The study aims were to examine temporal changes in obstetric anal sphincter injury (OASIS) incidence among women undergoing their first vaginal birth after a previous cesarean section (CS) during 1999-2022, a period of progressive implementation of manual perineal protection in Norway, and to compare OASIS incidence with nulliparous women having their first vaginal birth. Data were obtained from the Medical Birth Registry of Norway. Two cohorts were formed: women with a first birth by CS and a subsequent vaginal birth (vaginal birth after cesarean, VBAC) (n = 36,014) and nulliparous women having their first vaginal birth (n = 468,195). OASIS incidence declined over time among women undergoing VBAC, from 8.7% in 1999-2002 to 4.0% in 2019-2022. A similar decline was observed among nulliparous women, from 6.5 to 2.7%. Changes in obstetric interventions and birthweight did not account for these reductions. Despite this decline, OASIS incidence remained higher in VBAC compared with nulliparous women (6.2% vs. 4.3%; OR 1.46, 95% CI 1.40-1.53). These findings suggest that although OASIS incidence has decreased over time during implementation of manual perineal protection, the higher incidence after VBAC may reflect differences in underlying obstetric risk profiles between the groups.

Associations of Pain, Analgesia Technique, and Psychological Factors with Central Sensitization after Childbirth.

BackgroundAdverse birth outcomes are significant public health concern in Bangladesh and can severely affect the health and wellbeing of children in later life. This study aimed to assess the prevalence of adverse birth outcomes (i.e., stillbirth, preterm birth, low birth weight (LBW), neonatal death) and identify the associated factors among the Bangladeshi population.MethodsThe study utilized nationally representative data from the Bangladesh Demographic and Health Survey (BDHS) to analyze index pregnancy outcomes for 10,254 ever-married women. The prevalence and associated factors of both composite and individual adverse outcomes were determined using appropriate statistical procedures.ResultsThe findings indicate that 14.3% of pregnancies resulted in LBW, while 8.9% resulted in preterm birth, followed by stillbirths (1.3%) and neonatal deaths (1.3%). Overall, 14.2% of births were associated with at least one adverse outcome. Household wealth index, place of delivery, twin births, maternal desire, and regional factors were found to be associated with LBW. Factors affecting preterm birth included cesarean section delivery, wealth index, twin births and maternal desire to have children. Regarding stillbirths, associations were found with the cesarean section delivery, and twin births. For neonatal death, factors associated included cesarean section delivery, twin birth, and maternal desire. Lastly, the composite score of adverse birth outcomes was associated with wealth index, history of terminated pregnancies, place of delivery, decision-making autonomy, region, twin births, and maternal desire.ConclusionOne in seven births in Bangladesh involved at least one adverse outcome, with LBW being the most prevalent. Socioeconomic disadvantage and limited women’s decision-making autonomy were consistently associated with adverse outcomes. Policies should prioritize equity-oriented maternal care, strengthen women’s autonomy, and ensure appropriate use of obstetric interventions.

Maternal psychological stress is associated with adverse obstetric and neonatal outcomes, including preterm birth and low birthweight. Warfare represents a significant source of acute and chronic stress, yet its impact on pregnancy outcomes remains unclear. This study aimed to evaluate the association between a 6-month period of continuous wartime exposure following October 7, 2023, during the "Iron Swords" conflict and preterm birth, neonatal outcomes, and obstetric management. This retrospective cohort study included all deliveries at ZIV Medical Center during the 6-month conflict period, compared with a pre-war cohort from 2021 until October 6, 2023. The primary outcome was preterm birth (< 37 weeks). Secondary outcomes included early preterm birth (< 34 weeks), labor induction, mode of delivery, maternal complications, and neonatal outcomes. Multivariate logistic regression was used to identify independent predictors of preterm birth. A total of 699 conflict-period deliveries were compared with 7821 pre-war deliveries. Preterm birth rates were similar (< 37 weeks: 6.6% vs. 5.5%; < 34 weeks: 2.1% vs. 1.5%). Labor induction was markedly lower during the conflict (oxytocin 23.7% vs. 38.7%; cervical ripening balloon 3.3% vs. 7.7%; prostaglandins 4.1% vs. 6.5%), accompanied by reduced postpartum hemorrhage (7.9% vs. 12%). Neonatal outcomes, including birthweight distribution, NICU admissions, and survival, were comparable or slightly improved. Prolonged wartime exposure was not associated with increased rates of preterm birth or adverse neonatal outcomes. Lower rates of obstetric intervention were observed during the conflict period and coincided with lower rates of maternal complications, although causality cannot be established.

