A. Dhanya Mackeen

Cervical length screening with ultrasound-indicated cerclage compared with history-indicated cerclage for prevention of preterm birth: a meta-analysis.

OBJECTIVE: To compare pregnancy outcomes in singleton gestations with prior preterm birth that were managed either by cervical length screening with cerclage for short cervical length or history-indicated cerclage. DATA SOURCES AND METHODS OF STUDY SELECTION: Medline, Scopus, and the Cochrane Central Register of Controlled Trials were searched for the terms “cerclage,” “randomized trial,” and “clinical trial” from 1966 until January 2011. No restrictions for language were applied. We performed a meta-analysis of randomized trials of singleton gestations with prior preterm birth. Management by policy of transvaginal ultrasonography cervical length screening with cerclage placement for cervical shortening was compared with history-indicated cerclage. TABULATION, INTEGRATION, AND RESULTS: Four randomized trials met inclusion criteria, including 467 women. In women with a singleton gestation and prior preterm birth, cervical length screening with cerclage for short cervical length was associated with similar incidences of preterm birth before 37weeks (31% compared with 32%, relative risk 0.97, 95% confidence interval [CI] 0.73–1.29), preterm birth before 34 weeks (17% compared with 23%, relative risk 0.76, 95% CI 0.48–1.20), and perinatal mortality (5% compared with 3%, relative risk 1.77, 95% CI 0.58–5.35) compared with history-indicated cerclage. In the transvaginal ultrasound cervical length screening group, 42% developed a short cervical length and received cerclage. CONCLUSION: Singleton gestations in women with prior preterm birth may be monitored safely with a policy of transvaginal ultrasound cervical length screening as compared with a policy of routine history-indicated cerclage. Cerclage can be reserved for the minority of women who develop a short cervical length.

The Effect of 17α-Hydroxyprogesterone Caproate on Preterm Birth in Women with an Ultrasound-Indicated Cerclage

We sought to determine if 17α-hydroxyprogesterone caproate (17P) reduces the rate of preterm birth (PTB) in women with an ultrasound-indicated cerclage (UIC). We retrospectively reviewed a cohort of women with a previous spontaneous PTB and current UIC placement for cervical length (CL) < 25 mm at < 23 (6)/ (7) weeks. The study group consisted of women treated with 17P; the control group consisted of women not treated with 17P. Primary outcome was spontaneous PTB < 35 weeks. Secondary outcomes included PTB < 32 weeks, PTB < 28 weeks, gestational age at delivery, and birth weight. A total of 58 women were identified; 15 (25.9%) received 17P, and 43 (74.1%) did not. 17P did not have a significant effect on PTB < 35 weeks (odds ratio 1.72, 95% confidence interval 0.50 to 5.89), nor did it have a significant effect on the secondary outcomes. Among women with a prior spontaneous PTB and current UIC for CL < 25 mm, 17P did not reduce the rate of PTB < 35 weeks.

Cesarean skin closure preferences: a survey of obstetricians

Abstract Objective: In light of the limited evidence directing cesarean skin closure techniques, we evaluated the factors guiding obstetricians’ preferences for closure method. Methods: From 07/11 to 12/11, an online survey was sent to obstetricians in ACOG Regions I and II. Obstetricians were asked to indicate their cesarean skin closure preferences when considering various factors and to rank the importance of these factors in their decision. Practice type, experience and usual method of closure were also assessed. Results: Responses were received from 470 of 1400 surveyed (34% response rate), of which 422 were analyzed. Similar proportions reported primarily using sutures (39%) or staples (48%); 13% use both methods equally. More obstetricians at community hospitals primarily use sutures (48% versus 39%, p < 0.001), while more at university hospitals primarily use staples (57% versus 30%, p < 0.001). Listed in decreasing order of importance, sutures were preferred when considering patient satisfaction, keloid susceptibility, cosmesis, first Pfannenstiel incisions or cost. Staples were preferred when considering wound infections, obese patients, chorioamnionitis, HIV/AIDS or busy labor floors (p < 0.001). Conclusion: The limited evidence to guide cesarean skin closure forces obstetricians to rely on personal experience. Our survey indicates that despite this limitation, obstetricians have specific preferences for cesarean skin closure method.

Effectiveness of 17-α-hydroxyprogesterone caproate on preterm birth prevention in women with history-indicated cerclage.

OBJECTIVE To determine whether 17-α-hydroxyprogesterone caproate (17P) reduces the incidence of preterm birth in women with a history-indicated cerclage. STUDY DESIGN Retrospective cohort study of women who received a cerclage for a prior preterm birth, analyzed based on exposure to 17P. The primary outcome variable was delivery < 35 weeks. Secondary outcomes were preterm birth < 37, 32, 28, and 24 weeks; interval between cerclage placement and delivery; gestational age at delivery; and infant birth weight. RESULTS Fourteen women received 17P and 80 did not. Baseline characteristics did not differ between these two groups. Preterm delivery at < 35 weeks did not differ between those who received 17P and those who did not (29% versus 15%, p = 0.46). There were no significant differences between the groups for any other outcome. CONCLUSION 17P does not appear to have an effect on preterm birth < 35 weeks in women with a history-indicated cerclage.

