Linda Pelaez

Negative fetal fibronectin : Who is still treating for threatened preterm labor and does it help?

OBJECTIVE Fetal fibronectin (fFN) has a high negative predictive value for delivery in the next seven days in patients at risk for preterm birth. Providers sometimes disregard a negative result and manage the patient for threatened preterm labor. Our objective was to identify the rate at which patients with a negative fFN were managed for threatened preterm labor and if delivery outcomes were improved with such management. STUDY DESIGN Retrospective chart review of 111 patients at a single institution evaluated in the obstetrical triage unit for symptoms of threatened preterm labor with negative fFN results over a 19-month period between November 2004 and June 2006. Charts were reviewed for baseline patient characteristics such as gestational age at presentation to triage and fFN testing, prior obstetrical history, cervical examination and contraction frequency. Gestational age at delivery was documented. Rates of admission to the hospital and treatments for threatened preterm labor in this cohort were reviewed. RESULTS Thirty-seven of patients (33%) with a negative fFN result were managed for threatened preterm labor (admitted to the hospital, given tocolytics, steroids, or intravenous antibiotics) by their provider. Patients undergoing these interventions were more likely to have cervical dilatation, effacement and were contracting more frequently. Only one of the patients delivered within 7 or 14 days of fFN testing. There was no advantage seen to management of threatened preterm labor in the setting of a negative fFN in terms of pregnancy prolongation, even when analyzing the patients with meaningful clinical findings (dilated 2 cm, effaced >or=80%, or contracting >or=12 times/h). CONCLUSION Patients with meaningful clinical findings suspicious for preterm labor are more likely to undergo interventions by their physicians in the face of a negative fFN. This management does not improve length of gestation.

The relationship between placental histology and cervical length in twin gestations

Abstract Objective: To evaluate differences in placental lesions in twin pregnancies with and without mid-trimester sonographic cervical shortening. Methods: Two groups of women were identified: those with twin gestations and a cervical length ≤2.5 cm measured between 16 and 24 weeks of gestation and those with twin gestations and without evidence of cervical shortening. The placental pathology was then retrospectively reviewed. The placental lesions were categorized as either acute or chronic inflammatory lesions, lesions of malperfusion or coagulopathic lesions. Results: A total of 704 patients with twin gestations were identified. There was significantly more acute chorioamnionitis in patients with cervical shortening but no differences in the frequency of other placental lesions. Conclusion: Placentas with acute inflammatory lesions are significantly more frequent in twin gestations with mid-trimester cervical shortening.

Inappropriate use of vancomycin for preventing perinatal group B streptococcal (GBS) disease in laboring patients.

Abstract Objective: The 2002 CDC guidelines for the prevention of perinatal group B streptococcus (GBS) stipulate that vancomycin is reserved for penicillin-allergic women at high risk for beta-lactam anaphylaxis with resistance to clindamycin or erythromycin. Our objective was to evaluate practitioner adherence to these guidelines. Methods: This is a retrospective chart review of patients admitted to labor and delivery who received vancomycin for GBS prophylaxis from January 1st, 2005 to June 1st, 2007. Identification and documentation of allergic reactions to beta lactams and performance of GBS sensitivities at the time of screening were recorded. Results: Eighty-seven patients reporting a penicillin allergy received vancomycin during labor. In 71 patients screened at 35–37 weeks, sensitivities were not performed for 55 patients, of which 10 reported an anaphylactic-like reaction to penicillin. Of 15 patients who had sensitivities performed at the time of screening and were resistant to clindamycin and/or erythromycin, only two patients, however, described an anaphylactic-like reaction to penicillin. Fourteen patients received vancomycin due to an unknown GBS status at <35 weeks of gestation and only three patients from this group reported an anaphylactic-like reaction to penicillin. There were deviations from the CDC protocol in 82 (94%) of 87 patients who received intrapartum vancomycin there were deviations in the CDC protocol. Conclusion: Most patients receiving intrapartum vancomycin for perinatal GBS prophylaxis either did not have a culture with sensitivities performed at the time of GBS screening due to a history of anaphylactic-like reactions to penicillin or received vancomycin for a mild or unknown allergy. Physician adherence to the CDC guidelines with regards to the use of vancomycin is far from optimal.