Luis Cabero

Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial

BACKGROUND Most previous studies of the use of cervical pessaries were either retrospective or case controlled and their results showed that this intervention might be a preventive strategy for women at risk of preterm birth; no randomised controlled trials have been undertaken. We therefore undertook a randomised, controlled trial to investigate whether the insertion of a cervical pessary in women with a short cervix identified by use of routine transvaginal scanning at 20-23 weeks of gestation reduces the rate of early preterm delivery. METHODS The Pesario Cervical para Evitar Prematuridad (PECEP) trial was undertaken in five hospitals in Spain. Pregnant women (aged 18-43 years) with a cervical length of 25 mm or less were randomly assigned according to a computer-generated allocation sequence by use of central telephone in a 1:1 ratio to the cervical pessary or expectant management (without a cervical pessary) group. Because of the nature of the intervention, this study was not masked. The primary outcome was spontaneous delivery before 34 weeks of gestation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00706264. FINDINGS 385 pregnant women with a short cervix were assigned to the pessary (n=192) and expectant management groups (n=193), and 190 were analysed in each group. Spontaneous delivery before 34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (12 [6%] vs 51 [27%], odds ratio 0·18, 95% CI 0·08-0·37; p<0·0001). No serious adverse effects associated with the use of a cervical pessary were reported. INTERPRETATION Cervical pessary use could prevent preterm birth in a population of appropriately selected at-risk women previously screened for cervical length assessment at the midtrimester scan. FUNDING Instituto Carlos III.

Amniotic fluid glucose and cytokines values in the early diagnosis of amniotic infection in patients with preterm labor and intact membranes.

OBJECTIVE Our goal was to compare sensitivity, specificity, and predictive values of glucose and cytokines [interleukin-1 (IL-1), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor (TNF)] in amniotic fluid (AF) to detect an AF-positive culture. METHODS Amniocentesis was performed on 113 patients with preterm labour (PTL) and intact membranes. Fluid was cultured for aerobic and anaerobic bacteria, and for mycoplasmas. AF analysis included cytokines and glucose determinations. RESULTS The prevalence of positive AF cultures was 11.5% (13/113). Anaerobic bacteria were isolated in 9 patients (69.2%). The glucose <16 mg/dl and cytokines values; IL-1 >640 pg/ml, IL-6 >55,000 pg/ml, IL-8 >1,000 pg/ml, TNF >672 pg/ml, were significantly correlated (P < 0.01) with AF culture result. Glucose had a sensitivity of 69.2% and a specificity of 96% for the prediction of positive AF culture. The sensitivity and specificity of the cytokines ranged from 61.5-53.4% and 79.8-8.99%, respectively. CONCLUSIONS In the diagnosis of the AF-positive culture, glucose <16 mg/dl is more sensitive than cytokines.

Premature rupture of membranes before 34 weeks managed expectantly: maternal and perinatal outcomes in singletons

Objectives: To ascertain the risk factors for imminent delivery and infection in pregnant women with premature rupture of membranes (PPROM) before 34 weeks of gestation, evaluate maternal and fetal outcomes and identify obstetric factors for determining which patients meet the criteria for home follow-up. Methods: Medical charts of all women with PPROM admitted to the Vall d’Hebron Hospital (HVH) between January 2006 and December 2010 were retrospectively reviewed. Results: During the study period, 216 women were admitted with a diagnosis of PPROM <34 weeks of gestation with a singleton, live, structurally-normal fetus. Mean gestational age at delivery was 31 weeks. Sixty-two patients (28.7%) delivered before 28 weeks and 76 of the infants (35.2%) had birth weight <1,500 g. Overall, 202 infants (93.5%) survived to be discharged home. On stratifying by gestational age at PPROM diagnosis, prognosis was better when PPROM occurred near to term. Gestational age at delivery was increased in pregnant women with no oligohydramnios, no shortened cervix and with negative endocervical and vaginal cultures at PPROM diagnosis (33 weeks of gestation) vs. pregnant women with positive cultures at admission (27 weeks), oligohydramnios at admission (28 weeks) and shortened cervix (26 weeks). This difference was statistically significant (p = 0.005). Conclusions: Protective factors for PPROM could be normal AFI, cervical length >25 mm and negative cultures at PPROM diagnosis. These factors could permit home follow-up of this group of patients.

