Amniocentesis prior to physical exam-indicated cerclage in women with midtrimester cervical dilation: results from the expectant management compared to Physical Exam-indicated Cerclage international cohort study.

We evaluated whether the performance of an amniocentesis in women with a dilated cervix presenting at less than 26 weeks and subsequently managed by a physical exam-indicated cerclage increases the risk of spontaneous preterm birth (PTB) less than 28 weeks. Women between 15 (0)/ (7) to 25 (6)/ (7) weeks' gestation with a dilated cervix (1 to 4 cm) were identified. Multiple exclusion criteria were designated. The primary outcome was PTB less than 28 weeks. One hundred twenty-two women with a dilated cervix between 15 and 25 (6)/ (7) weeks gestational age were identified. Twenty-four (20%) of these had an amniocentesis performed. The unadjusted rate of PTB < 28 weeks differed between women who underwent amniocentesis compared with those who did not (58% versus 34%, respectively, P = 0.02), but after multivariate regression analysis, the performance of an amniocentesis was not an independent contributor to PTB < 28 weeks ( P = 0.90). The performance of an amniocentesis prior to cerclage did not independently contribute to PTB less than 28 weeks.

Indomethacin administration at the time of ultrasound-indicated cerclage: is there an association with a reduction in spontaneous preterm birth?

OBJECTIVE: The purpose of this study was to estimate the effect of indomethacin on the prevention of preterm birth (PTB) in women with an ultrasound-indicated cerclage. STUDY DESIGN: We performed a retrospective cohort study from 1995-2006. Asymptomatic women with a cerclage for a short cervical length (CL), which was defined as <25 mm, between 14-23 weeks 6 days of gestation were included. Women who received indomethacin therapy at the time of ultrasound-indicated cerclage for a short CL were compared with those women who did not. Our primary outcome was spontaneous PTB at <35 weeks of gestation. RESULTS: Fifty-one women received indomethacin, and 50 women did not. There were no differences between groups regarding previous PTB, gestational age, or CL at time of cerclage. The rate of spontaneous PTB at <35 weeks of gestation was similar between those who received indomethacin (20/51 [39%]) and those who did not (17/50 [34%]; relative risk, 1.15 [95% CI 0.69-1.93]). In our post hoc power analysis, 190 patients would have been needed to detect a 50% reduction in the rate of PTB. CONCLUSION: Administration of indomethacin around the time of ultrasound-indicated cerclage was not associated with a decrease in spontaneous PTB.

Clinical significance of proteinuria in pregnancy.

UNLABELLED: Urinary protein excretion is considered abnormal in pregnant women when it exceeds 300 mg/24 hours at anytime during gestation, a level that usually correlates with 1+ on urine dipstick. Proteinuria documented before pregnancy or before 20 weeks' gestation suggests preexisting renal disease. The National High Blood Pressure Education Program Working Group recommended that that the diagnosis of proteinuria be based on the 24-hour urine collection. Preeclampsia is the leading diagnosis that must be excluded in all women with proteinuria first identified after 20 weeks of gestation. Given the vasospastic nature of this condition, when it is present, the degree of proteinuria may fluctuate widely from hour-to-hour. Hypertension or proteinuria may be absent in 10-15% of patients with HELLP syndrome and in 38% of patients with eclampsia. The acute onset of proteinuria and worsening hypertension in women with chronic hypertension is suggestive of superimposed preeclampsia, which increases adverse outcomes. However, because proteinuria is not independently predictive of adverse outcome, an exclusive proteinuric criterion as an indication for preterm delivery in preeclampsia should be discouraged. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to state that measurement of urinary protein levels by simple techniques are not sensitive or specific, recall that both hypertension and proteinuria may be absent in patients with preeclampsia, and explain that proteinuria is not predictive of adverse outcomes and that delivery should not be based on protein excretion alone.

Hepatitis C and pregnancy.

UNLABELLED: Hepatitis C is the most common chronic bloodborne infection in the United States. The diagnosis of vertical transmission is reliably established by a positive serum hepatitis C virus (HCV) RNA on 2 occasions 3 to 4 months apart after the infant is at least 2 months old and/or by the detection of anti-HCV antibodies after the infant is 18 months old. Vertical transmission in HCV RNA-negative pregnant women is approximately 1% to 3% versus approximately 4% to 6% in HCV RNA-positive women. From the standpoint of vertical transmission, no critical HCV RNA titer has been established. Coinfection with HIV has been shown to increase the risk of vertical transmission of HCV, but highly active antiretroviral therapy may decrease the risk significantly. In HIV-negative women, route of delivery does not influence vertical transmission. In HCV/HIV-coinfected women, decisions regarding mode of delivery should be based on HIV status. There is no association between vertical transmission of HCV and gestational age at delivery or the presence of chorioamnionitis. The use of a scalp electrode has been associated with vertical transmission and this practice is discouraged. Data are conflicting regarding duration of ruptured membranes and the risk of vertical transmission of hepatitis C. When the duration of membrane rupture exceeds 6 hours, the risk may be increased. There is no evidence demonstrating an increased risk of HCV transmission in HIV-negative women who breast feed. In HCV/HIV-coinfected women, breast feeding is discouraged in women who have consistent access to safe infant formula. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that vertical transmission of hepatitis C (HCV) does occur, state that coinfection with HIV increases the transmission rate, and summarize that there is no association between gestational age or presence of chorioamnionitis and no evidence that a cesarean delivery prevents transmission.

