Cervical pessary and cerclage placement for preterm birth prevention and cervicovaginal microbiome changes.

INTRODUCTION: Our objective was to compare the vaginal microbiome in low-risk and high-risk pregnant women and to explore a potential association between vaginal microbiome and preterm birth. MATERIAL AND METHODS: A pilot, consecutive, longitudinal, multicenter study was conducted in pregnant women at 18-22 weeks of gestation. Participants were assigned to one of three groups: control (normal cervix), pessary (cervical length ≤25 mm) and cerclage (cervical length ≤25 mm or history of preterm birth). Analysis and comparison of vaginal microbiota as a primary outcome was performed at inclusion and at 30 weeks of gestation, along with a follow-up of pregnancy and perinatal outcomes. We assessed the vaginal microbiome of pregnant women presenting a short cervix with that of pregnant women having a normal cervix, and compared the vaginal microbiome of women with a short cervix before and after placement of a cervical pessary or a cervical cerclage. RESULTS: The microbiome of our control cohort was dominated by Lactobacillus crispatus and inners. Five community state types were identified and microbiome diversity did not change significantly over 10 weeks in controls. On the other hand, a short cervix was associated with a lower microbial load and higher microbial richness, and was not correlated with Lactobacillus relative abundance. After intervention, the cerclage group (n = 19) had a significant increase in microbial richness and a shift towards community state types driven by various bacterial species, including Lactobacillus mulieris, unidentified Bifidobacterium or Enterococcus. These changes were not significantly observed in the pessary (n = 26) and control (n = 35) groups. The cerclage group had more threatened preterm labor episodes and poorer outcomes than the control and pessary groups. CONCLUSIONS: These findings indicate that a short cervix is associated with an altered vaginal microbiome community structure. The use of a cerclage for preterm birth prevention, as compared with a pessary, was associated with a microbial community harboring a relatively low abundance of Lactobacillus, with more threatened preterm labor episodes, and with poorer clinical outcomes.

Maternal and Perinatal Outcomes Associated With Extremely High Values for the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor) Ratio.

Background There is little knowledge about the significance of extremely high values (>655) for the ratio of sFlt-1 (soluble fms-like tyrosine kinase 1) to PlGF (placental growth factor). We aim to describe the time-to-delivery interval and maternal and perinatal outcomes when such values are demonstrated while assessing suspected or confirmed placental dysfunction based on clinical or sonographic criteria. Methods and Results A multicenter retrospective cohort study was performed on 237 singleton gestations between 20+0 and 37+0 weeks included at the time of first demonstrating a sFlt-1/PlGF ratio >655. Clinicians were aware of this result, but standard protocols were followed for delivery indication. Main outcomes were compared for women with and without preeclampsia at inclusion. In those with preeclampsia (n=185, of whom 77.3% had fetal growth restriction), severe preeclampsia features and fetal growth restriction in stages III or IV were present in 49.2% and 13.5% cases, respectively, at inclusion and in 77.3% and 28.6% cases, respectively, at delivery. In the group without preeclampsia (n=52, 82.7% had fetal growth restriction), these figures were 0% and 30.8%, respectively, at inclusion and 21.2% and 50%, respectively, at delivery. Interestingly, 28% of women without initial preeclampsia developed it later. The median time to delivery was 4 days (interquartile range: 1-6 days) and 7 days (interquartile range: 3-12 days), respectively (P<0.01). Overall, perinatal mortality was 62.1% before 24 weeks; severe morbidity surpassed 50% before 29 weeks but became absent from 34 weeks. Maternal serious morbidity was high at any gestational age. Conclusions An sFlt-1/PlGF ratio >655 is almost invariably associated with preeclampsia or fetal growth restriction that progresses rapidly. In our tertiary care settings, we observed that maternal adverse outcomes were high throughout gestation, whereas perinatal adverse outcomes diminished as pregnancy advanced.

Modification of cervical length after cervical pessary insertion: correlation weeks of gestation.

