Use of hyaluronidase for cervical ripening: a randomized trial.

OBJECTIVE: To investigate the action of intracervical administration of hyaluronidase (HAase) as an inductor of cervical ripening on an outpatient basis. METHODS: A randomized double-blind trial was conducted with 168 pregnant women at term, Bishop score (BS)<5, normal fetal vitality and no uterine contractions. An evaluation was performed at the first visit, when either 20,000 UI of lyophilized HAase (5 ml) or placebo was administered via cervical injection. After 48 h, if the BS remained<5, a second dose was administered. The primary outcome was the BS after 48 h or 96 h. The outcome was considered positive when BS>/=5. RESULTS: The results indicate that the proportion of positive response for the HAase group (55%) after 48 h is significantly higher (p<0.0001) than the corresponding proportion for the placebo group (7%) with an absolute risk reduction (ARR) of 48%=55-7% (95%CI=40-56%). After 96 h, these proportions are 93% in the Haase group and 22% in the placebo group (p<0.0001, ARR=71%, 95%CI=61-81%). The average duration of labour for the nulliparae in the HAase group (6.5h) is significantly smaller (p<0.0001) than for those under placebo (12.0 h) with an absolute difference of 5.5h (95%CI=4.6-6.4h). For the multiparae, the results are 4.3h for the HAase patients versus 9.5h for the placebo patients (p<0.0001) with an absolute difference of 5.2h (95%CI=4.1-6.3h). The proportion of vaginal deliveries for women who received HAase was 82% versus 51% for the placebo group (p=0.0007, ARR=31%, 95%CI=19-44%). The proportion of vaginal deliveries for patients with prior cesareans in the HAase group (69%) was also significantly higher (p<0.0001) than that corresponding to the placebo group (13%) with ARR=56% (95%CI=26-86%). No uterine hyper stimulation occurred in the study. CONCLUSION: We detected significant associations between intracervical injection of HAase and ripening of the cervix, as well as with shorter duration of labour and larger chance of vaginal delivery, suggesting that this is a simple, effective and safe method even for women with prior cesarean.

Predicting preterm delivery in asymptomatic patients with prior preterm delivery by measurement of cervical length and phosphorylated insulin-like growth factor-binding protein-1.

OBJECTIVE: To evaluate the efficacy of cervical length measurement in combination with a bedside assessment of phosphorylated insulin-like growth factor-binding protein-1 (phIGFBP-1) as a predictor of preterm delivery in asymptomatic pregnant women with a history of preterm birth. METHODS: Cervical length was measured using transvaginal sonography at 22-24 weeks of gestation in 105 singleton pregnancies and a rapid strip test was performed to detect phIGFBP-1 in cervical secretions from 24 to 34 weeks. Receiver-operating characteristics (ROC) curves were constructed to compare the performance of phIGFBP-1 at different gestational ages, and cervical length at 22-24 weeks, in predicting preterm delivery. RESULTS: The rate of spontaneous delivery before 37 and 34 weeks was 23.8% and 11.4%, respectively. Women with cervical lengths less than 20 mm had a risk of spontaneous preterm delivery before 34 and 37 weeks of 43.5% and 69.6%, respectively. The performance of phIGFBP-1 levels as a predictor of preterm delivery was significantly higher when the test was carried out at 30 weeks' gestation. Cervical assessment in combination with phIGFBP-1 at 30 weeks had the steepest ROC curve (area under the curve=0.93; 95% CI, 0.88-0.98, P<0.001). CONCLUSION: Both cervical length and phIGFBP-1 measurement are useful in the prediction of preterm delivery in patients with a history of preterm birth and the combined method of measuring cervical length at 22-24 weeks and phIGFBP-1 at 30 weeks improves upon either method used alone.

Cervical fetal fibronectin in patients at increased risk for preterm delivery.

