Variation in Cervical Length over Time during a Single Transvaginal Ultrasound Examination.

OBJECTIVE: To quantify the degree of change in cervical length (CL) over a 3-minute transvaginal ultrasound. STUDY DESIGN: We conducted a prospective observational study of nulliparous patients who underwent routine transvaginal CL screening at the time of their second-trimester ultrasound. We recorded CL at four time points (0, 1, 2, 3 minutes) and compared these values to determine the minute-to-minute change within a single patient. RESULTS: A total of 771 patients were included. The mean gestational age was 20.8 weeks (±0.84). We used a linear mixed effect model to assess if each minute during the ultrasound is associated with a change in CL. The intraclass correlation coefficient between minute 0 to minute 3 was 0.82 (95% confidence interval: 0.80, 0.84). This indicates that there is a relatively high within-patient correlation in CL during their ultrasound. Additionally, we stratified patients based on their starting CL; the intraclass correlation coefficient remained high for all groups. We additionally compared CL at each minute. Although there is a statistically significant difference between several time points, the actual difference is small and not clinically meaningful. CONCLUSION: The variation in CL over a 3-minute transvaginal ultrasound examination is not clinically significant. It may be reasonable to conduct this examination over a shorter period.

Cervical Ripening Using Foley Balloon with or without Oxytocin: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess available evidence regarding the use of oxytocin in conjunction with Foley balloon (FB) for cervical ripening. METHODS: Databases from MEDLINE (U.S. National Library of Medicine, 1980-May 12, 2017), MEDLINE (Ovid, 1980-June 30, 2017), the Cochrane Library Controlled Trials Register, ClinicalTrials.gov, and Web of Science were queried for studies on FB cervical ripening with or without oxytocin in pregnant women. Search terms included: "balloon dilatation" OR "mechanical methods" OR "mechanical method" OR "mechanical dilation" OR "mechanical dilatation" OR "mechanical dilations" OR "mechanical dilatations" OR "balloon" OR "Foley" AND "Pitocin" OR "oxytocin." All relevant references were reviewed. Literature for inclusion and methodological quality were reviewed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: Out of 344 citations, six randomized clinical trials (1,133 patients) fulfilled our inclusion criteria. The pooled estimate showed that the cesarean delivery (CD) rate did not differ (relative risk [RR]: 0.91 (95% confidence interval [CI] [0.76-1.10]; p = 0.23) between patients who underwent preinduction cervical ripening with FB alone versus those who received oxytocin in addition to FB. Heterogeneity was not significant among studies (I 2 0.0%; p = 0.64). Furthermore, no differences in other outcomes such as composite and maternal outcomes were detected between these two groups. Compared with simultaneous use of oxytocin with FB, the Foley alone cervical ripening group had a longer induction to delivery time, and lower deliveries within 12 and 24 hours. Subgroup analysis showed that only multiparous women in the Foley alone group had lower rate of vaginal delivery within 24 hours (RR: 0.74, 95% CI [0.61-0.89], p = 0.002) along with a trend toward higher CD rates. CONCLUSION: Adding oxytocin to FB at the time of preinduction cervical ripening does not reduce cesarean rates nor improve maternal or neonatal outcomes. Multiparous women who received FB alone seem to have lower rates of vaginal deliveries within 24 hours, but these results should be interpreted with caution.

A randomized trial of Foley balloon induction of labor trial in nulliparas (FIAT-N).

BACKGROUND: With an increasing rate of induction of labor, it is important to choose induction methods that are safe and efficient in achieving a vaginal delivery. The optimal method for inducing nulliparous women with an unfavorable cervix is not known. OBJECTIVE: We sought to determine if induction of labor with simultaneous use of oxytocin and Foley balloon vs sequential use of Foley balloon followed by oxytocin decreases the time to delivery in nulliparous women. STUDY DESIGN: We conducted a randomized controlled trial of nulliparous women presenting for induction at a single institution from December 2013 through March 2015. After decision for induction was made by their primary provider, women with gestational age ≥24 weeks with a nonanomalous, singleton fetus in vertex presentation with intact membranes were offered participation. Exclusion criteria included history of uterine surgery, unexplained vaginal bleeding, latex allergy, or contraindication to vaginal delivery. Participants were randomized to either simultaneous (oxytocin and Foley balloon) or sequential (oxytocin after expulsion of Foley balloon) induction group. The primary outcome was time from induction to delivery. Secondary outcomes included mode of delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, and composite neonatal outcome. Maternal and neonatal outcomes were collected via chart review. Analyses were done on an intention-to-treat basis. RESULTS: A total of 166 patients were enrolled; 82 in the simultaneous and 84 in the sequential group. There were no differences in baseline characteristics in the 2 groups. Patients who received simultaneous oxytocin with insertion of a Foley balloon delivered significantly earlier (15.92 vs 18.87 hours, P = .004) than those in the sequential group. There was no difference in rate of cesarean delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, or composite neonatal outcome. CONCLUSION: Simultaneous use of oxytocin and Foley balloon for induction of labor results in a significantly shorter interval to delivery in nulliparas.