A multi-center randomized trial of two different intravenous fluids during labor.

OBJECTIVE: To determine if the intrapartum use of a 5% glucose-containing intravenous solution decreases the chance of a cesarean delivery for women presenting in active labor. METHODS: This was a multi-center, prospective, single (patient) blind, randomized study design implemented at four obstetric residency programs in Pennsylvania. Singleton, term, consenting women presenting in active spontaneous labor with a cervical dilation of <6 cm were randomized to lactated Ringer's with or without 5% glucose (LR versus D5LR) as their maintenance intravenous fluid. The primary outcome was the cesarean birth rate. Secondary outcomes included labor characteristics, as well as maternal or neonatal complications. RESULTS: There were 309 women analyzed. Demographic variables and admitting cervical dilation were similar among study groups. There was no significant difference in the cesarean delivery rate for the D5LR group (23/153 or 15.0%) versus the LR arm (18/156 or 11.5%), [RR (95% CI) of 1.32 (0.75, 2.35), p = 0.34]. There were no differences in augmentation rates or intrapartum complications. CONCLUSIONS: The use of intravenous fluid containing 5% dextrose does not lower the chance of cesarean delivery for women admitted in active labor.

Transvaginal ultrasonography of the cervix to predict preterm birth in women with uterine anomalies.

OBJECTIVE: Women with uterine anomalies have higher rates of preterm birth, but the reason for this has not been elucidated. Transvaginal ultrasound examination has been shown to be an accurate test for the prediction of preterm birth but has not been studied specifically in this population. METHODS: Pregnant women with uterine anomalies were followed prospectively with transvaginal ultrasound examination of the cervix, performed between 14 and 23 6/7 weeks of gestation. A short cervical length was defined as less than 25 mm of cervical length. The primary outcome was spontaneous preterm birth, defined as birth at less than 35 weeks. RESULTS: Of the 64 pregnancies available for analysis, there were 28 with a bicornuate uterus, 13 with a septate uterus, 11 with a uterine didelphys, and 12 with a unicornuate uterus. The overall incidence of spontaneous preterm birth at less than 35 weeks was 11%. Of the 10 (16%) women with a short cervical length, 5 (50%) had spontaneous preterm birth. Of the 54 women without a short cervical length, only 2 (4%) had a spontaneous preterm birth. The sensitivity, specificity, and positive and negative predictive values of a short cervical length for spontaneous preterm birth were 71%, 91%, 50%, and 96%, respectively (relative risk 13.5, 95% confidence interval 3.49-54.74). Of the 7 women with both short cervical length and preterm birth, all uterine subtypes were represented except septate uterus. CONCLUSION: A short cervical length on transvaginal ultrasonography in women with uterine anomalies has a 13-fold risk for preterm birth. Unicornuate uterus had the highest rate of cervical shortening and preterm delivery. LEVEL OF EVIDENCE: II-2.

Short cervical length after history-indicated cerclage: is a reinforcing cerclage beneficial?

OBJECTIVE: The purpose of this study was to determine if a reinforcing cerclage improves outcome in women with a history-indicated cerclage who develop a short cervix on ultrasound. STUDY DESIGN: The management of women with a history-indicated transvaginal cerclage who subsequently developed a short cervix (< or = 25 mm) on transvaginal ultrasound before 24 weeks was retrospectively reviewed. Exposed subjects that received a reinforcing cerclage were compared with similar unexposed subjects that were followed with expectant management. The primary outcome was preterm delivery <35 weeks. RESULTS: Twenty-four eligible women were identified, of which 5 received a reinforcing cerclage and 19 were managed expectantly. There was no difference in patient demographics and risk factors between the exposed and unexposed groups. Reinforcing cerclage was associated with a significantly earlier gestational age at delivery (20.8 vs 32.9 weeks, P = .002) as well as higher rates of both preterm delivery <35 weeks (100% vs 32%, P = .01) and previable delivery <24 weeks (80% vs 16%, P = .01). CONCLUSION: In pregnancies with a history-indicated cerclage and subsequently diagnosed ultrasound cervical shortening before 24 weeks, placement of a reinforcing cerclage is associated with earlier delivery than expectant management.