Clinical significance of soft markers in second trimester ultrasonography for pregnant Korean women: a multicenter study and literature review

Objective@#To evaluate the clinical significance of soft markers for aneuploidy screening in Korean women. @*Methods@#We retrospectively reviewed the medical records of 5,428 singleton pregnant women who underwent sonography during the second trimester at seven institutions in South Korea. We evaluated the prevalence of the following soft markers: intracardiac echogenic focus, choroid plexus cysts, pyelectasis, echogenic bowel, and mild ventriculomegaly. We developed best-fitted regression equations for the fetal femur and humerus length using our data and defined a short femur and humerus as both long bones below the fifth centile. The results of genetic testing and postnatal outcomes were investigated in patients who had been diagnosed with aforementioned soft markers. @*Results@#The median maternal age of our study population was 33 years, and the median gestational age at the time of ultrasonographic examination was 21 weeks. We detected soft markers in 10.0% (n=540) of fetuses: 9.3% (n=504) were isolated cases and 0.7% (n=36) of cases had two or more markers. We identified only two aneuploides (trisomy 18, 46,XX,t[8;10][q22.1;p13]), of which one was clinically significant. We presented the neonatal outcomes of the fetuses with the respective soft markers. Preterm delivery, low birth weight, and small-for-gestational-age (SGA) were significantly more common in women with a shortened fetal femur (P<0.001, all). However, the presence of a shortened fetal humerus was not associated with those outcomes excluding SGA. @*Conclusion@#Soft markers in second-trimester ultrasonography have limited use in screening for fetal aneuploidy in Korean women. However, these markers can be used as a screening tool for adverse outcomes other than chromosomal abnormality.

Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass

During routine antenatal ultrasound examinations, an ovarian mass can be found incidentally. In clinical practice, the differential diagnosis between benign and malignant ovarian masses is essential for planning further management. Ultrasound imaging has become the most popular diagnostic tool during pregnancy, with the recent development of ultrasonography. In non-pregnant women, several methods have been used to predict malignant ovarian masses before surgery. The International Ovarian Tumor Analysis (IOTA) group reported several scoring systems, such as the IOTA simple rules, IOTA logistic regression models, and IOTA assessment of different NEoplasias in the adneXa. Other researchers have also evaluated the malignancy of ovarian masses before surgery using scoring systems such as the Sassone score, pelvic mass score, DePriest score, Lerner score, and Ovarian-Adnexal Reporting and Data System. These researchers suggested specific features of ovarian masses that can be used for differential diagnosis, including size, proportion of solid tissue, papillary projections, inner wall structure, locules, wall thickness, septa, echogenicity, acoustic shadows, and presence of ascites. Although these factors can also be measured in pregnant women using ultrasound, only a few studies have applied ovarian scoring systems in pregnant women. In this article, we reviewed various scoring systems for predicting malignant tumors of the ovary and determined whether they can be applied to pregnant women.

Clinical Practice Guidelines for Prenatal Aneuploidy Screening and Diagnostic Testing from Korean Society of Maternal-Fetal Medicine:(2) Invasive Diagnostic Testing for Fetal Chromosomal Abnormalities

The Korean Society of Maternal Fetal Medicine proposed the first Korean guideline on prenatal aneuploidy screening and diagnostic testing, in April 2019. The clinical practice guideline (CPG) was developed for Korean women using an adaptation process based on good-quality practice guidelines, previously developed in other countries, on prenatal screening and invasive diagnostic testing for fetal chromosome abnormalities. We reviewed current guidelines and developed a Korean CPG on invasive diagnostic testing for fetal chromosome abnormalities according to the adaptation process. Recommendations for selected 11 key questions are: 1) Considering the increased risk of fetal loss in invasive prenatal diagnostic testing for fetal genetic disorders, it is not recommended for all pregnant women aged over 35 years. 2) Because early amniocentesis performed before 14 weeks of pregnancy increases the risk of fetal loss and malformation, chorionic villus sampling (CVS) is recommended for pregnant women who will undergo invasive prenatal diagnostic testing for fetal genetic disorders in the first trimester of pregnancy. However, CVS before 9 weeks of pregnancy also increases the risk of fetal loss and deformity. Thus, CVS is recommended after 9 weeks of pregnancy. 3) Amniocentesis is recommended to distinguish true fetal mosaicism from confined placental mosaicism. 4) Anti-immunoglobulin should be administered within 72 hours after the invasive diagnostic testing. 5) Since there is a high risk of vertical transmission, an invasive prenatal diagnostic testing is recommended according to the clinician's discretion with consideration of the condition of the pregnant woman. 6) The use of antibiotics is not recommended before or after an invasive diagnostic testing. 7) The chromosomal microarray test as an alternative to the conventional cytogenetic test is not recommended for all pregnant women who will undergo an invasive diagnostic testing. 8) Amniocentesis before 14 weeks of gestation is not recommended because it increases the risk of fetal loss and malformation. 9) CVS before 9 weeks of gestation is not recommended because it increases the risk of fetal loss and malformation. 10) Although the risk of fetal loss associated with invasive prenatal diagnostic testing (amniocentesis and CVS) may vary based on the proficiency of the operator, the risk of fetal loss due to invasive prenatal diagnostic testing is higher in twin pregnancies than in singleton pregnancies. 11) When a monochorionic twin is identified in early pregnancy and the growth and structure of both fetuses are consistent, an invasive prenatal diagnostic testing can be performed on one fetus alone. However, an invasive prenatal diagnostic testing is recommended for each fetus in cases of pregnancy conceived via in vitro fertilization, or in cases in which the growth of both fetuses differs, or in those in which at least one fetus has a structural abnormality. The guidelines were established and approved by the Korean Academy of Medical Sciences. This guideline is revised and presented every 5 years.

