Stroke remains a rare but life-threatening complication of pregnancy, with significant implications for both maternal and fetal health. Current stroke prevention and treatment guidelines offer limited guidance for managing stroke in pregnant and postpartum patients. Despite advances in obstetric and neurological care, the diagnosis and management of pregnancy-associated stroke continue to be challenged by delayed recognition, a lack of tailored clinical guidelines, and persistent disparities in outcomes. This scientific statement represents a multidisciplinary effort to synthesize current knowledge of the risk factors and diverse causes of stroke in pregnancy and to offer consensus-driven suggestions for prevention, acute management, and postpartum recovery. Nearly half of all US pregnancy-associated stroke hospitalizations occur in the setting of hypertensive disorders. Primary stroke prevention strategies include risk factor modification, aggressive hypertension management and prompt treatment of severe hypertension in pregnancy and postpartum, and antithrombotic therapy in some high-risk groups. Secondary stroke prevention strategies in pregnancy depend on the mechanism of the prior stroke. Pregnancy should not delay evidence-based treatments for acute stroke. The use of telemedicine can facilitate early consultation with a vascular neurologist and a maternal-fetal medicine specialist in cases of acute pregnancy-related stroke, helping to guide initial decision-making. Computed tomography, computed tomography angiography, and magnetic resonance imaging without contrast are all safe neuroimaging modalities for rapid evaluation of pregnant patients with acute stroke symptoms. Acute stroke alone is not an indication for immediate delivery, and stabilization of the mother should come first. Vaginal delivery after stroke is preferred when feasible because it avoids the surgical risks and hemodynamic stress associated with cesarean delivery. Survivors of pregnancy-associated stroke face unique challenges such as caring for an infant and breastfeeding and require support from a multidisciplinary rehabilitation team. Continued research, including inclusive clinical trials, is urgently needed to refine stroke risk assessment, to expand treatment options, and to improve maternal outcomes.

Background: Increased nuchal translucency (NT) is associated with an elevated risk of genetic abnormalities and structural malformations. The clinical utility of invasive testing and the optimal diagnostic approach in mildly increased NT (3.0–3.4 mm) is debated. This study aimed to evaluate genetic and ultrasound findings in this subgroup and to assess the diagnostic yield of advanced genetic testing. Methods: We retrospectively included a total of 107 fetuses with NT between 3.0 and 3.4 mm from a single fetal medicine unit. Complete outcome data were available for 97 pregnancies. Invasive prenatal testing with standard karyotype, chromosomal microarray analysis (CMA) and RASopathy panel testing were offered. All patients underwent detailed ultrasound examination to detect structural abnormalities at 16 and 20 weeks, regardless of whether invasive testing was performed. Results: Invasive prenatal testing, amniocentesis or chorionic villus sampling, (CVS), was performed in 77/97 cases (79.4%). Genetic abnormalities were detected in 28/97 (28.9%). Overall, five rare genetic anomalies were identified; none would have been detected by quantitative fluorescent polymerase chain reaction (QF-PCR) or non-invasive prenatal testing (NIPT). Two anomalies were detectable by standard karyotype, two exclusively by CMA and one exclusively by RASopathy panel. When considering all cases undergoing advanced genetic testing (CMA or RASopathy panel, n = 35) the overall diagnostic yield was 8.5% (3/35). When calculated across the entire cohort with complete follow-up, the additional diagnostic yield was 3.1% (3/97). Major structural malformations were identified in 17/97 cases (17.5%), of which 10 (58.8%) were associated with genetic abnormalities. Conclusions: Fetuses with NT measurements between 3.0 and 3.4 mm show a substantially increased risk of genetic abnormalities and structural malformations. These findings support a comprehensive prenatal evaluation, including invasive testing with advanced genetic analysis and detailed ultrasound assessment, to optimize diagnosis and counseling.

This research explored a cross-country comparison of qualitative and quantitative data assessing the experiences of prenatal genomic healthcare professionals (HCP) in Australia and the Netherlands. The interview script included open-ended questions on work experience, validated scales on compassion fatigue and stress, and demographic details. Content analysis with an inductive coding approach was used for the coding and analysis of qualitative data. Quantitative data were compared between professions and countries, using a one-way ANCOVA. Quantitative data were obtained from 93 participants and qualitative data from a subset of 63 participants, recruited from the departments of clinical genetics, maternal-fetal medicine and genomic laboratories. The following themes were constructed: (1) Advancements in prenatal genomics increase diagnostic rates but cause increased workloads; (2) Benefits and drawbacks of the current healthcare system; (3) The burden of equivocality: high stakes and ambiguous findings; and (4) Multidisciplinary teamwork, support and supervision may improve working conditions. There were no significant differences in compassion fatigue between professions, but Australian HCPs experienced significantly more symptoms of burnout and secondary traumatic stress than Dutch HCPs. Although participants had overall positive views and experiences, with high levels of job satisfaction and low levels of compassion fatigue, additional resources are required to minimize professional burnout while dealing with increasing demands.

