Clinical outcomes and predictors of response for adalimumab in patients with moderately to severely active ulcerative colitis: a KASID prospective multicenter cohort study

Background/Aims@#This study assessed the efficacy and safety of adalimumab (ADA) and explored predictors of response in Korean patients with ulcerative colitis (UC). @*Methods@#A prospective, observational, multicenter study was conducted over 56 weeks in adult patients with moderately to severely active UC who received ADA. Clinical response, remission, and mucosal healing were assessed using the Mayo score. @*Results@#A total of 146 patients were enrolled from 17 academic hospitals. Clinical response rates were 52.1% and 37.7% and clinical remission rates were 24.0% and 22.0% at weeks 8 and 56, respectively. Mucosal healing rates were 39.0% and 30.1% at weeks 8 and 56, respectively. Prior use of anti-tumor necrosis factor-α (anti-TNF-α) did not affect clinical and endoscopic responses. The ADA drug level was significantly higher in patients with better outcomes at week 8 (P<0.05). In patients with lower endoscopic activity, higher body mass index, and higher serum albumin levels at baseline, the clinical response rate was higher at week 8. In patients with lower Mayo scores and C-reactive protein levels, clinical responses, and mucosal healing at week 8, the clinical response rate was higher at week 56. Serious adverse drug reactions were identified in 2.8% of patients. @*Conclusions@#ADA is effective and safe for induction and maintenance in Korean patients with UC, regardless of prior anti-TNF-α therapy. The ADA drug level is associated with the efficacy of induction therapy. Patients with better short-term outcomes were predictive of those with an improved long-term response.

An Outbreak Associated with Sapovirus GI.3 in an Elementary School in Gyeonggi-do, Korea

On October 4, 2018, an outbreak of gastroenteritis associated with sapovirus occurred among elementary school students in Gyeonggi-do, Korea. Epidemiologic studies were conducted in a retrospective cohort approach. Using self-administered questionnaires, we collected information on symptoms and food items consumed. Of the 999 subjects, 17 developed patients that met the case definition. The main symptom was vomiting (100%), and the symptomatic age was 6-12 years. Positive samples were identified by conventional reverse transcription polymerase chain reaction for sequencing. They were classified into genotype GI.3 by phylogenetic analysis. This is the first report of an outbreak associated with sapovirus GI.3 in Korea.

De novo transcriptome sequencing and gene expression profiling with/without B-chromosome plants of Lilium amabile

Supernumerary B chromosomes were found in Lilium amabile (2n = 2x = 24), an endemic Korean lily that grows in the wild throughout the Korean Peninsula. The extra B chromosomes do not affect the host-plant morphology; therefore, whole transcriptome analysis was performed in 0B and 1B plants to identify differentially expressed genes. A total of 154,810 transcripts were obtained from over 10 Gbp data by de novo assembly. By mapping the raw reads to the de novo transcripts, we identified 7,852 differentially expressed genes (log₂FC > |10|), in which 4,059 and 3,794 were up-and down-regulated, respectively, in 1B plants compared to 0B plants. Functional enrichment analysis revealed that various differentially expressed genes were involved in cellular processes including the cell cycle, chromosome breakage and repair, and microtubule formation; all of which may be related to the occurrence and maintenance of B chromosomes. Our data provide insight into transcriptomic changes and evolution of plant B chromosomes and deliver an informative database for future study of B chromosome transcriptomes in the Korean lily.

Perinatal outcome of twin pregnancies according to maternal age

OBJECTIVE: To investigate the perinatal outcomes of twin pregnancies according to maternal age. METHODS: This is a retrospective cohort study of twin pregnancies delivered ≥24 weeks' gestation at a tertiary academic hospital from 1995 to 2016. Subjects were categorized into 5 groups according to maternal age: < 25, 25–29, 30–34, 35–39, and ≥40 years. Maternal and neonatal outcomes of each maternal age group were analyzed using the Jonckheere-Terpstra test and the linear-by-linear association test. RESULTS: A total of 1,936 twin pregnant women were included, of which 47 (2.4%), 470 (24.3%), 948 (49.0%), 417 (21.5%), and 54 (2.7%) women were aged < 25, 25–29, 30–34, 35–39, and ≥40 years, respectively. Higher maternal age was significantly associated with a higher rate of dichorionic twins and a higher risk of gestational diabetes and placenta previa. However, rates of preterm labor, preterm premature rupture of membranes, cervical incompetence, preterm delivery, preeclampsia, placenta abruption, and cesarean section were not associated with maternal age. Birth weight increased and the rate of admission to the neonatal intensive care unit (NICU) decreased with older maternal age, but other neonatal outcomes did not change with age. Maternal age was significantly associated with a lower rate of NICU admission after controlling for potential confounding factors in multivariable analysis. CONCLUSION: Advanced maternal age in twin pregnancies was associated with increased risk of gestational diabetes, placenta previa, and higher birth weight but a lower rate of NICU admission. However, other outcomes were not significantly associated with maternal age.

