Society For Maternal-Fetal Medicine Research Articles

Inflammatory markers in expectant COVID-19 positive patients: A relationship with clinical severity in a tertiary care referral facility.

Background: SARS-Co-V2 infection which was declared as a pandemic by the WHO has caused significant impact on morbidity and mortality to the mother and the fetus, especially the delta variant of the COVID-19. Hence it is important to identify the subgroup of women who are prone to adverse complications and prevent maternal and perinatal mortality. Inflammatory biomarker is one such tool to identify the high-risk expectant mothers. Methods and results: A total of 158 patients were identified in this retrospective study and they were classified based on the clinical signs and symptoms as per the society of maternal fetal medicine. 96.2% belonged to the non-severe group and 3.8% belonged to the severe infection group. Cough and fever were the most common symptoms. Inflammatory markers which were done on admission were correlated with the clinical disease severity. The difference in mean values of CRP, LDH and ferritin between the severe and non-severe group was significant statistically. The markers IL-6 and d-dimer were raised but did not correlate with disease severity. Neutrophil lymphocyte ratio (NLR) calculated from the blood counts was abnormal in all the patients in the severe group and statistically significant. Overall, the maternal outcome was good and maternal mortality rate was 1.89% (3/158). Neonatal outcome was good with stillbirth rate of 3.16% which was higher when compared to non-covid stillbirth rates (0.5%). Conclusion: inflammatory biomarkers like CRP and LDH are sensitive in predicting the adverse maternal fetal outcome. NLR is a simple ratio that has a good positive predictive value in identifying the need for more vigilant monitoring in expectant COVID-19 positive patients.

Society for Maternal-Fetal Medicine Special Statement: Clinical Quality Measures in Obstetrics

(Am J Obstet Gynecol. 2024;230(3):B2–B17. doi: 10.1016/j.ajog.2023.11.011) The Society for Maternal-Fetal Medicine (SMFM) has issued a special statement on clinical quality measures (CQMs) for obstetrics. The statement is an update to a 2016 statement on the same topic.

Society for Maternal-Fetal Medicine Consult Series #68: Sickle Cell Disease in Pregnancy

(Am J Obstet Gynecol. 2024;230(2):B17–B40. doi: 10.1016/j.ajog.2023.10.031) The Society for Maternal-Fetal Medicine (SMFM) has published recommendations for managing sickle cell disease (SCD) in pregnancy as part of its Consult Series. The guidance also summarizes what is known about the disease.

Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine.

Pain management in pregnant and postpartum people with an opioid-use disorder (OUD) requires a balance between risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement between the Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal-Fetal Medicine (SMFM), and American Society of Regional Anesthesia and Pain Medicine (ASRA) provides a framework for pain management in obstetric patients with OUD. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to health care providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia, and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for OUD (eg, buprenorphine, methadone), considerations regarding urine drug testing, and other social aspects of care for maternal-infant dyads, as well as a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and complications associated with OUD in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with OUD in the context of pregnancy to improve maternal and perinatal outcomes.

Provider Guidance for the Prevention of Respiratory Syncytial Virus in Infants: Maternal Vaccination Versus Infant Monoclonal Antibody Treatment.

In 2023, the Food and Drug Administration approved 2 new products to reduce the risk of lower respiratory infections caused by respiratory syncytial virus (RSV) in infants: Beyfortus (nirsevimab; AstraZeneca/Sanofi), a single-dose monoclonal antibody for infant administration, and Abrysvo (bivalent RSVpreF vaccine; Pfizer), a single-dose maternal vaccination. We aimed to synthesize data from the literature and the leading professional organizations to provide guidance on RSV and strategies to reduce the risk of infant infection. This information will assist prenatal care clinicians in counseling their patients regarding the choice between maternal vaccination and the infant monoclonal antibody. A descriptive review of the guidelines from the Centers for Disease Control and Prevention, American College of Obstetrics and Gynecology (ACOG), American Academy of Pediatrics, Society for Maternal-Fetal Medicine, and the American Academy of Family Physicians. All 5 organizations recommend that RSV vaccination should be offered to all pregnant people during the RSV season (September-January in the continental United States). Infants younger than 8 months entering into their first RSV season born to those who did not receive maternal vaccination or received vaccination less than 14 days prior to birth should be offered monoclonal antibody administration. RSV vaccination and monoclonal antibodies have the potential to significantly reduce the burden of lower respiratory tract infections due to RSV in infants. Future studies should further evaluate the durability of protection and other strategies to further protect the infant, including cocooning and the role of breast milk in immunity.

Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine

This document serves as a revision to the Society of Family Planning’s 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient’s beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians’ technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician’s technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

A tale of two societies: implications of conflicting Rh-immunoglobulin guidelines

National guidance conflicts regarding the use of RhD immune globulin administration <12w. Recent Society for Maternal Fetal Medicine (SMFM) guidelines suggest liberal use of this product while other guidelines, including Society of Family Planning and the World Health Organization, propose a more conservative approach. Medicine is not practiced in a vacuum, and potential harms must include not only individual but communal and public health effects. We aim to critically examine the practical implications of the new SMFM guidelines with a focus on equity and access.

Placental pathology lesions: International Society for Ultrasound in Obstetrics and Gynecology vs Society for Maternal-Fetal Medicine fetal growth restriction definitions

BackgroundResearch on the definition of fetal growth restriction (FGR) has focused on predicting adverse perinatal outcomes. A significant limitation of this approach is that the individual outcomes of interest could be related to the condition and the treatment. Evaluation of outcomes that reflect the pathophysiology of FGR may overcome this limitation. ObjectiveTo compare the diagnostic performance of the FGR definitions established by the International Society for Ultrasound in Obstetrics and Gynecology (ISUOG) and the Society for Maternal-Fetal Medicine (SMFM) to predict placental histopathological findings associated with placental insufficiency and a composite adverse neonatal outcome (ANeO). Study DesignIn this retrospective cohort study of singleton pregnancies, the ISUOG and the SMFM guidelines were used to identify pregnancies with FGR and a corresponding control group. The primary outcome was the prediction of placental histopathological findings associated with placental insufficiency, defined as lesions associated with maternal vascular malperfusion (MVM). A composite ANeO (ie, umbilical artery pH≤7.1, Apgar score at 5 minutes ≤4, neonatal intensive care unit admission, hypoglycemia, respiratory distress syndrome requiring mechanical ventilation, intrapartum fetal distress requiring expedited delivery, and perinatal death) was investigated as a secondary outcome. Sensitivity, specificity, positive and negative predictive values, and the areas under the receiver-operating-characteristics curves were determined for each FGR definition. Logistic regression models were used to assess the association between each definition and the studied outcomes. A subgroup analysis of the diagnostic performance of both definitions stratifying the population in early and late FGR was also performed. ResultsBoth societies’ definitions showed a similar diagnostic performance as well as a significant association with the primary (ISUOG adjusted odds ratio 3.01 [95% confidence interval 2.42, 3.75]; SMFM adjusted odds ratio 2.85 [95% confidence interval 2.31, 3.51]) and secondary outcomes (ISUOG adjusted odds ratio 1.95 [95% confidence interval 1.56, 2.43]; SMFM adjusted odds ratio 2.12 [95% confidence interval 1.70, 2.65]). Furthermore, both FGR definitions had a limited discriminatory capacity for placental histopathological findings of MVM and the composite ANeO (area under the receiver-operating-characteristics curve ISUOG 0.63 [95% confidence interval 0.61, 0.65], 0.59 [95% confidence interval 0.56, 0.61]; area under the receiver-operating-characteristics SMFM 0.63 [95% confidence interval 0.61, 0.66], 0.60 [95% confidence interval 0.57, 0.62]). ConclusionThe ISUOG and the SMFM FGR definitions have limited discriminatory capacity for placental histopathological findings associated with placental insufficiency and a composite ANeO.El resumen está disponible en Español al final del artículo.

Anesthetic Considerations and Outcomes in Amniotic Fluid Embolism: A Retrospective Study over a 15-Year Period.

