Vincenzo Berghella

Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data.

Objective: Preterm birth is the main cause of perinatal morbidity and mortality. A short cervical length on transvaginal ultrasonography predicts preterm birth. Our aim was to estimate by meta-analysis of randomized trials whether cerclage prevents preterm birth in women with a short cervical length. Data Sources: MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched with the terms “cerclage,” “cervical cerclage,” “short cervix,” “ultrasound,” and “randomized trial.” We included randomized trials involving the use of cerclage in women with short cervical length on transvaginal ultrasonography using patient-level data. Tabulation, Integration, and Results: Four properly conducted trials were identified. In the total population, preterm birth at less than 35 weeks of gestation occurred in 29.2% (89/305) of the cerclage group, compared with 34.8% (105/302) of the no-cerclage groups (relative risk [RR] 0.84, 95% confidence interval [CI] 0.67–1.06). There was no significant heterogeneity in the overall analysis (P = .29). There was a significant reduction in preterm birth at less than 35 weeks in the cerclage group compared with the no-cerclage groups in singleton gestations (RR 0.74, 95% CI 0.57–0.96), singleton gestations with prior preterm birth (RR 0.61, 95% CI 0.40–0.92), and singleton gestations with prior second-trimester loss (RR 0.57, 95% CI 0.33–0.99). There was a significant increase in preterm birth at less than 35 weeks in twin gestations (RR 2.15, 95% CI 1.15–4.01). Conclusion: Cerclage does not prevent preterm birth in all women with short cervical length on transvaginal ultrasonography. In the subgroup analysis of singleton gestations with short cervical length, especially those with a prior preterm birth, cerclage may reduce preterm birth, and a well-powered trial should be carried out in this group of patients. In contrast, in twins, cerclage was associated with a significantly higher incidence of preterm birth.

Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length

OBJECTIVE The objective of the study was to assess cerclage to prevent recurrent preterm birth in women with short cervix. STUDY DESIGN Women with prior spontaneous preterm birth less than 34 weeks were screened for short cervix and randomly assigned to cerclage if cervical length was less than 25 mm. RESULTS Of 1014 women screened, 302 were randomized; 42% of women not assigned and 32% of those assigned to cerclage delivered less than 35 weeks (P = .09). In planned analyses, birth less than 24 weeks (P = .03) and perinatal mortality (P = .046) were less frequent in the cerclage group. There was a significant interaction between cervical length and cerclage. Birth less than 35 weeks (P = .006) was reduced in the less than 15 mm stratum with a null effect in the 15-24 mm stratum. CONCLUSION In women with a prior spontaneous preterm birth less than 34 weeks and cervical length less than 25 mm, cerclage reduced previable birth and perinatal mortality but did not prevent birth less than 35 weeks, unless cervical length was less than 15 mm.

Practice guidelines for performance of the routine mid‐trimester fetal ultrasound scan

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, teaching and research for diagnostic imaging in women’s healthcare. The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide healthcare practitioners with a consensus-based approach for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be the best practices at the time at which they were issued. Although ISUOG has made every effort to ensure that guidelines are accurate when issued, neither the Society nor any of its employees or members accepts any liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC. They are not intended to establish a legal standard of care because interpretation of the evidence that underpins the guidelines may be influenced by individual circumstances and available resources. Approved guidelines can be distributed freely with the permission of ISUOG (info@isuog.org).

OPIOID DEPENDENCE DURING PREGNANCY Effects and Management

This article describes the complex problems associated with opioid dependence during pregnancy. Medical, obstetric, and psychosocial problems are presented. Methadone maintenance for the treatment of opioid dependence is described in this article. Specific issues of appropriate methadone dose during pregnancy, medical withdrawal, and the relationship of methadone dose and the severity of neonatal abstinence also are discussed.

Cerclage for Short Cervix on Ultrasonography in Women With Singleton Gestations and Previous Preterm Birth: A Meta-Analysis

OBJECTIVE: To estimate if cerclage prevents preterm birth and perinatal mortality and morbidity in women with previous preterm birth, singleton gestation, and short cervical length in a meta-analysis of randomized trials. DATA SOURCES: MEDLINE, PUBMED, EMBASE, and the Cochrane Library were searched using the terms “cerclage,” “short cervix,” “ultrasound,” and “randomized trial.” METHODS OF STUDY SELECTION: We included randomized trials of cerclage in women with short cervical length on transvaginal ultrasonography, limiting the analysis to women with previous spontaneous preterm birth and singleton gestation. TABULATION, INTEGRATION, AND RESULTS: Patient-level data abstraction and analysis were accomplished by two independent investigators. Five trials met inclusion criteria. In women with a singleton gestation, previous spontaneous preterm birth, and cervical length less than 25 mm before 24 weeks of gestation, preterm birth before 35 weeks of gestation was 28.4% (71/250) in the cerclage compared with 41.3% (105/254) in the no cerclage groups (relative risk 0.70, 95% confidence interval 0.55–0.89). Cerclage also significantly reduced preterm birth before 37, 32, 28, and 24 weeks of gestation. Composite perinatal mortality and morbidity were significantly reduced (15.6% in cerclage compared with 24.8% in no cerclage groups; relative risk 0.64, 95% confidence interval 0.45–0.91). CONCLUSION: In women with previous spontaneous preterm birth, singleton gestation, and cervical length less than 25 mm, cerclage significantly prevents preterm birth and composite perinatal mortality and morbidity.