An extremely rare case of hand prolapse with preterm premature rupture in the membrane of one twin

The latency in preterm premature rupture of membranes (PPROM) can last for weeks. We describe an extremely rare case of hand prolapse with PPROM that was exposed for 23 days before delivery. The patient had spontaneous PPROM of twin A at 21.4 weeks of gestation with shoulder presentation. The right arm of the fetus eventually protruded out the vagina and the hand was exposed for extended period of time of 23 days until delivery. Daily dressing by applying collagen to dry skin and silicone to keep moisture was done to the protruding hand to prevent dehydration and desquamation of the skin. Prophylactic antibiotics were used and the patient underwent emergent cesarean section due to uncontrolled preterm labor at 25.2 weeks. To the best of our knowledge, this is the first case of hand prolapse of one twin with extended period of latency before delivery.

Reference intervals of thyroid hormones during pregnancy in Korea, an iodine-replete area

BACKGROUND/AIMS: Maternal thyroid dysfunction has been associated with adverse pregnancy outcomes. The purpose of our study was to establish trimester-specific reference intervals for thyroid hormones in pregnant women in Korea, where iodine intake is more than adequate and to examine pregnancy and perinatal outcomes in their offspring. METHODS: Among 459 healthy pregnant women who were screened, we enrolled 417 subjects who had negative results for thyroid autoantibodies. Serum thyroid stimulating hormone (TSH) and free thyroxine were measured using an immunoradiometric assay. Urine iodine concentration was measured using inductively coupled plasma-mass spectrometry in 275 women. Reference ranges of thyroid hormones were determined according to the guidelines of the National Academy of Clinical Biochemistry. Pregnancy and perinatal outcomes were compared according to maternal thyroid function. RESULTS: The reference ranges of serum TSH were 0.03 to 4.24 mIU/L in the first trimester, 0.13 to 4.84 mIU/L in the second trimester, and 0.30 to 5.57 mIU/L in the third trimester. Pregnancy and perinatal outcomes did not vary in mothers with subtle changes in thyroid function. CONCLUSIONS: Trimester-specific thyroid hormone reference intervals in Korean pregnant women differ from those of other countries with different iodine nutrition status and ethnicity. The establishment of population-based, reliable trimester-specific reference intervals is critical for the interpretation of thyroid function in pregnant women to avoid unnecessary tests and treatments.

Prevalence of vaginal microorganisms among pregnant women according to trimester and association with preterm birth

OBJECTIVE: The aim of this study was to investigate the prevalence of abnormal vaginal microorganisms in pregnant women according to trimester, and to determine whether the presence of abnormal vaginal colonization is associated with higher risk of miscarriage or preterm delivery. Furthermore, we analyzed delivery outcomes according to individual microorganism species. METHODS: We included pregnant women who underwent vaginal culture during routine prenatal check-up between January 2011 and June 2016. We compared delivery outcomes according to the presence or absence of abnormal vaginal flora grouped by trimester. RESULTS: This study included 593 singleton pregnancies. We classified participants into 3 groups, according to the trimester in which vaginal culture was performed; 1st trimester (n=221), 2nd trimester (n=138), and 3rd trimester (n=234). Abnormal vaginal colonization rate significantly decreased with advancing trimester of pregnancy (21.7% for 1st, 21.0% for 2nd, 14.5% for 3rd; P=0.048). Abnormal vaginal colonization detected in the 2nd trimester but not in 1st trimester was associated with a significant increase in preterm delivery before 28 weeks of gestation (6.9% vs. 0%; P=0.006). Among abnormal vaginal flora isolated in the 2nd trimester, the presence of Klebsiella pneumonia was identified as significant microorganism associated with preterm delivery before 28 weeks of gestation (50% vs. 0.7% for K. pneumonia; P=0.029). CONCLUSION: There is an association between abnormal vaginal colonization detected in the 2nd trimester and preterm delivery before 28 weeks. K. pneumonia has been identified as the likely causative microorganisms.