OBJECTIVE: This study aimed to evaluate fetal fibronectin concentrations in cervical secretions measured by either a rapid immunoassay or an enzyme-linked immunosorbent assay as a tool for the screening of premature delivery in otherwise asymptomatic pregnant women at high risk for prematurity. STUDY DESIGN: One hundred two pregnant women at high risk for premature delivery were followed up. Samples of the cervical secretion were taken every 2 weeks between the twenty-fourth and the thirty-fourth weeks of pregnancy. The samples were obtained from the ectocervix with two swabs. One cervical sample was used for the immediate-reading membrane test, and the other one for the immunoenzyme test. The correlation between the presence of fetal fibronectin in the cervical secretions and preterm birth was evaluated. In addition, a comparison between tests was made. RESULTS: The rate of preterm birth was 37.25% (38/102). Membrane tests revealed a sensitivity of 73.68% and a specificity of 92.18%; its positive predictive value was 84.84% and the negative predictive value was 85.50%. The enzyme-linked immunosorbent assays revealed a sensitivity of 78.94% and a specificity of 85.93%; its positive predictive value was 76.92%, and the negative predictive value was 87.30%. When compared with each other, the tests were found essentially concordant (p < 0.05). The elapsed time between the last sampling and the occurrence of preterm birth was 2.9 +/- 1.8 weeks. CONCLUSION: The rapid result membrane test is comparable to the standard fetal fibronectin enzyme-linked immunosorbent assays for the detection of fetal fibronectin in cervical secretions between the twenty-fourth and thirty-fourth weeks of gestation. Moreover, both assays were found to be good tools for the prediction of premature delivery in asymptomatic pregnant women at high risk for prematurity. The availability of a rapid search for the presence of cervical fetal fibronectin should improve our ability to efficiently identify patients at risk for preterm delivery to discriminate between such patients and those with benign Braxton Hicks contractions.

PIP: Researchers evaluated the comparative effectiveness of measuring fetal fibronectin concentrations in cervical secretions by either a rapid immunoassay or an enzyme-linked immunosorbent assay as a tool for the screening of premature delivery in otherwise asymptomatic pregnant women at high risk for prematurity. Cervical secretion samples from the ectocervix were taken every two weeks between the 24th and the 34th week of pregnancy from 102 pregnant women at high risk for premature delivery. The samples were obtained with two swabs. One sample was used for the immediate-reading membrane test while the other was used for the immunoenzyme test. There was a 37.25% rate of preterm birth. Membrane tests yielded a 73.68% sensitivity and a 92.18% specificity, with a positive predictive value of 84.84% and a negative predictive value of 85.50%. The enzyme-linked immunosorbent assays were 78.94% sensitive and 85.93% specific, with a positive predictive value of 76.92% and a negative predictive value of 87.30%. The two tests were concordant with each other. There was a mean of 2.9 weeks between the last sampling and the occurrence of preterm birth. The rapid result membrane test is comparable to the standard fetal fibronectin enzyme-linked immunosorbent assays for the detection of fetal fibronectin in cervical secretions between the 24th and the 34th weeks of pregnancy.

Abruptio placentae following snake bite.

A case in which, besides the clinical complications that commonly follow snake biting, abruptio placentae occurred is reported here. None of the factors that are frequently associated with abruptio placentae were present. The laboratory tests performed showed that renal function was impaired and that a dramatic hypercoagulability was present. The relationship of the latter to the abruptio placentae is discussed.

Cervical length at 11-14 weeks' and 22-24 weeks' gestation evaluated by transvaginal sonography, and gestational age at delivery.

OBJECTIVE: To compare cervical length measurements obtained at 11 to 14 weeks and 22 to 24 weeks of gestation in an unselected group of pregnant women and to correlate the measurements with time of delivery. METHODS: This was a prospective study involving 529 pregnant women attending for routine antenatal care who underwent transvaginal scans at 11-14 weeks and 22-24 weeks for evaluation of cervical length. The mean cervical length was calculated at both stages of gestation and lengths were compared between groups which delivered at term or prematurely, this being defined as delivery before 37 completed weeks of gestation. RESULTS: The mean cervical lengths at 11-14 and 22-24 weeks were, respectively, 42.4 mm and 38.6 mm. Cervical length at 11-14 weeks was not significantly different between the groups which delivered at term (42.7 mm) and preterm (40.6 mm). However, at the 22-24-week evaluation, cervical length was significantly shorter in the group which had a preterm delivery than in that which had a term delivery (26.7 mm and 39.3 mm, respectively; P = 0.0001). In the group of women with a previous history of one or more preterm deliveries, there was a greater shortening in cervical length from the first to the second evaluation than there was in the group of women with no previous history of preterm delivery. This shortening was also more pronounced in the group which delivered prematurely (from 40.6 mm to 26.7 mm) than in that which delivered at term (from 42.7 mm to 39.3 mm). CONCLUSION: There is a spontaneous shortening in the pregnant cervix from the first to the second trimester of pregnancy. The shortening is more rapid in pregnant women who deliver prematurely and who have a history of previous preterm delivery.