This study compares birth experiences and clinical outcomes between women giving birth using mobility-enabling labor-birth-postpartum (LBP) beds and those using a traditional gynecological table (TGT). This quasi-experimental study was conducted between June and October 2025 in a secondary-level maternity unit in Turkey. A total of 320 women who had vaginal births were sequentially assigned to either the LBP group (n = 160) or the TGT group (n = 160). Continuous variables were analyzed using Mann-Whitney U-tests, with Bonferroni correction applied for multiple comparisons, and categorical variables using χ2-tests. Baseline characteristics were comparable between groups. Regarding the primary outcome, no significant difference in labor duration was observed between the groups (P = 0.254). After multiplicity adjustment, episiotomy (45.0% vs. 67.5%) and fundal compression (6.9% vs. 25.0%) were significantly less frequent in the LBP group (P < 0.001). Women using LBP beds reported lower pain scores and higher birth satisfaction (P < 0.001). There were no statistically significant differences between the groups in neonatal variables after adjusting the significance threshold (P > 0.0029). These results suggest that while mobility-enabling LBP beds do not shorten labor duration, they are associated with a substantial reduction in obstetric interventions from extremely high institutional levels and enhanced maternal birth experiences. By supporting maternal movement and positional flexibility, these beds may facilitate physiologic labor and represent a practical strategy for strengthening woman-centered intrapartum care. However, environmental modifications should be integrated with broader institutional policy shifts to fully align with global evidence-based standards and further reduce the need for routine interventions.

Cardiovascular disease (CVD) is an increasingly important contributor to maternal morbidity and mortality worldwide, but contemporary nationwide data in Japan remain limited. We conducted a retrospective cohort study using the Japan Society of Obstetrics and Gynecology Perinatal Database from 2014 to 2023. Among 2,189,852 registered pregnancies, 26,894 (1.23%) were complicated by maternal CVD. Pregnancies with CVD were compared with the low-risk population (pregnancies without any medical comorbidities; n=1,882,896). Pregnancies with CVD had lower parity and more frequently required cesarean delivery, general anesthesia, and labor analgesia than the low-risk population. Maternal cardiovascular complications, including hypertensive disorders of pregnancy, pulmonary embolism and pulmonary edema, occurred at higher rates among pregnancies with CVD. Maternal death was rare in both groups, but was more frequent in pregnancies with CVD than in the low-risk population (0.03% vs 0.01%, P<0.001). Neonatal outcomes were generally similar between groups. In this nationwide registry analysis, approximately 1% of pregnancies in Japan were complicated by maternal CVD. Women with CVD underwent more obstetric and anesthetic interventions and had a modestly higher risk of maternal morbidity and mortality. These findings underscore the importance of continued registry surveillance and may help inform risk-stratified perinatal management.

BackgroundSevere perineal trauma (SPT) is a serious complication of vaginal birth with potential physical and psychological consequences. Amniotomy is a commonly used labour intervention with uncertain evidence. A recent Norwegian study suggested a possible association between amniotomy and SPT. The aim of the study was to investigate whether amniotomy is independently associated with SPT, and whether the timing of amniotomy affects the occurrence of SPT in Swedish nulliparous and multiparous women.MethodsThis nationwide register-based study included 403 342 women who gave birth between 2015 and 2020. Data were obtained from the Swedish Pregnancy Register. The main outcome, SPT, was defined using International Classification of Diseases (ICD-10) diagnosis codes O70.2 and O70.3. Associations were assessed using binary and multiple logistic regression analyses, with adjustment for maternal, obstetric, and neonatal factors.ResultsThe incidence of SPT was 5.1% among nulliparous and 0.9% among multiparous women. In unadjusted analyses, amniotomy was associated with increased odds of SPT in both nulliparous [OR 1.11; 95% CI, 1.07–1.16] and multiparous women [OR 1.13; 95% CI, 1.03–1.23]. However, these associations were not present in adjusted analyses [nulliparous: OR 1.00; 95% CI, 0.95–1.05; multiparous: OR 0.96; 95% CI, 0.86–1.07]. Early amniotomy was associated with a higher prevalence of obstetric interventions, and labour characteristics linked to SPT risk, consistent with confounding by indication. In adjusted analyses, timing of amniotomy was not associated with SPT in multiparous women, while in nulliparous women a longer interval between amniotomy and birth was associated with lower odds of SPT.ConclusionsAmniotomy was not independently associated with severe perineal trauma after adjustment for maternal, obstetric, and neonatal factors in this large nationwide cohort. The observed associations with timing likely reflect underlying labour complexity rather than a causal effect. These findings support a cautious and individualised use of amniotomy in clinical practice.