Clinical Practice Guidelines for Prenatal Aneuploidy Screening and Diagnostic Testing from Korean Society of Maternal-Fetal Medicine:(1) Prenatal Aneuploidy Screening

In 2019, the Korean Society of Maternal-Fetal Medicine developed the first Korean clinical practice guidelines for prenatal aneuploidy screening and diagnostic testing. These guidelines were developed by adapting established clinical practice guidelines in other countries that were searched systematically, and the guidelines aim to assist in decision making of healthcare providers providing prenatal care and to be used as a source for education and communication with pregnant women in Korea. This article delineates clinical practice guidelines specifically for maternal serum screening for fetal aneuploidy and cell-free DNA (cfDNA) screening. A total of 19 key questions (12 for maternal serum and 7 for cfDNA screening) were defined. The main recommendations are: 1) Pregnant women should be informed of common fetal aneuploidy that can be detected, risks for chromosomal abnormality according to the maternal age, detection rate and false positive rate for common fetal aneuploidy with each screening test, limitations, as well as the benefits and risks of invasive diagnostic testing, 2) It is ideal to give counseling about prenatal aneuploidy screening and diagnostic testing at the first prenatal visit, and counseling is recommended to be given early in pregnancy, 3) All pregnant women should be informed about maternal serum screening regardless of their age, 4) cfDNA screening can be used for the screening of trisomy 21, 18, 13 and sex-chromosome aneuploidy. It is not recommended for the screening of microdeletion, 5) The optimal timing of cfDNA screening is 10 weeks of gestation and beyond, and 6) cfDNA screening is not recommended for women with multiple gestations. The guideline was reviewed and approved by the Korean Academy of Medical Sciences.

Management of isolated oligohydramnios in Korea: a questionnaire-based study of clinical practice patterns among the members of the Korean Society of Maternal Fetal Medicine

Objective@#The aim of this survey was to investigate the recommendations and clinical practice patterns of the Korean Society of Maternal and Fetal Medicine (KSMFM) members, regarding management of isolated oligohydramnios (IO). @*Methods@#From December 2018 to February 2019, questionnaires were e-mailed to the KSMFM members at 257 institutes that are listed by the Korean Statistical Information Services (KOSIS) as suitable labor premises. Responses to the seven questions on the management of IO, from diagnosis to treatment, were evaluated. @*Results@#A total of 72 KSMFM members responded to this survey. Nearly all participants (90.1%) used the amniotic fluid index (AFI) as the primary method for estimating amniotic fluid volume. The majority of the participants (73.6%) believed that IO was a risk factor for adverse pregnancy outcomes, including abnormal fetal heart rate (73.6%), need for cesarean delivery (58.3%), intrauterine fetal demise (52.8%), and meconium aspiration syndrome (50%). Almost 70% of the participants believed that induction of labor might decrease perinatal morbidities, and that late-preterm to early-term period (36–38 gestational weeks) was a suitable timeframe for delivery, if the fetus was sufficiently grown and antenatal testing revealed reassuring results. Less than half of the participants (47.2%) believed that maternal oral or intravenous hydration was a useful intervention for IO management. @*Conclusions@#KSMFM members preferred labor induction at late-preterm to early-term, to decrease perinatal morbidity in cases of IO, although it was still uncertain whether labor induction improved the outcomes. Further prospective studies are needed regarding IO management.

