Dawnette Lewis

Elective cesarean delivery and long-term motor function or ambulation status in infants with meningomyelocele

OBJECTIVE: To determine if elective cesarean delivery, when compared with trial of labor, is associated with better long-term motor function or ambulation status in infants with myelomeningocele. METHODS: This is a retrospective cohort study of patients with myelomeningocele followed at the Spinal Dysfunction Program at Alfred I. duPont Hospital for Children in Wilmington, Delaware. Medical records were reviewed for gestational age at delivery, birthweight, anatomical level of lesion, and initial (0–6 months) and long-term (10 years or longer) motor function. Ambulation status (independent ambulation, ambulant with assistance, or wheelchair-bound) at 2 and 10 years was compared with those delivered by elective cesarean versus those delivered after trial of labor. RESULTS: Of the 106 patients with myelomeningocele that were identified, 87 (82%) had all the data required for this review. There were 44 patients in the elective cesarean group and 43 in the trial of labor group. There was no significant difference in gestational age at delivery or birthweight between the groups. There was statistical difference between the 2 groups when anatomical, initial, and current motor levels were compared. Compared with the elective cesarean group, patients in the trial of labor group were more likely to be ambulatory at 2 years (independently ambulant 7% versus 28%, ambulant with assistance 63% versus 65%, or wheelchair-bound 30% versus 7%, P = .003) and at 10 years (independently ambulant 5% versus 21%, ambulant with assistance 30% versus 54%, or wheelchair-bound 65% versus 25%, P < .001). However, when logistic regression analysis was used to control for motor level of myelomeningocele, no significant association was observed in ambulatory status at ages 2 and 10 years between infants delivered by elective cesarean or after trial of labor. CONCLUSION: Elective cesarean delivery, when compared with delivery after trial of labor, was not associated with better motor function or ambulation status in myelomeningocele patients. LEVEL OF EVIDENCE: II-2

Prior cerclage: to repeat or not to repeat? That is the question.

Our objective was to compare obstetrical outcomes of women with a prior cerclage for nontraditional indications who in the subsequent pregnancy either received a history-indicated cerclage or were followed by transvaginal ultrasound (TVU) cervical length (CL). All women with a history- or ultrasound- indicated cerclage in a prior pregnancy and who had a subsequent pregnancy were retrospectively identified from a preexisting database of women at risk for preterm birth between 1995 and 2002. Only women who reached >or= 12 weeks of gestation were included for analysis. Women with a diagnosis other than classic cervical insufficiency were managed in the subsequent pregnancy either by history-indicated cerclage or by serial TVU CL. The primary outcome was spontaneous preterm birth < 35 weeks. We identified 56 women with a prior cerclage for nontraditional indications. In the subsequent pregnancy, 28 women were followed with TVU and 28 matched controls received history-indicated cerclage. The groups were matched for demographics and risk factors. There were no differences between the two groups in the incidence of preterm labor < 35 weeks (21% versus 11%; P = 0.5), preterm premature rupture membranes < 35 weeks (7% versus 11%; P = 1.0), spontaneous preterm birth < 35 weeks (11% versus 11%; P = 1.0), or the gestational age at delivery (36.3 +/- 6.6 versus 36.5 +/- 5.6; P = 0.5). We concluded that in women with prior cerclage for indications other than classic cervical insufficiency, repeat history-indicated cerclage may not improve outcome compared with management with TVU CL follow-up.

Uterine contractions in asymptomatic pregnant women with a short cervix on ultrasound

Objective. To estimate the incidence of uterine contractions in asymptomatic pregnant women with a short cervix on transvaginal ultrasound. Methods. Asymptomatic women with a short cervix on transvaginal ultrasound between 14 and 236/7 weeks of pregnancy were instructed to undergo uterine monitoring immediately. Women without available tracings were excluded. Women with and without contractions were compared with regard to demographics, risk factors, and outcomes. Results. One hundred and one women with a short cervix and available tracings were identified. Eighty-six (85%) had contractions and 15 (15%) did not have contractions immediately after identification of the short cervix. The median number of contractions per hour per woman was 4 (range 0–31). These two groups did not differ in demographics, risk factors, or outcomes, except for the fact that 33% of women with contractions versus 73% of women without uterine contractions had a prior second trimester loss (p = 0.004). Conclusions. In this study, 85% percent of pregnant women with a short cervix on transvaginal ultrasound between 14 and 24 weeks of pregnancy are having asymptomatic uterine contractions. This information is important for further investigation of the short cervix and preterm delivery.