To evaluate the clinical effectiveness and economic impact of implementing first-trimester screening involving placental growth factor (PlGF) followed by aspirin prophylaxis for the prevention of preterm pre-eclampsia in routine obstetric practice. This retrospective cohort study was conducted at a tertiary maternal-fetal medicine center that implemented a first-trimester screen-and-prevent strategy for preterm pre-eclampsia. Two time periods were compared: a preimplementation phase (August 2011 to June 2014), during which risk assessment for pre-eclampsia was performed for research purposes without prophylactic aspirin administration; and a postimplementation phase (July 2017 to February 2024), during which women who screened as high risk for preterm pre-eclampsia were given aspirin prophylaxis (160 mg daily until 36 weeks' gestation). Risk assessment was based on the Fetal Medicine Foundation competing-risks algorithm, applied with and without the inclusion of PlGF. The primary outcome was the incidence of preterm pre-eclampsia (< 37 weeks). Secondary outcomes included preterm birth (< 37 weeks), overall pre-eclampsia and estimated healthcare cost savings based on national birth data. This model included the direct medical costs of neonatal management of preterm birth and lifetime costs of cerebral palsy. Adjusted odds ratios (aORs) for preterm pre-eclampsia were estimated using multivariable logistic regression analysis. Among 11 061 singleton pregnancies screened between 11 + 0 and 13 + 6 weeks' gestation, 3216 were screened during the preimplementation period and 7845 during the postimplementation period. The incidence of preterm pre-eclampsia declined from 1.1% to 0.6% between phases (aOR, 0.41 (95% CI, 0.25-0.68)). The overall rate of pre-eclampsia also decreased between phases(2.5% vs 1.4%; aOR, 0.51 (95% CI, 0.37-0.70)), as did that of preterm birth (5.9% vs 4.7%; aOR, 0.76 (95% CI, 0.63-0.92)). The protective effect of aspirin was most pronounced among women identified as high risk using a PlGF-based screening algorithm (aOR, 0.51 (95% CI, 0.28-0.92)), while no significant effect was observed in the group identified as high risk using an algorithm without PlGF. An economic model projected that this strategy would prevent 403 cases of preterm pre-eclampsia annually in a national cohort of 110 000 pregnancies, with estimated cost savings of €27.7 million. Real-world implementation of PlGF-based screening with aspirin prophylaxis significantly reduced the incidence of preterm pre-eclampsia and preterm birth, and was associated theoretically with substantial health-system cost savings. These findings support consideration of the nationwide adoption of early screen-and-prevent strategies for hypertensive disorders of pregnancy. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

This study aimed to evaluate the impact of a modified surgical site infection (SSI) prevention bundle, focused on closing-phase equipment changes, on post-cesarean SSI rates.We conducted a retrospective cohort study of cesarean deliveries performed by a single, large, obstetrical and maternal-fetal medicine practice from April 1, 2018, to February 28, 2025. The amended bundle, implemented in September 2021, introduced universal glove changes, light handle replacement, suction catheter tip removal, Bovie replacement, sterile re-draping, and a new surgical tray and instruments for fascial closure. Standardized prophylactic antibiotics, abdominal and vaginal preparation, and dressing protocols remained unchanged. Deliveries were categorized as preimplementation (April 2018-August 2021) and postimplementation (October 2021-February 2025). SSI was defined as wound separation requiring packing or wound infection necessitating antibiotics within 30 days. Logistic regression models adjusted for maternal age and gestational age. Subgroup analyses stratified by labor status, primary versus repeat cesarean, and body mass index (BMI).A total of 2,467 cesarean deliveries were included, with 1,271 in the preimplementation and 1,196 in the postimplementation group. SSI occurred in 2.6% of preimplementation versus 3.3% of postimplementation deliveries (adjusted OR = 1.27, 95% CI: 0.80-2.04; p = 0.313). No significant temporal trends were observed before (p = 0.151) or after (p = 0.221) bundle implementation. Subgroup analyses by labor status, prior cesarean, and BMI similarly showed no significant associations between the bundle and SSI risk.Introducing closing-phase equipment changes on top of standardized SSI prevention practices did not reduce post-cesarean SSI rates. These findings suggest that once core measures such as antibiotics, prep, and dressings are standardized, additional equipment changes alone may not provide incremental benefit. These findings highlight the importance of rigorously evaluating process changes before widespread implementation. · Closing-phase equipment changes did not lower cesarean SSI rates.. · Bundle showed no effect in subgroup analyses by labor status, prior cesarean, and BMI.. · Findings question the value of costly closure-phase SSI prevention bundles..

Objective To identify maternal risk factors for gestational diabetes mellitus (GDM) and to evaluate its perinatal implications in dichorionic (DC) twin pregnancies, a population in which metabolic demands and placental physiology differ substantially from singleton gestations. Methods A retrospective cohort study was conducted among 378 women with confirmed DC twin pregnancies, including 122 women with GDM and 256 without GDM, delivered at a tertiary maternal–fetal medicine center between 2018 and 2023. GDM was diagnosed using IADPSG criteria following a 75-g oral glucose tolerance test. Maternal demographic factors, conception mode, early ultrasound parameters, obstetric outcomes, and neonatal outcomes were compared between women with and without GDM using univariate analyses and multivariate logistic regression. Results Pre-pregnancy BMI ≥25 kg/m2 (adjusted OR 1.857, 95% CI 1.050–3.284) and conception via assisted reproductive technology (adjusted OR 1.608, 95% CI 1.029–2.514) independently increased the likelihood of developing GDM. Most maternal and neonatal outcomes—including preterm birth, birth weight patterns, neonatal hypoglycemia, and NICU admission—did not differ significantly between the two groups. However, GDM was associated with a higher incidence of single intrauterine fetal demise (7.4% vs. 2.7%, p = 0.036). Conclusion In DC twin pregnancies, maternal overweight and ART conception constitute significant risk factors for GDM. While many perinatal outcomes appear unaffected, the elevated risk of single fetal demise underscores the need for intensified fetal surveillance and individualized management in this high-risk population.

