Begoña Muñoz

Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial

BACKGROUND Most previous studies of the use of cervical pessaries were either retrospective or case controlled and their results showed that this intervention might be a preventive strategy for women at risk of preterm birth; no randomised controlled trials have been undertaken. We therefore undertook a randomised, controlled trial to investigate whether the insertion of a cervical pessary in women with a short cervix identified by use of routine transvaginal scanning at 20-23 weeks of gestation reduces the rate of early preterm delivery. METHODS The Pesario Cervical para Evitar Prematuridad (PECEP) trial was undertaken in five hospitals in Spain. Pregnant women (aged 18-43 years) with a cervical length of 25 mm or less were randomly assigned according to a computer-generated allocation sequence by use of central telephone in a 1:1 ratio to the cervical pessary or expectant management (without a cervical pessary) group. Because of the nature of the intervention, this study was not masked. The primary outcome was spontaneous delivery before 34 weeks of gestation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00706264. FINDINGS 385 pregnant women with a short cervix were assigned to the pessary (n=192) and expectant management groups (n=193), and 190 were analysed in each group. Spontaneous delivery before 34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (12 [6%] vs 51 [27%], odds ratio 0·18, 95% CI 0·08-0·37; p<0·0001). No serious adverse effects associated with the use of a cervical pessary were reported. INTERPRETATION Cervical pessary use could prevent preterm birth in a population of appropriately selected at-risk women previously screened for cervical length assessment at the midtrimester scan. FUNDING Instituto Carlos III.

A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin

To evaluate a classification of selective intrauterine growth restriction (sIUGR) in monochorionic (MC) twins based on the characteristics of umbilical artery (UA) Doppler flow in the smaller twin, in terms of association with clinical outcome and with the pattern of placental anastomoses.

Modification of cervical length after cervical pessary insertion: correlation weeks of gestation.

Abstract Objectives: To observe the modifications in cervical length (CL) in patients with and without cervical pessary (Arabin® ASQ 65/25/32) and correlate these modifications with gestational age at delivery. Study design: Prospective study of asymptomatic singleton pregnancies (PECEP-Trial) between weeks 20 + 0 and 23 + 6 with maternal short cervix (<25 mm) randomised into two groups: expectant management and cervical pessary. Results: This study included 380 pregnant women: 190 with pessary and 190 without pessary. Mean CL in both groups at the time of randomisation showed no statistically-significant differences (pessary group: 19.0 mm and management group: 19.0 mm; p = 0.9). Mean CL measured after randomisation was 15.4 mm in patients of the expectant management group and 21.5 mm in the pessary group. These differences were statistically significant (p < 0.0001). When means at randomisation and at the second measurement were compared, CL had decreased by 3.6 mm in the expectant management group and increased by 2.6 mm in the pessary group; this difference was statistically significant (p < 0.0001). Coefficients of correlation showed that among patients of both groups with the same CL at 20 weeks of gestation, those with a pessary gave birth later. Conclusions: Insertion of an Arabin cervical pessary increased CL in asymptomatic patients with a short cervix, which correlated with shorter gestational age at delivery. The cervical pessary halted the progressive decrease in CL, which correlated with longer gestational age at delivery.

OC71: Fetal cardiac function evaluated with the modified myocardial performance index in twin–twin transfusion syndrome and impact of laser therapy

umbilical artery. Wall motion filter was kept at less than 100 MHz. Waveforms were assessed in triplicate. Percent AEDV (%AEDV) was calculated as time of the cycle spent in AEDV divided by total cardiac cycle × 100. Follow-up Dopplers were performed 16–24 hours later. IUFD was recorded if the donor twin died any time prior to delivery. A p < 0.05 was considered statistically significant. Results: Sixteen patients with pre-operative AEDV were identified during the study period, of which 5 were associated with IUFDD. Gestational age at the time of the procedure, number of anastomoses lasered, operating time or placental location were not different between patients with or without IUFD-D. The mean pre-op %AEDV was significantly higher in patients with IUFD-D than in those without (42.7% vs. 27.1%, respectively, p = 0.029). A %AEDV > 35 was 18 times more likely to be associated with IUFD-D (95% CI 1.2–260). AEDV resolved in 8 patients after surgery, with a mean %AEDV of 26.9% vs. 37% in those in whom AEDV did not resolve. However, this difference was not statistically significant. Conclusion: A %AEDV > 35 is associated with an increased risk of IUFD of the donor twin in TTTS patients treated with SLPCV. A high %AEDV is more predictive of IUFD-D than the lack of resolution of AEDV after surgery. Assessment of %AEDV should be considered part of the pre-operative evaluation of TTTS patients.

