Kelly Orzechowski

A Universal Transvaginal Cervical Length Screening Program for Preterm Birth Prevention

OBJECTIVE: To evaluate a universal transvaginal ultrasonogram cervical length screening program on the incidence of a cervical length 20 mm or less and adherence to the management protocol for a cervical length less than 25 mm. METHODS: We conducted a prospective cohort study of women with singleton gestations 18 0/7 to 23 6/7 weeks of gestation eligible for universal transvaginal ultrasonogram cervical length screening over an 18-month period. Only women receiving antenatal care at our institution were included. Women with a prior spontaneous preterm birth and without delivery data available were excluded. A transvaginal ultrasonogram cervical length of less than 25 mm was managed according to a predetermined protocol. Primary outcomes were the incidence of a cervical length 20 mm or less and adherence to the management protocol for a cervical length less than 25 mm. Secondary outcomes were the incidences of spontaneous preterm birth at less than 37, less than 34, or less than 32 weeks of gestation among women undergoing transvaginal ultrasonogram cervical length screening compared with those not screened. RESULTS: One thousand five hundred sixty-nine of 2,171 (72.3%) eligible women underwent transvaginal ultrasonogram cervical length screening. Overall, 17 (1.1%, 95% confidence interval [CI] 0.66–1.74) women had a cervical length 20 mm or less before 24 weeks of gestation. Management protocol deviations occurred in nine women with a cervical length less than 25 mm (43%, 95% CI 24.3–63.5). There was no difference in the incidence of spontaneous preterm birth at less than 37 weeks of gestation (4.1 compared with 4.7%, adjusted odds ratio [OR] 0.91, 95% CI 0.57–1.45), less than 34 weeks of gestation (1.5 compared with 1.3%, adjusted OR 1.19, 95% CI 0.52–2.74), or less than 32 weeks of gestation (0.8 compared with 0.8%, adjusted OR 0.0.76, 95% CI 0.26–2.25) among women receiving transvaginal ultrasonogram cervical length screening compared with those not screened. CONCLUSION: In a universal transvaginal ultrasonogram cervical length screening program, the incidence of a cervical length 20 mm or less was 1.1% in women with singleton gestations without prior spontaneous preterm birth. Protocol deviations occurred in 43% of women with a cervical length less than 25 mm. The incidence of spontaneous preterm birth was similar among women undergoing transvaginal cervical length screening compared with those not screened. LEVEL OF EVIEDENCE: II

Cervical length, risk factors, and delivery outcomes among women with spontaneous preterm birth

Abstract Objectives: To evaluate differences in risk factors and delivery outcomes among women with spontaneous preterm birth (sPTB) with short (≤25 mm) versus normal (>25 mm) cervical length (CL). Methods: Secondary analysis of a prospective cohort study of singleton gestations between 18 0/7 and 23 6/7 weeks, without prior sPTB, undergoing universal transvaginal CL screening between 1 January 2012 and 31 December 2013. Only women with sPTB (<37 0/7 weeks) were included. Demographic characteristics, risk factors for sPTB, delivery outcomes and presentation of PTB were collected. The primary outcome was mean number of risk factors. Results: The cohort included 2071 women, of which 145 (7%) had PTB and 84 (4%) had sPTB. Sixty-nine (82%) women with sPTB had a CL >25 mm and 15 (18%) had a CL≤25 mm. Women with a short CL did not differ from women with normal CL with respect to demographic variables or mean number of risk factors (4.20 ± 2.11 versus 3.52 ± 1.97, p = 0.23), but they did deliver at a significantly earlier gestational age (25.0 ± 1.1 versus 34.6 ± 3.1 weeks, p < 0.01). The distribution of the presentation of sPTB was different in women with a short versus normal CL (p < 0.01). Conclusions: Among women with sPTB, women with a short CL had similar number of risk factors, but were more likely to deliver at a significantly earlier gestational age. A short CL identifies women at risk for very early sPTB.