Pain perception during transabdominal chorionic villus sampling: a randomized trial comparing topical ethyl chloride anesthetic spray and lidocaine injection.

Background: Chorionic villus sampling is an important invasive procedure used for early antenatal genetic testing that can be associated with anxiety and fear of pain. Pain analgesia prior to chorionic villus sampling can be offered with subdermal lidocaine; however, lidocaine injection itself is associated with pain. Our objective was to determine whether administration of topical ethyl chloride anesthetic spray is associated with decreased pain perception during transabdominal chorionic villus sampling compared to 1% lidocaine subdermal injection.Study design: Women undergoing transabdominal chorionic villus sampling from 10 to 13 weeks and 6 days in an outpatient setting were randomized with equal allocation to either 1% lidocaine injection or topical ethyl chloride anesthetic spray prior to the procedure. Women were asked about their pain on a scale of 0-100 prior to, during, and after the procedure. The primary outcome was pain perception during time of transabdominal chorionic villus sampling as measured on a 100-mm visual analog scale. The secondary outcome was pain immediately after procedure.Results: From October 2016 to June 2017, a total of 120 women were enrolled (63 in the lidocaine injection group and 57 in the topical ethyl chloride anesthetic spray group). Baseline demographic characteristics were similar between groups. During the procedure, patients in the topical ethyl chloride arm demonstrated significantly higher pain scores compared to the lidocaine injection group (median score of 50 mm (interquartile range [IQR]: 40-65) versus 50 mm (IQR: 30-60); p = .03). There was no significant difference in pain scores before or after the procedure.Conclusion: During transabdominal chorionic villus sampling procedures, topical ethyl chloride anesthetic spray is associated with a higher distribution of pain scores as compared to 1% lidocaine subdermal injection, which suggests higher levels of pain.Clinical trial registration: This trial is registered with clinicaltrials.gov (NCT03140293). https://clinicaltrials.gov/ct2/show/NCT03140293?term=NCT03140293&rank=1.

Maternal clinical disease characteristics and maternal and neonatal outcomes in twin and singleton pregnancies with severe preeclampsia.

OBJECTIVE: Based on anecdotal observations, there is concern that severe preeclampsia leads to greater morbidity and mortality for mothers and neonates of twin pregnancies than for mothers and neonates of singleton pregnancies. Because few studies have been done, this study compared maternal disease characteristics and maternal/neonatal clinical outcomes of twin and singleton pregnancies complicated by severe preeclampsia. STUDY DESIGN: An historical cohort study of patients hospitalized at the Mount Sinai Hospital in New York City, NY, USA, from 2006 to 2010, compared 63 twin and 339 singleton pregnancies complicated by severe preeclampsia via chart review. Women were analyzed in two groups: hospitalized ≤34 weeks gestational age (GA) and hospitalized >34 weeks GA. Univariable analysis (using Chi-square test, Fisher's Exact test, Student's t-test, or Wilcoxon Rank-Sum test, as appropriate) then multivariable analysis (using multivariable linear regression or multivariable logistic regression, as appropriate) compared maternal disease characteristics and maternal/neonatal clinical outcomes in twin and singleton pregnancies. RESULTS: Women with twins were older [mean age 34.9 years (standard deviation (SD) 7.9 years) vs. 29.4 years (SD 7.4 years), P-value<.001] and women with singletons had a higher prevalence of chronic hypertension (21% vs. 8%, P=.02) and higher prevalence of history of preeclampsia (13% vs. 2%, P=.006). Women with twins were admitted for severe preeclampsia at an earlier gestational age (GA) [median twin 34.9 weeks GA (interquartile range, IQR, 32.7, 36.1) vs. median singleton 37.1 weeks GA (IQR 35.0, 38.9), P<.001]. Among women presenting ≤34 weeks GA (27 twins; 108 singletons), women with singletons had a higher mean systolic blood pressure (BP) (181.1 vs. 163.5, P<.001), higher mean diastolic BP (108.4 vs. 100.1, P=.002), and higher prevalence of headache (56% vs. 30%, P=.02). Among women presenting >34 weeks GA (36 twins; 231 singletons), women with singletons had a higher prevalence of headache (54% vs. 28%, P=.004). CONCLUSION: Mothers and neonates of twin pregnancies complicated by severe preeclampsia do not appear to have greater morbidity and mortality compared to mothers and neonates of singleton pregnancies complicated by severe preeclampsia.