies (0·06), cervical cerclage (0·15), progesterone supplementation (0·01), and reduction of non-medically indicated labour induction or caesarean delivery (0·29). These findings translate to roughly 58 000 preterm births averted and total annual economic cost savings of about US$3 billion. We recommend a conservative target of a relative reduction in preterm birth rates of 5% by 2015. Our findings highlight the urgent need for research into underlying mechanisms of preterm births, and development of innovative interventions. Furthermore, the highest preterm birth rates occur in low-income settings where the causes of prematurity might differ and have simpler solutions such as birth spacing and treatment of infections in pregnancy than in high-income countries. Urgent focus on these settings is also crucial to reduce preterm births worldwide. March of Dimes, USA, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Institutes of Health, USA.

In this trial comparing prenatal repair of myelomeningocele with standard postnatal repair, the prenatal-surgery group had better outcomes and better mental and motor function at the age of 30 months. However, these benefits came with some increased risks. Spina bifida is the most common of congenital anomalies of the central nervous system that are compatible with life. The most frequent form is myelomeningocele, characterized by the extrusion of the spinal cord into a sac filled with cerebrospinal fluid, resulting in lifelong disability. Despite folic acid fortification, the incidence of myelomeningocele has stabilized at 3.4 per 10,000 live births in the United States. 1 Liveborn infants with myelomeningocele have a death rate of approximately 10%. 2 – 4 Long-term survivors have major disabilities, including paralysis and bowel and bladder dysfunction. Damage to the spinal cord and peripheral nerves usually is evident at . . .

In this randomized trial of treatment versus no treatment for mild gestational diabetes mellitus, rates of the primary outcome (a composite of stillbirth or perinatal death and neonatal hyperbilirubinemia, hypoglycemia, hyperinsulinemia, or birth trauma) did not differ significantly between groups. However, there were significant reductions with treatment in several secondary outcomes, including the frequency of large-for-gestational-age infants, shoulder dystocia, cesarean delivery, and hypertension in pregnancy. In this randomized trial of treatment versus no treatment for mild gestational diabetes mellitus, rates of the primary outcome (a composite of stillbirth or perinatal death and neonatal hyperbilirubinemia, hypoglycemia, hyperinsulinemia, or birth trauma) did not differ significantly between groups. However, there were significant reductions with treatment in several secondary outcomes. Gestational diabetes mellitus is defined as glucose intolerance that first occurs or is first identified during pregnancy. 1 The frequency of this condition is rising in the United States and occurs in 1 to 14% of all pregnancies, depending on varying characteristics of the population. 2 More than 40 years ago, O'Sullivan and Mahan developed glucose-tolerance-test criteria for the diagnosis of gestational diabetes mellitus. 3 The diagnostic thresholds that they developed were based on the subsequent development of adult-onset diabetes and were not predicated on any association between carbohydrate intolerance discovered during gestation and adverse pregnancy outcomes. Although gestational diabetes mellitus is a . . .

Among a large cohort of women with viable singleton pregnancies who underwent elective repeat cesarean sections, more than a third of deliveries were performed before 39 weeks of gestation. As compared with deliveries at or after 39 weeks, deliveries before 39 weeks of gestation — even those during the last 3 days before week 39 — were associated with an increased risk of a composite primary outcome that included neonatal death, respiratory complications, need for mechanical ventilation, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit. As compared with deliveries at or after 39 weeks, cesarean deliveries before 39 weeks of gestation were associated with an increased risk of a composite primary outcome that included neonatal death, respiratory complications, need for mechanical ventilation, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit. Infants born before 39 weeks of gestation are at increased risk for neonatal adverse respiratory outcomes, and the risk increases progressively as gestational age at birth declines. 1 , 2 Thus, prelabor elective delivery (delivery in the absence of a specific maternal or fetal indication) is proscribed before 39 weeks unless fetal lung maturity has been demonstrated. 3 , 4 As compared with infants born vaginally, those born by cesarean section are at increased risk for adverse respiratory outcomes, especially when delivery occurs before the onset of labor. 1 , 2 , 5 – 11 This increased risk persists even in infants who are delivered by cesarean section . . .