(1) Background: A rare and unexpected consequence of childbirth, labor, or the immediate postpartum period is amniotic fluid embolism (AFE). This study aims to identify AFE cases during or immediately after birth from anesthetic management perspectives. Secondary goals include assessing patient clinical features, obstetric care techniques, birth outcomes, and case survival. (2) Methods: A retrospective observational study assessed AFE patients hospitalized in three Romanian clinical institutions from October 2007 to April 2023. Based on the Society of Maternal-Fetal Medicine (SMFM) criteria, we diagnosed 11 AFE patients. (3) Results: AFE occurred in eight cases (73%) during peripartum, two (18%) within 30 min after placental delivery, and 1 (9%) during a scheduled cesarean surgery. Only one of six cardiorespiratory arrest patients responded to external cardiac massage, while the other five (83%) needed defibrillation. The patients received, on average, five units of red blood cells, six of fresh frozen plasma, and two of activated platelets. Six patients (55%) received factor VIIa infusions. Maternal mortality was 36.3%. Six neonates (75%) needed neonatal resuscitation, and two (25%) died on the second and third days. (4) Conclusions: AFE management necessitates a multidisciplinary approach and the incorporation of advanced life support techniques to optimize outcomes for both the mother and newborn.

Correlation of Peripartum Acute Kidney Injury Severity With Obstetric Comorbidity Index Scores and Maternal Morbidity [ID 2683636

INTRODUCTION: Risk stratification systems are increasingly used to predict obstetric complications. The Obstetric Comorbidity Index (OB-CMI) is one validated prediction tool, applying weighted scores to maternal and obstetric conditions. Although acute kidney injury (AKI) is a severe maternal morbidity, there is limited information on predicting AKI severity. We aimed to investigate the utility of OB-CMI scores and its specific comorbidities in predicting obstetric AKI severity, and the relationship of AKI severity and other maternal morbidity outcomes. METHODS: This was an IRB-exempt, retrospective cohort study of AKI cases (ICD-10 code N17.0-17.9) between January 2018 and December 2022 at a single academic institution with ∼6,000 births annually. Information was extracted via chart review. Cases were stratified by those meeting American College of Obstetricians and Gynecologists (ACOG)/Society for Maternal-Fetal Medicine (SMFM) criteria for severe renal injury. Those with unknown baseline Cr were assigned 0.7 (the 95th percentile Cr value at 39–40 weeks). Groups were compared based on admission OB-CMI scores and comorbidities, and maternal morbidity events using independent t-tests, χ2, and Fisher's exact as appropriate. RESULTS: Two hundred thirty cases were reviewed: 8.3% (19 cases) met ACOG/SMFM AKI criteria. There was no significant difference in mean OB-CMI scores (mean 3.8 versus 4.1; P=.782) or incidence of individual comorbidities between groups. Regarding other maternal morbidity events, ACOG/SMFM criteria AKI was significantly associated with other severe morbidity events (47.4% versus 12.3%; P&lt;.001), including transfusion, disseminated intravascular coagulation, intubation, and intensive care unit admission. CONCLUSION: The OB-CMI score was poorly predictive of AKI severity; however, the occurrence of severe AKI by ACOG/SMFM criteria was associated with a 4-fold increased rate of co-occurring maternal morbidity events and a 2.5-fold increased rate of blood transfusion.

Society for Maternal-Fetal Medicine Position Statement: Gun violence and pregnancy

The Society for Maternal-Fetal Medicine (SMFM) acknowledges gun violence as a public health crisis in the United States, with a significant impact on pregnant and postpartum people. We recognize the urgent need for a robust, equitable, data-driven approach to mitigate the impact of access to firearms and accompanying violence on pregnant and postpartum individuals and communities. As such, SMFM endorses the following policy principles:- SMFM calls on relevant government agencies and public funders to support and finance anti-violence and firearm safety research, public health surveillance activities, education, and other initiatives. These initiatives should acknowledge and address the connection between access to firearms and the health and safety of pregnant and postpartum people, as well as their families and communities.- SMFM strongly opposes legislation or regulations that impede or limit clinician-patient discussions about firearms.- SMFM calls for enhanced access to mental health care services for pregnant and postpartum people.- SMFM calls for additional support for individuals experiencing intimate partner violence and their families.- SMFM supports the creation of and funding for training programs for maternal-fetal medicine (MFM) subspecialists and all clinicians about firearms and domestic violence prevention.- SMFM supports laws and regulations that restrict individuals with protective or restraining orders and those with intimate partner violence or stalking convictions from purchasing and owning firearms.

