Pre-cervical ripening and hygroscopic cervical dilators in pre-labor induction.

INTRODUCTION: Induction of labor (IOL) is becoming a universal topic in Obstetrics, when the risk of continuing a pregnancy outweighs the benefits. Preinduction is a more recent tool to prepare the cervix when the BISHOP-score is low. About one-third of IOL cases require cervical ripening, which is the physical softening, thinning, and dilation of the cervix in preparation for labor and birth. We report a single center experience regarding the use of hygroscopic dilators in the pre-labor phase to obtain cervical ripening before labor induction. MATERIALS & METHODS: We conducted a retrospective observational study comparing patient records from the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital in Prato, Tuscany. The inclusion criteria for participants were women who had undergone pre-labor induction because of a BISHOP-score < 3. The gestational age of all the pregnant women was at term (> 37 weeks). RESULTS: From January 2022 to April 2022, a total of 581 women delivered at term of gestational age at the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital. Cervical ripening was necessary for 82 women with a Bishop score < 3 and hygroscopic cervical dilators were used in 35/82 (42.7%) patients. All patients showed a change in Bishop-score upon removal of the dilators. All 35 patients (100%) reported an increase in terms of consistency and dilation of the cervix but not in terms of length. None of the patients reported discomfort during the 24 h that they kept the hygroscopic dilators in place. No patients reported uterine tachysystole on cardiotocographic tracing, vaginal bleeding, rupture of membranes or cervical tears. CONCLUSIONS: Our results are in line with those in the literature, demonstrating the validity of hygroscopic dilators in cervical maturation of pregnancies at term and their efficacy was again highlighted in terms of both maternal and fetal safety and patient satisfaction.

Induction of labour in case of premature rupture of membranes at term with an unfavourable cervix: protocol for a randomised controlled trial comparing double balloon catheter (+oxytocin) and vaginal prostaglandin (RUBAPRO) treatments.

INTRODUCTION: Premature rupture of membranes (PROM) occurs at term in 8% of pregnancies. Several studies have demonstrated that the risk of chorioamnionitis and neonatal sepsis increases with duration of PROM. Decreasing the time interval between PROM and delivery is associated with lower rates of maternal infections. In case of an unfavourable cervix, the use of prostaglandin for cervical maturation demonstrates some advantages over oxytocin. The use of double balloon catheter in reduction of PROM duration has not been evaluated in the literature. METHODS AND ANALYSIS: We are conducting a prospective, monocentric, randomised clinical trial on pregnant women with an unfavourable cervix showing PROM at term (RUBAPRO).After 12-24 hours of PROM, women are randomly assigned to one group treated with a double balloon catheter for 12 hours, with oxytocin administered after 6 hours or to the control group treated with 24 hours of vaginal prostaglandin followed by oxytocin infusion alone. Patients (n=80) are randomised at a 1:1 ratio with stratification on parity.The inclusion criteria are a Bishop score of <6, cephalic presentation at term and confirmed PROM. Women with suspected chorioamnionitis; group B streptococcus (GBS) carrier; a history of caesarean delivery or any contraindication for vaginal delivery are excluded.The time from induction to delivery is the primary outcome. Secondary outcomes were mode of delivery, maternofetal morbidity and the effect of parity on strategies for reduction of PROM duration.To sufficiently demonstrate a difference (10 hours) between groups-with a statistical power of 90% and a two-tailed α of 5%-40 patients per group will be required. ETHICS AND DISSEMINATION: Written informed consent is required from participants.National Ethics Committee approval was obtained in August 2017. The results will be published in a peer-reviewed journal and presented at relevant conferences. Access to raw data will be available only to members of the research team. TRIAL REGISTRATION NUMBER: NCT03310333.

Labor prediction based on the expression patterns of multiple genes related to cervical maturation in human term pregnancy.

PROBLEM: This study explored the possibility of evaluating cervical maturation using swabbed cervical cell samples at term pregnancy, and aimed to develop a novel approach to predict labor onset. METHOD OF STUDY: Women with uncomplicated pregnancies (n=117 from 62 women at term pregnancy) were recruited. Messenger RNA expression levels of cervical cells for ten genes were quantified by qPCR. Principal component analysis (PCA) was conducted, and principal components that significantly contributed to the prediction of days to delivery were determined. RESULTS: PCA demonstrated that 76% of the expression information from the ten genes can be represented by three principal components (PC1-3). By the multiple regression analysis, PC2 and Bishop score but not PC1 or PC3 were significant variables in the prediction of days to delivery. CONCLUSION: These findings support the concurrent assessment of multiple gene activities in cervical cells as a promising approach to predict the initiation of labor.