Perinatal outcomes and care patterns after centralisation of acute obstetric care in three Dutch regions: a retrospective cohort study.

Maternal and fetal outcomes of pregnancy-associated malignancy: A single-center retrospective cohort study.

Maternal satisfaction with neuraxial labor analgesia in spontaneous vs. assisted reproductive technology pregnancies: a single-center retrospective cohort study (2023-2024).

The widespread use of epidural labor analgesia has introduced new challenges in postpartum bladder function management. Postpartum urinary retention (PUR) not only causes maternal discomfort but may also lead to bladder overdistension and long-term voiding dysfunction. This study aimed to investigate the incidence and risk factors for PUR in women undergoing vaginal delivery under epidural analgesia and to develop a predictive model for early identification of high-risk individuals. A retrospective case-control study was conducted on 1002 parturients who underwent vaginal delivery under epidural analgesia at our hospital from January 2024 to January 2026. Clinical data including demographic characteristics, labor parameters, obstetric interventions, analgesia-related factors, and neonatal outcomes were collected. The incidence of PUR was 6.4% (64/1002). Multivariate logistic regression identified five independent risk factors: prolonged second stage of labor (≥ 60 min, OR = 2.000, 95% CI: 1.182-3.384), episiotomy (OR = 2.801, 95% CI: 1.450-5.412), second-degree or higher perineal laceration (OR = 3.099, 95% CI: 1.542-6.229), prolonged epidural analgesia (≥ 300 min, OR = 1.600, 95% CI: 1.019-2.513), and macrosomia (≥ 4.0 kg, OR = 2.199, 95% CI: 1.186-4.077). The simplified scoring model (range 0-5) demonstrated good predictive performance with an area under the ROC curve of 0.789. Prolonged second stage of labor, episiotomy, severe perineal laceration, prolonged epidural analgesia, and macrosomia are independent risk factors for PUR in women undergoing vaginal delivery under epidural analgesia. The simplified scoring model based on these factors exhibits satisfactory predictive accuracy and may serve as a practical clinical tool for early identification of high-risk parturients.

Cesarean section rates remain high worldwide, especially in Brazil, where they far exceed international recommendations. Arrest of labor progression is one of the main indications for intrapartum cesarean delivery and is frequently related to challenges in fetal descent, rotation, and positioning within the maternal pelvis. Maternal movement and positioning during labor are recognized strategies to support physiological labor progression. The Spinning Babies's® approach is a non-invasive method based on intentional movements and positioning, developed to facilitate fetal rotation and descent. Despite its widespread use in clinical practice, to date there are no randomized controlled trials evaluating the effectiveness of this approach, highlighting a relevant gap in scientific knowledge. This study aims to assess the effectiveness of the Spinning Babies® approach on labor progression and obstetric outcomes compared with standard intrapartum care. This is an open-label, single-center, parallel, two-arm randomized controlled trial conducted in a large public university maternity hospital in Southern Brazil. Nulliparous women aged 18 years or older, at term, with singleton pregnancies, cephalic fetal presentation, and fetuses located in the midpelvis during spontaneous labor will be included. Participants will be randomized in a 1:1 ratio to receive either the Spinning Babies® intervention or standard care. The intervention consists of applying Spinning Babies® positioning and movement exercises every two hours while the fetal presentation remains in the midpelvis. The primary outcome is total labor duration, measured from the diagnosis of active labor to birth. Secondary outcomes include measures of labor progression, use of obstetric interventions, mode of birth, and neonatal outcomes. Analyses will follow the intention-to-treat principle. This trial was designed to address the lack of randomized evidence regarding the Spinning Babies® approach, contributing to knowledge improvement of non-invasive strategies to support labor progression. By evaluating this intervention within the context of routine midwifery-led care, the study may inform evidence-based intrapartum practices and also may contribute to the reduction of unnecessary obstetric interventions such as cesarean sections. Brazilian Clinical Trials Registry (REBEC), identifier RBR-42pbbqq, prospectively registered.