Cervicovaginal fluid cytokines as predictive markers of preterm birth in symptomatic women

Objective@#Here, we investigated whether cytokines in the cervicovaginal fluid (CVF) can be predictive markers of preterm birth (PTB). @*Methods@#A multi-center prospective cohort study was conducted on 59 singleton pregnant women hospitalized for preterm labor (PTL) and/or preterm premature rupture of membranes (pPROM) between 22 weeks and 36 weeks 6 days of gestation from 2014 to 2015. The levels of 13 inflammatory cytokines (macrophage inflammatory protein [MIP]-1α, MIP-1β, tumor necrosis factor [TNF]-α, interleukin [IL]-1β, IL-6, IL-8, IL-17α, granulocyte colony stimulating factor [G-CSF], IL-7, IL-4, IL-5, IL-10, and IL-13) were measured using a multiplex bead-based immunoassay and that of fetal fibronectin (fFN) was measured using enzyme-linked immunosorbent assay (ELISA). Statistical analyses were performed using Student’s t-test, Mann-Whitney U test, Pearson’s correlation, and receiver operating characteristic (ROC) curve analysis in SPSS version 20.0. @*Results@#Among the 13 cytokines assessed, the levels of 3 cytokines (MIP-1α, IL-6, and IL-7) were negatively correlated with gestational age at delivery (P=0.028, P=0.002, and P=0.018, respectively). Sensitivities of MIP-1α, IL-6, and IL-17α were 70%, 80%, and 75%, respectively, and their specificities were 57%, 65%, and 69%, respectively. The sensitivity and specificity of fFN were 33% and 95%, respectively. @*Conclusion@#In symptomatic women diagnosed with PTL and/or pPROM, cytokines from cervicovaginal fluid, especially IL-6 and IL-17α, could be better predictive markers of PTB than fFN.

Evaluation of maternal rhesus blood type as a risk factor in adverse pregnancy outcomes in Korea: a nationwide health insurance database study

Objectives@#The current study aimed to investigate whether pregnancy outcomes are affected by maternal rhesus (Rh) status by comparing the primigravida pregnancy outcomes of Rh-negative women with those of Rh-positive women. @*Methods@#The study data were collected from the Korea National Health Insurance Claims Database and the National Health Screening Program for Infants and Children. In total, 1,664,882 primigravida women who gave birth between January 1, 2007 and December 31, 2014, were enrolled in this study. As the risk and severity of sensitization response increases with each subsequent pregnancy, only primigravida women were enrolled. The patients were divided into 2 groups according to Rh status, and the pregnancy outcomes were compared. @*Results@#In total, 1,661,320 women in the Rh-positive group and 3,290 in the Rh-negative group were assessed. With regard to adverse pregnancy outcomes, there was no statistically significant difference between the 2 groups in terms of the prevalence of preeclampsia, postpartum hemorrhage, abruptio placenta, placenta previa, and uterine artery embolization. A univariate analysis revealed that none of the adverse pregnancy outcomes were significantly correlated to Rh status (preeclampsia: odds ratio [OR], 1.00, 95% confidence interval [CI], 0.81–1.23; postpartum hemorrhage: OR, 1.10, 95% CI, 0.98–1.24; abruptio placenta: OR, 0.80, 95% CI, 0.46–1.37; and placenta previa: OR, 1.08, 95% CI, 0.78–1.42). The adjusted ORs of postpartum hemorrhage and preterm birth did not significantly differ. @*Conclusion@#Maternal Rh status is not associated with adverse outcomes in primigravida women.

Management of isolated oligohydramnios in Korea: a questionnaire-based study of clinical practice patterns among the members of the Korean Society of Maternal Fetal Medicine