Society for Maternal-Fetal Medicine Position Statement: Access to abortion care

The Society for Maternal-Fetal Medicine (SMFM) supports the right of all individuals to access the full spectrum of reproductive health services, including abortion care. Reproductive health decisions are best made by each individual with guidance and support from their healthcare providers.

Evaluation of Maternal-Fetal Medicine Fellowship Program Websites.

Introduction Due to the COVID-19 pandemic,the American Association of Medical Colleges (AAMC) recommended that all interviews for residencies and fellowships be conducted in a virtual format. As of March 2024, the Society of Maternal-Fetal Medicine (SMFM) continues to request that all fellowship interviews occur virtually. Without in-person interviews, prospective Maternal-Fetal Medicine (MFM) fellowship applicants must largely rely on program websites to gain insight into each program's offerings, culture, and application requirements. The purpose of this study was to evaluate the content of American College of Graduate Medical Education (ACGME)-accredited Maternal-Fetal Medicine (MFM) fellowship program websites and assess if regional differences exist among website content. Methods All ACGME-accredited MFM fellowship programwebsites were assessed for 21 defined criteria as of March 2024 and further compared by geographic regions (Midwest, Northeast, South, and West). Analyses were completed using chi-squared univariate tests, with a p < 0.05. Results Of the 108 accredited MFM fellowship programs, 106 programs had a dedicated website (98.15%). Most MFM programs (over 80%) included contact information (102/106), program director name (98/106), faculty names (95/106), application requirements (92/106), current fellow names (91/106), and the program coordinator name (89/106) on their website. Less programs (less than 30%) included diversity, equity, inclusion (DEI) content (28/106), interview dates (28/106), and current fellow research projects or publications (27/106). Western programs were less likely to include the program coordinator's name (12/18 (67%), p = 0.046), but more likely to include DEI content (10/18 (56%), p = 0.005). Northeastern programs were less likely to include their application requirements (24/32 (75%), p = 0.049) and less likely to include pictures of their current fellows (20/32 (63%), p = 0.045). Southern programs were more likely to include the yearly rotation schedule (19/32 (59%), p = 0.040). Midwestern programs were more likely to include information on fellowship benefits or salary (15/24 (63%), p = 0.046). Conclusion This study demonstrated that the content available on MFM fellowship websites varies greatly between programs and geographic regions. Efforts should be made by MFM training institutions to enhance website DEI content, curriculum information, recent fellow publications, and information on program alumni. A detailed and well-structured website may helpapplicants compare individual programs more equitablyin the age of virtual interviewing.

Do all patients with history of pelvic ring injuries need a cesarean section? – A survey of orthopaedic and obstetric providers

