Objective To describe periviability counseling practices and decision making. Study Design This is a retrospective review of mothers and newborns delivering between 22 and 24 completed weeks from 2011 to 2015 at six U.S. centers. Maternal and fetal/neonatal clinical and maternal sociodemographic data from medical records and geocoded sociodemographic information were collected. Separate analyses examined characteristics surrounding receiving neonatology consultation; planning neonatal resuscitation; and centers' planned resuscitation rates. Results Neonatology consultations were documented for 40, 63, and 72% of 498 mothers delivering at 22, 23, and 24 weeks, respectively. Consult versus no-consult mothers had longer median admission-to-delivery intervals (58.7 vs. 8.7 h, p < 0.001). Consultations were seen more frequently when parental decision making was evident. In total, 76% of mothers had neonatal resuscitation planned. Resuscitation versus no-resuscitation newborns had higher mean gestational ages (24.0 vs. 22.9 weeks, p < 0.001) and birthweights (618 vs. 469 g, p < 0.001). Planned resuscitation rates differed at higher (HR) versus lower (LR) rate centers at 22 (43 vs. 7%, p < 0.001) and 23 (85 vs. 58%, p < 0.001) weeks. HR versus LR centers' populations had more socioeconomic hardship markers but fewer social work consultations (odds ratio: 0.31; confidence interval: 0.15–0.59, p < 0.001). Conclusion Areas requiring improvement included delivery/content of neonatology consultations, social work support, consideration of centers' patient populations, and opportunities for shared decisions.

Objective To determine the utility of fetal echocardiography in diagnosing cardiac defects in fetuses with a single umbilical artery (SUA). Methods A retrospective cohort study of prenatally diagnosed SUA was conducted over a 10‐year period at a single institution. Cardiac anatomy on detailed anatomical survey was compared with fetal echocardiogram for fetuses with prenatally diagnosed SUA. A diagnostic meta‐analysis of studies comparing fetal anatomical survey to fetal echocardiogram in fetuses with SUA between 2010 to 2019 was also performed. Results Three hundred and twenty fetuses with SUA were identified, 113 of which had completed both ultrasound and echocardiography. There were 36 cases of cardiac defects on prenatal echocardiogram and all had abnormal anatomical ultrasounds. There were zero cases of abnormal cardiac exams (0%) when the cardiac views on anatomical survey were normal. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound were 100%, 77%, 73% and 100%, respectively. A summary ROC curve demonstrated a high predictive value of routine anatomic survey for cardiac defects (AUC: 0.99). Conclusion Anatomic survey is highly predictive in the detection of cardiac defects in fetuses with SUA. Fetal echocardiogram is unnecessary in SUA when cardiac views are normal on ultrasound.

the likelihood of twin TOLAC success was analysed. For statistical purposes, combined adverse outcome (uterine rupture, Apgar <7 at 5 minutes and umbilical cord pH < 7.1) was compared between the singleton and twin groups. Data was analysed using Fishers exact test and chi squared tests. RESULTS: 95 women with a twin gestation and one previous caesarean section comprised the study group. 5703 women with a singleton gestation and one previous caesarean section comprised the control group. 29 (30.5%) and 4734 (83%) women with twin and singleton gestation respectively underwent a trial of labor (p¼0.00, OR 0.087, 95% CI 0.056-0.135). Mean gestational age in the twin group was 36.7AE 1.5 weeks. Women in the twin TOLAC group were less likely to succeed (75.9% Vs 92.7%, p¼0.004, OR 4.02 95% CI 1.71-9.48) and less likely to have a spontaneous unassisted vaginal delivery (p¼0.003, OR 3.4 95% CI 1.6-7.2) compared to women in the singleton TOLAC group. Maternal age less than 35, parity greater than two and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, [2 cases (6.9%) vs 20 cases (0.4%) respectively, (p¼0.008, OR 17.5, 95% CI 3.89 e 78.4)] and for combined adverse outcome (p¼0.004, OR 10.81, 95% CI 3.17-36.9). CONCLUSION: Twin TOLAC is not common, even in extremely highly motivated parturients for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture and combined adverse perinatal outcome. Demographic and obstetric risk factors were identified and may aid the attending obstetrician in the challenging counselling of such cases.

BACKGROUND: Despite medical advances in the care of extremely preterm neonates and growing acceptance of resuscitation at 23 and even 22 weeks gestation, controversy remains concerning the use of antepartum obstetric intervention s that are intended to improve outcomes in the setting of anticipated extremely preterm birth. In the absence of demonstrated benefit at <23 weeks gestation and with uncertain benefit at 23 weeks gestation, previous obstetric committee opinions have advised against their use at these gestational ages. OBJECTIVE: The purpose of this study was to review the use of obstetric intervention s at the threshold of viability based on neonatal resuscitation plan and to review the odds of survival to neonatal intensive care unit discharge based on use of obstetric intervention s with adjustment for neonatal factors. STUDY DESIGN: This retrospective study of 6 study centers reviewed pregnant patients who were admitted between 22þ0/7 and 24þ6/7 weeks gestation facing delivery from 2011e2015. Patients with known anomalies or missing data were excluded. Records were reviewed for demographics, resuscitation plan, and obstetric intervention s. Mode of delivery, delivery room care, and final infant dispositions were recorded. Multiple gestations were included as 1 pregnancy in regard to the use of obstetric intervention s and were excluded from survival analysis. RESULTS: Four hundred seventy-eight mothers met the inclusion criteria. When resuscitation was planned, mothers were more likely to receive all conventional obstetric intervention s (antenatal steroids, magnesium sulfate for neuroprotection, tocolytics, and Group Beta Streptococcus prophylaxis), regardless of gestational age at admission, and were more likely to be delivered by cesarean section (P<.05). Analyzed as a group, when antenatal steroids, magnesium sulfate, tocolytics and Group Beta Streptococcus prophylaxis were administered, the odds of survival to neonatal intensive care unit discharge increased for newborn infants who were born at 22 (odds ratio, 11.33; 95% confidence interval, 1.405e91.4) and 23 weeks gestation (odds ratio, 15.5; 95% confidence interval, 3.747-64.11; P<.05). In singletons, the odds of survival to neonatal intensive care unit discharge was not improved by cesarean delivery vs vaginal delivery, even after adjustment for the use of additional interventions, weight, gender, and gestational age (odds ratio, 1.0; 95% confidence interval, 0.59e1.8; P¼.912). CONCLUSION: In this study, when postnatal resuscitation was planned at 22 and 23 weeks gestation, women were more likely to receive antenatal steroids, magnesium sulfate, and antibiotics; provision of this bundle imparted survival benefit at 23 weeks gestation but could not be demonstrated at 22 weeks gestation because of the small sample size. These findings support of neonate-oriented obstetric interventions in the setting of delivery at 23 weeks gestation when resuscitation is planned and further exploration of optimal obstetric care when resuscitation of infants ...