Indications and characteristics of obstetric patients admitted to the intensive care unit: a 22-year review in a tertiary care center

OBJECTIVE: Reviewing indications and characteristics of obstetric patients admitted to the intensive care unit (ICU) of a tertiary care center, comparing those patients by time period and place of delivery, and to verify clinical utility of acute physiology and chronic health evaluation (APACHE) II score in ICU-admitted women. METHODS: Retrospective analyses were carried out for parturients admitted to the ICU of our institution from 1994 to 2015. Clinical characteristics were compared between time period (period 1: 1994–2004; period 2: 2005–2015) and place of delivery (our institution and local hospitals). Receiver operating characteristic (ROC) curve analysis was used to evaluate the usefulness of APACHE II score to predict maternal mortality. RESULTS: During 22-year period, 176 women required ICU admission, showing the incidence of 2.2 per 1,000 deliveries. The most common reason for ICU admission was postpartum hemorrhage (56.3%), followed by hypertensive disorders (19.3%), sepsis (3.4%), and pulmonary and amniotic fluid embolism (2.3%). Period 2 showed older maternal age (32.7±4.8 vs. 30.8±4.4 years, P=0.006, higher embolization rate (26.4% vs.1.2%, P < 0.001), and lower hysterectomy rate (30.8% vs. 49.4%, P=0.012). Cases from local hospitals showed significantly higher proportion of postpartum hemorrhage (84.5% vs. 42.2%, P < 0.001). Overall maternal death occurred in 5.1% (9/176) including 6 direct maternal deaths. The APACHE II score showed area under the ROC curve of 0.813 (confidence interval [CI], 0.607–1.000) for prediction of maternal mortality. CONCLUSION: The incidence of obstetric ICU admission was 2.2 per 1,000 deliveries and the most common reason was postpartum hemorrhage followed by hypertensive disorders. APACHE II score could be used to predict mortality in obstetric ICU admission.

Clinical characteristics of pregnancies complicated by congenital myotonic dystrophy

OBJECTIVE: Although the conventional prevalence of myotonic dystrophy is 1:8,000, the prevalence in Korean population was recently reported as 1:1,245. With higher domestic result than expected, we aimed to investigate the clinical characteristics of pregnancies complicated by congenital myotonic dystrophy in our institution. METHODS: We have reviewed 11 paired cases of neonates diagnosed with congenital myotonic dystrophy and their mothers between July 2004 and May 2014, with clinical features including maternal history of infertility, prenatal ultrasonographic findings, and neonatal outcomes. Cytosine-thymine-guanine (CTG) repeat expansion in the myotonic dystrophy protein kinase gene of both neonates and their mothers was also examined. RESULTS: None of mother was aware of their myotonic dystrophy traits before pregnancy. History of infertility followed by assisted reproductive technology accounted for 57.1% (4/7). Distinctive prenatal ultrasonographic finding was severe idiopathic polyhydramnios (66.7%, 4/6) with median amniotic fluid index of 43 (range, 37 to 66). In 37.5% (3/8) cases, decreased fetal movement was evident during prenatal ultrasound examination. For neonatal outcomes, more than half (6/11) were complicated with preterm birth and the proportion of 1-minute Apgar score <4 and 5-minute Apgar score <7 was 44.4% (4/9) and 66.7% (6/9), respectively. Most of neonates were admitted to the neonatal intensive care unit (9/10) because of hypotonia with respiratory problems and there was one infant death. Median number of cytosine-thymine-guanine repeats in mothers and neonates was 400 (range, 166 to 1,000) and 1,300 (range, 700 to 2,000), respectively. CONCLUSION: Our data suggest that severe idiopathic polyhydramnios with decreased fetal movement in pregnant women, especially with a history of infertility, requires differential diagnosis of congenital myotonic dystrophy.

MERS-CoV Infection in a Pregnant Woman in Korea

Middle East respiratory syndrome (MERS) is a lethal respiratory disease — caused by MERS-coronavirus (MERS-CoV) which was first identified in 2012. Especially, pregnant women can be expected as highly vulnerable candidates for this viral infection. In May 2015, this virus was spread in Korea and a pregnant woman was confirmed with positive result of MERS-CoV polymerase chain reaction (PCR). Her condition was improved only with conservative treatment. After a full recovery of MERS, the patient manifested abrupt vaginal bleeding with rupture of membrane. Under an impression of placenta abruption, an emergent cesarean section was performed. Our team performed many laboratory tests related to MERS-CoV and all results were negative. We report the first case of MERS-CoV infection during pregnancy occurred outside of the Middle East. Also, this case showed relatively benign maternal course which resulted in full recovery with subsequent healthy full-term delivery without MERS-CoV transmission.