OC113: Amniotic fluid discordance in monochorionic twin pregnancies: how harmful is it?

(OR 8.45; P = 0.0094), together with abdominal circumference (AC) (OR 37.62; P = 0.0002) and concordant amniotic fluid (OR 0.19; P = 0.0030) at 16 weeks. The formula to predict outcome was calculated as Y = −1.8004 + (0.1423 × CRL) + (0.1170 × AC) − (0.8229 × amniotic fluid), where the probability for complicated outcome is 1/(1+exp(−Y)). With ‘> 50% chance of complicated outcome’ as cut-off, the sensitivity was 52% with a PPV of 75%. Conclusions: The survival rate was 89%, with most losses at ≤ 24 weeks. TTTS occurred in 8.8%, whereas 4.2% had severe hemoglobin discordances at birth. Combined firstand early secondtrimester scan identified 52% of cases with a complicated outcome.

OC67: Classification of selective intrauterine growth restriction in monochorionic twins according to umbilical artery Doppler of the smaller fetus

Objective: The aim of this study was to evaluate the outcome of screening for twin-to-twin transfusion syndrome (TTTS) among monochorionic (MC) twins through a number of scans from 12 weeks of gestation. Methods: In a prospective multicenter observational study twin pregnant women were included before 14 + 6 weeks. The MC pregnancies were scanned every second week until 23 weeks of gestation in order to rule out early TTTS. Further observation during pregnancy was done according to the departments’ guidelines. Zygosity was analysed by DNA analysis in all twin pairs with the same sex. All the participants were contacted eight months or more after delivery. Results: Among the 495 twin pregnancies 15% were MC. The incidence of TTTS was 23% from 12 weeks until delivery. In 15 out of 17 twin pregnancies signs of the TTTS syndrome were seen before 24 weeks and all those MC twin pregnancies who miscarried had signs of TTTS. None of the NT measurements in these fetuses were above the 95 TH centile. There was no difference in NT-discordance rate between MC twins with TTTS compared to MC twins without signs of TTTS. Conclusion: Assessment of chorionicity and follow-up of monochorionic pregnancies to detect signs of TTTS are essential in order also to treat early stages of TTTS. It was not possible by nuchal translucency measurement to detect those MC pregnancies that later developed TTTS.

OC81: Selective intrauterine growth restriction in monochorionics with intermittent absent/reverse diastolic flow: laser treatment vs elective delivery at 32 weeks

Methods: Eight early (< 17 wks), and 3 late (> 26 wks) cases were identified. Results: In EARLY cases, mean age at laser was 16.4 (14.8–16.9) wks. Maximum liquor pocket (MVP) in the recipient (R) was 8.2 (7.0–9.0) cm. Donor (D) bladder was small in 3 and empty in 5. Recipient bladder was large in 3, moderate size in 4, normal in 1. No fetus had systolic dysfunction, but 3 recipients had diastolic cardiac dysfunction. One was stage IV, 5 stage III, 2 stage II. Endoscopy time was 62 mins, laser time 42 mins; all had remifentanyl. Mean number of major anastomoses was 6.6 (2–11), mean amnioreduction was 920 (+610 to 2650) mL. There were no stillbirths (SB) or early neonatal deaths (NND); one late NND occurred in a donor. Delivery was at 32.1 (27.5–36) wks and mean latent interval was 16.2 (11–19.6) wks.; 6/8 were delivered vaginally. In LATE cases, mean age at laser was 26.7 (26.0–27.7) wks. Recipient MVP was 12.4 (9.0–14.3) cm. Donor’s bladders were empty and recipient’s distended in all cases. One recipient had systolic, and one diastolic cardiac dysfunction. Two were stage IV, one stage III. Endoscopy time was 61 mins, laser time 28 mins. Mean number of major anastomoses was 11.7 (11–12), mean amnioreduction was 1600 (800–2700) mL. There were 2 SB (1 donor, 1 recipient) but no NND. Delivery was at 33.3 (26.4–37) wks, and mean latent interval was 6.6 (0.4–10.6) wks.; 2/3 were delivered vaginally. Conclusion: We propose a role for laser therapy for TTTS beyond conventional gestational age guidelines. Diagnostic US criteria for TTTS must be modified in very early cases. The latent interval in very early cases is significanly longer than in our other laser cases (16.2 : 10.1 wks), and survival in this small series of very early TTTS was 95%. We suggest that laser may be a reasonable therapeutic option even > 26 wks, especially when the alternative is the delivery of a sick hydropic baby.