Effective pushing during the second stage of labor is critical for optimal birth outcomes, but many women-especially those under epidural analgesia-struggle with reduced pelvic sensation and pushing efficacy. Transperineal ultrasound is widely used to assess labor progression, and visual biofeedback has shown promise in improving physical and psychological outcomes in other fields. However, its application during labor remains underexplored. This study assesses the effect of sonographic visual biofeedback before and during labor on obstetric outcomes. We performed an electronic search using MEDLINE with the OvidSP interface PUBMED, Embase, Web of Science, and Cochrane Library up to August 13, 2024. We included experimental and non-experimental studies, comprising randomized controlled and observational (case-control, cohort, and cross-sectional) studies assessing the effect of sonographic visual biofeedback on delivery outcomes. Four references comprising 457 patients were eventually included. Primary data collection was performed using standardized data extraction procedures, with disagreements being settled by discussion. Analysis was conducted using RevMan 5.4 (Cochrane Collaboration, Oxford, UK). Visual biofeedback is associated with a more pronounced change in angle of progression (AoP) measurements when comparing resting state to active pushing (mean difference [MD] 5.04 [95% confidence interval [CI] 1.42-8.66], P = 0.006, I2 = 63%), and the overall AoP while pushing was notably greater in the visual feedback group (MD 9.23 [95% CI 0.94-17.53], P = 0.03, I2 = 76%). There were no statistically significant differences in mode of delivery, duration of second stage of labor, rates of intact perineum, and incidence of second- and third-degree perineal tears. A significant reduction in episiotomies among patients who received visual feedback was observed (OR 0.42 [95%CI 0.24-0.76], P = 0.004, I2 = 0%). Visual feedback might influence maternal pushing behavior and enhance pushing efficacy, potentially reducing obstetrical interventions such as episiotomies. Additional prospective randomized studies are needed to definitively determine the effect of visual biofeedback on a wide range of obstetric outcomes. Such research could help refine the use of this technique and potentially improve the labor experience and outcomes for many women. The study protocol can be assessed at the PROSPERO International prospective register of systematic reviews (www.crd.york.ac.uk/PROSPERO, registration number CRD42024570484).

Dengue fever is a major mosquito-borne viral infection with rising global prevalence in tropical and subtropical regions. Pregnant women represent a particularly vulnerable population due to altered immune and physiological responses. While dengue is endemic in Southeast Asia, population-based data on maternal outcomes in East Asian populations with advanced healthcare systems like Taiwan are scarce. A nationwide retrospective descriptive, non-comparative study identified 264 pregnant women with dengue (2012-2018) via the Taiwan NHIRD. Outcomes were analyzed descriptively; comparisons with national statistics are illustrative rather than formal risk estimates. The median maternal age was 32 years. The most common maternal intervention was Cesarean delivery (68.6%), while ICU admission occurred in 9.1%. For neonatal outcomes, a composite of preterm delivery or incubator care (aggregated due to coding limitations) occurred in 34.9%. Notably, the rate of low birth weight (9.5%) remained comparable to national baselines despite high intervention rates. High rates of obstetric intervention despite preserved biological outcomes may reflect defensive clinical practices and diagnostic uncertainty during epidemics. Refined guidelines are needed to balance safety and avoid unnecessary surgery.