OBJECTIVES: To observe the modifications in cervical length (CL) in patients with and without cervical pessary (Arabin® ASQ 65/25/32) and correlate these modifications with gestational age at delivery. STUDY DESIGN: Prospective study of asymptomatic singleton pregnancies (PECEP-Trial) between weeks 20 + 0 and 23 + 6 with maternal short cervix (<25 mm) randomised into two groups: expectant management and cervical pessary. RESULTS: This study included 380 pregnant women: 190 with pessary and 190 without pessary. Mean CL in both groups at the time of randomisation showed no statistically-significant differences (pessary group: 19.0 mm and management group: 19.0 mm; p = 0.9). Mean CL measured after randomisation was 15.4 mm in patients of the expectant management group and 21.5 mm in the pessary group. These differences were statistically significant (p < 0.0001). When means at randomisation and at the second measurement were compared, CL had decreased by 3.6 mm in the expectant management group and increased by 2.6 mm in the pessary group; this difference was statistically significant (p < 0.0001). Coefficients of correlation showed that among patients of both groups with the same CL at 20 weeks of gestation, those with a pessary gave birth later. CONCLUSIONS: Insertion of an Arabin cervical pessary increased CL in asymptomatic patients with a short cervix, which correlated with shorter gestational age at delivery. The cervical pessary halted the progressive decrease in CL, which correlated with longer gestational age at delivery.

Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial.

BACKGROUND: Most previous studies of the use of cervical pessaries were either retrospective or case controlled and their results showed that this intervention might be a preventive strategy for women at risk of preterm birth; no randomised controlled trials have been undertaken. We therefore undertook a randomised, controlled trial to investigate whether the insertion of a cervical pessary in women with a short cervix identified by use of routine transvaginal scanning at 20-23 weeks of gestation reduces the rate of early preterm delivery. METHODS: The Pesario Cervical para Evitar Prematuridad (PECEP) trial was undertaken in five hospitals in Spain. Pregnant women (aged 18-43 years) with a cervical length of 25 mm or less were randomly assigned according to a computer-generated allocation sequence by use of central telephone in a 1:1 ratio to the cervical pessary or expectant management (without a cervical pessary) group. Because of the nature of the intervention, this study was not masked. The primary outcome was spontaneous delivery before 34 weeks of gestation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00706264. FINDINGS: 385 pregnant women with a short cervix were assigned to the pessary (n=192) and expectant management groups (n=193), and 190 were analysed in each group. Spontaneous delivery before 34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (12 [6%] vs 51 [27%], odds ratio 0·18, 95% CI 0·08-0·37; p<0·0001). No serious adverse effects associated with the use of a cervical pessary were reported. INTERPRETATION: Cervical pessary use could prevent preterm birth in a population of appropriately selected at-risk women previously screened for cervical length assessment at the midtrimester scan. FUNDING: Instituto Carlos III.

Comparative study of transabdominal and transvaginal uterine artery Doppler pulsatility indices at 11-13 + 6 weeks.

OBJECTIVE: The objective of this study was to compare two approaches to determine the uterine artery pulsatility index (PI) as a screening measure for preeclampsia. METHODS: Comparative analysis of the PI values obtained from transabdominal and transvaginal Doppler ultrasound in 351 women with singleton pregnancies who were examined between May and June 2009 during routine morphological study and risk calculation of chromosome anomalies at 11-13 + 6 weeks of gestation. RESULTS: The mean PI measured transabdominally was 1.83 [95% confidence interval (CI) 1.78-1.89], but when measured transvaginally it was 1.98 (95% CI 1.93-2.08) (p < 0.05). Transabdominal mean PI was observed to decrease as the crown-rump length (CRL) increased: 1.96 (95% CI 1.80-2.12) for CRL <60 mm and 1.71 (95% CI 1.56-1.87) for CRL ≥70 mm (p < 0.05). The transvaginally measured indices were 2.09 (95% CI 1.93-2.26) and 1.78 (95% CI 1.64-1.92), respectively, for the same CRL groups (p < 0.05). A weak correlation was found between the mean PI and the mean CRL using Spearman's rho correlation (-0.20 for abdominal measures and -0.21 for vaginal measures, p < 0.001). CONCLUSIONS: Transabdominal and transvaginal Doppler ultrasound measurements of the uterine artery PI were significantly different. The latter approach yielded significantly higher values than the first.

Role of ultrasound in the labor ward.

