Continuous glucose monitoring in individuals undergoing gestational diabetes screening.

BACKGROUND: Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus. OBJECTIVE: This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening. STUDY DESIGN: This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes. RESULTS: Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups. CONCLUSION: In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).

Time in Range and Pregnancy Outcomes in People with Diabetes Using Continuous Glucose Monitoring.

OBJECTIVE: The international consensus on continuous glucose monitoring (CGM) recommends time in range (TIR) target of >70% for pregnant people. Our aim was to compare outcomes between pregnant people with TIR ≤ versus >70%. STUDY DESIGN: This study was a retrospective study of all people using CGM during pregnancy from January 2017 to May 2021 at a tertiary care center. All people with pregestational diabetes who used CGM and delivered at our center were included in the analysis. Primary neonatal outcome included any of the following: large for gestational age, neonatal intensive care unit (NICU) admission, need for intravenous (IV) glucose, or respiratory distress syndrome (RDS). Maternal outcomes included hypertensive disorders of pregnancy and delivery outcomes. Logistic regression was used to estimate unadjusted and adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: Of 78 people managed with CGM, 65 (80%) met inclusion criteria. While 33 people (50.1%) had TIR ≤70%, 32 (49.2%) had TIR >70%. People with TIR ≤70% were more likely to be younger, have a lower body mass index, and have type 1 diabetes than those with TIR >70%. After multivariable regression, there was no difference in the composite neonatal outcome between the groups (aOR: 0.56, 95% CI: 0.16-1.92). However, neonates of people with TIR ≤70% were more likely to be admitted to the NICU (p = 0.035), to receive IV glucose (p = 0.005), to have RDS (p = 0.012), and had a longer hospital stay (p = 0.012) compared with people with TIR >70%. Furthermore, people with TIR ≤70% were more likely to develop hypertensive disorders (p = 0.04) than those with TIR >70%. CONCLUSION: In this cohort, the target of TIR >70% was reached in about one out of two people with diabetes using CGM, which correlated with a reduction in neonatal and maternal complications. KEY POINTS: · Among people with diabetes, 50% reached the recommended time in range using CGM.. · Time in range >70% was associated with reducing the rate of some neonatal complications.. · Time in range ≤70% was associated with increased risk for adverse maternal outcomes..

Maternal and Neonatal Morbidity after Cesarean Delivery for Active Phase Arrest following Adoption of the Obstetric Care Consensus Guidelines.

OBJECTIVE: In an effort to reduce the primary cesarean delivery (CD) rate, the American College of Obstetricians and Gynecologists (ACOG) recommended new labor guidelines in 2014 that allow longer duration of labor times. There are little data on the impact of these guidelines on CD rates and pregnancy outcomes in a predominantly Hispanic population. This study aimed to compare the primary CD rates and maternal and neonatal outcomes in patients undergoing primary CD for arrest of labor before and after implementation of the 2014 guidelines. STUDY DESIGN: This was a retrospective cohort study of term patients who underwent a CD for an arrest disorder between January 2011 and April 2017 at a county teaching hospital. Our primary outcome was the composite maternal and neonatal morbidities (CMM and CNM, respectively). Differences in the demographic and clinical characteristics, CMM, and CNM stratified by time period (pre- vs. postimplementation) were examined. RESULTS: There were 4,976 deliveries in the study period: 525 (11%) underwent primary CD for arrest disorder; 298 (6%) prior to 2014, and 227 (5%) after 2014 (p = 0.62). There was no significant difference in the rate of CD between the two periods (13.4 vs. 13.3%, p = 0.81). In patients undergoing CD for arrest of dilation (n = 389), the CMM and CNM did not significantly change between both groups (63.3 vs. 56%, p = 0.15). In patients who had a CD for arrest of descent (n = 136), the rate of CMM significantly increased from 50 to 75% (p = 0.02) with no significant change in the CNM (13.2 vs. 20%, p = 0.3). CONCLUSION: Despite significant changes in labor management after the publication of the 2014 guidelines, our primary CD rate was not reduced, and we noticed an increase in CMM in patients who had CD for arrest of descent. A randomized controlled trial is needed to further evaluate the effect of these guidelines nationally. KEY POINTS: · The Obstetric Care Consensus statement aims to decrease the rate of cesarean delivery (CD).. · We observed an increase in morbidity in CD if done for arrest of descent (pre/post the consensus).. · A randomized controlled trial is needed to further assess the impact of the guidelines on morbidity..

Prior Term Birth Decreases the Risk of Preterm Birth in a Subsequent Twin Gestation.