Objective@#The aim of this survey was to investigate the recommendations and clinical practice patterns of the Korean Society of Maternal and Fetal Medicine (KSMFM) members, regarding management of isolated oligohydramnios (IO). @*Methods@#From December 2018 to February 2019, questionnaires were e-mailed to the KSMFM members at 257 institutes that are listed by the Korean Statistical Information Services (KOSIS) as suitable labor premises. Responses to the seven questions on the management of IO, from diagnosis to treatment, were evaluated. @*Results@#A total of 72 KSMFM members responded to this survey. Nearly all participants (90.1%) used the amniotic fluid index (AFI) as the primary method for estimating amniotic fluid volume. The majority of the participants (73.6%) believed that IO was a risk factor for adverse pregnancy outcomes, including abnormal fetal heart rate (73.6%), need for cesarean delivery (58.3%), intrauterine fetal demise (52.8%), and meconium aspiration syndrome (50%). Almost 70% of the participants believed that induction of labor might decrease perinatal morbidities, and that late-preterm to early-term period (36–38 gestational weeks) was a suitable timeframe for delivery, if the fetus was sufficiently grown and antenatal testing revealed reassuring results. Less than half of the participants (47.2%) believed that maternal oral or intravenous hydration was a useful intervention for IO management. @*Conclusions@#KSMFM members preferred labor induction at late-preterm to early-term, to decrease perinatal morbidity in cases of IO, although it was still uncertain whether labor induction improved the outcomes. Further prospective studies are needed regarding IO management.

Cervicovaginal fluid cytokines as predictive markers of preterm birth in symptomatic women

Objective@#Here, we investigated whether cytokines in the cervicovaginal fluid (CVF) can be predictive markers of preterm birth (PTB). @*Methods@#A multi-center prospective cohort study was conducted on 59 singleton pregnant women hospitalized for preterm labor (PTL) and/or preterm premature rupture of membranes (pPROM) between 22 weeks and 36 weeks 6 days of gestation from 2014 to 2015. The levels of 13 inflammatory cytokines (macrophage inflammatory protein [MIP]-1α, MIP-1β, tumor necrosis factor [TNF]-α, interleukin [IL]-1β, IL-6, IL-8, IL-17α, granulocyte colony stimulating factor [G-CSF], IL-7, IL-4, IL-5, IL-10, and IL-13) were measured using a multiplex bead-based immunoassay and that of fetal fibronectin (fFN) was measured using enzyme-linked immunosorbent assay (ELISA). Statistical analyses were performed using Student’s t-test, Mann-Whitney U test, Pearson’s correlation, and receiver operating characteristic (ROC) curve analysis in SPSS version 20.0. @*Results@#Among the 13 cytokines assessed, the levels of 3 cytokines (MIP-1α, IL-6, and IL-7) were negatively correlated with gestational age at delivery (P=0.028, P=0.002, and P=0.018, respectively). Sensitivities of MIP-1α, IL-6, and IL-17α were 70%, 80%, and 75%, respectively, and their specificities were 57%, 65%, and 69%, respectively. The sensitivity and specificity of fFN were 33% and 95%, respectively. @*Conclusion@#In symptomatic women diagnosed with PTL and/or pPROM, cytokines from cervicovaginal fluid, especially IL-6 and IL-17α, could be better predictive markers of PTB than fFN.

Evaluation of maternal rhesus blood type as a risk factor in adverse pregnancy outcomes in Korea: a nationwide health insurance database study

Objectives@#The current study aimed to investigate whether pregnancy outcomes are affected by maternal rhesus (Rh) status by comparing the primigravida pregnancy outcomes of Rh-negative women with those of Rh-positive women. @*Methods@#The study data were collected from the Korea National Health Insurance Claims Database and the National Health Screening Program for Infants and Children. In total, 1,664,882 primigravida women who gave birth between January 1, 2007 and December 31, 2014, were enrolled in this study. As the risk and severity of sensitization response increases with each subsequent pregnancy, only primigravida women were enrolled. The patients were divided into 2 groups according to Rh status, and the pregnancy outcomes were compared. @*Results@#In total, 1,661,320 women in the Rh-positive group and 3,290 in the Rh-negative group were assessed. With regard to adverse pregnancy outcomes, there was no statistically significant difference between the 2 groups in terms of the prevalence of preeclampsia, postpartum hemorrhage, abruptio placenta, placenta previa, and uterine artery embolization. A univariate analysis revealed that none of the adverse pregnancy outcomes were significantly correlated to Rh status (preeclampsia: odds ratio [OR], 1.00, 95% confidence interval [CI], 0.81–1.23; postpartum hemorrhage: OR, 1.10, 95% CI, 0.98–1.24; abruptio placenta: OR, 0.80, 95% CI, 0.46–1.37; and placenta previa: OR, 1.08, 95% CI, 0.78–1.42). The adjusted ORs of postpartum hemorrhage and preterm birth did not significantly differ. @*Conclusion@#Maternal Rh status is not associated with adverse outcomes in primigravida women.