Intrapartum ultrasound is commonly used to evaluate fetal vitality, presentation and status as well as placental location. Health professionals are increasingly using intrapartum ultrasound for advanced applications that have not yet been shown to be effective by controlled research studies, using advanced ultrasound technologies such as bi-dimensional ultrasound, color ultrasound, pulsed Doppler ultrasound and three-dimensional ultrasound. This article reviews the current applications of intrapartum ultrasound and considers which advanced technologies can add to the standard of care in the delivery ward.

Preterm delivery and ultrasound measurement of cervical length in Gran Canaria, Spain.

OBJECTIVE: To study the relationship between cervical length measured by ultrasound and risk of preterm delivery. METHODS: We measured cervical length in 2351 women between the 18th and 22nd week of pregnancy. Preterm delivery was categorized as before 37 weeks, before 34 weeks, and before 30 weeks. RESULTS: Before the 37th week, the odds ratios (ORs) of spontaneous delivery for cervical lengths in the 3rd, 5th, and 10th percentiles were, respectively, 25.47 (95% confidence intervals [CI], 15.5-41.73); 16.98 (95% CI, 11.51-25.05); and 7.55 (95% CI, 5.44-10.5). Before the 34th week the ORs were 28.7 (95% CI, 14.54-41.73); 20.5 (95% CI, 11.51-25.05); and 10.3 (95% CI, 5.44-10.5). And before the 30th week they were 29.8 (95% CI, 15.54-41.73); 23.1 (95% CI, 11.51-25.05); and 19.1 (95% CI, 7.44-31.5). In predicting premature delivery, the sensitivity, specificity, positive predictive value, and negative predictive value of cervical length were 26%, 98%, 63.6%, and 93.57% for the 3rd percentile; 34%, 97%, 51%, and 94% for the 5th percentile; and 39%, 92%, 31%, and 94% for the 10th percentile. CONCLUSION: Transvaginal measurement of cervical length during routine fetal morphological examination between the 18th and 22nd week of pregnancy helps identify asymptomatic women at risk for preterm delivery.

Prenatal diagnosis and tridimensional ultrasound features of bilateral femoral hypoplasia--unusual facies syndrome.

The femoral hypoplasia - unusual facies syndrome is a rare disorder, which was described first three decades ago. It is characterised by the occurrence of short femurs with certain associated alterations mainly affecting the face, of which micrognathia is the most frequently found. Although the etiology of this condition is unknown, clear relationship with maternal insulin-dependent diabetes has often been reported, which suggests some sort of inherited component. Nevertheless, most cases occur sporadically. This entity is usually diagnosed after birth because prenatal ultrasound detection is rather difficult. Here, we report a case of prospective detection. So far, such cases have been seldom described in the literature.

Efectos adversos en la intervención de la histerectomía. Registro informatizado 2002-2003 / Adverse effects in hysterectomy. Computerized registry 2002-2003

Estudio prospectivo realizado en la Unidad de Ginecología del Servicio de Obstetricia y Ginecología del Hospital Materno Infantil de Canarias, durante el bienio 2002-2003. Durante éste se analizan las complicaciones quirúrgicas atribuibles a la realización de la histerectomía y su estancia postoperatoria; para ello se comparan ambos años y las vías de abordaje (abdominal y vaginal). La tasa global de complicaciones fue del 45,1 y el 35%, respectivamente, para la histerectomía abdominal y vaginal durante el año 2002, y disminuyó al 40 y el 13,8%, respectivamente, en 2003. El conocimiento detallado de las complicaciones de la cirugía permite un seguimiento de los índices de calidad pre y postoperatorios, que conlleva una revisión y una mejora continua de éstos y permite minimizar, en lo posible, el riesgo de complicaciones

We performed a prospective study at the Obstetrics and Gynecology Unit of the Maternity Hospital of Gran Canaria from 2002 to 2003. Surgical complications and postoperative length of hospital stay after hysterectomy were analyzed, comparing both years and the surgical approach (abdominal and vaginal). The overall rate of complications was 45.1% and 35% for abdominal and vaginal hysterectomy respectively in 2002 and was 40% and 13.8% in 2003. Detailed knowledge of surgical complications allows pre- and postoperative quality indicators to be monitored, which in turn allows assessment and continuous improvement, reducing the risk of complications