Rupsa C. Boelig

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.

Preconception counseling and care in the setting of HIV: clinical characteristics and comorbidities.

Objective. To describe the demographic and clinical characteristics of HIV-infected individuals and HIV-affected couples who were referred for preconception counseling (PCC) at a large urban US-based HIV clinic. Methods. Electronic medical records were reviewed for HIV-infected individuals and HIV-affected couples. Medical, reproductive, surgical, psychosocial, and family history data were abstracted. Univariate analyses were done. Results. There were 8 single HIV-infected women and 100 HIV-affected couples who underwent PCC. HIV-infected women were older (mean age 35 years versus 32 years, P = 0.06), were more likely to smoke (23% versus 0%, P < 0.01), and had more medical comorbidities (57% versus 33%, P = 0.04) than HIV-uninfected women. The majority of couples were serodiscordant (77%), and of these couples, 32% had a detectable plasma viral load and 33% report inconsistent condom use. Conclusions. HIV-infected women have a number of medical and psychosocial issues, including those related to HIV that may increase the risk of adverse pregnancy outcomes and HIV perinatal and sexual transmission. PCC is an important intervention to optimize maternal management to improve perinatal outcomes and minimize transmission risks.

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.

Interventions for treating hyperemesis gravidarum: a Cochrane systematic review and meta-analysis

Abstract Introduction: While nausea and vomiting in early pregnancy are very common, affecting approximately 80% of the pregnancies, hyperemesis gravidarum is a severe form affecting 0.3–1.0% of the pregnancies. Although hyperemesis gravidarum is rarely a source of mortality, it is a significant source of morbidity. It is one of the most common indications for hospitalization in pregnancy. Beyond the maternal and fetal consequences of malnutrition, the severity of hyperemesis symptoms causes a major psychosocial burden leading to depression, anxiety, and even pregnancy termination. The aim of this meta-analysis was to examine all randomized controlled trials of interventions specifically for hyperemesis gravidarum and evaluate them based on both subjective and objective measures of efficacy, maternal and fetal/neonatal safety, and economic costs. Material and methods: Randomized controlled trials were identified by searching electronic databases. We included all randomized controlled trials for the treatment of hyperemesis gravidarum. The primary outcome was intervention efficacy as defined by severity, reduction, or cessation in nausea/vomiting; number of episodes of emesis; and days of hospital admission. Secondary outcomes included other measures of intervention efficacy, adverse maternal/fetal/neonatal outcomes, quality of life measures, and economic costs. Results: Twenty-five trials (2052 women) met the inclusion criteria but the majority of 18 different comparisons described in the review include data from single studies with small numbers of participants. Selected comparisons reported below: No primary outcome data were available when acupuncture was compared with placebo. There was insufficient evidence to identify clear differences between acupuncture and metoclopramide in a study with 81 participants regarding reduction/cessation in nausea or vomiting (risk ratio (RR) 1.40, 95% CI 0.79–2.49 and RR 1.51, 95% CI 0.92–2.48, respectively). Midwife-led outpatient care was associated with fewer hours of hospital admission than routine inpatient admission (mean difference (MD) − 33.20, 95% CI −46.91 to −19.49) with no difference in pregnancy-unique quantification of emesis and nausea (PUQE) score, decision to terminate the pregnancy, miscarriage, small-for-gestational age infants, or time off work when compared with routine care. Women taking vitamin B6 had a slightly longer hospital stay compared with placebo (MD 0.80 days, 95% CI 0.08–1.52). There was insufficient evidence to demonstrate a difference in other outcomes including mean number of episodes of emesis (MD 0.50, 95% CI −0.40–1.40) or side effects. A comparison between metoclopramide and ondansetron identified no clear difference in the severity of nausea or vomiting (MD 1.70, 95% CI −0.15–3.55, and MD −0.10, 95% CI −1.63–1.43; one study, 83 women, respectively). However, more women taking metoclopramide complained of drowsiness and dry mouth (RR 2.40, 95% CI 1.23–4.69, and RR 2.38, 95% CI 1.10–5.11, respectively). There were no clear differences between groups for other side effects. In a single study with 146 participants comparing metoclopramide with promethazine, more women taking promethazine reported drowsiness, dizziness, and dystonia (risk ratio (RR) 0.70, 95% CI 0.56–0.87, RR 0.48, 95% CI 0.34–0.69, and RR 0.31, 95% CI 0.11–0.90, respectively). There were no clear differences between groups for other important outcomes including quality of life and other side effects. In a single trial with 30 women, those receiving ondansetron had no difference in duration of hospital admission compared to those receiving promethazine (mean difference (MD) 0.00, 95% CI −1.39–1.39), although there was increased sedation with promethazine (RR 0.06, 95% CI 0.00–0.94). Regarding corticosteroids, in a study with 110 participants there was no difference in days of hospital admission compared to placebo (MD −0.30, 95% CI −0.70–0.10), but there was a decreased readmission rate (RR 0.69, 95% CI 0.50–0.94; 4 studies, 269 women). For hydrocortisone compared with metoclopramide, no data were available for primary outcomes and there was no difference in the readmission rate (RR 0.08, 95% CI 0.00–1.28; one study, 40 women). In a study with 80 women, compared to promethazine, those receiving prednisolone had increased nausea at 48 h (RR 2.00, 95% CI 1.08–3.72), but not at 17 days (RR 0.81, 95% CI 0.58–1.15). There was no clear difference in the number of episodes of emesis or subjective improvement in nausea/vomiting. Conclusions: While there were a wide range of interventions studied, both pharmaceutical and otherwise, there were a limited number of placebo controlled trials. In comparing the efficacy of the commonly used antiemetics, metoclopramide, ondansetron, and promethazine, the results of this review do not support the clear superiority of one over the other in symptomatic relief. Other factors such as side effect profile medication safety and healthcare costs should also be considered when selecting an intervention.