To investigate the impact of a previous cesarean section on maternal and perinatal outcomes in term pregnancies undergoing labor induction. In this retrospective cohort study, women with singleton, low-risk term pregnancies and labor induction were compared according to the presence or absence of a previous cesarean delivery. The primary outcome was a composite of adverse maternal and perinatal events. Secondary outcomes included cesarean section rate, mode of vaginal delivery, and specific maternal or neonatal complications. The rate of composite adverse outcomes was comparable between groups (21.9% vs. 23.7%, p = 0.4826). However, placental abruption (1.3% vs. 0.3%, p = 0.0251), suspected triple I (1.9% vs. 0.4%, p = 0.0040), and shoulder dystocia (2.3% vs. 0.8%, p = 0.0265) occurred more frequently in women with a previous cesarean section. Abnormal cardiotocography (27.1% vs. 20.4%, p = 0.0058), operative vaginal delivery (17.8% vs. 11.9%, p = 0.0052), umbilical artery pH < 7.10 (4.9% vs. 2.8%, p = 0.0381), and the need for fetal blood sampling (8.7% vs. 5.0%, p = 0.0055) were also more common in this group. There was no difference in neonatal unit transfer (10.0% vs. 11.5%, p = 0.4328) or low Apgar scores (< 5 at 5min: 0.3% vs. 0.4%, p = 1.0000). Cesarean section rates were similar (14.8% vs. 14.9%, p = 0.9692). In multivariable analysis, absence of prior vaginal delivery (OR = 3.460, p < 0.0001), higher maternal BMI (OR = 1.038, p < 0.0001), and older maternal age (OR = 1.033, p = 0.0002) were independently associated with adverse outcomes, whereas previous cesarean section was not. Labor induction in women with a prior cesarean section was not associated with increased risk for composite adverse maternal or perinatal outcomes. Nonetheless, TOLAC should be conducted in settings with immediate access to obstetric and neonatal intervention.

Objective To conduct a retrospective multicenter study using objective data from a large sample size, which in order to identify reliable risk factors for hypospadias and establish a practical predictive model. Methods We retrospectively studied the medical records of the mothers who gave birth at Women’s Hospital of Zhejiang University, School of Medicine, which was the obstetric treatment center in East China, and Xinchang Maternal and Child Health Hospital, and Quzhou Maternal and Child Health Hospital, from January 2019 to December 2021. Results 42809 male babies were born in the three hospitals, including 139 of which were diagnosed with hypospadias. The incidence of hypospadias was 0.325%. 33591 mothers and 35517 newborns were finally included to the statistical analysis. Among them, there were 121 newborns diagnosed with hypospadias and 121 mothers who gave birth to the hypospadias newborns. Premature birth, multiple pregnancies, gestational hypertension, fetal distress and abnormal placental morphology were set as the predictor to construct the nomogram model. The internal verification results displayed the area under the curve (AUC) was 0.834 (95% CI = 0.769–0.900), with a specificity of 85.6% and a sensitivity of 68.9%. The temporal verification results displayed the AUC was 0.857 (95% CI = 0.795–0.919), with a specificity of 74.2% and a sensitivity of 85.0%. The slope of the calibration curves were both close to 1, indicating high fitting degree of the model. Conclusion Our findings suggested that premature birth, multiple pregnancies, gestational hypertension, fetal distress and abnormal placental morphology were independent risk factors for hypospadias in newborns. We successfully established a nomogram predictive model for hypospadias, which can effectively, conveniently, clearly and visually predict the risk of hypospadias occurrence.

A service evaluation of departmental compliance with obstetric neuraxial intervention follow-up.

Background: Cardiotocography (CTG) is a vital tool in obstetric practice for real-time fetal monitoring. However, its predictive value in identifying neonatal asphyxia remains underexplored, particularly in the critical hour before delivery. Aim of the Study: This study investigates the association between CTG monitoring in the last hour before delivery and neonatal asphyxia, aiming to evaluate its predictive value. Patients and Methods:This study is a descriptive retrospectivecohort study conducted at Al-Elwiya Maternity Teaching Hospital between January 2024 and January 2025. The study included 250 pregnant women presented with labourcondition to the mentionedhospital, CTG monitoring was applied continuously. After delivery (whether by vaginal delivery or caesarean section)CTG of last hour before delivery was compared for the neonates who had asphyxia and those without asphyxia. Inclusion criteria were: Term months, no history of taking drug, before delivery that affects the heart rate of the foetus (as magnesium sulphate, narcotics and pain killers), no history of fever, no history of drugs, addition, not smoker, not alcoholic, babies without congenital anomalies. Exclusion criteria: Preterms, mothers with medical disease like diabetes mellitus and hypertension,addiction to smoking and alcohol, mothers taking drugs that affect the heart rate of the focus like (magnesium sulphate, narcotics and pain killers, maternal fever, neonates with congenital anomaly, extremes of reproductive age group and extremes of BMI (&lt;18.5 or ≥ 25 kg/m2). Results: Pathological CTG patterns were observed in 70% of the asphyxia group, compared to 1.6% in the non-asphyxia group. Late decelerations, absent variability, and accelerations were significantly associated with asphyxia. Caesarean delivery was more common in the asphyxia group. The need of NICU admissions further emphasized the poor neonatal outcomes. Conclusion: CTG monitoring in the last hour before delivery shows significant predictive potential for neonatal asphyxia. Specific CTG patterns can guide timely obstetric interventions, which can lead to improve neonatal outcomes.