Congenital parvovirus B19 (PB19) infection can lead to severe fetal anemia and hydrops fetalis, necessitating in-utero transfusion (IUT) as a life-saving intervention. This study aimed to identify risk factors associated with unfavorable perinatal outcome following IUT in hydropic fetuses with PB19 infection, with the goal of optimizing transfusion strategies and improving fetal survival. A retrospective, multicenter, international cohort study was conducted across nine specialized fetal medicine centers in France, Belgium and the Czech Republic. This study included pregnant women with a fetus diagnosed with hydrops due to PB19 infection that underwent at least one IUT for severe fetal anemia between January 2014 and May 2024. Clinical, demographic and procedural data were analyzed. The primary outcome was to identify maternal, fetal, obstetric or IUT-related risk factors associated with adverse fetal or neonatal outcome, defined by a composite criterion of unfavorable outcome that included perinatal mortality and/or severe and persistent fetal anomalies, including severe fetal brain injury at follow-up. Statistical analysis was conducted using logistic regression models to assess potential risk factors. Of the 84 eligible cases, 78 pregnancies were included in the final analysis. The rate of perinatal survival without severe brain injury was 59.0% (46/78), while 41.0% (32/78) of cases had an unfavorable outcome, including 20 (25.6%) cases of stillbirth, nine (11.5%) cases of termination of pregnancy, one (1.3%) case of continuation of pregnancy despite severe prenatal neurological findings and two (2.6%) cases of neonatal death. Notably, a higher fetal hemoglobin (Hb) level (> 9.3 g/dL) after the first or second IUT was significantly associated with a reduced risk of unfavorable outcome (adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.8)). A femur length Z-score of < -2 was associated with unfavorable outcome (aOR, 5.4 (95% CI, 1.3-27.0)). Transplacental vs transamniotic funicular puncture was not significantly associated with perinatal survival. IUT remains a cornerstone intervention for managing severe fetal anemia caused by PB19 infection; however, rates of perinatal loss continue to be substantial, especially in the presence of severe hydrops. Achieving higher post-transfusion Hb levels appears to be an important factor in improving survival outcomes for hydropic fetuses with PB19 infection. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

Imperfect first-trimester screening for hypertensive disorders of pregnancy (HDP) means many high-risk women miss the window for preventive aspirin, and the biological heterogeneity of HDPs is overlooked. This study aimed to leverage first-trimester serum proteomics to create a more precise tool for predicting preeclampsia (PE) and differentiating it from other HDPs. A prospective nested case-control study (n = 172) was conducted using targeted liquid chromatography-multiple reaction monitoring-mass spectrometry (LC-MRM-MS) proteomic profiling of 115 proteins. Machine learning (ML) methods were used to develop classifiers from the proteomic data. The signature predictive of PE was characterized by dysregulation of the complement and coagulation cascades (F10, C8A, C1QA, SERPING1, VTN). The profile differentiating gestational hypertension (GAH) from chronic hypertension (CAH) was linked to lipid metabolism (HRG, APOA4, APOC2). An 18-protein support vector machine (SVM) model for predicting PE demonstrated exceptional performance, with 94% sensitivity and 100% specificity, significantly outperforming the standard Fetal Medicine Foundation (FMF) screening algorithm. Pathway analysis confirmed that PE is associated with early activation of innate immunity and coagulation pathways, while GAH is linked to a pregnancy-induced metabolic response. A targeted serum proteomic combined with ML approach represents a new perspective diagnostic tool with strong potential to personalize monitoring for women at the highest risk for specific hypertensive pregnancy complications.

Colonic volvulus, although the cause of less than 2% of large bowel obstructions, is the overall third leading cause of large bowel obstruction in the USA. Of these cases, less than 1% are described to be volvulus of the transverse colon, as volvulus most commonly affects the sigmoid colon or caecum. In the context of pregnancy, there is an even greater paucity of information regarding the management of volvulus. We report a case of a female in her 20s who presented at 33 weeks and 6 days during her first pregnancy with concern for large bowel volvulus. Initially managed endoscopically, after extensive discussion with family, obstetrics team and maternal foetal medicine team, the decision was made to pursue delivery and surgical intervention concurrently.