Volumetric Assessment of Longitudinal Placental Growth

INTRODUCTION: Small placental volumes are associated with adverse pregnancy outcomes such as intrauterine growth restriction. Normative growth curves for the fetus exist but not for normal placental growth. This study examines longitudinal placental growth pattern in a healthy cohort. METHODS: This prospective longitudinal cohort study of placental volume enrolled 12 gravidas with uncomplicated pregnancies less than 12 weeks of gestation. Placental volumes were measured for each at 12, 17, 22, 27, and 32 weeks of gestation. Placental volume was calculated with VOCAL (Virtual Organ Computer-aided AnaLysis) in the 4DVIEW 6.0 software. Placental growth rate was calculated using the logistic growth function Linear regression was used for correlation between actual and predicted placental volume. P<.05 was significant. RESULTS: Eleven participants were analyzed and one with preeclampsia was excluded. Placental growth rate was calculated and growth constant, rp (0.3±0.037), empirically determined. The fitted plot showed exponential growth to 27 weeks of gestation with growth slowing thereafter with sigmoidal shape (Fig. 1). The actual and predicted placental volumes were strongly correlated (R2=0.99, P<.001; Fig. 2). Fig. 1. Fitted placental volume (mL) compared with gestational age. Fig. 2. Correlation of actual and predicted placental volume (PV). R2 =0.99, Root Mean Square Error =23.95, P<.001. CONCLUSION: This study suggests placental growth may be exponential until 27 weeks of gestation in uncomplicated pregnancies. Maternal and fetal variables may influence placental volumetric growth later in pregnancy. Knowledge of the normal placental growth pattern is an initial step in understanding the association of placental volumetric growth and perinatal outcomes.

Common respiratory issues in ambulatory obstetrics.

This article reviews the diagnosis and management of the most common respiratory conditions complicating pregnancy--asthma and influenza. We also review strategies for smoking cessation in pregnancy as, in addition to exacerbating all other pulmonary conditions, smoking is the most modifiable risk factor for poor pregnancy outcome. Moreover, the obstetrician frequently encounters each of these conditions in the ambulatory setting. A thorough knowledge of the normal pregnancy-induced physiological respiratory changes combined with a comprehensive understanding of how to manage these conditions, will provide the obstetrician with the armamentarium needed to optimize health outcomes for mothers and their fetuses.

Prior Uterine Evacuation and the Risk of Short Cervical Length: A Retrospective Cohort Study: Prior Uterine Evacuation and Risk of a Short Cervix

To determine whether a prior uterine evacuation procedure is associated with an increased risk of short cervical length (≤20 mm) in women without prior spontaneous preterm birth.

Racial disparities in cervical length for prediction of preterm birth in a low risk population.

Abstract Purpose: Racial minorities experience higher rates of spontaneous preterm birth (sPTB). Our objective was to evaluate whether there are racial discrepancies in the incidence of second trimester short cervical length (≤25 mm). Materials and methods: Retrospective cohort of women with singleton gestations without prior sPTB undergoing universal second trimester transvaginal ultrasound cervical length (CL) screening between January 2012 and December 2013. Black women were compared to non-Hispanic white women. Our primary outcome was the incidence of CL ≤25 mm. Secondary outcomes were incidence of PTB ≤37 weeks, delivery mode, birth weight and neonatal intensive care unit (NICU) admission. Results: Black women (n = 1092) differed from non-Hispanic white women (n = 659) with respect to maternal age (26.0 versus 30.7 years), gravidity (3.1 versus 2.1), prepregnancy BMI (29.6 versus 25.0 kg/m2), and smoking status (9.8% versus 16%), respectively (p < 0.001). Black women had higher incidence of CL ≤25 mm (1.9% versus 0.6%; OR: 3.21 [1.1–9.4]), rates of sPTB (8.5% versus 4.4%; aOR: 1.95 [1.1–3.4]), incidence of low birthweight infants (<2500 g, 8.3% versus 5.6%; aOR 1.80 [1.1–3.0]) and were more likely to have their infants admitted to the NICU (16% versus 11%; OR: 1.52 [1.0–2.3]). Conclusions: Black women had a 2.8-fold increased risk of CL ≤25 mm compared non-Hispanic white women in a low-risk population.