Foley catheter vs prostaglandin as ripening agent in pregnant women with premature rupture of membranes.

CONTEXT Although studies support the efficacy of the Foley catheter (FC) as a cervical ripening agent in pregnant women at term with intact membranes, its efficacy has not been well studied in women with premature rupture of membranes (PROM). OBJECTIVE To compare the interval to delivery in women with PROM who underwent induction of labor and cervical ripening with mechanical (FC) vs nonmechanical (prostaglandin [PG]) cervical ripening agents. DESIGN Retrospective medical record review at 2 hospitals of pregnant women who delivered between January 2009 and April 2011. SETTING Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, and Christiana Care Health System in Newark, Delaware. PATIENTS Pregnant women with singleton gestations 36 weeks or greater who presented with PROM. INTERVENTIONS Cervical ripening with FC or PG. MAIN OUTCOME MEASURES The primary outcome was time from induction until delivery. Secondary outcomes included epidural use, maximum temperature during labor, number of vaginal examinations, occurrence of tachysystole, oxytocin dose, delivery mode, chorioamnionitis, and neonatal Apgar score. RESULTS Of 155 medical records of patients who met the inclusion criteria, 33 women underwent cervical ripening with PG (ie, misoprostol) and 122 with FC. The interval to delivery was almost halved in women who underwent cervical ripening with FC compared with misoprostol (736 vs 1354 minutes; P<.01). Compared with the women in the misoprostol group, those in the FC group received a statistically significant higher dose of oxytocin (P<.01). There were no statistically significant differences between the groups with respect to the remaining secondary outcomes. Of note, all of the women who received FC were from Christiana Care Health System, and all women who received misoprostol were from Thomas Jefferson University Hospital. CONCLUSION Foley catheters may help shorten the interval to delivery in women who are candidates for cervical ripening after PROM at or near term. There does not appear to be an increased risk for cesarean delivery or chorioamnionitis in those treated with FC.

Pain Associated With Cesarean Delivery Skin Closure: A Randomized Controlled Trial.

OBJECTIVE: To assess pain perception and pain medication use between women who underwent suture and those who underwent stapling for skin closure after cesarean delivery. METHODS: This was a secondary analysis of a prospective, multicenter, randomized clinical trial conducted from 2010 to 2012 at three hospitals in the United States. We evaluated pain outcomes associated with skin closure of a low transverse skin incision for cesarean delivery. Patient-reported pain and pain medication use during hospitalization and 6 weeks postpartum were evaluated as prespecified secondary outcomes of the trial. RESULTS: A total of 746 women were randomized to cesarean skin closure with sutures (n=370) or staples (n=376). There were no significant differences between the two groups with regard to pain perception during hospitalization (median average in-hospital pain score 3.9 in each group, P=.914), or at 4–8 weeks postsurgery (one in each group, P=.949). There were no significant differences in pain medication use during hospitalization (suture: 56 mg of intravenous morphine; staples: 54 mg, P=.545) or 4–8 weeks postpartum. CONCLUSION: We observed no differences in patient-reported pain or pain medication use among women who underwent skin closure with suture and those who underwent stapling after cesarean delivery. Taken in conjunction with the primary analysis that showed decreased wound morbidity with suture closure, the results of this study support the use of suture closure of the cesarean delivery skin incision. CLINCAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01211600. LEVEL OF EVIDENCE: I

The utility of screening for historical risk factors for preterm birth in women with known second trimester cervical length.

Abstract Objective: To evaluate for the presence of risk factors (RFs) for preterm birth (PTB) in women without prior PTB having second trimester cervical length (CL) screening, and to estimate the utility of RF screening. Methods: “Low-risk” singletons were prospectively screened with midtrimester transvaginal ultrasound CL. Prior PTB, intrauterine fetal demise and lethal anomalies were excluded. Women were analyzed based on second trimester CL (<25 mm versus ≥25 mm) and the presence of RFs for PTB. A p-value of < 0.05 was considered significant. Results: A total of 639 women were screened; 8% had CL <25 mm. Ninety-eight percent of women with CL <25 mm and 95% of women with CL ≥25 mm had RFs for PTB. Five percent of women with a CL ≥25 mm delivered preterm as compared to 18% with CL <25 mm (p < 0.01). Treatment of cervical dysplasia, drug use during the pregnancy and unmarried status were significantly more common in women with CL <25 mm than CL ≥25 mm. When data were analyzed by CL, the presence of additional RFs did not add to the prediction of PTB <37 weeks. Discussion: Over 95% of singleton gestations without prior PTB have ≥1 other RF for PTB. In women without prior PTB, assessment of other PTB RFs does not add to prediction of PTB provided by CL alone.