Cancer occurs in ∼1 per 1,000 pregnancies; thousands of patients may require radiation procedures for diagnosis and treatment each year. This rare but high-risk scenario, coupled with fear of radiation, has created ambiguity in the ideal management of pregnant patients. Without a comprehensive guide for the use of radiation in imaging and treatment for pregnant cancer patients, it is difficult for providers to provide optimal patient-centered care without introducing disparities. The goal of this paper is to provide guidance on the use of radiation for screening, diagnosis, staging, and treatment of cancer, while highlighting gaps in existing knowledge and guidelines. The intention is that physicians, medical physicists, and patients could use this document as a resource for shared decision-making, ensuring safe and effective practice. A team of physicians and medical physicists with expertise in imaging, radiotherapy, and maternal fetal medicine was assembled, along with a patient advocate and lawyer. Existing guidelines and recent literature were reviewed. Authors also drew from their experience where published guidance was lacking. The resulting document discusses best practice to guide use of radiation for cancer, as well as patient-centered care management and legal considerations. It is possible to safely and effectively deliver radiation to pregnant patients in numerous circumstances. Use of radiation or other modalities should be discussed through shared decision-making with the physician and patient, contextualizing the maternal and fetal risk from treatments. Healthcare providers should support wide access to reproductive healthcare to allow equitable, evidence-based, patient-centered healthcare.

Stroke remains a rare but life-threatening complication of pregnancy, with significant implications for both maternal and fetal health. Current stroke prevention and treatment guidelines offer limited guidance for managing stroke in pregnant and postpartum patients. Despite advances in obstetric and neurological care, the diagnosis and management of pregnancy-associated stroke continue to be challenged by delayed recognition, a lack of tailored clinical guidelines, and persistent disparities in outcomes. This scientific statement represents a multidisciplinary effort to synthesize current knowledge of the risk factors and diverse causes of stroke in pregnancy and to offer consensus-driven suggestions for prevention, acute management, and postpartum recovery. Nearly half of all US pregnancy-associated stroke hospitalizations occur in the setting of hypertensive disorders. Primary stroke prevention strategies include risk factor modification, aggressive hypertension management and prompt treatment of severe hypertension in pregnancy and postpartum, and antithrombotic therapy in some high-risk groups. Secondary stroke prevention strategies in pregnancy depend on the mechanism of the prior stroke. Pregnancy should not delay evidence-based treatments for acute stroke. The use of telemedicine can facilitate early consultation with a vascular neurologist and a maternal-fetal medicine specialist in cases of acute pregnancy-related stroke, helping to guide initial decision-making. Computed tomography, computed tomography angiography, and magnetic resonance imaging without contrast are all safe neuroimaging modalities for rapid evaluation of pregnant patients with acute stroke symptoms. Acute stroke alone is not an indication for immediate delivery, and stabilization of the mother should come first. Vaginal delivery after stroke is preferred when feasible because it avoids the surgical risks and hemodynamic stress associated with cesarean delivery. Survivors of pregnancy-associated stroke face unique challenges such as caring for an infant and breastfeeding and require support from a multidisciplinary rehabilitation team. Continued research, including inclusive clinical trials, is urgently needed to refine stroke risk assessment, to expand treatment options, and to improve maternal outcomes.

Understanding the mechanisms that promote or hinder healthy placental development and functionality is fundamental to advancing the field of fetal and reproductive medicine. Syncytiotrophoblast (STB) are highly specialized trophoblast which develop and gain functional maturity during the first trimester of pregnancy. STB are critical to many placental functions and are often implicated in the etiology of placental pathologies. Recent advancements in cell biology have facilitated the development of innovative in vitro STB model systems. However, as the variety of available in vitro STB models grows, a critical assessment of the strengths, limitations, and appropriate applications of both established and emerging model systems is important for the field. With this review, we set out to compile and synthesize current knowledge on in vitro modeling of STB. Using this information, we sought to develop a balanced and thoughtful discussion regarding the use and suitability of various in vitro STB models. Our approach is grounded in a framework that considers placental development and physiology, with a specific focus on the capability of different models to recapitulate and thus enable the study of human STB differentiation, development, function, and dysfunction. This review assessed published literature sourced through the PubMed database. Search terms included 'human placenta models,' 'syncytiotrophoblast models,' 'syncytiotrophoblast development,' 'trophoblast stem cells,' 'trophoblast organoids,' and 'trophoblast cell models.' The literature search was limited to English-language publications available up to August 2025. We provide a narrative which explores the features, potential applications, and limitations of various STB models, including explant systems, immortalized trophoblast cell lines, stem cell-derived trophoblast, and a range of established and emerging 3D culture systems. Our evaluation focuses on the potential of each model to address specific research questions and highlights the challenges associated with modeling different stages of STB development and different unique aspects of STB functionality. Moreover, while remarkable progress in developing STB models has been made, no single system fully recapitulates the complex in vivo features of STB formation and function. Rather than being exhaustive, this review seeks to provide an evidence-based perspective on STB modeling in vitro which can encourage the careful consideration of the strengths and limitations of STB models. This review provides an overview of the in vitro STB models currently available and a commentary of the knowledge that these systems have contributed to our understanding of STB biology. While the field has made significant progress, ongoing refinement of existing models is essential for advancing our understanding of STB and their role in both the health and dysfunction of the human placenta. By summarizing the unique adaptations and physiological changes of STB throughout gestation and aligning these with the capabilities of current models, we have developed a framework to guide future research and innovation in STB modeling. This framework is underscored by the importance of selecting models which align with specific research questions and simultaneously acknowledging the inherent limitations in extrapolating data from any in vitro systems to the biological context of the developing human placenta. By generating this discussion, we hope to contribute to the ongoing refinement of placental research methodologies and to inspire continued innovation in STB model systems. N/A.