Clinical outcomes and neurodevelopmental outcome of prenatally diagnosed agenesis of corpus callosum in single center of Korea

OBJECTIVE: With recent advances and frequent use of prenatal ultrasound, the antenatal diagnosis of agenesis of the corpus callosum (ACC) is not rare in obstetrics practices. However, information regarding the long-term neurological outcome remains uncertain. The aim of this study was to investigate clinical outcomes of prenatally diagnosed ACC and to analyze postnatal neurodevelopmental outcomes of ACC neonates born in our single center. METHODS: We retrospectively reviewed 56 cases of prenatally suspected ACC referred to our center. RESULTS: Fifty-six fetuses were diagnosed with ACC, and 12 of those were followed-up in our center until delivery. Of the remaining 44, 7 were delivered after being referred back to the original hospital, 23 were lost to follow-up, and 14 had unknown outcomes. Among all 56, 29 were considered to have isolated ACC and 27 were considered to have non-isolated ACC. Of the 10 live fetuses delivered in our center, four had isolated ACC, three had non-isolated ACC, and the rest had outcomes unrelated to ACC. Neurodevelopmental outcome was followed-up until approximately age 3 years. Of the four with isolated ACC, three (75%) had normal neurodevelopmental outcomes. CONCLUSION: Similar to other studies, the results of our single-center study included positive neurodevelopmental outcomes for those with isolated ACC. However, despite our endeavor to counsel patients with prenatally diagnosed ACC, the delivery rate in our center was quite low. Therefore, larger, multicenter, retrospective studies including long-term neurological development outcomes are crucial and urgently needed to provide better counseling.

Predicting factors for success of vaginal delivery in preterm induction with prostaglandin E₂

OBJECTIVE: To evaluate the efficacy and safety of prostaglandin (PG) E₂ for preterm labor induction and to investigate the predictive factors for the success of vaginal delivery. METHODS: A retrospective cohort study was performed in women (n=155) at 24+0 to 36+6 weeks of gestation who underwent induction of labor using a PGE₂ vaginal pessary (10 mg, Propess) from January 2009 to December 2015. Success rates of vaginal delivery according to gestational age at induction and incidence of intrapartum complications such as tachysystole and nonreassuring fetal heart rate were investigated. Multivariable logistic regression analysis was performed to evaluate the predictive factors for success of labor induction. RESULTS: The vaginal delivery rate was 57% (n=89) and the rate of cesarean delivery after induction was 43% (n=66). According to gestational age, labor induction was successful in 16.7%, 50.0%, and 62.8% of patients at 24 to 31, 32 to 33, and 34 to 36 weeks, showing a stepwise increase (P=0.006). There were 18 cases (11%) of fetal distress, 9 cases (5.8%) of tachysystole, and 6 cases (3.8%) of massive postpartum bleeding (>1,000 mL). After adjusting for confounding factors, multiparity (odds ratio [OR], 8.47; 95% confidence interval [CI], 3.10 to 23.14), younger maternal age (OR, 0.84; 95% CI, 0.75 to 0.94), advanced gestational age at induction (OR, 1.06; 95% CI, 1.02 to 1.09), rupture of membranes (OR, 11.83; 95% CI, 3.55 to 39.40), and the Bishop score change after removal of PGE₂ (OR, 2.19; 95% CI, 1.0 to 4.8) were significant predictors of successful preterm vaginal delivery. CONCLUSION: An understanding of the principal predictive factors of successful preterm labor induction, as well as the safety of PGE₂, will provide useful information when clinicians consult with preterm pregnant women requiring premature delivery.

Determination of the Main Theme and Tasks for an Obesity Educator Training Program

After discussion about the need to develop an obesity educator training program and certification for obesity educators, the Education Committee of the Korean Society for the Study of Obesity has developed and determined the main theme for the Obesity Educator Training Program implemented as a workshop and public hearing. We reviewed the process of the determination of the main theme and discuss topics such as subjects, operation of the program, and certification processing to design a credible obesity educator training program.

