BACKGROUND. Administration of conventional antithrombotic treatment (low-dose aspirin plus low–molecular weight heparin [LDA+LMWH]) for obstetric antiphospholipid syndrome (APS) does not prevent life-threatening placenta insufficiency–associated complications such as preeclampsia (PE) and intrauterine growth restriction (IUGR) in 20% of patients. Statins have been linked to improved pregnancy outcomes in mouse models of PE and APS, possibly due to their protective effects on endothelium. Here, we investigated the use of pravastatin in LDA+LMWH-refractory APS in patients at an increased risk of adverse pregnancy outcomes. METHODS. We studied 21 pregnant women with APS who developed PE and/or IUGR during treatment with LDA+LMWH. A control group of 10 patients received only LDA+LMWH. Eleven patients received pravastatin (20 mg/d) in addition to LDA+LMWH at the onset of PE and/or IUGR. Uteroplacental blood hemodynamics, progression of PE features (hypertension and proteinuria), and fetal/neonatal outcomes were evaluated. RESULTS. In the control group, all deliveries occurred preterm and only 6 of 11 neonates survived. Of the 6 surviving neonates, 3 showed abnormal development. Patients who received both pravastatin and LDA+LMWH exhibited increased placental blood flow and improvements in PE features. These beneficial effects were observed as early as 10 days after pravastatin treatment onset. Pravastatin treatment combined with LDA+LMWH was also associated with live births that occurred close to full term in all patients. CONCLUSION. The present study suggests that pravastatin may improve pregnancy outcomes in women with refractory obstetric APS when taken at the onset of PE or IUGR until the end of pregnancy.

Objective: To examine the possible role of Doppler ultrasound assessment of ductus venosus blood flow in screening for major cardiac defects in chromosomally normal fetuses with increased nuchal translucency (NT) thickness at 11 + 0 to 13 + 6 weeks' gestation.Methods: Ductus venosus blood flow velocity waveforms were obtained immediately before chorionic villus sampling for fetal karyotyping in fetuses with NT thickness of 3.5 mm or more at 11 + 0 to 13 + 6 weeks of gestation. In the chromosomally normal group fetal echocardiography was performed by a specialist pediatric cardiologist at 11 + 0 to 13 + 6 weeks and/or 18–22 weeks' gestation.Results: Major cardiac defects were diagnosed in 16 (8.4%) of the 191 chromosomally normal fetuses. Reversed or absent flow in the ductus venosus during atrial contraction was observed in 11 of the 16 (68.8%) fetuses with cardiac defects and in 40 of the 175 (22.9%) with no cardiac defects. Multivariate analysis demonstrated that the prevalence of an abnormal A‐wave in the ductus venosus in fetuses without major cardiac defects increased with fetal NT thickness (odds ratio (OR), 1.463; 95% CI, 1.183–1.809; P < 0.0001) but in those with cardiac defects it did not change significantly with NT thickness (OR, 2.054; 95% CI, 0.573–7.360; P = 0.269). The likelihood ratio for a major cardiac defect when the ductus venosus flow was abnormal decreased with fetal NT thickness from 4.58 at NT 3.5 mm to 2.47 for NT 5.5 mm, and the likelihood ratio when the ductus venosus flow was normal increased from 0.37 at NT 3.5 mm to 0.43 for NT 5.5 mm.Conclusion: In chromosomally normal fetuses with increased NT the finding of an absent or reversed A‐wave in the ductus venosus is associated with a three‐fold increase in the likelihood of a major cardiac defect, whereas the finding of normal ductal flow is associated with a halving in risk for such defects. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.

Importance: Induction of labor (IOL) is a common obstetric intervention that stimulates the onset of labor using artificial methods. Objective: The aim of this study was to summarize and compare recommendations from 4 national or international medical societies on the IOL. Evidence Acquisition: A descriptive review was conducted of major published guidelines on IOL: the American College of Obstetricians and Gynecologists' “Induction of Labor” and “Management of Late-Term and Postterm Pregnancies,” the guidelines of the Society of Obstetricians and Gynaecologists of Canada (SOGC) on “Induction of Labour,” those of the National Institute for Health and Care Excellence (NICE) on “Inducing Labour,” and the World Health Organization's (WHO's) “Recommendations for Induction of Labour” and “WHO Recommendations: Induction of Labour at or Beyond Term.” These guidelines were compared in terms of their recommendations on clinical indications and methods. Results: Many similar indications and contraindications to IOL are identified between American College of Obstetricians and Gynecologists and SOGC, whereas NICE and WHO do not mention any contraindications. The timing of IOL in postterm pregnancies also differs among the guidelines. Regarding the methods of induction, all the medical societies recommend the use of membrane sweeping, mechanical methods, prostaglandins, and oxytocin, whereas NICE argues against the use of misoprostol for IOL. The American College of Obstetricians and Gynecologists and SOGC consider amniotomy a method of IOL, whereas NICE and WHO do not recommend it. All the guidelines also make similar recommendations regarding the management of uterine tachysystole in cases of IOL. Conclusions: The World Health Organization seems to be the most evidence-based guideline with recommendations based mainly on Cochrane reviews. The variation in the clinical indications and methods of IOL highlights the need to adopt an international consensus, which may help to optimize the quality of obstetric care and further promote evidence-based medicine. Target Audience: Obstetricians and gynecologists, family physicians. Learning Objectives: After participating in this activity, the learner should be better able to identify the appropriate indications for induction of labor; explain the effectiveness and associated risks of using prostaglandins, misoprostol, oxytocin, and amniotomy for induction of labor; and assess the definition and alternatives of failure of induction of labor.

Objective: To determine the value of placental volume measured by 3D ultrasound at 11–13 weeks’ gestation in combination with maternal characteristics and serum pregnancy-associated plasma protein-A (PAPP-A) in the prediction of small and large for gestational age (SGA and LGA) neonates. Methods: Maternal serum PAPP-A and placental volume were measured at 11–13 weeks in 3,104 singleton pregnancies. Regression analysis was used to examine the contribution of maternal characteristics, placental volume and PAPP-A in the prediction of SGA and LGA neonates. Results: There was a significant association between placental volume and PAPP-A (r = 0.268, p < 0.0001). Median placental volume and PAPP-A, expressed as multiples of the median (MoM) in appropriate for gestational age (AGA) neonates, were reduced in the SGA group (placental volume 0.88 MoM, vs. 1.00 MoM in AGA, p < 0.0001; PAPP-A 0.92 MoM vs. 1.00 MoM in AGA, p = 0.019) and increased in the LGA group (placental volume 1.09 MoM vs. 1.00 MoM in AGA, p < 0.0001; PAPP-A 1.15 MoM vs. 1.00 MoM in AGA, p = 0.015). Maternal characteristics with either placental volume or PAPP-A detected about 30% of the SGA or LGA neonates, at a false positive rate of 10%. Conclusion: Measurement of placental volume and serum PAPP-A can improve the prediction of SGA or LGA neonates provided by maternal characteristics alone.