OBJECTIVE: The aim of the study is to examine the association between the risk of preterm delivery among women with twin pregnancies and their obstetric history. STUDY DESIGN: We designed a retrospective cohort study of live twin births in 2008 in the United States that delivered after 240/7 weeks. Women were categorized into nulliparas, multiparas with prior term delivery, and multiparas with prior preterm delivery. The incidence of preterm birth was compared using Chi-square test and multivariable logistic regression models. RESULTS: A total of 32,895 nulliparous and 64,701 multiparous women with twin pregnancies were included in the study. Of the multiparous women, 2,505 (4%) had a history of a prior preterm delivery. Multiparous women with prior term birth were more likely to deliver at term (: 43%): in the index twin pregnancy than nulliparous women (40%) and multiparous women with a prior preterm birth (21%; p < 0.001). Compared with nulliparous women, prior term birth was protective against preterm delivery (adjusted odds ratio [aOR] = 0.67 [95% confidence interval: 0.60-0.74] for delivery <28 weeks and aOR = 0.79 [0.71-0.77] for delivery <34 weeks). CONCLUSION: Among multiparous women with twins, a prior term delivery appeared to be protective against preterm delivery compared with nulliparous women with twins. KEY POINTS: · Prior term birth is protective against preterm birth in subsequent twin pregnancy.. · A prior term birth confers an OR of 0.66 for delivery prior to 28 weeks in twin pregnancies.. · A prior preterm birth renders a twin pregnancy nearly twice as likely to deliver before 28 weeks..

Clinical Predictors of Failed Medical Treatment in Patients with Tubo-ovarian Abscess: External Validation of a Recently Published Risk Score.

STUDY OBJECTIVE: To assess the external validity of a recently published clinical risk score estimating the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) based on 4 clinical variables on admission. DESIGN: The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. Results were assessed using rigorous methods for clinical prediction models. SETTING: Safety-net teaching hospital system in Houston, Texas. PATIENTS: One hundred and sixty nine consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with intravenous antibiotic agents; others required a drainage procedure. INTERVENTION: Electronic health records were reviewed and the 4 clinical predictors of failed conservative treatment were captured (age, white blood cell count on admission, abscess size, and presence of bilateral abscess). A clinical risk score was calculated for each patient. The prediction model was created using the risk score in a multivariate logistic regression. Then the calibration, discrimination, and accuracy of the model were evaluated to perform the external validation analysis. MEASUREMENTS AND MAIN RESULTS: Among 169 eligible patients, 50.2% were successfully treated with intravenous antibiotic agents and 49.8% needed abscess drainage. Patients undergoing drainage were more likely to be older, be diabetic, to present with elevated white blood cell count and fever, and to have a larger abscess size on univariate analysis. Among the 4 known predictors of drainage, abscess size was found to be the strongest. Significant difference in clinical characteristics was noted between our cohort and the reference cohort, and the model needed recalibration to adjust for these differences. The area under the receiver operating characteristic curve was 0.77 (0.71-0.84) indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. CONCLUSIONS: Our results provide external validation of a simple clinical risk score predicting failed medical treatment in patients with TOA.

Does the presence of epidural analgesia reduce the risk of neonatal sepsis in the setting of an intrapartum fever?

OBJECTIVE: Epidural analgesia has been associated with more frequent intrapartum fever as well as neonatal antibiotic therapy. We examined whether intrapartum fever carries the same risk for neonatal sepsis with and without epidural. METHODS: This is a retrospective cohort study of 34,371 deliveries at a single institution. Primary outcome variables included neonatal sepsis, Apgar scores, neonatal intensive care (NICU) admission, postpartum hemorrhage, prolonged labor, and cesarean delivery. Univariate analysis and multivariable logistic regression were used to assess the risk of sepsis while controlling for possible confounding covariables. RESULTS: A total of 34,371 patients were included in the study, 16,917 (49.9%) of whom had epidural anesthesia. Of the patients who had an epidural, 2103 (12.4%) had an intrapartum fever, compared to 446 (2.6%) of those who did not have an epidural (p < .001). Overall, there was a decreased risk of neonatal sepsis in the setting of intrapartum fever with an epidural after controlling for potential confounders. (aOR 0.53 [95% CI 0.29-0.98]). In preterm patients, an epidural was associated with a decreased risk for neonatal sepsis (5.7% vs. 10.0%, p = .04), 5-minute Apgar score <7 (23.5% vs. 33.6%, p = .006), and NICU admission (66.6% vs. 76.5%, p = .008) compared to those born in the setting of a fever without an epidural. CONCLUSIONS: Neonates were less likely to sustain a diagnosis of sepsis in the setting of an epidural-associated fever compared to those in the setting of an intrapartum fever without an epidural. These data may be used by providers in counseling and guideline creation.

