Helen How

Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length

OBJECTIVE The objective of the study was to assess cerclage to prevent recurrent preterm birth in women with short cervix. STUDY DESIGN Women with prior spontaneous preterm birth less than 34 weeks were screened for short cervix and randomly assigned to cerclage if cervical length was less than 25 mm. RESULTS Of 1014 women screened, 302 were randomized; 42% of women not assigned and 32% of those assigned to cerclage delivered less than 35 weeks (P = .09). In planned analyses, birth less than 24 weeks (P = .03) and perinatal mortality (P = .046) were less frequent in the cerclage group. There was a significant interaction between cervical length and cerclage. Birth less than 35 weeks (P = .006) was reduced in the less than 15 mm stratum with a null effect in the 15-24 mm stratum. CONCLUSION In women with a prior spontaneous preterm birth less than 34 weeks and cervical length less than 25 mm, cerclage reduced previable birth and perinatal mortality but did not prevent birth less than 35 weeks, unless cervical length was less than 15 mm.

Expectant management of severe preeclampsia at less than 27 weeks' gestation: maternal and perinatal outcomes according to gestational age by weeks at onset of expectant management

OBJECTIVE The objective of the study was to determine perinatal outcome and maternal morbidities based on gestational age (GA) at the onset of expectant management in severe preeclampsia at less than 27 weeks. STUDY DESIGN This was a retrospective analysis of outcome in patients with severe preeclampsia. Forty-six patients (51 fetuses) with severe preeclampsia at less than 27 weeks were studied. Corticosteroids were administered beyond 23 weeks. Perinatal and maternal complications (a composite maternal morbidities including HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, pulmonary edema, eclampsia, and renal insufficiency were analyzed. RESULTS Four patients had multifetal gestations (1 triplet, 3 twins). Median days of prolongation was 6 (range 2-46). Overall perinatal survival was 29 of 51 (57%). Birthweights of 27 (53%) were less than 10%, and 18 (35%) were less than 5%. There were no perinatal survivors in those with a GA less than 23 weeks, at 23 to 23 6/7 weeks, 2 of 10 (20%) survived, and both reached 26 weeks at delivery. For those at 24 to 24 6/7, 25 to 25 6/7, and 26 to 26 6/7 weeks, the perinatal survival rates were 5 of 7 (71%), 13 of 17 (76%), and 9 of 10 (90%), respectively; but rates of respiratory complications were high. There were no maternal deaths, but overall maternal morbidity was 21 of 46 (46%), but was 9 of 14 (64%) in those at less than 24 weeks. CONCLUSION Perinatal outcome in severe preeclampsia in the midtrimester is dependent on GA at onset of expectant management and GA at delivery. Given the high maternal morbidity and extremely low perinatal survival in expectant management at less than 24 weeks, termination of pregnancies should be offered after extensive counseling.

Indications for delivery and short-term neonatal outcomes in late preterm as compared with term births

OBJECTIVE The objective of the study was to evaluate the indications for late preterm birth and compare outcomes by gestational age among late preterm (34-36 weeks) and term (> or = 37 weeks) neonates at our institution. STUDY DESIGN This was a retrospective analysis of delivery indications and short-term neonatal outcomes in women who delivered at the University Hospital between January 1, 2005 and Dec. 31, 2006. Data were analyzed using chi(2), Students t-test, analysis of variance, and post hoc Tukey tests. RESULTS One hundred forty-nine late preterm (n = 49 for 34, n = 50 for 35, n = 50 for 36 weeks) and 150 term infants (n = 50 for 37, n = 50 for 38, n = 50 for 39 weeks or longer) were evaluated. Differences among groups (ie, 34 vs 35 vs 36 vs 37, etc) as well as combinations of differences between 2 groups (ie, 34-36 weeks vs > or = 37 or > or = 38 weeks) were analyzed. Spontaneous labor and/or rupture of membranes were the most common indications for late preterm delivery (92%). Compared with term, late preterm infants had longer hospital stays (5 days vs 2.4 days; P < .001) and higher rates of neonatal intensive care unit (NICU) admissions (56% vs 4%; P < .001), feeding problems (36% vs 5%; P < .001), hyperbilirubinemia (25% vs 3%; P < .001), and respiratory complications (20% vs 5%; P < .001). Neonatal complications were minimal at 38 weeks or longer. CONCLUSION Rates of neonatal intensive care unit admission, length of stay, and neonatal morbidities are significantly higher in late preterm as compared with term births.

Long-term maternal and subsequent pregnancy outcomes 5 years after hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome

OBJECTIVE To evaluate subsequent pregnancy outcome and impact of gestational age at onset of HELLP on long-term prognosis after HELLP over an average follow-up of 5 years STUDY DESIGN One hundred twenty-eight patients with a history of HELLP filled out questionnaires and sent their medical records. Hemolysis, elevated liver enzymes, and low platelets data were stratified according to gestational age at onset of HELLP < or =28 weeks and >28 weeks. RESULTS Fifty-three patients had subsequent pregnancies with 24% complicated by HELLP and 28% by preeclampsia. During follow-up, 33% of the patients had new onset hypertension develop, 32% had depression develop, 26% had anxiety develop, and 2.4% required dialysis. There was no significant difference in long-term outcome between comparison groups. CONCLUSION Patients with a history of HELLP are at increased risk for preeclampsia and HELLP as well as long-term morbidities as depression and chronic hypertension. Gestational age at the onset of HELLP could be a predictor for long-term outcome.