Associação entre a idade óssea determinada pelas vértebras cervicais e estágios de desenvolvimento de formação dentária / Association between bone age determined by cervical vertebrae and dental formation development stages

A proposta deste estudo foi verificar a associação entre estágios de formação radicular de caninos e primeiros pré-molares em radiografias panorâmicas e a idade óssea determinada por meio da 3ª vértebra cervical em telerradiografias em norma lateral e buscar uma alternativa à determinação da idade esquelética, utilizando-se apenas uma variável de análise vértebra C3 ou Índice Nolla, dispensando-se uma segunda comprovação por meio da radiografia carpal. A pesquisa deu-se através da análise de telerradiografias e radiografias panorâmicas de 122 pacientes, com idades entre 8 e 12 anos de idade, com calibração Kappa de 100% de confiabilidade. Pela amostra analisada, pôde-se concluir que a utilização de forma isolada dos estágios de maturação esquelética é compatível com os índices de correlação positivos apresentados para a maturação vertebral. No entanto, houve uma baixa correlação entre os estágios de maturação radicular dentária pela escala de Nolla e os estágios de maturação vertebral. (AU)

The aim of this study was to verify the association between dental root formation stages of canines and first premolars in panoramic radiographies and the bone age determined by means of the third cervical vertebra in lateral teleradiography, as well as to seek for an alternative to determine skeletal age using a single analysis variable - C3 vertebra or Nolla Index eliminating the require for a second validation through carpal radiography. The research consisted on the analysis of teleradiography and panoramic radiography of 122 patients, aged between 8 and 12, with 100% Kappa calibration reliability. Through the sample analyzed, it was possible to conclude that the isolated use of skeletal maturation is compatible with the positive correlation coefficients presented for vertebral maturation. However, Nolla scale showed low correlation between the stages of dental root maturation and vertebral maturation.(AU)

Reliability, efficacy and reproducibility of the cervical vertebrae maturation index (CVMI) / Validade, efetividade e reprodutibilidade do índice de maturação das vértebras cervicais

Assessing skeletal maturation is an important determinant of successful orthodontic treatment planning for children and adolescents. While several methods are used skeletal maturation assessment, the hand-wrist radiograph is one of the most widely used. However, it does require additional exposing growing patients to additional radiation. Information on skeletal maturation can also be retrieved after evaluation of cervical vertebrae, which are commonly portrayed on the lateral cephalometric radiographs included in standard orthodontic documentation. By means of a systematic review of the available literature, this work aimed to verify the reliability, efficacy, and reproducibility of skeletal age determination based on the evaluation of cervical vertebrae. The LILACS, SciELO and PubMed databases were searched using the keywords "cervical vertebrae" and "cervical maturation". Only texts in Portuguese, Spanish, and English published in the last 10 years were selected. Twenty-nine full articles were retrieved and critically appraised. According to these references, the Cervical Vertebrae Maturation Index appears to be a valid, reliable, and reproducible method for skeletal maturation assessment and may substitute the analysis of hand-wrist radiograph in orthodontic treatment planning.

A determinação da fase de maturação esquelética é ponto fundamental no tratamento ortodôntico de crianças e adolescentes, e muitos métodos são utilizados com este objetivo, sendo a análise da radiografia de mão e punho o mais comumente difundido no meio ortodôntico. Entretanto, esta informação também pode ser obtida por meio de radiografias cefalométricas laterais, com base na avaliação das vértebras cervicais, eliminando a necessidade de exposição a mais de radiação e o custo associado de novos exames. O objetivo deste trabalho foi checar, com base na literatura, a confiabilidade, a efetividade e a reprodutibilidade do método de estimativa da idade esquelética, por meio das vértebras cervicais. Para tanto, foi realizada uma revisão crítica da literatura, utilizando as palavras-chave "vértebras cervicais" e "maturação cervical". Foram encontrados 29 artigos nas bases de dados LILACS, PubMed e SciELO. De acordo com as referências encontradas, o Índice de Maturação das Vértebras Cervicais pode ser considerado um método válido, confiável e reprodutível na análise da maturação óssea, podendo ser utilizado na prática ortodôntica, em substituição à análise da radiografia de mão e punho.

[Induction of labor in twin pregnancies compared to singleton pregnancies; risk factors for failure]. / Déclenchement du travail des grossesses gémellaires: comparaison avec les grossesses monofœtales et facteurs associés au risque d'échec.