Hepatic infarction in a pregnant woman with antiphospholipid syndrome and triple antibody positivity: A case report focusing on catastrophic antiphospholipid syndrome

Pregnant women with antiphospholipid syndrome (APS) carry a high risk of arterial or venous thrombosis. Such thrombotic conditions occur more frequently in patients with triple positivity to antiphospholipid antibodies or with high antibody titers. Hepatic infarction is a rare complication in pregnant women with APS, and it sometimes mimics HELLP syndrome. This report describes a preeclamptic pregnant woman with APS who had high titers of three antiphospholipid antibodies. She experienced severe epigastric pain with elevated liver enzymes; in addition, she had tachycardia and tachypnea. The clinical findings suggested hepatic infarction and pulmonary thromboembolism, a partial manifestation of catastrophic APS. Therefore, she underwent emergent cesarean section at 25+2 weeks of gestation. After the delivery, her laboratory test indicated HELLP-like features, and computed tomography confirmed hepatic infarction and pulmonary micro-thromboembolism. Here, we report a case of a partial manifestation of catastrophic APS in a pregnant woman with triple antibody positivity, including a brief literature review.

Hepatic infarction in a pregnant woman with antiphospholipid syndrome and triple antibody positivity: A case report focusing on catastrophic antiphospholipid syndrome

Pregnant women with antiphospholipid syndrome (APS) carry a high risk of arterial or venous thrombosis. Such thrombotic conditions occur more frequently in patients with triple positivity to antiphospholipid antibodies or with high antibody titers. Hepatic infarction is a rare complication in pregnant women with APS, and it sometimes mimics HELLP syndrome. This report describes a preeclamptic pregnant woman with APS who had high titers of three antiphospholipid antibodies. She experienced severe epigastric pain with elevated liver enzymes; in addition, she had tachycardia and tachypnea. The clinical findings suggested hepatic infarction and pulmonary thromboembolism, a partial manifestation of catastrophic APS. Therefore, she underwent emergent cesarean section at 25+2 weeks of gestation. After the delivery, her laboratory test indicated HELLP-like features, and computed tomography confirmed hepatic infarction and pulmonary micro-thromboembolism. Here, we report a case of a partial manifestation of catastrophic APS in a pregnant woman with triple antibody positivity, including a brief literature review.

Emergency cesarean section in an epidemic of the middle east respiratory syndrome: a case report / 대한마취과학회지

Only a few reports have been published on women with an infectious respiratory viral pathogen, such as Middle East Respiratory Syndrome (MERS) Coronavirus delivering a baby. A laboratory confirmed case of MERS was reported during a MERS outbreak in the Republic of Korea in a woman at gestational week 35 + 4. She recovered, and delivered a healthy baby by emergency cesarean section (C-sec). We present the clinical course and the emergency C-sec in a pregnant woman with MERS.

How high is too high in cutoff levels from 50-g glucose challenge test

OBJECTIVE: To determine the highest 50-g glucose challenge test (GCT) value that indicates no further diagnostic test is needed to confirm a diagnosis of gestational diabetes mellitus (GDM) under the criteria of National Diabetes Data Group (NDDG) or the Carpenter and Coustan (C&C) and fasting glucose thresholds from the International Association of Diabetes and Pregnancy Study Group (IADPSG). METHODS: We collected the 50-g GCT results from 16,560 pregnancies and identified 2,457 gravidas with positive 50-g GCT (≥130 mg/dL) values who underwent the 100-g glucose tolerance test. We investigated GDM prevalence in pregnancies with positive 50-g GCT according to the respective diagnostic thresholds and determined the 50-g GCT cutoff values with 100% positive predictive value for GDM under each diagnostic threshold. RESULTS: Twelve point five percent (306/2,457), 20.0% (492/2,457), and 9.6% (235/2,457) met the diagnostic criteria of GDM with the application of NDDG, C&C criteria, and fasting glucose thresholds from IADPSG (≥92 mg/dL), respectively. We also found that the prevalence of GDM increased with increasing 50-g GCT values using each diagnostic criterion. Importantly, we identified that all subjects with a 50-g GCT value ≥223, ≥217, or ≥228 mg/dL can be exclusively diagnosed as having gestational diabetes according to the criteria of NDDG, C&C, and fasting glucose thresholds from IADPSG, respectively. CONCLUSION: We propose that women with a 50-g GCT screening value ≥228 mg/dL can be reliably omitted from further confirmative tests for GDM, such as 100- or 75-g glucose tolerance test.