Do knowledge of uterine artery resistance in the second trimester and targeted surveillance improve maternal and perinatal outcome

To ascertain whether screening for pre‐eclampsia (PE) and intrauterine growth restriction (IUGR) by uterine artery (UtA) Doppler in the second trimester of pregnancy and targeted surveillance improve maternal and perinatal outcomes in an unselected population.

Curvas de normalidad de la longitud cervical ecográfica según edad gestacional en población española

Resumen Objetivo Obtener curvas de normalidad de la longitud cervical uterina en poblacion espanola, en gestacion unica y gemelar. Sujetos y metodos Gestantes derivadas a nuestro centro para control ecografico rutinario entre las 12 y 36 semanas. Se realizaron 285 ecografias transvaginales en gestaciones unicas y 281 en multiples. Se calculo la media y los percentiles 5 y 95 de la longitud cervical para cada semana de gestacion, y se obtuvieron las curvas de normalidad. Resultados La longitud cervical media disminuyo de forma progresiva durante el embarazo. Tanto en gestaciones unicas como multiples, el percentil 5 al inicio del segundo trimestre se situo en 25 mm. Sin embargo, en el tercer trimestre se observo una disminucion muy marcada especialmente en gestaciones multiples, que llego a ser de 15 mm en gestaciones unicas e inferior a 10 mm en multiples. Conclusiones Nuestros resultados aportan puntos de corte para la evaluacion de la utilizacion clinica o en investigacion de la longitud cervical ecografica. Las diferencias observadas en gestacion unica y multiple justifican la utilizacion de curvas diferenciadas.

Serum fructosamine is not a useful screening test for gestational diabetes

Serum fructosamine was measured in 569 samples of pregnant women without gestational diabetes. We defined abnormal fructosamine as mean + 2SD, and analysed its potential value to detect patients with gestational diabetes diagnosed with current screening criteria. We found serum fructosamine to be an insensitive parameter: Measured at the time of a positive 50 g glucose screening, SF would have detected 4/48 gestational diabetes.

Long-term hospitalization and ß-mimetic therapy in the treatment of intrauterine growth retardation of unknown etiology

A group of 98 third trimester pregnant women whose ultrasonographic studies raised the suspicion of intrauterine fetal growth retardation was studied. The patients were randomly assigned to two groups: Group A (Treatment group: 44 patients) and Group B (Control group: 54 patients). All patients were admitted to the hospital upon diagnosis for baseline evaluation. Those in Group A remained in the hospital until delivery (mean stay 15 +/- 5 days) and received treatment with 10 mg/t.i.d. of p.o. ritodrine. Group B patients were discharged after an average stay of 7 +/- 3 days. This group was not treated with ritodrine, and they were seen weekly in an outpatient setting. The prevalence of low-birth-weight infants for their gestational age was 47.73% in the treatment group and 40.74% in the control group. Of the deliveries in the treatment group, 40.9% were induced (half for fetal indications). In the control group 35.18% of the induced labors was (47.35% for fetal indications). Of the cases in the treatment group 18.18% were delivered by cesarean section, of which 62.5% were performed for fetal distress. The control group showed similar figures: 16.66% cesarean sections with 77.7% of them done for fetal distress. We observed an incidence of 20.45% of acute fetal distress in the study group against 12.96% in the control group. Such a difference is not statistically significant. The group under study demonstrated a rate of 6.82% pathological pH value in the umbilical artery, while the rate of abnormal values in the control group was 18.52%. In both groups, the greatest percentage of acidotic pH was observed in patients with IGR.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral venous blood flow in growth restricted fetuses with an abnormal blood flow in the umbilical artery before 32 weeks of gestation