OBJECTIVES: The aim of this study was to evaluate the modalities of induction of labour in twin pregnancies compared with singleton pregnancies and to identify risk factors for failure. MATERIALS ET METHODS: A retrospective population-based study was conducted at the Toulouse University Hospital to compare a cohort of diamniotic twin gestations (Twin A in vertex presentation), with induction of labour ≥36 weeks of gestation, between January 2007 and December 2012, to a singleton's cohort that were induced ≥36 weeks of gestation during the 2007 year. One singleton pregnancy was matched for each twin pregnancy with parity and gestational age. RESULTS: One hundred and fifty-six twins pregnancies met the inclusion criteria for an induction of labor and were compared to 156 single pregnancies. The same and standard protocol of induction of labor was used for the two cohorts (intrauterine balloon catheter±dinoprostone/ocytocine). The cesarean section rate for failed labor induction (cesarean in latent phase) was similar in the 2 populations (14.7% for twin vs 13.5% for single; P=0.66). The factors associated to failed induction of labor in the total population were nulliparity (OR=1.49) and Bishop score<6 at the beginning of the induction (OR=2.83). CONCLUSION: Twin did not appear as risk of failed induction. The protocol for induction of labor in singletons may be safely proposed to twin gestations.

The relationship between salivary insulin-like growth factor I and quantitative cervical maturational stages of skeletal maturity.

OBJECTIVE: Insulin-like growth factor (IGF-I) has been used as an indicator of growth hormone levels and hence can also be used as a marker of growth. The main objective of the study was to quantify salivary IGF-I levels and its secretion rate at different quantitative cervical maturation (QCVM) stages and evaluate a possible role for salivary IGF-I in evaluating skeletal growth. METHODS: Forty-five subjects (24 female, 21 male) between the ages of 7 and 23 years were included in the study. Each subject had personal information, a lateral cephalogram, and a parotid saliva sample collected on the same day. RESULTS: Salivary IGF-I levels and salivary secretion rates were lowest at QCVM skeletal stages previously associated with the acceleration phase of mandibular growth. Highest levels were found at the high velocity stage. After this there was gradual drop in salivary IGF-I levels and secretion rate at deceleration and completing velocity stages. Relatively high levels in the decelerating velocity stage may be an indication of residual skeletal growth. There was a negative correlation between patient age and levels of IGF-I and its secretion rate, once growth velocity decreased. CONCLUSIONS: Salivary IGF-I levels or its secretion rate can be used as an indicator of skeletal growth but longitudinal data are necessary to confirm salivary IGF-I as a marker for skeletal growth prediction and residual mandibular growth.

Relationship between detection of the cervical gland area during the late third trimester and necessity for induction of labor to prevent post-term delivery.

OBJECTIVES: With the maturation of the cervical canal during pregnancy, the cervical gland area (CGA) as observed on transvaginal ultrasonography is gradually obscured. The aim of this study was to elucidate the significance of CGA in the late third trimester as a determinant of the outcome of labor. METHODS: We investigated 123 primiparous women with singleton pregnancies at 36-41 weeks' gestation. The women were divided into two groups: a normal delivery group (93 women), which had vaginal delivery without medical intervention, and an induction of labor group (30 women), which required induction of labor after 41 weeks and 0 day. At outpatient prenatal checkups, the Bishop score (BS) was assessed by pelvic examination, and cervical length (CL) and CGA were evaluated by transvaginal ultrasonography. The relationship between each parameter and induction of labor was retrospectively determined and compared. RESULTS: Time-dependent assessment of each outcome determinant showed that the CGA detection rate was higher and the CL was longer in the induction of labor group from 3 weeks to 1 week before delivery at a significant level (P < 0.05); however, the BS was significantly lower in the induction of labor group only at 1 week before delivery (P < 0.05). When multiple logistic regression analysis of the necessity of induction of labor was conducted using BS, CL, and CGA parameters as explanatory variables at 1 week before delivery, CGA alone was shown to be an independent predictor of induction of labor (OR = 6.1, 95 % CI 2.3-16.2). CONCLUSION: The present study suggests that in the late third trimester, evaluation of CGA with transvaginal ultrasonography is most useful in predicting the necessity of induction of labor to prevent post-term delivery.

The expression of glycosaminoglycans and proteoglycans in the uterine cervix of albino rats after local hyaluronidase infusion.