The risk of meconium aspiration syndrome (MAS) increases with gestational age at term.

OBJECTIVE: To examine the risk of meconium aspiration syndrome (MAS) by the week of gestational age in pregnancies with meconium-stained amniotic fluid (MSAF). METHODS: This is a retrospective cohort study derived from term pregnancies at a single tertiary institution over an 18-year period. Outcomes analyzed included MAS, acidemia, and Apgar scores. Univariate analysis was performed using chi-square and multivariable logistic regression was used to adjust for potential confounders. RESULTS: A total of 34,303 deliveries ≥37 weeks were included; 23.7% were complicated by MSAF. Of the total study cohort, 272 (0.7%) neonates were diagnosed with MAS; this represented 3% of all deliveries complicated by MSAF. In the presence of MSAF, the risk of MAS increased with gestational age, from 1.3% at 38 weeks to 4.8% at 42 weeks (p < .001). Similarly, the risk of acidemia increased from 3.0% at 38 weeks to 7.0% at 42 weeks (p < .001). These findings were also demonstrated in patients with MAS in the absence of MSAF. The risk for both MAS and acidemia in the presence of MSAF persisted after controlling for potential confounders (aOR 1.31 [95% CI 1.18-1.46] and 1.20 [95% CI 1.05-1.37], respectively). CONCLUSION: In women with MSAF, as gestational age increases, the risk of meconium aspiration syndrome also increases. Other factors with late-term and post-term pregnancy besides the presence of meconium may contribute to the evolution of MAS.

Late preterm births: neonatal mortality and morbidity in twins vs. singletons.

OBJECTIVE: To examine the outcomes of twins and singletons in the late preterm period. MATERIALS AND METHODS: This is a retrospective cohort study of data obtained for 165,894 births in California who delivered between 34 + 0 and 36 + 6 weeks. The primary outcome was neonatal and infant mortality. The secondary outcomes included the following neonatal morbidities: respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), seizure, and sepsis. Univariate analysis was performed using chi-square test and multivariable logistic regression was used to adjust for potential confounders. RESULTS: There were 143,891 singleton and 22,003 twin gestations included in the study. There was no difference in the primary outcome, neonatal and infant mortality between twins and singletons delivered at 34 and 36 weeks. After controlling for multiple potential confounders, significant differences in secondary outcomes of neonatal morbidity were identified. At 34 weeks, twins had significantly higher rates of IVH (aOR 2.47 (95%CI 1.08-5.64)), NEC (aOR 2.46 (95%CI 1.42-4.29)), RDS (aOR 1.60 (95%CI 1.45-1.77)), and sepsis (aOR 1.19 (95%CI 1.05-1.34)) compared to singletons. By 36 weeks, only an increased risk of RDS persisted among twins. CONCLUSIONS: While there was no difference in mortality among twins and singletons in the late preterm period, twins may have significantly increased neonatal morbidity compared to singletons delivered between 34 + 0 and 36 + 6 weeks.

Type 2 diabetes and neonatal hypoglycemia: role of route of delivery and insulin infusion.

OBJECTIVE: To compare the rate of neonatal hypoglycemia among newborns delivered by individuals with Type 2 diabetes mellitus (T2DM) in two clinical scenarios: who attempted vaginal delivery vs. had a planned cesarean delivery (CD); who had intrapartum insulin infusion vs. who did not. METHODS: This was a retrospective cohort study of individuals with insulin-treated T2DM who had non-anomalous singleton pregnancy and delivered at a single tertiary center (March 2012 and May 2018). Individuals with chronic renal failure, proliferative retinopathy, or major congenital anomalies were excluded. The primary outcome was neonatal hypoglycemia (blood glucose < 40 mg/dl <24 h of age or < 50 mg/dl >24 h of age). Secondary outcomes included neonatal outcomes. Multivariable Poisson regression models with robust error variance were used to examine the association between groups and the primary outcome. Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated. RESULTS: Of 233 individuals with T2DM, 215 (92.2%) met the inclusion criteria, of whom 95 (44%) attempted vaginal delivery and 120 (56%) had a planned CD. Individuals who labored had a higher gestational age at delivery (36.6 vs. 35.8 weeks, p = .005), and higher blood glucose levels upon admission (125 vs 103, p < .001) compared to those with a planned CD. After adjustment for potential confounders, there was no difference in risk of neonatal hypoglycemia between the groups (41.2 vs 44.1%, aRR 1.05, 95% CI = 0.75-1.45). Among those who attempted vaginal delivery, 34 (35.8%) required insulin infusion. There was no difference in the risk of neonatal hypoglycemia (aRR = 0.79, 95% CI = 0.45-1.37) between newborns delivered by individuals who required insulin infusion and those who did not. CONCLUSION: Over 40% of newborns delivered by individuals with insulin-dependent T2DM had hypoglycemia; however, there was no significant difference in the risk of hypoglycemia, irrespective of the route of delivery and the use of insulin infusion.