Advances in artificial intelligence and multi-omic analysis are transforming fetal medicine from a diagnostic discipline into a predictive one. Yet the legal, deontological, and ethical frameworks that govern prenatal and fetal data have not evolved accordingly. Current regulations protect the mother as a patient but do not recognize the fetus-or the future child-as a legal data subject. As a result, information generated before birth remains confined within maternal medical records, creating uncertainty about who may later access or reuse it. This paper examines the emerging ethical and legal challenges of predictive fetal medicine, focusing on the transition from maternal consent to the child's future right to their own prenatal data. Through the lens of professional deontology and comparative law, we analyze the tensions between confidentiality, autonomy, and beneficence. We propose a framework of prenatal data stewardship, shifting from static notions of data ownership to shared responsibility across time. Establishing national or international repositories under transparent governance could enable ethical reuse of fetal data while safeguarding maternal privacy and ensuring future individuals' rights. Ultimately, aligning predictive fetal medicine with ethical and legal coherence requires collective action among clinicians, ethicists, jurists, policymakers, and industry. Only through such stewardship can information generated before birth become a trusted tool for care rather than control.

Purpose To develop a deep learning algorithm to automatically assess the posterior fossa on first-trimester US screening scans and identify open spina bifida (OSB) and cystic posterior fossa (CPF) anomalies. Materials and Methods This is the retrospective part of an international study involving 10 fetal medicine centers. Normal and abnormal (OSB, CPF anomaly) midsagittal fetal brain US images acquired between 11 and 14 weeks of gestation (July 2009-January 2024) with confirmed diagnosis at follow-up were evaluated. Images were manually annotated to delineate the posterior fossa. The dataset was split into a training/validation (70%) and internal test (30%) set. Three convolutional neural networks were trained via threefold cross-validation on the training/validation set, with predictions on the internal test set obtained by ensemble averaging across folds. Model performance in detecting OSB and CPF anomalies was evaluated for the whole cohort and for fetuses with OSB or CPF anomalies separately. Results Images from 251 fetuses were analyzed (mean gestational age, 12.7±0.65 weeks; 150 normal, 101 abnormal: 43 OSB, 58 CPF anomalies). On the internal test, the MobileNetV3 Large Weights achieved the best performance (area under the receiver operating characteristic curve, 0.94 [95% CI: 0.88, 0.99]; accuracy, 88% (67/76); recall, 81% (25/31); specificity, 93% (42/45); precision, 89% (25/28); NPV, 88% (42/48); and F1-score, 0.85). OSB was classified more accurately (93% (52/56) vs 88% (57/65), P = .38) and with higher recall (91% (10/11) versus 75% (15/20), P = .38 although the difference was not significant. Conclusion MobileNetV3 Large Weights accurately assessed the fetal posterior fossa between 11 and 14 weeks of gestation, distinguishing normal images from those showing OSB or CPF anomalies. ©RSNA, 2026.

Introduction: The last 40 years have seen an increase in fetal diagnosis and therapy centers and the emergence of professional societies such as IFMSS, NAFTNet, iFetus, Eurofetus, and ISPD. Despite the progress and cross-collaboration, it is still unclear what resources are needed for the creation of new fetal diagnosis and treatment centers (FDTCs). Our study aimed to ascertain the key resources essential for effective FDTC implementation. Methods: A cross-sectional study using a questionnaire was distributed to providers at North American FDTCs. The questionnaire ranked the importance of providers, facilities, interventions, and resources. Data analysis used descriptive statistics and series cross-tabulations for significance. Results: Overall, 40.2% completed the questionnaire. Maternal-fetal medicine (MFM) specialists and pediatric surgeons (92%) predominated. Most centers were >10 years old. Critical resources included MFM providers, a dedicated nurse coordinator, high-resolution US capabilities, needle-based interventions, and patient access to an FDTC close to their home. Although specialty-based differences were not significant between newer and long-established centers, centers older than 10 years ranked additional surgical specialties and a mandatory reporting system as more important. Conclusion: Our findings offer valuable insights into the perspectives of fetal therapy providers, informing the strategic allocation of resources for establishing new FDTCs.