Objective(s)The recommended mode of delivery following pelvic ring fractures with surgical fixation is unclear. The objective of this study was to assess expert opinions from orthopaedic surgeons and obstetrician gynecologists on their recommended delivery recommendations for pregnant individuals with a history of pelvic ring injury, and to see if there was any difference in recommendations between the two specialties, and what factors influenced recommendations. Study designAn electronic, web-based survey was administered to a convenience sample of orthopaedic surgeons and obstetrician gynecologists, via advertisement to members of the Orthopaedic Trauma Association (OTA), the Society for Maternal Fetal Medicine, and querying obstetrician gynecologists practicing within the Military Health System. The survey was administered from November 2021 to December 2022. A two-proportion z-test, Chi-square or Fisher's Exact Test, and descriptive statistics were used to analyze data. ResultsSurvey respondents included 44 orthopaedic surgeons and 37 obstetricians. A total of 74 % obstetricians would recommend a trial of labor with hardware in place, while orthopaedic surgeon's recommendations varied based on the type of fixation. Forty four, 100 % of orthopaedic surgeons, recommended trial of labor if non-operative pelvic injury or unilateral posterior fixation only, 88 % recommended trial of labor if bilateral posterior fixation only, and 47.7 % for anterior trans-symphyseal plating only, 50 % for unilateral posterior and trans-symphyseal plating, and 43.2 % for bilateral posterior fixation with trans-symphyseal plating. ConclusionsThe results of these surveys demonstrate the lack of consensus as to the most appropriate birth plan for patients with a history of pelvic ring injuries. Vaginal delivery following pelvic ring fracture and fixation is possible, yet these patients are significantly more likely to undergo cesarean section than the general population. As such, we recommend that women who become pregnant after operative treatment of a pelvic ring injury develop an in-depth birthing plan with their obstetrician to determine the best course.

COVID-19 Vaccination and Reproductive Health: a Comprehensive Review for Healthcare Providers.

With all the current misinformation on social media platforms about the COVID-19 vaccine and its potential effects on fertility, it is essential for healthcare providers to have evidenced-based research to educate their patients, especially those who are trying to conceive, of the risks to mothers and fetuses of being unvaccinated. It is well known that COVID-19 infection puts pregnant women at higher risk of complications, including ICU admission, placentitis, stillbirth, and death. In February of 2021, the American College of Obstetricians and Gynecologists (ACOG), the American Society for Reproductive Medicine (ASRM), and the Society for Maternal-Fetal Medicine (SMFM) released a statement denying any link between COVID vaccination and infertility. ASRM later confirmed and stated that "everyone, including pregnant women and those seeking to become pregnant, should get a COVID-19 vaccine". In this review, we aim to provide a compilation of data that denies any link between vaccination and infertility for healthcare providers to be able to educate their patients based on evidence-based medicine. We also reviewed the effect of COVID-19 virus and vaccination on various parameters and processes that are essential to obtaining a successful pregnancy.

Pituitary and Pancreatic Iron Is Present at an Early Age in Transfused Patients with Alpha Thalassemia Major

Introduction Alpha thalassemia major is generally fatal in utero or shortly after birth without aggressive red cell transfusion therapy both pre- and postnatally. The Society for Maternal-Fetal Medicine has released evidence-based practice guidelines for the diagnosis and management of fetal anemia, largely focused on red cell alloimmunization, with intrauterine transfusion typically starting at 18 weeks gestational age.((SMFM) et al., 2015) Early initiation of intrauterine transfusion allows quick correction of anemia and a prolonged reduction of hemoglobin Bart's concentration leading up to birth.(Chmait, Baskin, Carson, Randolph, &amp; Hamilton, 2015) Long-term transfusion regimens postnatally invariably lead to iron overload, which can lead to organ dysfunction.(Taher &amp; Saliba, 2017) Minimal data is currently available regarding the pattern of iron overload in young patients with alpha thalassemia major given the rarity of the disease itself and variations in iron overload monitoring. Methods We reviewed patients with alpha thalassemia major treated at our center who had iron overload evaluations prior to 10 years of age. Diagnoses were confirmed by genetic testing. Iron deposition measurements were collected using multiple gradient echo pulse sequences on 1.5 Tesla magnets. Results Six subjects were included in the study. All but one subject received several intrauterine transfusions and were delivered at term. The last subject did not receive any intrauterine transfusions and was born at 24 weeks gestational age. Subjects were routinely transfused postnatally to keep fast migrating hemoglobin below 10%. Initial MRI was done prior to 4 years of age and as early as 1.5 years. All subjects had moderate to severe iron overload based on liver iron concentration (LIC) by R2* MRI, which decreased significantly after starting chelation in the four subjects who had subsequent MRI assessments (Figure 1A). Pancreatic iron was also elevated in all subjects, and none had cardiac siderosis. All but one subject had pituitary R2 by Z-score for age and sex greater than 2 in the coronal and sagittal planes, indicating pituitary siderosis, but none had pituitary volume loss (Figure 2B). Discussion This study shows significant extrahepatic iron deposition (pancreas, pituitary) at a very young age indicating exposure to toxic reactive ferrous iron (Fe 2+). The pancreas is known to load temporally before the heart.(Noetzli, Papudesi, Coates, &amp; Wood, 2009) None of the subjects in this study had cardiac iron by MRI, probably reflecting slower cardiac loading and lowering of Fe 2+ by chelation. It is very rare to have cardiac loading from transfusion in patients less than 2 years old.(Berdoukas et al., 2013) It is reassuring that none of the patients had pituitary volume loss, which has been associated with pituitary dysfunction,(Noetzli et al., 2012) although we know very little about pituitary function and iron in very young children. Our observation that some subjects had loading at 1.5 years old suggests there is significant circulating Fe 2+ in this population and the pituitary may be at risk. Chelation is rarely started prior to 2 years of age due to concerns about theoretical effects of chelation on neurodevelopment.(Coates, 2019) Despite significant levels of iron overload seen in initial assessments, hepatic iron rapidly improved with chelation despite aggressive red cell transfusion in this cohort. There are many unknowns here, including effects of prenatal iron exposure from transfusion, the extent to which iron seen by MRI signifies organ damage, and response of extrahepatic iron to chelation. However, the effects of iron deficiency on brain development are well documented(Idjradinata &amp; Pollitt, 1993; Lozoff et al., 2013) and the possible effects of chelators on the newborn/infant brain could be serious. Long-term pituitary iron data are still needed to support earlier implementation of iron chelation in this population.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine.

