Use of cerclage in triplet pregnancies with an asymptomatic short cervix.

OBJECTIVES: The purpose of this study was to compare the outcomes of triplet pregnancies in women with asymptomatic cervical shortening with and without a cervical cerclage. METHODS: A retrospective review of all triplet pregnancies with biweekly serial cervical length surveillance was performed. Cervical shortening was defined as a cervical length of 2.5 cm or less before 24 weeks' gestation. Patients with cervical shortening managed with cerclage were compared to those managed expectantly. The primary outcome was the gestational age at delivery, with secondary outcomes including birth weight, neonatal intensive care unit length of stay, and composite neonatal outcome. Statistical significance was defined as P < .05. RESULTS: Sixteen patients underwent cerclage placement versus 8 managed expectantly (control group). The median gestational ages at delivery were similar between the groups (cerclage, 31.3 weeks; interquartile range [IQR], 29.3-32.3 weeks; control, 29.8 weeks; IQR, 27.5-32.4 weeks; P = .71). The median birth weights were also similar between the groups (cerclage, 1283 g; IQR, 800-1626 g; control, 1109 g; IQR, 776-1500 g; P = .54). There was no significant difference in composite neonatal outcomes between the cerclage and control groups (P = .67). CONCLUSIONS: In this limited case-control study, we found no benefit in terms of pregnancy prolongation or neonatal outcomes with cerclage placement for triplet gestations complicated by an asymptomatic short cervix.

Obstetric outcomes and maternal satisfaction in nulliparous women using patient-controlled epidural analgesia.

OBJECTIVE: The purpose of this study was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor who used patient-controlled epidural analgesia (PCEA) vs continuous epidural infusion (CEI). STUDY DESIGN: We conducted a double-masked trial of 270 nulliparous women who were assigned randomly to 3 groups (with a concentration 0.1% bupivacaine and 2 µg/mL fentanyl): group I, CEI-only (10 mL/h); group II, CEI + PCEA (CEI 10 mL/h plus PCEA 10 mL, at 20 minutes); group III, PCEA-only (10 mL, at 20 minutes). A PCEA bolus button was given to each subject. The primary outcome was the dosage of local anesthetic that was used. RESULTS: The total milligrams of bupivacaine that were used was less in the PCEA-only group compared with CEI: group I. 74.8 ± 36 mg; group II, 97.3 ± 53 mg; group III, 52.4 ± 42 mg (P < .001). Pain with pushing, however, was worse in the PCEA-only group. Median satisfaction scores were similar (scale, 0 [best] to 100 [worst]: group I, 0; group II, 0; group III, 0 (P = .23). CONCLUSION: PCEA results in less anesthetic used, and maternal satisfaction remains high without a continuous infusion. Pain with pushing, however, was worse with the PCEA alone.

The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns.

OBJECTIVE: Using fetal pulse oximetry, we sought to quantify the impact of maternal oxygen administration in the management of nonreassuring fetal heart rate patterns. STUDY DESIGN: In fetuses with specified abnormal nonreassuring fetal heart rate patterns, oxygen was administered to the mother, and fetal oxygenation was monitored with fetal pulse oximetry. After the fetal oxygen saturation on room air was recorded as a baseline, oxygen was administered to the mother for 30 minutes at 40% fraction of inspired oxygen and then 30 minutes at 100% of inspired oxygen. The average fetal oxygen saturation during the last 15 minutes of each period was calculated. Paired Student t test was used for comparison to baseline values. RESULTS: Compared with baseline values, a significant increase in fetal oxygen saturation was identified in women who received oxygen at 40% fraction of inspired oxygen (mean increase, 4.9%; P = .001) and at 100% of inspired oxygen (mean increase, 6.5%; P = .003). CONCLUSION: The administration of supplemental oxygen to laboring patients with nonreassuring fetal heart rate patterns increases fetal oxygen saturation substantially and significantly. Fetuses with the lowest initial oxygen saturations appear to increase the most.

The relationship between previous treatment for cervical dysplasia and preterm delivery in twin gestations.

OBJECTIVE: To describe the impact of previous cervical surgery on preterm birth prior to 34 weeks in twins. METHODS: A retrospective review of twin pregnancies delivered between January 1998 and December 2005 at two institutions was performed. Women with a prior cold knife cone (CKC), loop electrosurgical excision procedure (LEEP), or ablative procedure were compared to a control group of women who had not undergone a previous treatment for cervical dysplasia. The primary outcome was delivery before 34 weeks of gestation. RESULTS: A total of 876 women met inclusion criteria. Of these, 110 (12.6%) had previous surgical procedures for cervical dysplasia, including CKC (n = 10), LEEP (n = 36), cryotherapy (n = 59) and CO2 laser treatment (n = 5). Delivery prior to 34 weeks was more common in women with a previous CKC compared to women with no prior treatment (40% versus 11.3%; odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-8.0). Delivery prior to 34 weeks was not more common in women with a previous LEEP (8.3%; OR, 0.8; 95% CI, 0.3-2.3) or ablative procedure (9.4%; OR, 0.9; 95% CI, 0.4-1.9) in comparison to the untreated group. Adjusting for the potential confounders of age, tobacco use, infertility treatments and previous preterm birth did not change the results. CONCLUSIONS: Previous CKC is associated with delivery prior to 34 weeks while LEEP and ablative procedures are not. CKC should be carefully considered and avoided when possible in reproductive age women.