Recommendations for the preventive management of pre-eclampsia remain inconsistent across existing guidelines, which may adversely affect clinical decision-making. It is crucial to summarize and compare the existing guidelines to identify inconsistencies and guide future research. We conducted a systematic review and quality assessment of clinical guidelines for the preventive management of pre-eclampsia. Six literature databases and 19 guideline databases or official websites were searched from their inception to May 31, 2024. Two reviewers initially screened the retrieved articles. Data extraction was performed by one reviewer and verified by another. Five reviewers appraised the quality using the AGREE II instrument. Basic characteristics of the guidelines were described as frequency and proportion. A qualitative analysis was performed to compare inconsistencies in the recommendations. The intraclass correlation coefficient (ICC) was calculated to evaluate the consistency of item scores in the AGREE II tool among reviewers. The standardized domain scores for all guidelines were expressed as median and interquartile range (IQR). The Heat maps and Sankey diagrams were generated to visualize variations. A total of 32 guidelines published between 2004 and 2024 were included. Recommendations for risk factors exhibited marked variations, with only 8 (27%) guidelines integrating all three categories (maternal, biochemical, imaging-defined). Most guidelines (12 of 14) recommended qualitative methods to classify patients into low-, moderate-, or high-risk categories. The Fetal Medicine Foundation (FMF) algorithm was the only quantitative model endorsed for prediction. Aspirin was universally recommended for high-risk women, but with wide variations in dose and timing. The highest recommended dose was more than three times the lowest dose. The most frequently recommended initiation time was before 16 weeks' gestation, with cessation at 36 weeks' gestation the most common. Guideline quality was generally high (87.5% rated excellent overall), but the "Rigour of Development" domain scored lowest (median 43.8%), revealing key methodological shortcomings in updating procedures. Substantial inconsistencies persist in recommendations for the preventive management of pre-eclampsia across existing guidelines, highlighting the need for further research. Moreover, the methodological rigor of guideline development requires enhancement to ensure more reliable clinical advice. ID CRD42024557782.

Preterm birth occurs in approximately 10% of all pregnancies, and is not only the leading cause of neonatal mortality but also a major contributor to short- and long-term morbidities due to immaturity. Preterm birth has also been linked to an increased risk of maternal cardiovascular and cerebrovascular diseases, making it a critical concern in both perinatal medicine and women's lifelong health. Effective treatment requires interventions during threatened preterm labor, and several tocolytic agents have been developed and used in clinical practice. However, no pharmacological agent has been shown to prolong gestation and improve neonatal outcomes. Nifedipine, a calcium channel blocker, is widely used as a first-line tocolytic agent because of its oral administration route and relatively favorable safety profile compared with other drugs. Evidence from randomized controlled trials, meta-analyses, and Cochrane reviews suggests that nifedipine can delay delivery for a short period; however, robust evidence demonstrating sustained prolongation of pregnancy or improved neonatal survival is still lacking. Moreover, data on maternal hemodynamic changes and fetal effects are limited, highlighting the need for optimal dosing strategies and monitoring protocols. In this study, we discuss the clinical significance and limitations of nifedipine in the management of threatened preterm labor and outlined future directions. Future studies should involve large and homogeneous populations, continuous assessment of maternal hemodynamics, and application of novel biomarkers to support individualized therapy. Accumulation of such evidence is expected to optimize the management of threatened preterm labor and ultimately improve outcomes for mothers and infants.

Purpose: To report a rare case of cesarean scar ectopic pregnancy (CSEP) complicated by placenta accreta spectrum (PAS), managed expectantly, culminating in cesarean hysterectomy at 32 weeks of gestation. Methods: Case Report. Results: A 40-year-old G5P3013 with three prior cesarean deliveries presented with spotting and pelvic cramping. Transvaginal ultrasound suggested a 6-week CSEP. She was hemodynamically stable, with minimal vaginal bleeding and a closed cervix. Her body mass index (BMI) was 40 kg/m², and she had a 15-pack-year smoking history. Maternal-fetal medicine (MFM) confirmed the diagnosis and counseled her extensively on risks, benefits, and alternatives, recommending management via termination or hysterectomy. Risks of significant hemorrhage, cesarean hysterectomy, bladder injury, uterine rupture, miscarriage, and other serious maternal morbidities were discussed thoroughly. The patient chose expectant management and close MFM follow-up. At 15 weeks, her ultrasound raised concerns for placenta accreta spectrum (PAS). She also had several blood pressures around 140/90 mmHg and was started on 81 mg of daily aspirin for preeclampsia prevention in the setting of her chronic hypertension. She failed both the 1-hour and 3-hour glucose tolerance tests, despite an early first-trimester A1c of 4.9%. She met with a diabetes educator and began logging her blood sugar levels. At 24 weeks, ultrasound confirmed placenta increta. Risks of hemorrhage, invasion of surrounding structures, cesarean hysterectomy, blood transfusion, and maternal and fetal death were again extensively discussed. Gynecologic Oncology was consulted and noted definitive need for hysterectomy and the possibility of leaving the placenta in situ to avoid life-threatening hemorrhage. This would be a decision at time of cesarean delivery, regardless of imaging. Magnetic resonance imaging was negative for placenta percreta. At 32 weeks, she was admitted from high-risk clinic due to ultrasound findings of extreme thinning of the lower uterine segment, with much of the pregnancy either bulging or extrauterine. Betamethasone was administered for fetal lung maturation, which lead to hyperglycemia. The decision was made to deliver within the week. Four units of type and crossmatched packed red blood cells (pRBCs) were made available. The day prior to delivery, the patient became hypoxic, and a chest x-ray revealed pulmonary edema and/or atelectasis. She was placed on an IV insulin drip for 24 hours preoperatively, and tight glucose control was achieved. At 32 weeks and 4 days, she underwent cesarean delivery via vertical midline and vertical uterine incisions. The infant had APGARs of 8 and 9 and weighed 5 lbs 14 oz. Gynecology oncology then performed an exploratory laparotomy, cesarean hysterectomy, and lysis of adhesions. Estimated blood loss was 2,300 mL. She received 2 units of pRBCs, 1 unit of fresh frozen plasma, and 4.6 L of crystalloids intraoperatively. Placental vessels were visualized invading the bladder dome serosa anteriorly. Pathology confirmed placenta increta, maternal and fetal vascular malperfusion, and a 3-vessel cord with marginal insertion. On postoperative day (POD) 0, she was diagnosed with chronic hypertension with superimposed severe preeclampsia. On POD 1, she again developed hypoxia and pulmonary edema. One MFM specialist suggested her hypertension and pulmonary edema were likely due to volume overload rather than severe preeclampsia. She was discharged home on POD 4. Her baby was doing well in the NICU. On POD 9, the patient returned with a 1 cm area of superficial wound dehiscence, serosanguineous discharge, induration, erythema, and a leukocytosis of 17,000 cells/µL. Wound culture grew Serratia marcescens, and she was treated with antibiotics. At her six-week postpartum visit, her wound was closed and the visit was unremarkable. Conclusions: CSEP is rare type of ectopic pregnancy with significant maternal morbidity and mortality risk. Scar tissue from a prior cesarean delivery is weaker and less vascular than the surrounding uterine wall. In rare cases, a CSEP embryo may have a heartbeat, leading to a difficult decision to either terminate the pregnancy or accept serious risks including hemorrhage, uterine rupture, PAS, cesarean hysterectomy. If expectant management is chosen, a multimodal team is essential to ensure the patient is receiving appropriate management.