Morphine sleep in pregnancy.

OBJECTIVES To determine the incidence of admission in labor after morphine sleep (therapeutic rest), patient characteristics associated with labor, and adverse outcomes associated with treatment. METHODS We reviewed medical records of women treated with morphine sleep from December 2005 to December 2009. Variables evaluated included medications used for treatment, cervical examination, maternal demographic characteristics and obstetric history, fetal heart rate patterns, and maternal/neonatal outcomes. These characteristics were compared between those admitted in labor after morphine sleep versus those discharged. RESULTS Fifty-eight women received morphine sleep: 36 (62%) were admitted in labor, 17 (29%) were discharged, and 5 (9%) were admitted secondary to category II fetal heart rate tracings. All fetuses had category I fetal heart rate tracings prior to treatment. Median dose of morphine sulfate was 20 mg. Those with effacement > 50% (p < 0.01) and carrying term gestations (p < 0.01) were more likely to be admitted in labor after treatment. There were no adverse maternal outcomes. There were no significant differences in neonatal outcomes. CONCLUSION Sixty-two percent of women were admitted in labor after morphine sleep. Admission effacement > 50% and term gestational age were associated with admission in labor. There were no significant differences in maternal or neonatal morbidity in those admitted versus discharged home after treatment with morphine sleep.

The effect of standardized counseling on patient knowledge about induction of labor

Objective: Our goal was to evaluate if standardized counseling improves patient knowledge, as compared to pre-counseling knowledge, and as compared to knowledge after non-standardized counseling. Methods: This was an IRB-approved prospective study conducted at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, from October 2010 to June 2011. Two groups of patients were evaluated: Group A received standardized counseling in the resident clinic; Group B received non-standardized counseling, in the resident clinic or private practice. The standardized counseling group received questionnaires before and after standardized counseling; the non-standardized counseling group received questionnaires after non-standardized counseling. Results: Sixty-six patients were enrolled in this study: 23 in Group A and 43 Group B. Baseline characteristics were similar among the groups. Group A showed statistically significant improvement in knowledge after standardized counseling (17.1%, p ≤ 0.01). Group A also scored significantly better on the post-counseling test than Group B (84.7% vs. 64.6%, p ≤ 0.01). In further analysis, this significant improvement was shown regardless of whether the non-standardized counseling was performed in the resident clinic or private practice. Conclusion: Standardized counseling improves patient knowledge about induction of labor. In the future, this information can be used to appropriately direct patients’ expectations and improve satisfaction with the induction process.

Patient satisfaction and cosmetic outcome in a randomized study of cesarean skin closure

Abstract Objective: To evaluate patient satisfaction and patient and physician assessment of scar appearance after cesarean skin closure with suture versus staples. Methods: Women undergoing cesarean delivery (CD) at ≥23 weeks’ gestation via low-transverse skin incisions at three hospitals in the CROSS Consortium were randomized to receive skin closure using subcuticular absorbable suture or nonabsorbable metal staples. The primary outcome of this substudy, patient satisfaction, was assessed by surveys at the postpartum visit using a 10-point Likert scale. Scar outcomes according to patients and trained observers were assessed at the primary research site using the Patient and Observer Scar Assessment Scale (POSAS). The POSAS is comprised of a patient-completed assessment including subjective data such as pain and itchiness, and an observer-completed assessment about cosmetic criteria. Results: Between June 2010 and August 2012, 746 women were randomized; 370 received suture and 376 received staples. Satisfaction data were available for 606 (81%). Complete patient scar assessment data were available for 577 (77%) and complete observer scar assessment data were available for 275 (57% of the 480 planned for evaluation at the primary research site). Demographic data for women in the two groups were similar. Satisfaction with the closure method was higher (superior) among women who received suture closure: median 10 (interquartile range 9, 10) versus 9 (interquartile ranges (IQR) 6, 10); p < .01. The suture group also had higher satisfaction with the scar’s appearance at the postpartum visit: median nine (IQR 7, 10) versus 8 (IQR 6, 10); p = .02. Receiving one’s preferred closure method was associated with higher patient satisfaction, and wound complications were associated with lower satisfaction. POSAS scores were superior (lower) in the suture group. Patient Scar Assessment Scale scores were median 15 (IQR 10, 25) for sutures versus 20 (IQR 11, 28) for staples; p < .01. Observer Scar Assessment Scale scores were median 12 (IQR 9, 15) for sutures versus 13 (IQR 9, 16) for staples; p = .01. Conclusions: Satisfaction with the closure method, satisfaction with the scar’s appearance, and patient and physician assessments of scar cosmesis were all superior in those closed with suture. These results further support the use of sutures for cesarean skin closure.