Usefulness of the Forrest Classification to Predict Artificial Ulcer Rebleeding during Second-Look Endoscopy after Endoscopic Submucosal Dissection

BACKGROUND/AIMS: Delayed post-endoscopic submucosal dissection (ESD) bleeding (DPEB) is difficult to predict and there is controversy regarding the usefulness of prophylactic hemostasis during second-look endoscopy. This study evaluated the risk factors related to DPEB, the relationship between clinical outcomes and the Forrest classification, and the results of prophylactic hemostasis during second-look endoscopy. METHODS: Second-look endoscopy was performed on the day after ESD to check for recent hemorrhage or potential bleeding and the presence of artificial ulcers in all patients. RESULTS: DPEB occurred in 42 of 581 patients (7.2%). Multivariate analysis determined that a specimen size ≥40 mm (odds ratio [OR], 3.03; p=0.003), and a high-risk Forrest classification (Forrest Ib+IIa+IIb; OR, 6.88; p<0.001) were risk factors for DPEB. DPEB was significantly more likely in patients classified with Forrest Ib (OR, 24.35; p<0.001), IIa (OR, 12.91; p<0.001), or IIb (OR, 8.31; p<0.001) ulcers compared with Forrest III ulcers. There was no statistically significant difference between the prophylactic hemostasis and non-hemostasis groups (Forrest Ib, p=0.938; IIa, p=0.438; IIb, p=0.397; IIc, p=0.773) during second-look endoscopy. CONCLUSIONS: The Forrest classification of artificial gastric ulcers during second-look endoscopy seems to be a useful tool for predicting delayed bleeding. However, routine prophylactic hemostasis during second-look endoscopy seemed to not be useful for preventing DPEB.

Gestational age at delivery and neonatal outcome in uncomplicated twin pregnancies: what is the optimal gestational age for delivery according to chorionicity?

OBJECTIVE: To investigate the neonatal outcome according to the gestational age at delivery and to determine the optimal timing for delivery in uncomplicated monochorionic and dichorionic twin pregnancies. METHODS: This is a retrospective cohort study of women with uncomplicated twin pregnancies delivered at or beyond 35 weeks of gestation from 1995 to 2013. The primary outcome was neonatal composite morbidity, which was defined as when either one or both twins have one or more of the followings: fetal death after 35 weeks gestation, admission to neonatal intensive care unit, mechanical ventilator requirement, respiratory distress syndrome and neonatal death. To determine the optimal gestational age for delivery according to chorionicity, we compared the neonatal composite morbidity rate between women who delivered and women who remained undelivered at each gestational week in both monochorionic and dichorionic twin pregnancies. RESULTS: A total of 697 twin pregnancies were included (171 monochorionic and 526 dichorionic twins). The neonatal composite morbidity rate significantly decreased with advancing gestational age at delivery and its nadir was observed at 38 and > or =39 weeks of gestation in monochorionic and dichorionic twins, respectively. However, the composite morbidity rate did not differ between women who delivered and women who remained undelivered > or =36 and > or =37 weeks in monochorionic and dichorionic twins, respectively. CONCLUSION: Our data suggest that the optimal gestational age for delivery was at > or =36 and > or =37 weeks in uncomplicated monochorionic and dichorionic twin pregnancies, respectively.

Post-cerclage ultrasonographic cervical length can predict preterm delivery in elective cervical cerclage patients

OBJECTIVE: To evaluate the usefulness of transvaginal ultrasound measurements of cervical length before and after elective prophylactic cervical cerclage in predicting preterm delivery before 32 weeks of gestation. METHODS: Women who underwent an elective cerclage operation at 14 to 19 weeks of gestation and who delivered between January 2004 and December 2009 were enrolled in this study (n=52). Ultrasonography was performed to measure cervical length before and after cerclage. The primary outcome was defined as preterm delivery before 32 weeks of gestation. A receiver operating characteristic curve was used to determine the most discriminating cut-off values of ultrasonographic cervical parameters predictive of preterm delivery before 32 weeks of gestation. RESULTS: Among the 52 patients studied, ten delivered before 32 weeks of gestation. Among the ultrasonographic cervical parameters compared, only the cervical length after cerclage was significantly different (shorter) in patients who delivered before 32 weeks of gestation (P=0.037) compared to that of those who delivered after 32 weeks of gestation in univariate and multivariate analyses (odds ratio, 0.402; 95% confidence interval, 0.174 to 0.925; P=0.021). The receiver operating characteristic curve showed that a cervical length of 25 mm or less after cerclage was predictive of preterm delivery before 32 weeks of gestation (area under curve, 0.71; 95% confidence interval, 0.56 to 0.87; P=0.029) with a sensitivity of 91.0% and a specificity of 30.0%. CONCLUSION: Patients with a cervical length less than 25 mm after elective cerclage may be at higher risk of preterm delivery before 32 weeks of gestation.