Effectiveness of Educational Materials Designed to Improve Knowledge Regarding Crying and Shaken Baby Syndrome in Mothers of Hispanic Population.

Background: Caregiver frustration with inconsolable crying is a commonly cited antecedent factor of Abusive head trauma (AHT) in infants. Objective: To assess the effectiveness of an educational intervention to improve patients' knowledge of normal crying patterns in infants and the implications of AHT among women of Hispanic population. Methods: The Period of PURPLE Crying program was piloted as part of Centering Prenatal Care at an outpatient clinic site in the Harris County Health Department system, which cares for a primarily underserved and Spanish speaking population. Educational material and direct counseling were delivered by the clinician. Demographic data was collected and a pre- and post-test survey was administrated to assess participant's knowledge and behavior. Results: Between April 2017 and April 2018, 63 Hispanic women were included in this study. Prior to implementation of the educational tool, most of the survey questions were answered incorrectly. After the intervention, knowledge regarding normal infant crying patterns was significantly improved in all questions. However, knowledge gaps persisted especially in relation to the adequacy of parents' ability to soothe a crying infant and normalcy of excessive crying. Conclusions: The educational curriculum was an effective tool for improving knowledge about normal infant crying patterns in Hispanic mothers.

Detemir vs neutral protamine Hagedorn insulin for diabetes mellitus in pregnancy: a comparative effectiveness, randomized controlled trial.

BACKGROUND: Insulin detemir, being used increasingly during pregnancy, may have pharmacologic benefits compared with neutral protamine Hagedorn. OBJECTIVE: We evaluated the probability that compared with treatment with neutral protamine Hagedorn, treatment with insulin detemir reduces the risk for adverse neonatal outcome among individuals with type 2 or overt type 2 diabetes mellitus (gestational diabetes mellitus diagnosed at <20 weeks' gestation). STUDY DESIGN: We performed a multiclinic randomized controlled trial (September 2018 to January 2020), which included women with singleton gestation with type 2 or overt type 2 diabetes mellitus who sought obstetrical care at ≤21 weeks' gestation. Participants were randomized to receive either insulin detemir or neutral protamine Hagedorn by a clinic-stratified scheme. The primary outcome was a composite of adverse neonatal outcomes, including shoulder dystocia, large for gestational age, neonatal intensive care unit admission, respiratory distress (defined as the need of at least 4 hours of respiratory support with supplemental oxygen, continuous positive airway pressure or ventilation at the first 24 hours of life), or hypoglycemia. The secondary neonatal outcomes included gestational age at delivery, small for gestational age, 5-minute Apgar score of <7, lowest glucose level, need for intravenous glucose, respiratory distress syndrome, need for mechanical ventilation or continuous positive airway pressure, neonatal jaundice requiring therapy, brachial plexus injury, and hospital length of stay. The secondary maternal outcomes included hypoglycemic events, hospital admission for glucose control, hypertensive disorder of pregnancy, maternal weight gain, cesarean delivery, and postpartum complications. We used the Bayesian statistics to estimate a sample size of 108 to have >75% probability of any reduction in the primary outcome, assuming 80% power and a hypothesized effect of 33% reduction with insulin detemir. All analyses were intent to treat under a Bayesian framework with neutral priors (a priori assumed a 50:50 likelihood of either intervention being better; National Clinical Trial identifier 03620890). RESULTS: There were 108 women randomized in this trial (57 in insulin detemir and 51 in neutral protamine Hagedorn), and 103 women were available for analysis of the primary outcome (n=5 for pregnancy loss before 24 weeks' gestation). Bayesian analysis indicated an 87% posterior probability of reduced primary outcome with insulin detemir compared with neutral protamine Hagedorn (posterior adjusted relative risk, 0.88; 95% credible interval, 0.61-1.12). Bayesian analyses for secondary outcomes showed consistent findings of lower adverse maternal outcomes with the use of insulin detemir vs neutral protamine Hagedorn: for example, maternal hypoglycemic events (97% probability of benefit; posterior adjusted relative risk, 0.59; 95% credible interval, 0.29-1.08) and hypertensive disorders (88% probability of benefit; posterior adjusted relative risk, 0.81; 95% credible interval, 0.54-1.16). CONCLUSION: In our comparative effectiveness trial involving individuals with type 2 or overt type 2 diabetes mellitus, use of insulin detemir resulted in lower rates of adverse neonatal and maternal outcomes compared with neutral protamine Hagedorn.

