Jolene Seibel-Seamon

Effect of antenatal corticosteroids on survival for neonates born at 23 weeks of gestation.

OBJECTIVE: To estimate if exposure to antenatal corticosteroids was associated with decreased rate of death in neonates born at 23 weeks of gestation. METHODS: This is a retrospective cohort study performed at three tertiary centers of neonates born at 23 weeks of gestation between 1998 and 2007. Stillbirths, voluntary terminations, or parental elected nonresuscitations were excluded. Clinical and demographic variables were examined to determine possible confounding variables. A multivariable logistic regression model was used to assess the effect of steroids on the odds of death after adjustment for these confounders. RESULTS: The sample included 181 neonates. Of the multiple variables examined (institution, race, diagnosis, illicit drug use, antibiotics, assisted reproduction, birth weight, gender, and route of delivery), only multiple gestations were significantly associated (P≤.15) with steroid use and increased odds of death (odds ratio [OR] 3.66, 95% confidence interval [CI] 1.05–12.73) and controlled for in the final model. The multivariable model revealed those exposed to antenatal corticosteroids had decreased odds of death (OR 0.32, 95% CI 0.12–0.84), with no significant differences in the occurrence of necrotizing enterocolitis among survivors (15.4% compared with 28.6%, P=.59) or severe intraventricular hemorrhage (23.1% compared with 57.1%, P=.17). In analyzing the effect of steroid dose, only a complete course of corticosteroids was associated with a decreased odds of death (OR 0.18, 95% CI 0.06–0.54). CONCLUSION: Neonates at 23 weeks of gestation whose mothers completed a course of antenatal corticosteroids had an associated 82% reduction in odds of death. LEVEL OF EVIDENCE: II

Tocolytics for preterm premature rupture of membranes

BACKGROUNDnIn women with preterm labor, tocolysis has not been shown to improve perinatal mortality; however, it is often given for 48 hours to allow for the corticosteroid effect for fetal maturation. In women with preterm premature rupture of membranes (PPROM), the use of tocolysis is still controversial. In theory, tocolysis may prolong pregnancy in women with PPROM, thereby allowing for the corticosteroid benefit and reducing the morbidity and mortality associated with prematurity.nnnOBJECTIVESnTo assess the potential benefits and harms of tocolysis in women with preterm premature rupture of membranes.nnnSEARCH METHODSnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (15 January 2014).nnnSELECTION CRITERIAnWe included pregnant women with singleton pregnancies and PPROM (23 weeks to 36 weeks and six days). We included any tocolytic therapy compared to no tocolytic, placebo, or another tocolytic.nnnDATA COLLECTION AND ANALYSISnAll review authors assessed the studies for inclusion. We extracted and quality assessed data.nnnMAIN RESULTSnWe included eight studies with a total of 408 women. Seven of the studies compared tocolysis to no tocolysis. One study compared nifedipine to terbutaline. Compared to no tocolysis, tocolysis was not associated with a significant effect on perinatal mortality in women with PPROM (risk ratio (RR) 1.67; 95% confidence interval (CI) 0.85 to 3.29). Tocolysis was associated with longer latency (mean difference (MD) 73.12 hours; 95% CI 20.21 to 126.03; three trials of 198 women) and fewer births within 48 hours (average RR 0.55; 95% CI 0.32 to 0.95; six trials of 354 women; random-effects, Tau² = 0.18, I² = 43%) compared to no tocolysis. However, tocolysis was associated with increased five-minute Apgar of less than seven (RR 6.05; 95% CI 1.65 to 22.23; two trials of 160 women) and increased need for ventilation of the neonate (RR 2.46; 95% CI 1.14 to 5.34; one trial of 81 women). In the subgroup analysis comparing betamimetic to no betamimetics, tocolysis was associated with increased latency and borderline significance for chorioamnionitis. Prophylactic tocolysis with PPROM was associated with increased overall latency, without additional benefits for maternal/neonatal outcomes. For women with PPROM before 34 weeks, there was a significantly increased risk of chorioamnionitis in women who received tocolysis. However, neonatal outcomes were not significantly different. There were no significant differences in maternal/neonatal outcomes in subgroup analyses comparing cox inhibitor versus no tocolysis, calcium channel blocker versus betamimetic, antibiotic, corticosteroid or combined antibiotic/corticosteroid.nnnAUTHORS CONCLUSIONSnOur review suggests there is insufficient evidence to support tocolytic therapy for women with PPROM, as there was an increase in maternal chorioamnionitis without significant benefits to the infant. However, studies did not consistently administer latency antibiotics and corticosteroids, both of which are now considered standard of care.

Contemporary use of cervical cerclage.

Although it was devised over 50 years ago, only recently controlled randomized trials have evaluated the efficacy of cervical cerclage. Cerclage was originally devised for women with both prior preterm birth (PTB) and cervical changes in the current pregnancy. Evidence suggests that transvaginal cerclage probably prevents second trimester loss/PTB in women with ≥3 PTB/second trimester loss (history-indicated cerclage best placed at 12 to 14u2009wk); and in women with a prior PTB 16 to 36 weeks and transvaginal ultrasound cervical length<25u2009mm in the current pregnancy (ultrasound-indicated cerclage at 14 to 23 6/7u2009wk).

Interval to spontaneous delivery after elective removal of cerclage

OBJECTIVEnThe purpose of this study was to estimate the time interval between elective cerclage removal and spontaneous delivery.nnnMETHODSnSingleton pregnancies with McDonald cerclage were evaluated for the interval between elective cerclage removal (36-37 weeks) and spontaneous delivery. We also compared spontaneous delivery within 48 hours after cerclage removal between women with ultrasound-indicated vs history-indicated cerclage.nnnRESULTSnWe identified 141 women with elective cerclage removal. The mean interval between removal and delivery was 14 days. Only 11% of women delivered within 48 hours. Women with ultrasound-indicated cerclage were more likely to deliver within 48 hours, compared with women with history-indicated cerclage (odds ratio, 5.14; 95% confidence interval, 1.10-24.05).nnnCONCLUSIONnThe mean interval between elective cerclage removal and spontaneous delivery is 14 days. Women with cerclage who achieved 36-37 weeks should be counseled that their chance of spontaneous delivery within 48 hours after elective cerclage removal is only 11%.