Cesarean scar ectopic pregnancies (CSEP) are becoming increasingly more common due to rising rates of cesarean deliveries worldwide. Approximately 21% of pregnancies are currently delivered by cesarean delivery, with a projected increase to 33% by 20301.. This method of delivery whether by classical, low transverse, or low vertical incision requires incision and subsequent sutured closure of the uterus at time of delivery, which can result in varying degrees of scarring within the myometrium. CSEP is a rare form of ectopic pregnancy in which the gestational sac implants within the myometrial defect of a previous cesarean scar. It poses significant risks, including uterine rupture and severe hemorrhage. According to the Society for Maternal-Fetal Medicine, it is a Grade B recommendation not to proceed with expectant management.2. Diagnosis is primarily achieved through transvaginal ultrasound, which typically reveals a gestational sac embedded in the anterior lower uterine segment with absent or thin overlying myometrium. Doppler imaging can further confirm the diagnosis by demonstrating increased vascularity around the implantation site. Due to the potential for a thin myometrium at that scar site, the potential for morbidly adherent placentation due to placenta accreta spectrum can add additional morbidity, as this can frequently result in significant hemorrhage at time of delivery, necessitating hysterectomy. Combining these two co-morbid conditions with history of postpartum cardiomyopathy presents a significantly high risk to the life of a pregnant patient and necessitates collaboration and insight from a multiprofessional team in order to develop the most appropriate treatment plan. Case: A 30yr G3P1102 at 9 weeks gestation presented to clinic to establish care. She had a medical history significant for recent postpartum cardiomyopathy with an ejection fraction of 20-25%, history of preeclampsia, hypertension, obesity, and history of two cesarean deliveries. She had discontinued her sacubitril, valsartan, carvedilol, dapagliflozin, spironolactone, and furosemide in December 2024 following loss of insurance coverage and learning she was pregnant. She was symptomatic at intake and was sent to the hospital for evaluation. Her electrocardiogram showed no evidence of acute myocardial infarction, but a possible old infarct was noted. Echocardiogram demonstrated global left ventricular hypokinesis with ejection fraction of 20-25%. A V/Q scan was negative for pulmonary thromboembolism. Cardiology recommended to avoid pregnancy and adjusted the patient’s medication regimen to metoprolol succinate 12.5 mg daily. On ultrasound, a CSEP was noted along with thin overlying myometrium and early trophoblastic invasion anteriorly concerning for possible placenta accreta spectrum. The patient was counseled regarding the extreme morbidity of her condition and termination was discussed. Patient requested a week to process the information and had her metoprolol increased to 25mg daily. At follow-up, the patient elected to proceed with termination of pregnancy. She requested a bilateral tubal ligation at time of the procedure. A multidisciplinary meeting was held between Maternal Fetal Medicine, Gynecologic Oncology, Academic Generalist Specialists, and Anesthesiology to discuss possible management options for addressing this patient’s CSEP: hysterectomy en bloc, potassium chloride and methotrexate injection, and/or ultrasound guided suction dilation and curettage (D&amp;C). Given the patient’s cardiac risks, desire to minimize fluid shifts/blood loss, and gestational sac communication with cervical/endometrial cavity, the group recommended suction D&amp;C via ultrasound guidance with neuraxial anesthesia. Due to concerns of general anesthesia, laparoscopy could not be performed for sterilization. The requirements for termination of pregnancy in compliance with Alabama law were completed. She was re-evaluated twenty-four hours prior to procedure and was stratified to moderate/high risk. The patient was counseled about the option to start with hysteroscopy, and she consented. On day of surgery, spinal anesthesia was administered without complication. Her cervix was serially dilated under ultrasound guidance. An operative hysteroscope was then introduced into the uterus. The ectopic pregnancy was visualized near the cervical-uterine junction, which was confirmed with ultrasound. A tissue removal device was utilized to remove the ectopic tissue under ultrasound guidance. When the fluid deficit reached 1000 cc of normal saline, the decision was made to transition to suction curettage to remove the remaining anterior placenta, under ultrasound guidance. At the end of the procedure, a levonorgestrel releasing intrauterine device (IUD) was placed under ultrasound guidance. The patient tolerated the procedure well with minimal blood loss and was admitted for observation. She received a dose of methotrexate for the treatment of potential residual tissue. The patient was discharged later that day with no apparent complications. Discussion: This high risk patient was able to have a minimally invasive procedure to manage a complex CSEP with potential placenta accreta spectrum under spinal anesthesia. She is currently asymptomatic, and her beta-hcg levels are nearing zero. Currently there exist several alternative measures of management, which were considered individually and in combination as part of treatment planning above.