Methadone for Opioid Use Treatment during Pregnancy: Trends in Postpartum Dose Adjustments.

Objective This study examines methadone dose adjustment postpartum. Methods A retrospective study of women with methadone for opioid use treatment (OUT) during pregnancy was performed. Patient charts were reviewed and data were extracted. Methadone doses from five temporal data points for each patient were used: starting dose, day of delivery, and 1, 2, and 6 months postpartum. Results Over 26 months, 49 pregnancies to women using methadone for OUT were evaluated and 20 (41%) were included. The mean methadone starting dose was 47 mg, compared with 86 mg at the time of delivery. The mean dose postpartum remained unchanged from delivery and 75% of pregnancies required the same dose or higher 1 month postpartum. By 2 months postpartum, only 33% were able to decrease their methadone dose. Twelve pregnancies completed follow-up until 6 months postpartum; only 17% of patients were able to decrease their dose, with an overall mean dose decrease was 12%. There was no difference between the mean dose at delivery and the 6-month postpartum dose. Conclusion Patients using methadone for OUT during pregnancy achieved minimal dose decreases postpartum. Patients should be counseled that postpartum dose tapers may be challenging and about alternatives to methadone for OUT.

Basal Insulin Analogs versus Neutral Protamine Hagedorn for Type 2 Diabetics.

OBJECTIVE: To determine whether basal insulin analogs reduce the rate of composite neonatal morbidity compared with neutral protamine Hagedorn (NPH) in women with type 2 diabetes mellitus (T2DM). STUDY DESIGN: This was a retrospective cohort study of women with T2DM and singleton pregnancy at a single tertiary center. Primary outcome was a composite neonatal morbidity of any of the following: shoulder dystocia, large for gestational age, neonatal intensive care unit admission, neonatal hypoglycemia, or respiratory distress syndrome. Secondary outcomes were rates of maternal hypoglycemic events, hypertensive disorders, preterm birth, and primary cesarean delivery. Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated. RESULTS: Of 233 women with T2DM that met the inclusion criteria, 114 (49%) were treated with basal insulin analogs and 119 (51%) with NPH. The rate of composite neonatal morbidity was similar between groups (73 vs. 60%; aRR: 1.18; 95% CI: 0.92-1.51). There were no differences in the rates of maternal adverse outcomes between the groups. Basal insulin analog was associated with a lower rate of primary cesarean delivery as compared with NPH (21 vs. 36%; aRR: 0.44; 95% CI: 0.25-0.78). CONCLUSION: Among pregnant women with T2DM managed with either basal or NPH insulin regimen, the rates of composite neonatal morbidity and maternal complications were similar.

The risk of impending preterm delivery in asymptomatic patients with a nonmeasurable cervical length in the second trimester.

OBJECTIVE: The purpose of this study was to determine the pregnancy outcome of asymptomatic patients in the second trimester with a nonmeasurable cervical length (0 mm). STUDY DESIGN: This retrospective cohort study included 78 patients with singleton pregnancies and a sonographic nonmeasurable cervix that was detected at 14-28 weeks of gestation. Patients with cervical cerclage were excluded. RESULTS: We found that (1) 75.3% of the patients delivered before 32 weeks of gestation; (2) the median diagnosis-to-delivery interval was 20.5 days, and the delivery rate within 7 and 14 days was 28.2% and 35.6%, respectively; and (3) patients with a nonmeasurable cervix that was diagnosed at <24 weeks of gestation had a shorter median diagnosis-to-delivery interval than patients who were diagnosed at 24-28 weeks of gestation (17.5 vs 41 days; P = .009). CONCLUSION: Asymptomatic women with a nonmeasurable cervix in the second trimester have a median diagnosis-to-delivery interval of approximately 3 weeks. Almost 65% of these patients will not deliver within 2 weeks, yet 75% of them will deliver before 32 weeks of gestation. The earlier a nonmeasurable cervix is identified, the shorter the diagnosis-to-delivery interval.