Second trimester cervical length and prolonged pregnancy

Abstract Objective: To determine whether second trimester transvaginal ultrasound cervical length (CL) is associated with prolonged pregnancy (≥41 0/7 weeks) in nulliparous women who reach term (≥37 weeks) with a planned vaginal delivery. Methods: Retrospective cohort of nulliparous singletons 18 0/7–23 6/7 weeks gestation undergoing CL screening from 1/1/12 to 12/31/13. Women who delivered at term with spontaneous labor or reached 41 weeks were included. Primary outcome was incidence of prolonged pregnancy. Risk of prolonged pregnancy was assessed by CL quartile using odds ratio, adjusted for confounders (aOR) and a receiver operating characteristic (ROC) curve. Results: 722 women were included, among them 171 (24%) had a prolonged pregnancy. There was a significant difference in BMI and race across CL quartiles. The aOR of having a prolonged pregnancy with CL in quartiles 2, 3, and 4 versus quartile 1 were 2.14(1.27–3.62), 2.72(1.59–4.65), and 1.69(1.02–3.03), respectively. CL ≥ 37 mm (beyond first quartile) was associated with a two-fold increased risk of prolonged pregnancy versus CL < 37 mm, (27% vs 15%, p < 0.01, aOR 2.17 (1.38–3.41)). ROC curve did not identify a CL cutoff that was predictive of prolonged pregnancy (AUC 0.544, p = 0.079). Conclusions: Although a longer second trimester CL is associated with an increased risk for prolonged pregnancy, it is not predictive.

Severe First Trimester Recurrent Intrahepatic Cholestasis of Pregnancy: A Case Report and Literature Review

Background Intrahepatic cholestasis of pregnancy (ICP) is a disorder of defective bile acid transport that results in systemic accumulation of bile acids and typically presents in the third trimester of pregnancy with intense pruritus. A positive linear correlation exists between total bile acid level and poor pregnancy outcome, and labor is typically induced at 37 weeks gestation to prevent intrauterine fetal demise (IUFD). Case Study We present the most severe reported case of recurrent ICP presenting early in the first trimester. The patient was delivered by repeat cesarean section at 31 6/7 weeks gestation resulting in a viable female infant. Conclusion Iatrogenic preterm delivery may be indicated in early-severe recurrent ICP to prevent IUFD, but more research is needed.

Second Trimester Cervical Length and Its Association with Vaginal Birth after Cesarean Delivery

OBJECTIVE This study aims to evaluate the relationship between cervical length (CL) and trial of labor after cesarean (TOLAC) delivery. STUDY DESIGN This retrospective cohort study evaluated second trimester CL and likelihood of successful TOLAC. Women undergoing TOLAC from January 2009 to December 2011 who underwent transvaginal ultrasound CL between 18(0/7) to 23(6/7) weeks gestation were included. The threshold for CL was assessed using a receiver operating characteristics curve, with ≥ 45 mm determined to be the optimal threshold. Women with CL < 45 mm were compared with women with CL ≥ 45 mm with respect to TOLAC. Multivariate analysis was used to assess the association of CL with TOLAC. RESULTS A total of 45 patients met inclusion criteria, 14 (31%) with a long CL (≥ 45 mm) and 31 (69%) with CL < 45 mm. Groups did not differ in demographics or factors predictive of vaginal birth after cesarean (VBAC) delivery. More women with CL < 45 mm had successful VBAC (81%) than women with long CL (43%, relative risk 1.9, p = 0.03). Prior vaginal delivery and CL < 45 mm were both significant predictors of VBAC (odds ratio 1.8 and 2.0, respectively). CONCLUSION CL < 45 mm is associated with VBAC.

Early pregnancy failure as a training tool for chorionic villus sampling

The goal of this study is to evaluate the success of a training program in chorionic villus sampling (CVS) of early pregnancy failure (EPF) for maternal‐fetal medicine (MFM) fellows.