Jack Ludmir

Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS)

OBJECTIVE The purpose of this study was to test whether treating periodontal disease (PD) in pregnancy will reduce the incidence of spontaneous preterm delivery (SPTD) at < or = 35 weeks of gestation. STUDY DESIGN A multicenter, randomized clinical trial was performed. Subjects with PD were randomized to scaling and root planing (active) or tooth polishing (control). The primary outcome was the occurrence of SPTD at <35 weeks of gestation. RESULTS We screened 3563 subjects for PD; the prevalence of PD was 50%. Seven hundred fifty-seven subjects were assigned randomly; 378 subjects were assigned to the active group, and 379 subjects were assigned to the placebo group. Active treatment did not reduce the risk of SPTD at <35 weeks of gestation (relative risk, 1.19; 95% confidence interval [CI], 0.62-2.28) or composite neonatal morbidity (relative risk, 1.30; 95% CI, 0.83-2.04). There was a suggestion of an increase in the risk of indicated SPTD at <35 weeks of gestation in those subjects who received active treatment (relative risk, 3.01; 95% CI, 0.95-4.24). CONCLUSION Treating periodontal disease does not reduce the incidence of SPTD.

Transvaginal ultrasonography of the cervix to predict preterm birth in women with uterine anomalies

Objective: Women with uterine anomalies have higher rates of preterm birth, but the reason for this has not been elucidated. Transvaginal ultrasound examination has been shown to be an accurate test for the prediction of preterm birth but has not been studied specifically in this population. Methods: Pregnant women with uterine anomalies were followed prospectively with transvaginal ultrasound examination of the cervix, performed between 14 and 23 6/7 weeks of gestation. A short cervical length was defined as less than 25 mm of cervical length. The primary outcome was spontaneous preterm birth, defined as birth at less than 35 weeks. Results: Of the 64 pregnancies available for analysis, there were 28 with a bicornuate uterus, 13 with a septate uterus, 11 with a uterine didelphys, and 12 with a unicornuate uterus. The overall incidence of spontaneous preterm birth at less than 35 weeks was 11%. Of the 10 (16%) women with a short cervical length, 5 (50%) had spontaneous preterm birth. Of the 54 women without a short cervical length, only 2 (4%) had a spontaneous preterm birth. The sensitivity, specificity, and positive and negative predictive values of a short cervical length for spontaneous preterm birth were 71%, 91%, 50%, and 96%, respectively (relative risk 13.5, 95% confidence interval 3.49–54.74). Of the 7 women with both short cervical length and preterm birth, all uterine subtypes were represented except septate uterus. Conclusion: A short cervical length on transvaginal ultrasonography in women with uterine anomalies has a 13-fold risk for preterm birth. Unicornuate uterus had the highest rate of cervical shortening and preterm delivery. Level of Evidence: II-2

Transvaginal cervical cerclage: evidence for perioperative management strategies

The objective was to review the evidence supporting various perioperative technical and management strategies for transvaginal cervical cerclage. We performed MEDLINE, PubMed, EMBASE, and COCHRANE searches with the terms, cerclage, cervical cerclage, cervical insufficiency, and randomized trials, plus each technical aspect (eg, suture, amniocentesis, etc) considered. The search spanned 1966 through September 2012 and was not restricted by language. Each retrieved manuscript was carefully evaluated, and any pertinent references from the reports were also obtained and reviewed. All randomized trials covering surgical and selected perioperative, nonsurgical aspects of cerclage were included in the review. The evidence was assessed separately for history-, ultrasound-, and physical examination-indicated cerclage. Evidence levels according to the new method outlined by the US Preventive Services Task Force were assigned based on the evidence. There are no grade A high-certainty recommendations regarding technical aspects of transvaginal cervical cerclage. Grade B moderate-certainty recommendations include performing a fetal ultrasound before cerclage to ensure fetal viability, confirm gestational age, and assess fetal anatomy to rule out clinically significant structural abnormalities; administering spinal, and not general, anesthesia; performing a McDonald cerclage, with 1 stitch, placed as high as possible; and outpatient setting. Unfortunately, no other recommendations can be made regarding the other technical aspects of cerclage.

Sonographic Detection of Cervical Incompetence

The diagnosis of cervical incompetence is based primarily on prior obstetrical history and clinical findings. Sonographic evaluation of the cervix and lower uterine segment does offer an objective means of establishing this diagnosis during gestation. Bulging of the membranes into a partly dilated cervical canal seems to be the most reliable sign of cervical incompetence. Standardization of the scanning techniques and large prospective studies will be necessary in order to determine the value of this diagnostic tool.

Racial differences in the predictive value of the TDx fetal lung maturity assay.

OBJECTIVE Black newborns have lower rates of neonatal respiratory distress syndrome compared with nonblack newborns. This has been attributed to accelerated lung maturation. Previous studies have demonstrated a difference in the predictive value of the lecithin/sphingomyelin ratio, a test for lung maturity, between races. Our study examines the predictive value of the newer TDx Fetal Lung Maturity Surfactant-to-Albumin assay. STUDY DESIGN We reviewed the records of 393 nonblack and 87 black infants delivered within 72 hours of the TDx FLM S/A assay testing. We compared the rates of neonatal respiratory distress syndrome by race, stratified by results. RESULTS In our study population black newborns had less than one half the rate of respiratory distress syndrome compared with nonblack newborns (4.6% vs 10.4%). To adjust for possible differences in the timing of lung maturation, the results were stratified by the TDx FLM S/A assay result. Black race had a protective effect (Mantel-Haenszel weighted odds ratio 0.30, 95% confidence interval 0.06 to 0.93, p < 0.05). This significant racial difference remained when both TDx FLM S/A assay result and gestational age were controlled in a multiple logistic regression analysis. CONCLUSIONS There are differences in the predictive value of the TDx FLM S/A assay among races. Black fetuses are less likely to have respiratory distress syndrome. The difference in rates of respiratory distress syndrome between races must be due to either a qualitative difference in the surfactant or to an anatomic difference in fetal lungs. Consideration should be given to a lower cutoff value for a mature test result in black women.

