Maria Bisulli

Tranexamic acid for preventing postpartum blood loss after cesarean delivery: a systematic review and meta-analysis of randomized controlled trials

There are several published clinical trials of the use of tranexamic acid (TXA) in an obstetric setting, but no consensus on its use or guidelines for management.

Fetal cerebellar damage in fetuses with severe anemia undergoing intrauterine transfusions

Abstract Objective: To evaluate radiologic findings and outcomes of cerebellar injuries in fetuses with severe anemia due to RhD alloimmunization undergoing intrauterine transfusions. Methods: Imaging of multiplanar neurosonography and magnetic resonance imaging (MRI) were reviewed. Pregnancy outcomes were recorded. Results: Cerebellar injuries were identified after the first intravascular transfusion in four fetuses. Two of these cases were previously reported. The median hemoglobin concentration was 2.1 g/dL. Prenatal neurosonography identified an echogenic collection involving the cerebellum suggestive for hemorrhage in three cases. A progressive hypoplasia of a hemisphere was demonstrated at follow-up examination in one of these cases. Hypoplasia of a cerebellar hemisphere was seen in the fourth fetus. Ultrasound diagnosis was confirmed by prenatal MRI in two cases. In the third case, the postnatal MRI showed as additional finding vermian involvement. One pregnancy was terminated and autopsy confirmed the presence of infratentorial hemorrhage. The remaining infants were delivered alive. At time of writing, a truncal ataxia was diagnosed in the child with vermian hypoplasia, while the other children have met all age-appropriate milestones. Conclusions: A severe anemia seems to put the fetus at risk of cerebellar damage, despite successful intravascular transfusion.

Interval to spontaneous delivery after elective removal of cerclage

OBJECTIVE The purpose of this study was to estimate the time interval between elective cerclage removal and spontaneous delivery. METHODS Singleton 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. RESULTS We 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). CONCLUSION The 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%.

Trends in cerclage use

The indications of placement of cerclage have recently changed, and so it is important to evaluate how many women are undergoing this procedure. With the recent completion of clinical trials, it is plausible that obstetricians and perinatologists may have become more selective in terms of the best candidates for cerclage.

Evaluation of quantitative fFn test in predicting the risk of preterm birth

Abstract Objective: To evaluate diagnostic accuracy of quantitative fetal fibronectin (qfFN) test in predicting preterm birth (PTB) risk <34 weeks’ gestation or within 14 days from testing. We explored the predictive potential of the test in five-predefined PTB risk categories based on predefined qfFN thresholds (<10, 10–49, 50–199, 200–499 and ≥500 ng/mL). Methods: Measurement of cervicovaginal qfFN with Rapid fFN 10Q System (Hologic) in 126 women with singleton pregnancy (23–33 weeks’ gestation) reporting signs and symptoms indicative of preterm labour (PTL). Results: For PTB prediction risk <34 weeks’ gestation, sensitivity decreased from 100% to 41.7% and specificity increased from 0% to 99.1% with increasing fFN thresholds. Positive predictive value (PPV) increased from 9.5% to 83.3% with increasing qfFN thresholds, while negative predictive value (NPV) was higher than 90% among the fFN-predefined categories. Diagnostic accuracy results showed an area under a receiving operator characteristic (ROC) curve of 84.5% (95% CI, 0.770–0.903). For delivery prediction within 14 days from the testing, sensitivity decreased from 100% to 42.8% and specificity increased from 0% to 100% with increasing fFN thresholds. Diagnostic accuracy determined by the ROC curve was 66.1% (95% CI, 0.330–0.902). Conclusions: The QfFN thresholds of tests are a useful tool to distinguish pregnant women for PTB prediction risk <34 weeks’ gestation.

Cervical lacerations in planned versus labor cerclage removal: a systematic review

OBJECTIVE The aim of this study was to evaluate the incidence of cervical lacerations with cerclage removal planned before labor compared to after the onset of labor by a systematic review of published studies. STUDY DESIGN Searches were performed in electronic databases from inception of each database to November 2014. We identified all studies reporting the rate of cervical lacerations and the timing of cerclage removal (either before or after the onset of labor). The primary outcome was the incidence of spontaneous and clinically significant intrapartum cervical lacerations (i.e. lacerations requiring suturing). RESULTS Six studies, which met the inclusion criteria, were included in the analysis. The overall incidence of cervical lacerations was 8.9% (32/359). There were 23/280 (6.4%) cervical lacerations in the planned removal group, and 9/79 (11.4%) in the removal after labor group (odds ratio 0.70, 95% confidence interval 0.31-1.57). CONCLUSIONS In summary, planned removal of cerclage before labor was not shown to be associated with statistically significant reduction in the incidence of cervical lacerations. However, since that our data probably did not reach statistical significance because of a type II error, further studies are needed.

Effect of cerclage on cesarean delivery.

We sought to estimate if there is an association between cerclage and cesarean delivery. We performed a retrospective cohort study of women with high-risk factors for preterm birth. Those with a cerclage were compared with those without. Outcomes included overall incidence of cesarean delivery and incidence of cesarean delivery secondary to labor arrest. We identified 724 women at high risk for preterm birth; 232 (32%) women had cerclage placement, and 492 (68%) did not. There was no significant difference in the overall incidence of cesarean delivery between the two groups (odds ratio 1.15; 95% confidence interval 0.81 to 1.63). When comparison was limited to women who underwent a cesarean section secondary to labor arrest, the incidence of cesarean delivery between the two groups remained nonsignificant (odds ratio 1.85; 95% confidence interval 0.97 to 3.53). Women with cerclage in the current pregnancy do not have a higher incidence of cesarean delivery secondary to arrest of labor.

OP09.09: Risk of placental abruption in patients with abnormal uterine artery Doppler in the second trimester of pregnancy

Objectives: To evaluate the correlation between abnormal uterine artery Doppler in the second trimester and placental abruption. Methods: We conducted a retrospective study which included 344 pregnancies with abnormal uterine artery Doppler during the second trimester and 750 patients with normal uterine Doppler in a 1 : 2 match. Statistical analysis has been performed by means of logistic regression analysis. Variables of interest were resistance index and notch (absent, monolateral and bilateral). Age, parity, history of placental abruption and other previous adverse pregnancy outcomes (hypertension disorders, intrauterine growth restriction or intrauterine fetal death) have been used as possible covariates upon the outcome of interest. Results: There were 6 cases of placental abruption in the control group (0.8%) and 11 cases within the study group (3.2%) (Pvalue < .05). The median gestational age at the time of abruption was 28 (24–29) in the first group and 30 weeks (25–39) in the second group. None further covariates reached any statistical association with placental abruption and were therefore excluded from further analyses. Both resistance index and bilateral notch have been associated to the event with OR of 4.4 and 2.0, respectively (P-value < .05). Conclusions: From our data a correlation between altered uterine Doppler in the second trimester and placental abruption is present. The higher the pulsatility index, the higher is the risk. Highly altered wave form with bilateral notch implies a particularly high risk.