Pregnancy outcome in isolated single umbilical artery.

Our objective was to determine whether the rate of small for gestational age (SGA) infants and adverse perinatal outcome are increased in pregnancies diagnosed with an isolated single umbilical artery (SUA). We compared 297 pregnancies with a SUA diagnosed on routine obstetrical ultrasound with 297 pregnancies with a three-vessel cord control. Pregnancies complicated by major fetal anomalies were excluded. The rate of SGA, fetal death, and neonatal outcomes were compared between the two groups. Data analysis were performed using the T-test and chi-square test. The sample size had 80% power to detect a 50% difference between groups assuming a SGA rate of 20% in the SUA group and 10% in the control, alpha = 0.05. Among the SUA group, in 21 neonates (7.1%) the presence of a SUA could not be confirmed by postnatal examination, and 21 (7.1%) had major congenital anomalies, leaving 255 for final analysis. In the control group, 8 of the 297 (2.7%) had major congenital anomalies, leaving 289 for final analysis. The incidence of SGA neonates was 35 of 255 (13.7%) in the isolated SUA group compared with 38 of 289 (13.1%) in the control group ( P = 0.93). The composite perinatal outcomes (fetal death and/or SGA) were also similar between the groups (16.1% versus 14.5%; P = 0.72). We concluded that pregnancies with isolated SUA have a similar rate of SGA to those with 3VC. When a SUA is identified antenatally, a targeted ultrasound is warranted to rule out associated anomalies. Serial antepartum ultrasound for fetal growth is not necessary in managing pregnancies complicated by isolated SUA.

Preterm Premature Rupture of Membranes: Aggressive Tocolysis Versus Expectant Management

The objective of our study is to determine whether aggressive tocolysis in patients with preterm premature rupture of membranes between 24 and 34 weeks gestation improves neonatal outcome. Patients with documented preterm premature rupture of membranes between 24 and 34 weeks gestation were prospectively randomized to group I, aggressive tocolysis with intravenous magnesium sulfate, or to group II, no tocolysis. The lecithin/sphingomyelin ratio was determined upon hospital admission and every 48-96 hours until delivery. Both groups received weekly steroids and antibiotics pending culture results and were promptly delivered when chorioamnionitis, fetal stress, or an Lecithin/sphingomyelin ratio of > or = 2.0 occurred. The study group involved 145 patients. No statistically significant differences between groups I (n = 78) and II (n = 67) were observed regarding demographic characteristics, gestational age at enrollment or at delivery, latency, development of clinical chorioamnionitis, birth weight, number of days in neonatal intensive care unit, days on oxygen or ventilatory support, frequency of hyaline membrane disease, necrotizing enterocolitis, intraventricular hemorrhage, neonatal sepsis, or neonatal mortality. Our data suggest that tocolysis in patients with preterm premature rupture of membranes does not significantly improve perinatal outcome.

The diagnostic dilemma of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in the obstetric triage and emergency department : lessons from 4 tertiary hospitals

OBJECTIVE We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis. STUDY DESIGN Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment. RESULTS There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each. CONCLUSION TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Progesterone for the prevention of preterm birth: indications, when to initiate, efficacy and safety.

Preterm birth is the leading cause of neonatal mortality and morbidity and long-term disability of non-anomalous infants. Previous studies have identified a prior early spontaneous preterm birth as the risk factor with the highest predictive value for recurrence. Two recent double blind randomized placebo controlled trials reported lower preterm birth rate with the use of either intramuscular 17 alpha-hydroxyprogesterone caproate (IM 17OHP-C) or intravaginal micronized progesterone suppositories in women at risk for preterm delivery. However, it is still unclear which high-risk women would truly benefit from this treatment in a general clinical setting and whether socio-cultural, racial and genetic differences play a role in patient’s response to supplemental progesterone. In addition the patient’s acceptance of such recommendation is also in question. More research is still required on identification of at risk group, the optimal gestational age at initiation, mode of administration, dose of progesterone and long-term safety.

Perforation rate using a single pair of orthopedic gloves vs. a double pair of gloves in obstetric cases.

Our purpose was to determine the perforation rate for a single pair of orthopedic gloves vs. a double pair of regular gloves in obstetric cases. Faculty, residents, medical students, and surgical technicians were assigned randomly to use either double gloves or single orthopedic gloves. After each procedure, the gloves were examined by filling with water, occluding the cuff, and observing for streams of water. The perforation rate for the double gloves (both inner and outer glove at the same location) was 7% (12/169), similar to the 7% (12/172) for single orthopedic gloves (P < 0.9). After adjusting for procedure type there was no association between the type of gloves and perforation rate. Fifty-four percent of all perforations were not recognized intraoperatively. Of those individuals with glove perforations, 4/24 (17%) observed blood on the hand at the end of the procedure. Double-gloved users complained more frequently than single-gloved users of loss of dexterity (77/169, 46%, 95% CI 38-53%) vs. (6/172, 3.5%, 95% CI 0.7-6%) (P < 0.001) and numbness (12/169, 7%, 95% CI 3.2-11%) vs (1/172 0.6%, 95% CI 0.55-1.7%) (P < 0.005). Although the use of a single pair of orthopedic gloves is more costly than a double pair of regular gloves (

Chorioamnionitis : Is continuation of antibiotic therapy necessary after cesarean section?

78 vs.