Eduardo B. Fonseca

Relationship between second-trimester uterine artery Doppler and spontaneous early preterm delivery

To evaluate the relationship between impedance to flow in the uterine arteries at 22–24 weeks and subsequent spontaneous delivery before 33 weeks.

Prematurity prevention: the role of progesterone.

Purpose of review This review summarizes the evidence of the effectiveness of progesterone on the rate of preterm birth and evaluates the most recent studies. Recent findings The incidence of preterm delivery is about 7–11% of all pregnant women and preterm birth is one of the most important causes of neonatal morbidity and mortality. Interventions to reduce such complications have been attempted for several years. Most efforts so far have been tertiary interventions, such as treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. Some of these measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Recently, researches have suggested prophylactic progesterone could reduce the preterm birth rate in a select group presenting previous preterm birth and a short cervical length by transvaginal scan at mid-trimester pregnancy. Summary This review intends to define the current indication for administration of progesterone for pregnant women. On the basis of current knowledge, progesterone should be offered to women with a documented history of a previous spontaneous birth at less than 37 weeks and for those found to have a short cervical length of 15 mm or less. Studies are needed to evaluate progesterone efficacy on other risk factors.

Reference ranges for cervical length by transvaginal scan in singleton pregnancies

Objective. The aim was to construct a chart for cervical length measured by transvaginal ultrasound. Research design and methods. Singleton pregnant women underwent a transvaginal scan to measure the cervical length (CxL) from 20 to 34 weeks. Exclusion criteria were preterm delivery, preterm rupture of membranes, multiple pregnancies, cerclage, and those who have taken vaginal progesterone. For statistical evaluation, we used regression analysis and calculation of 5th, 50th, and 95th centiles was performed. Results. In the 1061 women with follow up, there were 94 (8.8%) spontaneous and 27 (2.5%) iatrogenic preterm delivery before 37 weeks. The CxL decreased with gestational age (r2 = 0.0799). The coefficient for the interpolated median is y = 37.754 − 0.0148 × (GA)2 + 0.2556 × (GA) (r2 = 0.7247); for the 5th centile is y = 5.9171 − 0.0467 × (GA)2 + 1.7059 × (GA) (r2 = 0.6502); and for the 95th centile is y = 114.72 + 0.0758 × (GA)2 − 4.6706 × (GA) (r2 = 0.7783). Conclusion. CxL shortened throughout the pregnancy. The chart present 5th, 50th, and 95th centile, respectively, at 23 weeks of 20 mm, 36 mm, and 47 mm; at 28 weeks of 17 mm, 33 mm, and 43 mm; and at 34 weeks of 10 mm, 29 mm, and 43 mm.

Prevention of Preterm Birth Based on Short Cervix: Progesterone

Preterm delivery, which occurs in about 5%-13% of pregnancies in most countries, is the main cause of neonatal morbidity and mortality. Symptomatic treatment of pregnancies presenting in preterm labor with corticosteroids has improved perinatal outcome but has not reduced the incidence of preterm delivery. Recent evidence suggests that the rate of preterm delivery may be reduced by the prophylactic use of progesterone in women with a history of preterm delivery and in those with a short cervical length identified by routine transvaginal sonography. This review summarizes the evidence (level A evidence) of the effectiveness of progesterone on the rate of preterm birth.

Stress and anxiety in pregnant women exposed to ultrasound

Aim. To investigate the levels of anxiety and stress during pregnancy among women who are routinely offered ultrasound at first and second trimesters. Methods. This is a cross-sectional study involving 296 women, in which 146 pregnant women without any medical problem were compared with 150 nonpregnant women. Both groups were submitted to the Lipp Inventory of Stress Symptoms for Adults and to the State-Trait Anxiety Inventory. Logistic regression analysis was used to evaluate the effect of pregnancy on the anxiety and stress levels. Results. There was no statistical difference between pregnant and nonpregnant women [56.8% (83/146) vs. 48.6% (73/150), odds ratio (OR) 1.39 95% confidence interval (CI) 0.88–2.19] regarding the level of stress. Logistic regression analysis demonstrated that the only significant independent predictor of stress was maternal age (OR 0.95, 95% CI 0.91–0.96; P = 0.045) for the pregnant women and monthly income and religious belief for the nonpregnant group. Pregnant women had a higher level of anxiety compared with the nonpregnant (15.7% vs. 2.6%, P = 0.0002) and ultrasound examination decreased the anxiety level. Conclusion. Pregnant women did not have a higher level of stress compared with the nonpregnant women, and maternal age is the only significant independent predictor of stress. Pregnant women are more anxious, and after the ultrasound examination, the level of anxiety decreased.

Evaluation of the Risk of Spreading Endometrial Cell by Hysteroscopy: A Prospective Longitudinal Study

Objective. The aim was to assess the intraperitoneal spread of endometrial cells during hysteroscopy. Study Design. Seventy-six women were submitted to a hysteroscopy with CO2 under a low pressure. Group 1 had not previous diagnosis of endometrial cancer, and group 2 had previous diagnosis of endometrial cancer (stage I-92.3%). Two peritoneal washing samples were taken before (PW1) and immediately after (PW2) the procedure. The dissemination for the peritoneal cavity was defined by the presence of endometrial cells in the PW2; such cells should be absent in WP1. Results. Four patients were excluded for presenting endometrial cells in PW1. In the 72 patients left, there was no passage of cells for the peritoneal cavity. In group 1, 88% presented secretory endometrial phase with correlation of 80% between hysteroscopy and biopsy. Conclusion. Hysteroscopy performed under a low pressure of CO2 does not cause spreading of endometrial cells into the peritoneal cavity.

Progesterone and the Risk of Preterm Birth among Women With a Short Cervix

METHODS Cervical length was measured by transvaginal ultrasonography at a median of 22 weeks of gestation (range, 20 to 25) in 24,620 pregnant women seen for routine prenatal care. Cervical length was 15 mm or less in 413 of the women (1.7%), and 250 (60.5%) of these 413 women were randomly assigned to receive vaginal progesterone (200 mg each night) or placebo from 24 to 34 weeks of gestation. The primary outcome was spontaneous delivery before 34 weeks.

OC87: Uterine artery Doppler and cervical assessment in the prediction of early preterm delivery

Objective: To examine the value of combining maternal history with cervical length and uterine artery Doppler at 22–24 weeks in the prediction of early preterm delivery. Methods: This was a prospective multicentre observational study in seven hospitals in London, UK. We used transvaginal sonography to measure cervical length and uterine artery pulsatility index (PI) at 22–24 weeks in singleton pregnancies. Logistic regression was used to determine the contribution of maternal characteristics, previous obstetric history, cervical length and uterine artery PI in the prediction of delivery before 33 weeks. Results: 32,150 women were recruited and 1,373 women (4.3%) were lost to follow-up. Delivery before 33 weeks occurred in 439 (1.4%) women, including spontaneous or iatrogenic delivery of stillbirths in 52 (0.2%) cases, spontaneous delivery of live births in 238 (0.8%) and iatrogenic delivery of live births in 149 (0.5%). For a 5% false positive rate, the detection rate of spontaneous early delivery was 30% for maternal factors and this was improved to 50% by combining maternal factors with cervical length. Similarly, for iatrogenic delivery and fetal death, the detection rate was improved from 44% and 33% respectively from maternal history alone to 81% and 67% respectively with the addition of uterine artery PI. Conclusion: The combination of maternal history, cervical length and uterine artery PI at 22–24 weeks can identify a high proportion of women that subsequently deliver before 33 weeks.