Purpose: To report a rare case of pituitary macroadenoma in pregnancy. Pituitary macroadenomas are benign tumors of the pituitary gland. Routine presentation may include endocrine abnormalities or visual field defects. The prevalence of pituitary macroadenomas in the general population is approximately 40.67 per 100,000 individuals. In pregnancy, the occurrence is even more rare, and diagnosis and management require a multidisciplinary approach to minimize potential complications. This case highlights the diagnostic process, management considerations, and potential impact on pregnancy outcomes. Method: Case Report Results: A 38-year-old G8P3043 female at 26+2 weeks of gestation presented with intractable headache. The patient stated she choked while drinking juice the night before, which led to a coughing spell. She reported that the headache began soon after the coughing spell. The headache was persistent, dull, and diffuse in nature and associated with photophobia, phonophobia, and two episodes of vomiting. She denied visual changes, dizziness, or weakness. The patient was administered a pain cocktail with minimal relief. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head showed a 2.6 x 1.3 x 1.8 cm expansile mass in the sella with suprasellar extension, elevating and compressing the optic chiasm. The primary diagnosis was a pituitary macroadenoma. Neurology was consulted, and the patient was evaluated. Neurological physical exam was unremarkable, including cranial nerves, motor, sensation, coordination, and higher integrative functions. Neurology concluded there was no need for further neurological workup at this time and to follow up with the neurologist in 2 months. Her pregnancy has been complicated by fetal growth restriction (FGR), abnormal non-invasive prenatal testing (NIPT) with high suspicion for Trisomy 21, chronic hypertension, and advanced maternal age. Past medical history includes chronic hypertension on labetalol 100 mg twice a day and occasional migraines. She was never evaluated by a neurologist for the migraines because she reported only a few episodes a year. The patient was receiving twice weekly fetal testing for FGR with follow up ultrasounds every 3 weeks to assess fetal growth in the setting of highly suspected Trisomy 21. The patient remained asymptomatic throughout this time and did not require pain medication. The patient expressed a desire for a vaginal delivery. Due to the findings of pituitary adenoma and concerns for labor, an anesthesia referral was requested to determine if she was an appropriate candidate for regional anesthesia. She was evaluated by anesthesia, and they deemed her an appropriate candidate. At her 2 month follow-up visit with neurology, she denied any complaints, including headache or visual changes. Neurology referred her to neurosurgery for further evaluation. Neurology plans to follow up with her in 6 months. The team plans for delivery at 38 weeks pending continued normal antenatal testing. Conclusion: Pregnancy is a physiological state that induces significant changes in the endocrine system, particularly affecting the pituitary gland. These anatomical and functional changes make the management of pituitary disease more complex compared to the non-pregnant state. Due to hyperplasia and hypertrophy of lactotroph cells, the pituitary gland may increase in size by up to 40% in the second trimester and up to 70% in the third trimester, reaching two to three times its normal size. A pituitary adenoma greater than 10 mm in diameter, classified as a macroadenoma, has a 15-36 % chance of increasing in size during pregnancy. This growth risk necessitates close monitoring for symptoms such as headaches or visual disturbances, which may indicate tumor progression and could require neurosurgical evaluation. The treatment and surveillance of macroadenomas during pregnancy should be individualized. Patients should undergo close clinical follow-up with visual field testing during each trimester. In cases of non-functioning adenomas or hormone-secreting adenomas, surgery may be considered when there is significant visual impairment or life-threatening endocrine dysfunction. The second trimester is typically considered the safest period for surgical intervention, as it is associated with lower risks of congenital anomalies and preterm birth. The majority of women with macroprolactinomas or non-functioning adenomas experience favorable pregnancy outcomes. The primary goal of management is to ensure maternal and fetal safety while effectively controlling the tumor. Although rare, pituitary apoplexy, which involves infarction or hemorrhage within the pituitary gland often in the context of a pre-existing adenoma, can occur and may require emergency intervention. A collaborative, multidisciplinary approach involving obstetrics, endocrinology, neurology, neurosurgery, and maternal-fetal medicine is essential to optimize outcomes for both the mother and the fetus.