OBJECTIVE To evaluate the brain venous circulation in fetuses with severe intrauterine growth restriction (IUGR) before 32 weeks of gestation. STUDY DESIGN Fifty fetuses with severe IUGR diagnosed between 27 and 32 weeks of gestation and 50 appropriate-for-gestational age (AGA) fetuses matched by gestational age were evaluated. IUGR fetuses were classified according to their hemodynamic deterioration pattern in relation to the Doppler examination of the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV). The fetal venous brain blood flow was evaluated in the vein of Galen (VG), superior sagittal (SS), straight and transverse venous sinuses. RESULTS Only the transverse sinus (TS) showed a significant reduction in the pulsatility index (PI) values in IUGR fetuses. All other veins showed similar PI values between IUGR and AGA fetuses. All cerebral veins of IUGR fetuses showed significantly increased maximum and mean velocities. All these findings did not change in relation to the hemodynamic IUGR deterioration. In nearly all normal and all IUGR fetuses, a pulsatile blood flow pattern was observed in the straight and transverse sinuses, whereas an increased pulsatile pattern in the VG and in the SS was noted in IUGR fetuses. CONCLUSION Brain venous blood flow in IUGR fetuses shows an increment in the maximum and mean velocities of all veins and a reduction in the PI in the transverse sinus.

Serial measurements of a plasma prostacyclin inhibitor in a patient with recurrent abortions and lupus anticoagulant; a case report

Defective plasmatic stimulation of prostacyclin (PGI2) production by vascular cells has been described in patients with lupus anticoagulant (LAC). A young woman with recurrent abortions, LAC and evidence for deficient PGI2 production was studied. Serial measurements of a plasma PGI2 inhibitor, LAC and anticardiolipin antibodies (ACA) have been performed before and throughout her fourth pregnancy. Antenatal care and treatment with prednisone and heparin started at 10 weeks gestation. The plasma of our patient continued to inhibit PGI2 production by vascular cells despite treatment. The presence of inhibitor(s) of PGI2 release was confirmed by mixing the patients plasma with normal plasma. In addition, an IgM lupus anticoagulant fraction (but not the IgG fraction) interfered with the release of arachidonic acid in human endothelial cells induced by thrombin. Despite prednisone and heparin treatment we did not find a complete correction of the LAC activity and the ACA (IgM type) still remained positive before the detection of a fetal death at 26 weeks. The placenta showed abundant infarcts and areas of ischaemic necrosis. We suggest that the defect in vascular PGI2 release could compromise fetal outcome.

Physical examination-indicated cerclage in singleton and twin pregnancies: maternal–fetal outcomes

Abstract Objectives: To study maternal and perinatal outcomes after physical examination-indicated cerclage in both singleton and twin pregnancies and evaluate the possible risk factors associated. Study design: Retrospective review of all women undergoing physical examination-indicated cerclage at the Hospital Vall d’Hebro, Barcelona from January 2009 to December 2012 after being diagnosed with cervical incompetence and risk of premature birth. Results: During the study period, 60 cases of women diagnosed with cervical incompetence who were carrying live and morphologically-normal fetuses (53 singleton and 7 twin pregnancies), and who had an imminent risk of premature birth were evaluated. Mean gestational age until birth was 35 weeks in singleton and 32 weeks in twin pregnancies. Four cases (7.5%) of immature births and one case (2.0%) of neonatal death were recorded in singleton pregnancies. No cases of immature births or neonatal deaths were recorded in twin pregnancies. Diagnostic amniocentesis was performed IN all cases to rule out possible chorioamnionitis. Conclusions: Physical examination-indicated cerclage for cervical incompetence in women at risk for immature or preterm birth demonstrates good perinatal prognosis without increasing maternal morbidity in either singleton or twin pregnancies. The increase in gestation time in our study may also have been due to the fact that patients with subclinical chorioamnionitis were excluded by diagnostic amniocentesis.