Cervical Length as a Predictor of Preterm Delivery in an Unselected Cohort of Women with Twin Pregnancies.

OBJECTIVE: To determine the risk of spontaneous preterm delivery (SPTD) associated with transvaginal cervical length (TVCL) in an unselected cohort. STUDY DESIGN: This is a retrospective study of serial TVCLs in unselected twin gestations. Receiver operator curves for SPTD were constructed from TVCLs at 18, 20, 22, and 24 weeks. Prediction thresholds were determined using a false discovery rate of 10%. The risk of SPTD was compared with previously published, prospective data from a meta-analysis. RESULTS: A total of 1,228 women were included. SPTD occurred prior to 35 weeks in 232 (18.9%), 126 (10.3%), and 24 (2.0%) women prior to 35, 32, and 28 weeks. TVCL was most predictive at 22 weeks (area under the curve = 0.67). TVCL thresholds for predicting SPTD prior to 35, 32, and 28 weeks were 3.1, 3.0, and 2.9 cm. Compared with a previous meta-analysis, the risk of SPTD < 34, 32, and 28 weeks was lower (positive likelihood ratio 9.0 vs. 5.4, 10.1 vs. 5.9, and 9.6 vs. 4.3). CONCLUSION: TVCL is modestly predictive of SPTD in twin gestations. Compared with previous prospective studies, this cohort has lower risk of SPTD at similar TVCLs.

Association between change in cervical length and spontaneous preterm birth in twin pregnancies.

BACKGROUND: There is a lack of consensus on the optimal transvaginal cervical length for determining risk for spontaneous preterm birth in twin pregnancies. Change in transvaginal cervical length over time may reflect early activation of the parturition process, as has been demonstrated in singleton pregnancies. The association between change in transvaginal cervical length and the risk for spontaneous preterm birth has not yet been described in the population of women with diamniotic twin pregnancies. OBJECTIVE: Our primary objective is to determine whether rate of change in transvaginal cervical length in the midtrimester is associated with spontaneous preterm birth in twin gestations. Our secondary objective is to describe parameters for identifying patients at increased risk for spontaneous preterm birth based on change in transvaginal cervical length over time. STUDY DESIGN: This is a retrospective cohort of serial transvaginal cervical length performed for twin pregnancies at a single institution from 2008 through 2015. Women with diamniotic twin pregnancies who had transvaginal cervical length measurements at 18 and 22 weeks' gestation and outcome data available were included. Logistic regression was used to determine the relationship between the rate of change in transvaginal cervical length and the risk for the primary outcome of spontaneous preterm birth <35 weeks as well as spontaneous preterm birth <32 weeks. RESULTS: In all, 527 subjects met inclusion criteria for this study. The average rate of change in transvaginal cervical length for patients with spontaneous preterm birth <35 weeks was -0.21 cm/wk (SD 0.27) vs -0.10 cm/wk (SD 0.24) for patients who delivered ≥35 weeks (P < .01). The rate of change in transvaginal cervical length was associated with spontaneous preterm birth <35 weeks when controlling for initial transvaginal cervical length and other important risk factors for spontaneous preterm birth. Results for spontaneous preterm birth <32 weeks were similar. This association remained significant when the rate of weekly change was treated as a dichotomous variable based on an apparent inflection point in the risk for spontaneous preterm birth: women with rapid change in transvaginal cervical length, ≥-0.2 cm/wk, had 3.45 times the odds of spontaneous preterm birth as those with less rapid change (95% confidence interval, 2.15-5.52) when controlling for initial transvaginal cervical length. CONCLUSION: Change in transvaginal cervical length in the midtrimester is associated with spontaneous preterm birth, and therefore protocols for serial transvaginal cervical length measurement can provide the clinician with information to identify at-risk patients. A decrease of ≥0.2 cm/wk of transvaginal cervical length identifies patients at increased risk for spontaneous preterm birth <35 weeks.

Rate of sonographic cervical shortening and biologic pathways of spontaneous preterm birth.

