The aim of this study was to examine the contribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) to pregnancy-related complications including gestational diabetes mellitus (GDM), preterm birth (PTB), intrauterine growth restriction (IUGR), pre-eclampsia, antepartum haemorrhage and cholestasis. The Nationwide Inpatient Sample was queried for all pregnancy-related discharges, pregnancy complications and viral hepatitis from 1995 to 2005. Logistic regression was used to examine the association between HBV, HCV, HBV + HCV and pregnancy-related complications including GDM, PTB, IUGR, pre-eclampsia, antepartum haemorrhage, cholestasis and caesarean delivery. Model covariates included maternal age, race, insurance status, substance use and medical complications including liver complication, hypertension, HIV, anaemia, thrombocytopenia and sexually transmitted infections. Of 297 664 pregnant women data available for analysis, 1446 had a coded diagnosis of HBV, HCV or both. High-risk behaviours, such as smoking, alcohol and substance use were higher in women with either HBV or HCV. Women with HBV had an increased risk for PTB (aOR 1.65, CI [1.3, 2.0]) but a decreased risk for caesarean delivery (aOR 0.686, CI [0.53, 0.88]). Individuals with HCV had an increased risk for GDM (aOR 1.6, CI [1.0, 2.6]). Individuals with both HBV and HCV co-infection had an increased risk for antepartum haemorrhage (aOR 2.82, CI [1.1, 7.2]). There was no association of viral hepatitis with IUGR or pre-eclampsia. Women with hepatitis have an increased risk for complications during pregnancy. Research to determine the efficacy and cost-effectiveness of counselling patients about potential risks for adverse outcomes is warranted.

Objective Societal pressures against smoking during pregnancy may lead to a reduction in disclosure of smoking status. The objective of this study was to compare prevalence of smoking at prenatal intake by self-report with anonymous biochemical validation. Methods Women receiving care at the Duke Obstetrics Clinic from February 2005 through January 2006 were eligible for evaluation. Self-reported smoking and urine samples were obtained anonymously at prenatal intake. The NicCheck™ I semi-quantitative dipstick was used to detect urinary nicotine, cotinine, and 3-hydroxycotinine. The difference, with 95% confidence interval, between the proportions of smokers by self-report and urine testing was calculated for (1) high-positive vs. low-positive and negative results combined and (2) any positive vs. negative results. Results Among 297 subjects, self-reported smoking was 18.2 vs. 14.8% for low-positive and negative results combined with an absolute difference of 3.4%, [−2.9%, 9.6%]. When comparing self-report with any positive result (43.1%), the absolute difference was 24.9%, [17.4%, 32.1%]. Conclusions Our findings suggest that most pregnant women disclose their smoking and many nonsmokers may have significant second-hand exposure. Universal urinary cotinine screening of pregnant women could aid in appropriately counseling women about second-hand exposure as well as monitoring women at high risk for adverse pregnancy outcomes.

Markers of fibrinolysis were not significantly altered by IPCs in this study of low-risk pregnant women. Further research regarding the mechanism and efficacy of IPCs in pregnant women is warranted.

Cervicovaginal fistula is a recognized complication of induced mid-trimester termination of pregnancy CASE REPORTA 36-year-old woman, gravida 13 para 0-2-10-0, with a history of cervical incompetence, presented at 14 weeks' gestation for prophylactic Shirodkar cerclage. Her obstetric history was complicated, involving three firsttrimester elective terminations of pregnancy (TOP) and five first-trimester spontaneous miscarriages. These were followed by three mid-trimester losses, each with painless dilatation, at 18, 19 and 21 weeks' gestation. Her most recent delivery occurred at 22 weeks' gestation. During that pregnancy she underwent a prophylactic McDonald cerclage at 14 weeks. She then presented at 20 weeks' with membranes protruding through a dilated cervix, despite having the McDonald cerclage in place. Two additional rescue McDonald cerclages were then placed, one suture placed proximal to the original cerclage and a second placed distal. Two weeks later the patient presented with chorioamnionitis in the setting of preterm premature rupture of the fetal membranes. The cerclages were removed and she delivered a non-viable fetus at 22 weeks.During the current pregnancy, prior to the placement of a prophylactic Shirodkar cerclage, the patient reported a 2-day history of cramping and vaginal spotting. Physical examination revealed a 1-cm diameter defect in the posterior aspect of the cervix, communicating with the cervical canal. Because of concern for spontaneous miscarriage, cerclage placement was postponed and she was referred for ultrasound examination 3 days later.A transvaginal ultrasound examination revealed the internal os to be dilated and the external cervical os to be closed. In the midline, the amniotic sac was observed to protrude into the posterior wall of the cervix and appeared to be covered by a thin rim of cervical tissue (Figure 1). To the right of the midline, the sac could be seen to completely protrude through the posterior wall of the cervix (Figure 2). A bimanual examination was performed, which confirmed that the amniotic sac was protruding through a defect in the posterior wall of the cervix, consistent with a cervicovaginal fistula. Because of the risk for extension of the fistula into adjacent organs, the patient was taken to the operating room for dilatation and evacuation. At the time of the evacuation 2 h later, the amniotic sac was found to completely traverse the cervicovaginal fistula, protruding further into the vagina (Figure 3).Three months after the pregnancy evacuation, the patient underwent saline contrast sonohysterography (SCSH) for assessment of her uterine cavity. This revealed a normal uterine cavity and normal external uterine contour. The patient had a normal thrombophilia panel and karyotype. After extensive counseling, the patient decided