OBJECTIVE: To assess the local effect of hyaluronidase injection on the expression of glycosaminoglycans (GAGs) and proteoglycans (PGs) in the extracellular matrix of the uterine cervix from pregnant albino rats. METHODS: Ten pregnant rats were divided into two groups on day 18 of pregnancy. The experimental group (Gexp) of rats received an intracervical infusion of 0.02 mL of hyaluronidase diluted to 1 mL with distilled water, whereas the control group (Gc) received 1 mL of distilled water. On day 20 of pregnancy, the pregnant rats were sacrificed and the uterine cervixes from all rats were then dissected. The qualitative expression of hyaluronic acid (HA) was assessed by immunohistochemistry and quantified by sandwich ELISA. To compare the quantitative GAG values between groups, a Student's t-test for independent samples was performed. PGs were also assessed by immunohistochemical analysis. RESULTS: The electrophoretic profile of newly synthesized radioactively labeled GAGs degraded by specific enzymes showed that there were two predominant GAGs in both Gc and Gexp, i.e. heparan sulfate (HS) and a mixture of hondroitin sulfate (CS) and dermatan sulfate (DS). The concentrations of GAGs showed a significant reduction of CS/DS (p < 0.004) and HS (p < 0.005) relative to Gc. HA staining was less intense in the lamina propria and area surrounding the blood vessels in Gexp compared to Gc. The HA contents were also significantly reduced (p < 0.012). CONCLUSIONS: Intracervical hyaluronidase infusion promoted a significant reduction in the concentration of sulfated GAGs as assessed by both qualitative (histochemical) and quantitative (fluorometric) measurements of HA.

A comparison of skeletal maturation in patients with tooth agenesis and unaffected controls assessed by the cervical vertebral maturation (CVM) index.

OBJECTIVE: The aims of this study were to (1) investigate if there is a difference in skeletal maturation between tooth agenesis and control patients and (2) whether skeletal maturation is affected by the severity of tooth agenesis. The cervical vertebral maturation (CVM) index can be used to assess skeletal maturation. DESIGN: A retrospective cross-sectional study. SETTING: Eastman Dental Hospital, London, UK. METHODS AND MATERIALS: A total of 360 cephalograms of patients aged 9-17 years (164 males and 196 females) allocated to four subgroups (mild, moderate and severe tooth agenesis patients, and controls) were assessed retrospectively. There were 90 patients in each of the four subgroups. The skeletal maturation of each subject was assessed both quantitatively and qualitatively using the CVM index. All patients in the study were either currently receiving treatment or had been discharged from the hospital. RESULTS: There was no statistically significant relationship between skeletal maturation and the presence of tooth agenesis. Furthermore, there was no statistically significant relationship between the skeletal maturity of patients and different severities of tooth agenesis. CONCLUSIONS: The data obtained from this group of patients and using this measurement tool alone does not supply sufficient reason to reject the null hypothesis. However, it suggests that it is possible that no difference exists between the groups.

Avaliação da relação entre o Padrão II e as fases de maturação das vértebras cervicais / Evaluation of the relation between Standard II and phases of cervical vertebral maturation

Este estudo objetivou prever o melhor momento do crescimento crânio-facial e instituir a terapia mais apropriada para cada caso, seja ela ortodôntica ou ortopédica. É um desafio que vem sendo superado pelos profissionais da Odontologia após a introdução do método de avaliação da idade esquelética através da visualização das vértebras cervicais, utilizando a telerradiografia em norma lateral. Assim, o presente estudo teve o objetivo de avaliar a relação entre o padrão II facial e as fases de maturação óssea das vértebras cervicais C2, C3 e C4, em indivíduos dos sexos masculino e feminino, apresentando padrão II facial, com idades entre 8 e 13 anos, e nas diferentes fases de maturação óssea das vértebras cervicais. A amostra foi formada por 29 telerradiografias em norma lateral de indivíduos sem prévio tratamento ortodôntico ou ortopédico facial. Os resultados mostraram que a discrepância entre os arcos (ANB) é maior quando a fase de maturação óssea das vértebras cervicais é mais precoce, e as demais medidas analisadas (AFAI, CoA, CoGn e SN.GoM) apresentaram variação, atingindo seu valor máximo na fase 6 (finalização). Diante do exposto, conclui-se que, das medidas estudadas, apenas o ângulo da discrepância maxilomandibular (ANB) diminui à proporção que as fases de maturação das vértebras cervicais avançam em direção à finalização.

This article aimed at predicting the best moment of the cranium-facial growth and applying the most appropriate therapy for each case, either orthodontic or orthopedic. This is a challenge which has been overcome by dentistry professionals after the introduction of skeletal age evaluation method through cervical vertebrae visualization using lateral cephalometric radiography. Thus, this study aimed to evaluate the relation between facial pattern II and phases of skeletal maturation of cervical vertebrae C2, C3 and C4, in both gender individuals, age between 8 and 13 years old, in different phases of skeletal maturation of cervical vertebrae. The sample was composed of 29 lateral cephalometric radiographies of individuals without previous facial orthodontic or orthopedic treatment. The results showed that the discrepancy between the arches (ANB) is greater when the phase of skeletal maturation of cervical vertebrae is premature, and the other analyzed measures (AFAI, CoA, CoGn and SN.GoM) showed variation, reaching its maximum value at phase 6 (termination). It was concluded that among the studied measures, only the maxillomandibular discrepancy angle (ANB) decreases on the proportion that the phases of skeletal maturation of cervical vertebrae progress toward termination.