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND@#This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).@*METHODS@#This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.@*RESULTS@#For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.@*CONCLUSION@#Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND: This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).METHODS: This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.RESULTS: For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.CONCLUSION: Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

Standardization of measurement of cervical elastography, its reproducibility, and analysis of baseline clinical factors affecting elastographic parameters

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND@#This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).@*METHODS@#This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.@*RESULTS@#For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.@*CONCLUSION@#Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

Alteration of Genomic Imprinting Status of Human Parthenogenetic Induced Pluripotent Stem Cells during Neural Lineage Differentiation

BACKGROUND AND OBJECTIVES: Genomic imprinting modulates growth and development in mammals and is associated with genetic disorders. Although uniparental embryonic stem cells have been used to study genomic imprinting, there is an ethical issue associated with the destruction of human embryos. In this study, to investigate the genomic imprinting status in human neurodevelopment, we used human uniparental induced pluripotent stem cells (iPSCs) that possessed only maternal alleles and differentiated into neural cell lineages. METHODS: Human somatic iPSCs (hSiPSCs) and human parthenogenetic iPSCs (hPgiPSCs) were differentiated into neural stem cells (NSCs) and named hSi-NSCs and hPgi-NSCs respectively. DNA methylation and gene expression of imprinted genes related neurodevelopment was analyzed during reprogramming and neural lineage differentiation. RESULTS: The DNA methylation and expression of imprinted genes were altered or maintained after differentiation into NSCs. The imprinting status in NSCs were maintained after terminal differentiation into neurons and astrocytes. In contrast, gene expression was differentially presented in a cell type-specific manner. CONCLUSIONS: This study suggests that genomic imprinting should be determined in each neural cell type because the genomic imprinting status can differ in a cell type-specific manner. In addition, the in vitro model established in this study would be useful for verifying the epigenetic alteration of imprinted genes which can be differentially changed during neurodevelopment in human and for screening novel imprinted genes related to neurodevelopment. Moreover, the confirmed genomic imprinting status could be used to find out an abnormal genomic imprinting status of imprinted genes related with neurogenetic disorders according to uniparental genotypes.

Addition of Cervical Elastography May Increase Preterm Delivery Prediction Performance in Pregnant Women with Short Cervix: a Prospective Study

BACKGROUND: We investigated whether there is a difference in elastographic parameters between pregnancies with and without spontaneous preterm delivery (sPTD) in women with a short cervix (≤ 25 mm), and examined the ability of elastographic parameters to predict sPTD in those women. METHODS: E-CervixTM (WS80A; Samsung Medison, Seoul, Korea) elastography was used to examine the cervical strain. Elastographic parameters were compared between pregnancies with and without sPTD. Diagnostic performance of elastographic parameters to predict sPTD ≤ 37 weeks, both alone and in combination with other parameters, was compared with that of cervical length (CL) using area under receiver operating characteristic curve (AUC) analysis. RESULTS: A total of 130 women were included. Median gestational age (GA) at examination was 24.4 weeks (interquartile range, 21.4–28.9), and the prevalence of sPTD was 20.0% (26/130). Both the elastographic parameters and CL did not show statistical difference between those with and without sPTD. However, when only patients with CL ≥ 1.5 cm (n = 110) were included in the analysis, there was a significant difference between two groups in elasticity contrast index (ECI) within 0.5/1.0/1.5 cm from the cervical canal (P < 0.05) which is one of elastographic parameters generated by E-Cervix. When AUC analysis was performed in women with CL ≥ 1.5 cm, the combination of parameters (CL + pre-pregnancy body mass index + GA at exam + ECI within 0.5/1.0/1.5 cm) showed a significantly higher AUC than CL alone (P < 0.05). CONCLUSION: An addition of cervical elastography may improve the ability to predict sPTD in women with a short CL between 1.5 and 2.5 cm.