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

What's trending? Reach and content of the Society for Maternal-Fetal Medicine on social media

The Society for Maternal-Fetal Medicine (SMFM) uses social media to increase awareness of the Society and its key programs and to foster community and discussion around perinatal health, especially on Twitter. The influence and role of the SMFM Twitter account in public discourse around issues relevant to pregnancy have not been studied. We sought to evaluate trends in engagement with SMFM on Twitter by analyzing SMFM follower growth and discussion topics on Twitter compared with Facebook and by quantifying public engagement during the SMFM Annual Pregnancy Meeting. This retrospective study analyzed follower growth data from August 2019 to July 2022 for SMFM Twitter (@MySMFM) and SMFM Facebook (@SocietyforMaternalFetalMedicine). We identified the top 10 Tweets and Facebook posts during the study period using Twitter analytics and Facebook data. Popularity of Tweets and Facebook posts was determined by "impressions" and "reach", respectively; these metrics reflect the number of times a post was viewed. To evaluate annual trends in SMFM Twitter engagement, we analyzed data associated with the SMFM Annual Pregnancy Meeting, including the number of Tweets using the hashtag (#SMFM(Year)) and overall impressions for the SMFM Twitter account for each meeting from 2016-20223. The absolute number of new followers for SMFM Twitter and Facebook was similar, but the relative increase and rate of follower growth was higher for Twitter than for Facebook. The Twitter account consistently gained followers while the Facebook account experienced intermittent periods of stagnancy or follower loss. More than half of the top ranked posts on Twitter and Facebook mentioned the COVID vaccine; other popular topics included COVID-19 and abortion. During the SMFM Annual Pregnancy Meeting, Tweets using the meeting hashtag consistently peaked on meeting day 4, coincident with the opening plenary session (mean number of Tweets = 1270 +/- 499). An upward trend in Annual Pregnancy meeting tweets was observed each year until 2021 - the first virtual SMFM meeting. Trends in SMFM Twitter engagement suggest increasing use and popularity of the platform for timely dissemination of pregnancy-related news, guidelines, and research. The reduction in Annual Pregnancy Meeting Tweets and impressions in 2021 and 2022 suggests the potential negative impact of virtual meetings on SMFM member engagement around Annual Meeting content.

Selection of Standards for Sonographic Fetal Head Circumference by Use of z-Scores.

