Objective: To evaluate the efficacy of long-term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin-to-twin transfusion syndrome (TTTS). Design: Retrospective cohort study of prospectively collected data. Setting: Collaborative multicenter study Population: 557 consecutive TTTS cases that underwent FLS Methods: LIT was defined as indomethacin use for at least 48 hours. Log-binomial regression was used to estimate the relative risk (RR) of PTB in LIT compared to non-LIT group. Cox regression was used to evaluate the association between LIT use and FLS-to-delivery survival. Main outcome measures: gestational age (GA) at delivery Results: Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared to the non-LIT group (31.1weeks), p<0.001. FLS-to-delivery interval was significantly longer in the LIT group (P<0.001). The risk of PTB prior to 34, 32, 28, and 26 weeks gestation were all significantly lower in the LIT group compared to the non-LIT group (RR=0.69, 0.51, 0.37, and 0.18, respectively). The number needed to treat (NNT) with LIT to prevent one PTB<32 weeks gestation was 4, and to prevent one PTB<34 weeks was 5. Conclusion: Long-term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reducing the risk for PTB.

Objective To evaluate whether there is a difference in immediate neonatal outcomes with general anesthesia (GA) vs. regional anesthesia (RA) when induction of anesthesia to delivery time (IADT) is prolonged (≥10 minutes). Methods This is a retrospective case-control study that included cases from July 2014 until August 2020. We reviewed all singleton pregnancies delivered between 24 and 42 weeks of gestation with IADT ≥ 10 minutes. The propensity score (PS) matching method was performed using baseline characteristics. Analyses were performed with SAS software version 9.4. Results During the study period, we identified 258 cases meeting inclusion criteria. After the PS matching was applied, the study sample was reduced to 60 cases in each group. The median IADT was similar between groups [41.5m (30.5,52) vs. 46m (38-53.5), p=0.2]. There was no significant difference between groups with respect to arterial cord pH [7.24 (7.21,7.26) vs. 7.23 (7.2,7.27), p=0.7]. Nor were there any associations between maternal characteristics and Apgar score at 5 minutes except Apgar score at 1 minute (p<0.001). No significant difference was identified in the rate of admission to the neonatal intensive care unit (NICU) [11 (52.4) vs. 10 (47.60], p=0.8] or NICU length of stay between GA vs. RA [4(3-14) vs. 4.5(3-11), p=0.9]. Conclusion Our data indicate that with prolonged IADT, favorable neonatal outcomes are seen with both GA and RA, in contrast with previous studies performed decades ago. This underscores the need for re-appraisal of historic outcomes reflecting new modalities, techniques, and advances in the medical field.

Proning in Pregnancies Complicated by Acute Respiratory Distress Syndrome. A Call to Action During the COVID-19 Pandemic.Authors: L Cojocaru, OM Turan, A Levine, L Sollecito, S Williams, E Elsamadicy, S Crimmins, S Turan.Liviu Cojocaru, MD: Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science. University of Maryland School of Medicine, Baltimore, MD, USA.([email protected]) (ORCID No: 0000-0003-1558-702X).Ozhan M Turan, MD, Ph.D.: Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science. University of Maryland School of Medicine, Baltimore, MD, USA.([email protected])Andrea Levine, MD: Division of Pulmonary and Critical Care Medicine. Department of Medicine. University of Maryland School of Medicine, Baltimore, MD, USA.([email protected])Linda Sollecito, BSN, RN, CCRN: Medical Intensive Care Unit. University of Maryland Medical Center, Baltimore, MD, USA.([email protected])Susan Williams, MS, RN, CCRN: Medical Intensive Care Unit. University of Maryland Medical Center, Baltimore, MD, USA.([email protected])Emad Elsamadicy, MD: Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science. University of Maryland School of Medicine, Baltimore, MD, USA.([email protected])Sarah Crimmins, DO: Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science. University of Maryland School of Medicine, Baltimore, MD, USA.([email protected])Shifa Turan, MD, RDMS: Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science. University of Maryland School of Medicine, Baltimore, MD, USA.([email protected])Correspondence to: Liviu Cojocaru, MD: Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA.([email protected])Disclosures: None.Acknowledgments: We are grateful to Bill Seiler, Erin Rummel, Kelly Kennedy, Alexandra Bessent, Chris Wells, McLellan Shelby, Jessica Peterson, and Amanda Sullivan for assistance in creating the proning video instructions.Short title: Proning in pregnancies complicated by ARDS. It’s time!

Objective: To evaluate the role of intertwin differences in umbilical artery (UA) pulsatility index (DUAPI) in predicting infant survival in twin-to-twin transfusion syndrome (TTTS) Design: Retrospective cohort study Setting: Baylor College of Medicine, Texas Children’s Hospital and University of Maryland School of Medicine Population: Women who underwent laser surgery due to TTTS between 2002 and 2018. Methods: Absolute DUAPI were calculated prior to laser surgery. ROC analysis was done to derive a DUAPI cutoff value of 0.4 for the prediction of double infant survival. Regression analyses were performed to evaluate the association of DUAPI <0.4 and infant survival in the whole cohort, in TTTS cases with Quintero stages I/II and in those with Quintero stage III/IV; adjustments for gestational age at delivery, Quintero stage, selective fetal growth restriction (sFGR) and other confounders were done. Main Outcome Measure: Double infant survival to 30 days of life Results: 349 TTTS cases were included. Double twin survival to 30 days was observed in 67% (234/349) of cases. Intertwin DUAPI <0.4 was associated with increased double twin survival in the whole cohort (aOR: 3.40; 95% CI: 2.02-5.70; p<0.001), in women with TTTS Quintero stage I or II (aOR: 3.05; 95% CI: 1.32-7.09; p=0.009) and in women with TTTS Quintero stage III or IV (aOR: 3.23; 95% CI: 1.52-8.85; p=0.002). Neither Quintero stage nor sFGR were associated with infant survival. Conclusions: Intertwin differences in UA pulsatility index supersede the Quintero classification in the prediction of double infant survival following laser surgery in TTTS cases.