Water birth has gained increasing attention as an alternative childbirth method intended to promote maternal comfort and physiological labor while potentially reducing obstetric interventions. However, evidence regarding its maternal and neonatal safety compared with conventional delivery approaches remains heterogeneous. This study aimed to evaluate maternal and neonatal outcomes associated with water birth compared with conventional spontaneous vaginal delivery in a secondary obstetric center. By focusing on vaginal births, the study evaluates the specific impact of water immersion on perineal integrity and neonatal transition. We conducted a retrospective cohort study including 3747 deliveries recorded at a tertiary maternity unit over a five-year period. Among these, 692 births occurred in water (water birth group) and 561 were conventional vaginal deliveries (land birth group), both managed under a standardized institutional protocol. Maternal characteristics, obstetric outcomes, and neonatal parameters were extracted from medical records and compared between the two cohorts. Primary outcomes included rates of episiotomy, perineal trauma and neonatal indicators such as Apgar score. Statistical analyses were performed to assess differences between groups using appropriate comparative tests. Water birth was associated with a significantly lower rate of episiotomy compared with land birth (5.06% vs. 13.72%, OR 0.33, 95% CI 0.22-0.50, p < 0.001). Neonatal outcomes, including Apgar scores and NICU admissions, did not differ significantly between the two cohorts. In this retrospective cohort, water birth among selected low-risk pregnancies was associated with reduced obstetric intervention, particularly episiotomy, without evidence of adverse neonatal outcomes. These findings suggest that water birth may represent a safe and feasible option in carefully selected low-risk pregnancies when strict clinical protocols are applied.

Introduction: Trauma during pregnancy poses significant diagnostic and therapeutic challenges, as physiological adaptations can obscure early signs of instability and increase both maternal and fetal vulnerability. High-energy blunt trauma often results in multisystem injuries involving the pelvis, thorax, diaphragm, and long bones. When these injuries occur in mid-pregnancy, the risk of intrauterine fetal demise rises sharply, and the complexity of maternal stabilization frequently delays obstetric intervention. Clear guidance on long-term management remains limited, especially when fetal demise is retained during recovery from extensive surgical trauma. Case Illustration: A pregnant woman in mid-gestation sustained severe multisystem injuries following high-impact blunt trauma. Her injuries included pelvic ring disruption, femoral and tibial fractures, hemothorax requiring thoracic drainage, and a left-sided traumatic diaphragmatic hernia with herniation of abdominal organs into the thoracic cavity. Early intrauterine fetal demise was identified shortly after resuscitation. She underwent thoracoabdominal surgery and orthopedic fixation, achieved postoperative stabilization, and was discharged in improving condition. Several days, she developed progressive abdominal pain, systemic deterioration, and severe sepsis. Imaging and clinical evaluation suggested that the retained fetal tissue, combined with prior thoracoabdominal and orthopedic injuries, contributed to the delayed infectious complication. She underwent uterine evacuation and intensive management, leading to eventual clinical improvement. Discussion: This case illustrates how multisystem trauma in pregnancy can generate a prolonged and unpredictable clinical trajectory. The need to prioritize maternal stabilization often necessitates delaying uterine evacuation, yet retained fetal demise, especially in patients recovering from major surgery, may predispose to delayed sepsis. This interplay between trauma physiology, surgical recovery, and obstetric timing highlights a critical gap in current guidelines. The case underscores the importance of multidisciplinary coordination, extended monitoring beyond initial discharge, and heightened vigilance for delayed infectious complications. Conclusion: Severe maternal trauma with concurrent pelvic, thoracic, and diaphragmatic injuries requires individualized, maternal-centered care. When fetal demise occurs, timing of evacuation must balance surgical risk with the potential for long-term complications. This case emphasizes the need for structured follow-up and clearer clinical pathways to prevent delayed sepsis in similar high-risk presentations.