OBJECTIVE: The objective of the study was to estimate the relationship between midtrimester cervical length (CL) and maternal serum markers of systemic inflammation, activation of the maternal-fetal hypothalamic-pituitary axis, and alterations in thrombosis-hemostasis. STUDY DESIGN: This is a secondary analysis of a prospective cohort study designed to predict preterm birth in the general obstetric population. Women had serial CL ultrasounds and assessment of maternal serum corticotrophin-releasing hormone, C-reactive protein, and thrombin-antithrombin III complexes between 20 and 33 weeks' gestation and were followed up until delivery. RESULTS: Shortening of CL was associated with the rate of rise in corticotrophin-releasing hormone (r(2) = 0.34, P = .014) and C-reactive protein (r(2) = 0.44, P = .001) for women with CL less than 25 mm but not for the cohort overall. There was no association of change in CL with change in thrombin-antithrombin III concentration. CONCLUSION: Among women with a midtrimester sonographically short cervix, changes in serum markers suggest that a shortening CL may be associated with systemic inflammation and activation of the maternal-fetal hypothalamic-pituitary axis but not systemic thrombosis-hemostasis.

Rate of sonographic cervical shortening and the risk of spontaneous preterm birth.

OBJECTIVE: We hypothesized that change in cervical length (CL) on serial ultrasounds is associated with spontaneous preterm birth (SPTB) <36 weeks for women with a short cervix (CL <25 mm). STUDY DESIGN: This was a secondary analysis of a multicenter prospective observational study designed to study predictors of preterm birth. Women from the general obstetric population had serial CL ultrasounds between 20-33 weeks' gestation and were followed up until delivery. RESULTS: Two thousand six hundred ninety five women had sonographic CL measurements. Change in CL was associated with SPTB for women with CL <25 mm (odds ratio, 0.97; 95% confidence interval, 0.96-0.98). Among women with a short cervix, for every 1 mm of cervical shortening between ultrasounds, there was a 3% increase in odds of SPTB. The association between change in CL and SPTB remained significant after controlling for age, race, body mass index, tobacco use, and fetal fibronectin test status. CONCLUSION: Among women with a sonographically short cervix, the rate of change in CL is associated with SPTB, independent of fetal fibronectin test and other important risk factors for SPTB.

Pulmonary embolism management in the critical care setting.

The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE. This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk. The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE.1 This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk.

Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes.

OBJECTIVE: We aimed to determine whether obstetrician-gynecologists provided postpartum type 2 diabetes mellitus screening for women with a history of gestational diabetes. STUDY DESIGN: We identified women diagnosed with gestational diabetes, and then assessed whether obstetrician-gynecologists provided postpartum diabetes mellitus screening by ordering American Diabetes Association-recommended glucose tests or by referring women to primary care physicians for such testing. RESULTS: Of 2617 gravid women with a 1-hour glucose challenge test, 90 had gestational diabetes and postpartum follow-up. Only 20.0% (18/90) of women with a history of gestational diabetes had documented orders from obstetrician-gynecologists for American Diabetes Association-recommended postpartum diabetes mellitus screening tests. Even when we broadened our definition of "providing postpartum diabetes mellitus screening" to also include referrals to primary care physicians, only 33.3% (30/90) of women met such criteria. CONCLUSION: Obstetrician-gynecologists at an academic medical center did not provide postpartum diabetes mellitus screening for 66.7% of women with a history of gestational diabetes.

Management of severe hypertension in pregnancy.

While hemorrhage is the leading cause of maternal death in most of the world, hypertensive disorders of pregnancy are the leading cause of maternal mortality in the United States. The opportunity to improve outcomes lies in timely and appropriate response to severe hypertension. The purpose of this article is to review the diagnostic criteria for severe hypertension, choice of antihypertensive agents, and recommended algorithms for evaluation and management of acute changes in clinical status. Adhering to standard practices ensures that care teams can timely and appropriate care to these high risk patients. With heightened surveillance and prompt evaluation of signs and symptoms of worsening hypertension, maternal morbidity and mortality can be decreased.