Decrease in the incidence of threatened preterm labor after implementation of transvaginal ultrasound cervical length universal screening

Abstract Background: It is unknown if universal second-trimester transvaginal ultrasound (TVU) cervical length (CL) screening in asymptomatic women with singleton gestations and no prior spontaneous preterm birth (SPTB) affects the incidence of symptoms of preterm labor (PTL) later in pregnancy. Objective: To evaluate the incidence of threatened PTL before and after the implementation of universal second trimester TVU CL screening. Study design: This was a retrospective cohort study of all consecutive singleton gestations without prior SPTB presenting to obstetric triage for threatened PTL between 23 0/7 and 33 6/7 week in 2011 (1 January–31 December), and in 2014 (1 January–31 December) at Thomas Jefferson University Hospital (TJU) (Philadelphia, PA). These 2 years were chosen as a new protocol for universal TVU CL screening was started on 1 January 2012. This protocol involved one measurement of TVU CL in all singleton gestations without a prior SPTB at 18 0/7 − 23 6/7 week, the time of the “anatomy” scan. Women with prior SPTB were excluded from this study. The primary outcome included the incidence of threatened PTL, defined as the number of women with singleton gestations without prior SPTB who presented with threatened PTL to our labor and delivery (L&D) triage unit annually, divided by the total number of annual deliveries of women with singleton gestation without prior SPTB. Secondary outcomes were the incidence of PTL, defined as the number of women with singleton gestations without prior SPTB admitted for PTL annually divided by the total number of annual deliveries of women with singleton gestation and without prior SPTB; and length of stay in the hospital. We aimed to compare primary and secondary outcome in the “2011” versus the “2014” group. Results: In 2011, there were a total of 1745 deliveries at TJU, of which 1550 (88.8%) were singletons without prior SPTB. In 2014, there were a total of 1924 deliveries at TJU, 1751 (91.0%) were singletons without prior SPTB who were offered universal TVU CL screening. One hundred and seventy-two women with singletons without prior SPTB presented in L&D triage unit in 2011; and 118 women with singletons without prior SPTB presented in L&D triage unit in 2014. There were significant decreases in the incidence of threatened PTL from 11.1% (172/1550) in 2011 to 6.7% (118/1751) in 2014 (p < .001), as well as in the rate of admission for PTL from 2.3% (35/1550) to 1.4% (24/1751), respectively (p = .04). Length of stay was not significantly different between the two groups. Conclusion: The introduction of a universal TVU CL screening program in women with singleton gestations without a history of SPTB is associated with a reduction in the frequency of threatened PTL and admission for PTL. Key Message The introduction of a second trimester universal transvaginal ultrasound (TVU) cervical length (CL) screening program in women without a history of spontaneous preterm birth (SPTB) is associated with a reduction in the incidence of threatened preterm labor (PTL) and admission for PTL.