Pregnancy after uterine artery embolization

BACKGROUND Uterine artery embolization is an increasingly popular alternative to hysterectomy and myomectomy as a treatment for uterine leiomyoma. Whether this procedure is safe for women desiring future fertility is controversial. CASES A primigravida who had previously undergone uterine artery embolization had premature rupture of membranes at 24 weeks. She had a cesarean delivery at 28 weeks, which was followed by uterine atony requiring hysterectomy. A primigravida who had previously undergone uterine artery embolization delivered appropriately grown dichorionic twins at 36 weeks. An analysis of the 50 published cases of pregnancy after uterine artery embolization revealed the following complications: malpresentation (17%), small for gestational age (7%), premature delivery (28%), cesarean delivery (58%), and postpartum hemorrhage (13%). CONCLUSION Women who become pregnant after uterine artery embolization are at risk for malpresentation, pre‐term birth, cesarean delivery, and postpartum hemorrhage.

Twins: Prevalence, problems, and preterm births

The rate of twin pregnancies in the United States has stabilized at 32 per 1000 births in 2006. Aside from determining chorionicity, first-trimester screening and second-trimester ultrasound scanning should ascertain whether there are structural or chromosomal abnormalities. Compared with singleton births, genetic amniocentesis-related loss at <24 weeks of gestation for twin births is higher (0.9% vs 2.9%, respectively). Selective termination for an anomalous fetus is an option, although the pregnancy loss rate is 7% at experienced centers. For singleton and twin births for African American and white women, approximately 50% of preterm births are indicated; approximately one-third of these births are spontaneous, and 10% of the births occur after preterm premature rupture of membranes. From 1989-2000, the rate of preterm twin births increased, for African American and white women alike, although the perinatal mortality rate has actually decreased. As with singleton births, tocolytics should be used judiciously and only for a limited time (<48 hours) in twin births. Administration of antenatal corticosteroids is an evidence-based recommendation.

Gestational age at cervical length measurement and incidence of preterm birth.

OBJECTIVE: To estimate the risk of spontaneous preterm birth based on transvaginal ultrasound cervical length and gestational age at which cervical length was measured. METHODS: Women at high risk for spontaneous preterm birth and with transvaginal ultrasound cervical length measurements between weeks 12 and 32 were identified at one institution between July 1995 and June 2005. Inclusion criteria for women at high risk for spontaneous preterm birth were prior spontaneous preterm birth at 14 to 35 weeks, cone biopsy, müllerian anomaly, or two or more dilation and evacuations. Women with multiple gestations, cerclage, indicated preterm birth, or fetal anomalies were excluded. Logistic regression was used to estimate the spontaneous preterm birth risk before 35, 32, and 28 weeks. RESULTS: Seven hundred five women received 2,601 transvaginal ultrasound measurements for cervical length. The incidences of spontaneous preterm birth before 35, 32, and 28 weeks were 17.7, 10.6, and 6.7%, respectively. The risk of spontaneous preterm birth before 35 weeks decreased by approximately 6% for each additional millimeter of cervical length (odds ratio 0.94, 95% confidence interval, 0.92–0.95, P=.001) and by approximately 5% for each additional week of pregnancy at which the cervical length was measured (odds ratio 0.95, 95% confidence interval 0.92–0.98, P=.004). Similar results were obtained for spontaneous preterm birth before 32 and 28 weeks. CONCLUSION: Gestational age at which transvaginal ultrasound cervical length is measured significantly affects the calculation of risk of spontaneous preterm birth. The spontaneous preterm birth risk increases as the length of the cervix declines and as the gestational age decreases. These spontaneous preterm birth risks are important for counseling and management for women with various degrees of short cervical length at different gestational ages. LEVEL OF EVIDENCE: II

Non-Placental Causes of Intrauterine Growth Restriction

Placental insufficiency, in some form or fashion, is associated with the majority of cases of intrauterine growth restriction (IUGR). There are numerous causes of IUGR which are not caused primarily by placental insufficiency, but indirectly lead to it. The causes of IUGR can be subdivided into fetal and maternal etiologies. The fetal etiologies consist of genetic diseases, congenital malformations, infections, multiple gestations, and placental/cord abnormalities. The maternal etiologies are categorized as follows: (1) decreased uteroplacental blood flow, (2) reduced blood volume, (3) decreased oxygen carrying capacity, (4) nutrition status, (5) teratogens, and (6) miscellaneous causes such as short interpregnancy intervals, race, maternal age, and low socioeconomic status. Knowledge of the etiologies of fetal growth restriction is essential, so that future care can be targeted at prevention. There are several primary and secondary prevention strategies that can be adopted.

Prescription drug use during pregnancy: a population-based study in Regione Emilia-Romagna, Italy

PurposeDrug utilization studies in pregnant women are crucial to inform pharmacovigilance efforts in human teratogenicity. The purpose of this study was to estimate the prevalence of prescription drug use among pregnant women in Regione Emilia-Romagna (RER), Italy.MethodsWe conducted a retrospective prevalence study using data from the RER health care database. Outpatient prescription drug data were reconciled for RER residents who delivered a baby in a hospital between January 1, 2004 and December 31, 2004. Drug data were stratified by trimester of use, pregnancy risk categorization, and anatomical classification.ResultsAmong the 33,343 deliveries identified in 2004, 70% of women were exposed to at least one prescription medication during pregnancy and 48% were exposed to at least one prescription medication after excluding vitamin and mineral products. Many of the most commonly used medications were anti-infectives, such as amoxicillin, fosfomycin, and ampicillin. Nearly 1% of women were exposed to drugs contraindicated (i.e., category X) in pregnancy, including 189 women (0.6%) who received these drugs during the first trimester. Several statin medications were among the most common contraindicated drug exposures.ConclusionA large proportion of women who gave birth in RER in 2004 were exposed to prescription medications. Approximately 1 in 100 women were exposed to contraindicated drugs. The most commonly identified drug exposures can help focus pharmacoepidemiologic efforts in drug-induced birth defects.