This study aimed to evaluate which of five established norms should be used for sonographic assessment of fetal head circumference (HC). Cross-sectional study using pooled data from four maternal-fetal medicine practices. Inclusion criteria were singleton fetus, gestational age 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Five norms of HC were studied: Jeanty et al, Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies unified standard (NICHD-U). The fit of our HC measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, low Kolmogorov-Smirnov D-statistic, high Youden J-statistic, close to 10% of exams >90th percentile, close to 10% of exams <10th percentile, and close to 2.28% of exams >2 SD below the mean. In 23,565 ultrasound exams, our HC measurements had the best fit to the WHO standard (mean z-score 0.10, SD of z = 1.01, D-statistic <0.01, J-statistic 0.83-0.94). The SD of the Jeanty reference was much larger than all the other norms and our measurements, resulting in underdiagnosis of abnormal HC. The means of the IG-21st and NICHD-U standards were smaller than the other norms and our measurements, resulting in underdiagnosis of small HC. The means of the Hadlock reference were larger than all the other norms and our measurements, resulting in overdiagnosis of small HC. Restricting the analysis to a low-risk subgroup of 4,423 exams without risk factors for large- or small-for-gestational age produced similar results. The WHO standard is likely best for diagnosis of abnormal HC. The Jeanty (Chervenak) reference suggested by the Society for Maternal-Fetal Medicine had poor sensitivity for microcephaly screening. · There are >30 norms for fetal HC.. · It is unknown which norm should be used.. · The WHO standard fits our data best.. · The Chervenak reference is not sensitive for microcephaly..

Do differences in diagnostic criteria for late fetal growth restriction matter?

Criteria for diagnosis of fetal growth restriction differ widely according to national and international guidelines, and further heterogeneity arises from the use of different biometric and Doppler reference charts, making the diagnosis of fetal growth restriction highly variable. This study aimed to compare fetal growth restriction definitions between Delphi consensus and Society for Maternal-Fetal Medicine definitions, using different standards/charts for fetal biometry and different reference ranges for Doppler velocimetry parameters. From the TRUFFLE 2 feasibility study (856 women with singleton pregnancy at 32+0 to 36+6 weeks of gestation and at risk of fetal growth restriction), we selected 564 women with available mid-pregnancy biometry. For the comparison, we used standards/charts for estimated fetal weight and abdominal circumference from Hadlock, INTERGROWTH-21st, and GROW and Chitty. Percentiles for umbilical artery pulsatility index and its ratios with middle cerebral artery pulsatility index were calculated using Arduini and Ebbing reference charts. Sensitivity and specificity for low birthweight and adverse perinatal outcome were evaluated. Different combinations of definitions and reference charts identified substantially different proportions of fetuses within our population as having fetal growth restriction, varying from 38% (with Delphi consensus definition, INTERGROWTH-21st biometric standards, and Arduini Doppler reference ranges) to 93% (with Society for Maternal-Fetal Medicine definition and Hadlock biometric standards). None of the different combinations tested appeared effective, with relative risk for birthweight <10th percentile between 1.4 and 2.1. Birthweight <10th percentile was observed most frequently when selection was made with the GROW/Chitty charts, slightly less with the Hadlock standard, and least frequently with the INTERGROWTH-21st standard. Using the Ebbing Doppler reference ranges resulted in a far higher proportion identified as having fetal growth restriction compared with the Arduini Doppler reference ranges, whereas Delphi consensus definition with Ebbing Doppler reference ranges produced similar results to those of the Society for Maternal-Fetal Medicine definition. Application of Delphi consensus definition with Arduini Doppler reference ranges was significantly associated with adverse perinatal outcome, with any biometric standards/charts. The Society for Maternal-Fetal Medicine definition could not accurately detect adverse perinatal outcome irrespective of estimated fetal weight standard/chart used. Different combinations of fetal growth restriction definitions, biometry standards/charts, and Doppler reference ranges identify different proportions of fetuses with fetal growth restriction. The difference in adverse perinatal outcome may be modest, but can have a significant impact in terms of rate of intervention.