Gender-based Comparison of Knowledge on Preconception Care

BACKGROUND: There have been many voices highlighting the necessity of preconception care as a preventive approach to achieve better pregnancy outcomes for health promotion of mothers and babies. It is important to get preconception care for both men and women, as they play equally important roles for healthy pregnancy. Also, awareness and knowledge of men and women about their health are important factors for behavioral changes for preconception care. PURPOSE: The purpose of this study is to analyze the level of awareness about men and women's preconception care and knowledge of the determinants of healthy pregnancy by gender. Our second goal was to compare men and women's level of awareness and knowledge on it. METHODS: The participants were 500 males and females (aged over 19 years and under 49 years old) either living or working in Seoul city. The data collection period of the study was from July to December, 2017. An online survey was conducted using a panel of online vendors. Then the collected data were analyzed using SPSS 24.0. RESULTS: Awareness about both men and women's preconception care was significantly higher in women than in men (p=0.004, p=0.002). Furthermore, there was a significant difference between men and women (p=0.00) in the total score of knowledge on the determinants of preconception care, including smoking, alcohol drinking, age, folic acid intake, and check-up for infectious disease (p=0.00; means women 8.20±1.95 and men 7.27±2.38). Significant gender differences were also found on some items, such as men's alcohol drinking, men's age, men's check-up for infectious disease, women's intake of folic acid, women's check-up for infectious disease. The level of knowledge on men's folic acid intake was the lowest in both men and women. CONCLUSION: Based on the results on the analysis of gender differences in the awareness and knowledge about preconception care, it is necessary to develop and implement preconception care programs based on the gender perspective approach to make women and men equally share responsibility of the birth result.

Incarceration of early gravid uterus with adenomyosis and myoma: report of two patients managed with uterine reduction

Although gravid uterine incarceration is typically diagnosed during the early second trimester, we encountered two unusual cases in early pregnancy. A 34-year-old multiparous woman with adenomyosis presented at 7 + 2 weeks of gestation with increased urinary frequency and a sensation of incomplete bladder emptying. The uterine incarceration was successfully reduced by manual reduction and pessary insertion, and she delivered a normal infant at term. In the second case, a 31-year-old nulliparous woman with a large myoma complained of dysuria, acute urinary retention, and intense back pain at 6 weeks of gestation. Manual reduction was successful in the knee-chest position. Subsequent pessary insertion failed; however, a slight reduction in pain was achieved. After a week, the fetus spontaneously aborted. In summary, gravid uterine incarceration is a rare but potentially fatal condition for the fetus, and a suspicion of this condition in patients with urinary symptoms, especially urinary retention and pelvic pain, is important in the early gestation period.

Port site infiltration of local anesthetic after laparoendoscopic single site surgery for benign adnexal disease

OBJECTIVE: To determine whether local bupivacaine injection into the incision site after gynecologic laparoendoscopic single site surgery (LESS) improves postoperative pain. METHODS: This prospective cohort study included consecutive 158 patients who had LESS for benign adnexal disease from March 2013 to December 2015. Chronologically, 82 patients (March 2013 to August 2014) received no bupivacaine (group 1) and 76 (August 2014 to December 2015) received a bupivacaine block (group 2). For group 2, 10 mL 0.25% bupivacaine was injected into the 20 mm-incision site through all preperitoneal layers after LESS completion. Primary outcome is postoperative pain score using the visual analog scale (VAS). RESULTS: There was no difference in clinicopathological characteristics between the groups. Operating time (expressed as median [range], 92 [55–222] vs. 100 [50–185] minutes, P=0.137) and estimated blood loss (50 [30–1,500] vs. 125 [30–1,000] mL, P=0.482) were similar between the groups. Post-surgical VAS pain scores after 3 hours (3.5 [2–6] vs. 3.5 [2–5], P=0.478), 6 to 8 hours (3.5 [2–6] vs. 3 [1–8], P=0.478), and 16 to 24 hours (3 [2–4] vs. 3 [1–7], P=0.664) did not differ between groups. CONCLUSION: Bupivacaine injection into the trocar site did not improve postoperative pain after LESS. Randomized trials are needed to evaluate the benefits of local bupivacaine anesthetic for postoperative pain reduction.

Elastographic measurement of the cervix during pregnancy: Current status and future challenges

The cervix is a cylindrical structure that is proximally connected to the uterus and distally to the vaginal cavity. The Bishop score has been used to evaluate the cervix during pregnancy. However, alternatives have been evaluated because the Bishop score is uncomfortable for patients, relies on a subjective examination, and lacks internal os data. Elastography has been used to assess the cervix, as it can estimate tissue stiffness. Recent articles on elastography for cervical assessment during pregnancy have focused on its usefulness for prediction of preterm birth and successful labor induction. There is a clinical need for cervical elastography, as an evaluation of biomechanical factors, because cervical length only assesses morphological changes. However, until now, cervical elastography has been studied in the limited field, and not shown a uniformed methodological technique. In this review, the current status, limitations, and future possibility of cervical elastography were discussed. Future studies should focus on overcoming the limitations of cervical elastography. Although the cervical elastography is presently an incompletely defined technique, it needs to be improved and evaluated as a method for use in combination with cervical length.