Tocolysis compared with no tocolysis in women with threatened preterm birth and ruptured membranes: A propensity score analysis.

INTRODUCTION: In women with preterm ruptured membranes and contractions, the administration of tocolysis is controversial. This study compares tocolysis with no tocolysis in women with threatened preterm birth and ruptured membranes. OBJECTIVE: To compare tocolysis with no tocolysis in women with threatened preterm birth and ruptured membranes. STUDY DESIGN: Data from the APOSTEL III RCT was combined with data from the National Maternity Hospital, Dublin. In the APOSTEL III trial, women with threatened preterm birth were randomized to atosiban or nifedipine. Patient data from Ireland were obtained from a cohort of women with threatened preterm birth with ruptured membranes. The Irish women received no tocolytic treatment. Only women with ruptured membranes and contractions were selected. We studied women with singleton or twin pregnancies and a gestational age between 25+0 and 33+6 weeks. Propensity score matching was performed to create comparable groups. Primary outcome was a composite adverse neonatal outcome. Secondary outcomes were individual components of the primary outcome, as well as neonatal intensive care unit (NICU) admission, gestational age at delivery, prolongation of pregnancy and mode of delivery. RESULTS: 153 women from the Apostel III trial were compared with 51 eligible women of the Irish cohort. We could match 46 women who received tocolysis and 46 women who received no tocolysis. All women had ruptured membranes. Maternal age, BMI, parity and gestational age at study entry were comparable between the groups after matching. There were no statistically significant differences in neonatal composite outcome (9.6 % in the tocolysis group versus 18 % in the control group, OR 0.46, 95 % CI 0.13-1.63). We found a lower incidence of NICU admission in the tocolysis group (63 %) than in the control group (94 %; OR 0.11, 95 % CI 0.03-0.41), which could be explained by differences in national admission policies. There were no statistically significant differences between tocolysis and no tocolysis in any of the other outcomes including sepsis, gestational age at delivery and time to delivery. CONCLUSION: In this propensity score analysis of women with threatened preterm birth and ruptured membranes, tocolytic therapy did not alter composite adverse neonatal outcome or time to delivery.

Effect of nifedipine and atosiban on perinatal brain injury: secondary analysis of the APOSTEL-III trial.

OBJECTIVE: Brain injury in neonates born prematurely is associated strongly with poor neurodevelopmental outcome. The aim of this study was to evaluate whether tocolysis with nifedipine or atosiban in women with threatened preterm birth can reduce the incidence of overall brain injury in neonates born prematurely. METHODS: This was a secondary analysis of the APOSTEL-III trial (Dutch Clinical Trial Registry, no. NTR2947), a randomized clinical trial in which women with threatened preterm labor between 25 and 34 weeks of gestation were allocated to treatment with nifedipine or atosiban. In this secondary analysis, women delivered at ≤ 32 weeks of gestational age in the two main contributing centers were included. Primary outcome was the presence of neonatal brain injury, which was defined as presence of abnormalities on ultrasound investigation and classified into mild and severe. To evaluate type and severity of brain injury, all neonatal ultrasounds performed during neonatal intensive and medium care admission were analyzed. To test the robustness of our results, a sensitivity analysis was performed assessing differences in baseline or known risk factors for brain injury. RESULTS: A total of 117 neonates (from 102 women) were studied, of which 51 had been exposed to nifedipine and 66 to atosiban. Brain injury was observed in 22 (43.1%) neonates in the nifedipine group compared with 37 (56.1%) in the atosiban group (OR, 0.60; 95% CI, 0.29-1.24). Presence of mild brain injury was comparable between the nifedipine (33.3%) and atosiban (48.5%) groups (OR, 0.53; 95% CI, 0.25-1.13). Severe brain injury was also comparable between the groups, observed in 9.8% of neonates in the nifedipine vs 7.6% of those in the atosiban group (OR, 1.33; 95% CI, 0.36-4.85). Intraventricular hemorrhage (≥ Grade I) was the most frequently seen ultrasound abnormality, observed in 18 (35.3%) neonates in the nifedipine group vs 25 (37.9%) in the atosiban group (OR, 0.90; 95% CI, 0.42-1.91). The sensitivity analysis, with adjustment for maternal age and gestational age at randomization, showed no statistical difference between the groups for presence of brain injury (OR, 0.58; 95% CI, 0.27-1.27). CONCLUSION: In children born before 32 weeks of gestation after the use of tocolytics, the prevalence of brain injury was high. No significant differences were found with respect to overall brain injury between neonates exposed to nifedipine and those exposed to atosiban. However, as this study was a secondary analysis of the APOSTEL III trial, it was underpowered for brain injury. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Risk assessment and management to prevent preterm birth.

Preterm birth is the most important cause of neonatal mortality and morbidity worldwide. In this review, we review potential risk factors associated with preterm birth and the subsequent management to prevent preterm birth in low and high risk women with a singleton or multiple pregnancy. A history of preterm birth is considered the most important risk factor for preterm birth in subsequent pregnancy. General risk factors with a much lower impact include ethnicity, low socio-economic status, maternal weight, smoking, and periodontal status. Pregnancy-related characteristics, including bacterial vaginosis and asymptomatic bacteriuria, appear to be of limited value in the prediction of preterm birth. By contrast, a mid-pregnancy cervical length measurement is independently associated with preterm birth and could be used to identify women at risk of a premature delivery. A fetal fibronectin test may be of additional value in the prediction of preterm birth. The most effective methods to prevent preterm birth depend on the obstetric history, which makes the identification of women at risk of preterm birth an important task for clinical care providers.

Antepartum and intrapartum interventions to prevent preterm birth and its sequelae.

Preterm birth is the main cause of neonatal morbidity and mortality. This review provides an overview of antepartum and intrapartum management of threatened preterm birth. The most effective method to identify women at high risk of delivering within seven days is the combination of cervical length and fetal fibronectin test. Antenatal corticosteroids administered for 48 h improve neonatal outcome. Although tocolysis has been shown to prolong pregnancy, there is no evidence that tocolytic therapy improves neonatal outcomes. Intrapartum administration of magnesium sulfate improves neurologic outcomes, such as cerebral palsy and gross motor function. In women with preterm premature rupture of membranes, prophylactic antibiotic treatment with erythromycin improves short-term neonatal outcomes, but proof of long-term benefit is lacking. In threatened preterm birth with intact membranes, prophylactic antibiotic treatment is thought to be harmful. Critical appraisal of the long-term benefits and harms of all these treatments questions their use.

Sentinel node procedure in vulvar carcinoma during pregnancy: A case report.

► Description of a rare case: vulvar cancer during pregnancy. ► First report of vulvar sentinel node procedure during pregnancy. ► Discussion about the safety of sentinel node procedure during pregnancy.