Neonatal outcome after exposure to indomethacin in utero: a retrospective case cohort study

OBJECTIVE This study was undertaken to determine the clinical outcome for neonates who were exposed to indomethacin during gestation. STUDY DESIGN We identified 124 infants with in utero exposure to indomethacin and matched them to 124 infants whose mothers did not receive indomethacin. The two groups were matched for gestational age at birth, sex, and exposure to antenatal betamethasone. Sixty-two of the indomethacin-exposed infants were born within 48 hours of last exposure. These infants were also compared with their matched controls. RESULTS There were no significant differences between the indomethacin-exposed infants and control infants in birth weight, Apgar scores, frequency of cesarean section deliveries, and multiple gestation. The incidence of respiratory distress syndrome, need for surfactant treatment, patent ductus arteriosus, necrotizing enterocolitis, and intraventricular hemorrhage was similar between the indomethacin-exposed group and the control group. Indomethacin-exposed infants who were born within 48 hours of last exposure had similar incidence of respiratory distress syndrome but greater need for surfactant treatment (P=.02) compared with controls. All other complication rates were similar. CONCLUSION Indomethacin exposure in our study was not associated with increased neonatal complications for infants delivered within or beyond 48 hours of last exposure.

Doppler Umbilical Artery Velocimetry in Pregnancy Complicated by Insulin-Dependent Diabetes Mellitus

&NA; The mean peak systolic to end‐diastolic (S/D) umbilical artery ratio was measured in 291 Doppler studies performed during pregnancy in 35 insulin‐dependent diabetic women. A normal decline was observed in the umbilical artery S/D ratio, from 4.2 ± 0.21 at 18 weeks to 2.18 ± 0.22 at 38 weeks. There was no significant correlation between mean third‐trimester S/D and either glycosylated hemoglobin (r = 0.25) or mean blood glucose levels (r = 0.15). Fetuses of women with vascular disease (class F/R or chronic hypertension) had a mean third‐trimester S/D of 3.0 or higher in five of ten cases, compared with three of 25 in patients with uncomplicated diabetes (P < .03). Mean second‐ and third‐trimester S/D ratios differed significantly in patients with and without vascular disease: 4.34 ± 0.7 and 3.2 ± 0.65 versus 3.72 ± 0.42 and 2.55 ± 0.32, respectively (P < .03). Two of three women without vascular disease who demonstrated an elevated mean S/D ratio developed preeclampsia and delivered appropriate for gestational age infants. In women with vascular disease, four of five with an abnormal mean third‐trimester umbilical artery S/D ratio were delivered of growth‐retarded infants, whereas all five with normal umbilical artery S/D ratios had appropriate for gestational age infants. In three of the abnormal cases, elevated S/D ratios were present in the second trimester before ultrasound documentation of fetal growth retardation. These data suggest the following: 1) Normal fetal placental resistance can be expected in most pregnancies complicated by diabetes in the absence of maternal vasculopathy; 2) the umbilical artery S/D ratio is independent of glycemic control in a well‐controlled diabetic population; and 3) patients with vasculopathy (class F/R or chronic hypertension) represent a high‐risk group for fetal growth retardation, which may be detected by early umbilical artery Doppler studies. (Obstet Gynecol 73:961, 1989)

Expression of different potassium channels in cells isolated from human myometrium and leiomyomas.

OBJECTIVE Electrophysiologic characteristics of human myometrial and leiomyomatous cells isolated in culture were investigated. Both types of cell were shown to be smooth muscle cells by immunofluorescence. STUDY DESIGN Voltage-activated potassium currents were recorded by whole-cell patch-clamp techniques and analyzed for differences in expression, voltage-dependence, kinetics, and inactivation. RESULTS Depolarizing-voltage steps from -90 mV to +30 mV elicited two types of noninactivating outward currents that differed in their kinetics in 83% (n = 36) of normal cells in culture for 3 to 5 days; 6% responded with fast (3.5 milliseconds) outward inactivating currents; 11% in culture for 1 day responded only with long-lasting inactivating currents (33.2 +/- 7.2 milliseconds). Cells isolated from leiomyomas responded preferentially (65%, n = 31) with fast (3.3 +/- 0.1 milliseconds) outward inactivating currents; 35% responded with noninactivating outward currents similar to those from normal cells. CONCLUSION Different potassium channel currents, noninactivating and inactivating, are predominantly expressed in cells isolated from human myometrium and leiomyomas, respectively.

Can transabdominal ultrasound identify women at high risk for short cervical length

To determine whether transabdominal cervical length screening could identify women at high risk for having a short cervix on transvaginal ultrasound.

Cervical Pessary for Preventing Preterm Birth in Singleton Pregnancies With Short Cervical Length: A Systematic Review and Meta‐analysis

To evaluate the effectiveness of cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with a second trimester short cervix.