Objectives To evaluate longitudinal placental perfusion using pseudo-continuous arterial spin–labeled (pCASL) MRI in normal pregnancies and in pregnancies affected by chronic hypertension (cHTN), who are at the greatest risk for placental-mediated disease conditions. Methods Eighteen normal and 23 pregnant subjects with cHTN requiring antihypertensive therapy were scanned at 3 T using free-breathing pCASL-MRI at 16–20 and 24–28 weeks of gestational age. Results Mean placental perfusion was 103.1 ± 48.0 and 71.4 ± 18.3 mL/100 g/min at 16–20 and 24–28 weeks respectively in normal pregnancies and 79.4 ± 27.4 and 74.9 ± 26.6 mL/100 g/min in cHTN pregnancies. There was a significant decrease in perfusion between the first and second scans in normal pregnancies ( p  = 0.004), which was not observed in cHTN pregnancies ( p  = 0.36). The mean perfusion was not statistically different between normal and cHTN pregnancies at both scans, but the absolute change in perfusion per week was statistically different between these groups ( p  = 0.044). Furthermore, placental perfusion was significantly lower at both time points ( p  = 0.027 and 0.044 respectively) in the four pregnant subjects with cHTN who went on to have infants that were small for gestational age (52.7 ± 20.4 and 50.4 ± 20.9 mL/100 g/min) versus those who did not (85 ± 25.6 and 80.0 ± 25.1 mL/100 g/min). Conclusion pCASL-MRI enables longitudinal assessment of placental perfusion in pregnant subjects. Placental perfusion in the second trimester declined in normal pregnancies whereas it remained unchanged in cHTN pregnancies, consistent with alterations due to vascular disease pathology. Perfusion was significantly lower in those with small for gestational age infants, indicating that pCASL-MRI-measured perfusion may be an effective imaging biomarker for placental insufficiency. Clinical relevance statement pCASL-MRI enables longitudinal assessment of placental perfusion without administering exogenous contrast agent and can identify placental insufficiency in pregnant subjects with chronic hypertension that can lead to earlier interventions. Key Points • Arterial spin–labeled (ASL) magnetic resonance imaging (MRI) enables longitudinal assessment of placental perfusion without administering exogenous contrast agent. • ASL-MRI-measured placental perfusion decreased significantly between 16-20 week and 24-28 week gestational age in normal pregnancies, while it remained relatively constant in hypertensive pregnancies, attributed to vascular disease pathology. • ASL-MRI-measured placental perfusion was significantly lower in subjects with hypertension who had a small for gestational age infant at 16–20-week gestation, indicating perfusion as an effective biomarker of placental insufficiency.

The definition for anemia in pregnancy is outdated, derived from Scandinavian studies in the 1970's to 1980's. To identity women at risk of blood transfusion, a common cause of Severe Maternal Morbidity, a standard definition of anemia in pregnancy in a modern, healthy United States cohort is needed. To define anemia in pregnancy in a United States population including a large county vs. private hospital population using uncomplicated patients. Inclusion criteria were healthy women with the first prenatal visit before 20 weeks. Exclusion criteria included preterm birth, preeclampsia, hypertension, diabetes, short interval pregnancy (<18 months), multiple gestation, abruption, and fetal demise. All women had iron fortification (Ferrous sulfate 325 mg daily) recommended. The presentation to care and pre-delivery hematocrits were obtained, and the percentiles determined. A total of 2000 patients were included, 1000 from the public county hospital and 1000 from the private hospital. Each cohort had 250 patients in each 2011, 2013, 2015, and 2018. The cohorts were compared for differences in the fifth percentile for each antepartum epoch. Student's t-test and chi-squared statistical tests were used for analysis, p-value of ≤0.05 was considered significant. In the public and private populations, 777 and 785 women presented in the first trimester while 223 and 215 presented in the second. The women at the private hospital were more likely to be older, Caucasian race, nulliparous, and present earlier to care. The fifth percentile was compared between the women in the private and public hospitals and were clinically indistinguishable. When combining the cohorts, the fifth percentile for hemoglobin/hematocrit was 11 g/dL/32.8% in the first trimester, 10.3 g/dL/30.6% in the second trimester, and 10.0 g/dL/30.2% pre-delivery. Fifth percentile determinations were made from a combined cohort of normal, uncomplicated pregnancies to define anemia in pregnancy. Comparison of two different cohorts confirms that the same definition for anemia is appropriate regardless of demographics or patient mix.

Unfortunately, the discussion regarding the minimal risk associated with VBAC, and the need to advocate for more VBAC, is likely to remain academic. [...]these two studies are likely to increase the fear of trial of labor rather than alleviate it. [...]the onus falls on the clinicians.

Women with a history of preterm delivery are at high risk for recurrence in subsequent pregnancies, and an effective strategy to reduce this risk has been lacking. In this randomized, placebo-controlled trial, weekly injections of 17 alpha-hydroxyprogesterone caproate reduced the risk of delivery before 37 weeks of gestation by one third among such high-risk women. Injections of 17 alpha-hydroxyprogesterone reduced the risk among high-risk women. Preterm delivery — that is, delivery before 37 completed weeks of gestation — is the major determinant of infant mortality in developed countries. 1 Preterm delivery is more common in the United States than in many other developed countries and is the factor most responsible for the relatively high infant mortality in this country. 1 The rate of preterm delivery in the United States has increased progressively from 9 percent to 12 percent over the past two decades. 2 Despite many trials of reduced activity, tocolytic therapy, antibiotic therapy, and other strategies for prevention, no effective and reproducible method of preventing preterm delivery . . .

Stillbirth remains a major and tragic obstetric complication The number of deaths due to stillbirth are greater than those due to preterm birth and sudden infant death syndrome combined. Stillbirth: Prediction, Prevention and Management provides a comprehensive guide to the topic of stillbirth. Distilling recent groundbreaking research, expert authors consider: * The epidemiology of stillbirth throughout the world * The various possible causes of stillbirth * The psychological effects on mothers and families who suffer a stillbirth * Management of stillbirth * Managing pregnancies following stillbirth Stillbirth: Prediction, Prevention and Management is packed with crucial evidence-based information and practical insights. It enables all obstetric healthcare providers to manage one of the most traumatic yet all too common situations they will encounter.

More than half of new mothers take one or more medications in the months after delivery. But health care providers often lack the evidence they need to counsel breast-feeding women on medications’ potential effects on lactation, on mothers, or on their babies.