Current options for mechanical prevention of preterm birth

Cervical insufficiency can be defined by a combination of obstetric history, cervical dilation on exam, and/or short cervical length in women with prior preterm birth. Options for mechanical intervention include cerclage and pessary. There is evidence to support the benefit of a cervical cerclage in women with singleton gestations who have a diagnosis of cervical insufficiency either based on second trimester painless cervical dilatation leading to recurrent early preterm births, or a history of early spontaneous preterm birth and a second trimester transvaginal ultrasound short cervical length or cervical dilation on exam. For women with multiple gestations, the benefit of a cerclage is uncertain, and further study is warranted. The pessary has also been studied for mechanical prevention of preterm birth in various populations, however the results so far have been mixed and warrants further study prior to routine use.

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.

Bilateral Bell palsy as a presenting sign of preeclampsia.

BACKGROUND: Bell palsy is a facial nerve neuropathy that is a rare disorder but occurs at higher frequency in pregnancy. Almost 30% of cases are associated with preeclampsia or gestational hypertension. Bilateral Bell palsy occurs in only 0.3%–2.0% of cases of facial paralysis, has a poorer prognosis for recovery, and may be associated with a systemic disorder. CASE: We describe a case of a 24-year-old primigravid woman with a twin gestation at 35 weeks diagnosed initially with bilateral facial palsy and subsequently with preeclampsia. She then developed partial hemolysis, elevated liver enzymes, and low platelet count syndrome, prompting the diagnosis of severe preeclampsia, and was delivered. CONCLUSION: Bilateral facial palsy is a rare entity in pregnancy that may be the first sign of preeclampsia and suggests increased severity of disease, warranting close monitoring.

Second-trimester cervical length and outcomes of induction of labor at term

Abstract Objective: To evaluate whether second-trimester cervical length (CL) is associated with induction of labor (IOL) outcomes. Methods: Retrospective cohort study of nulliparous singletons undergoing CL screening at 18 0/7–23 6/7 weeks from 1/1/2012 to 12/31/2013. Women induced at term (≥37 weeks) were included. Primary outcome was vaginal delivery (VD) within 24 h. The effect of CL on outcomes was assessed by incidence across CL quartiles and a receiver operating characteristics (ROC) curve. Odds ratios (OR) were adjusted (aOR) for confounders. Results: Two-hundred-and-sixty-eight women were included. Aside from a difference in incidence of prior cervical surgery between CL quartiles (p <. 02), other characteristics were similar. Ninety-two women (35%) had a VD within 24 h (versus a CD or VD >24 h). A longer a CL was associated with a decreased likelihood of a VD within 24 h with aORs of the third and fourth quartiles of 0.35 (0.16–0.75) and 0.43 (0.21–0.90), respectively, compared to the first quartile. A CL >40 mm was predictive of not having a VD within 24 h with a sensitivity of 56%, specificity of 58% and a positive predictive value of 72%. Conclusion: A second-trimester CL >40 mm is associated with a decreased likelihood of VD within 24 h in an IOL.