Comparison and Characterization of Prenatal Nutrition Counseling among Large-for-Gestational Age Deliveries by Pre-Pregnancy BMI.

It is recommended that prenatal care include nutrition counseling; however, <70% of women report receipt of nutrition counseling during pregnancy. In this study, we aimed to characterize prenatal nutrition counseling (PNC) among large-for-gestational age deliveries at a low-income and minority-serving hospital by performing a retrospective chart review of infants with a birth weight > 4000 g. Of the 2380 deliveries, 165 met the inclusion criteria. Demographics, PNC receipt, and pregnancy outcomes were compared among normal-weight (NW; BMI: 18.5-24.9 kg/m2, 19%, n = 31), overweight (OW; BMI: 25-29.9 kg/m2, 29%, n = 48), and obese (OB; BMI > 30 kg/m2, 52%, n = 86) women. The majority (78%, n = 129) of women were Hispanic White with a mean age of 30.4 ± 5.7 yrs and gestational weight gain of 12.1 ± 5.8 kgs. A total of 62% (n = 103) of women received PNC. A total of 57% gained above the Institute of Medicine (IOM) recommendations (n = 94). OB women were 2.6 and 2.1 times more likely to receive PNC than OW (95% CI: 1.1-2.0) and NW (95% CI: 0.9-1.9) women, respectively. Women who gained within the IOM recommendations for their pre-pregnancy body mass index (BMI) were 50% less likely to receive PNC than women who gained above the IOM recommendations for their pre-pregnancy weight (χ = 4.45, p = 0.035; OR = 0.48, CI: 0.24 to 0.95). Infant birthweight was significantly higher among women who received PNC (4314 ± 285 vs. 4197 ± 175 g, p = 0.004). These data suggest that PNC was directed toward women who enter pregnancy in the obese weight category and/or gain excessively across gestation. Future studies should provide PNC to all women to evaluate whether it reduces the risk of delivering large-for-gestational age deliveries across all maternal weight categories. Additionally, more work is needed to identify the types of PNC that are most effective for this high-risk population.

Effect of obesity on preterm delivery prediction by transabdominal recording of uterine electromyography.

OBJECTIVE: It has been shown that noninvasive uterine electromyography (EMG) can identify true preterm labor more accurately than methods available to clinicians today. The objective of this study was to evaluate the effect of body mass index (BMI) on the accuracy of uterine EMG in predicting preterm delivery. MATERIALS AND METHODS: Predictive values of uterine EMG for preterm delivery were compared in obese versus overweight/normal BMI patients. Hanley-McNeil test was used to compare receiver operator characteristics curves in these groups. Previously reported EMG cutoffs were used to determine groups with false positive/false negative and true positive/true negative EMG results. BMI in these groups was compared with Student t test (p < 0.05 significant). RESULTS: A total of 88 patients were included: 20 obese, 64 overweight, and four with normal BMI. EMG predicted preterm delivery within 7 days with area under the curve = 0.95 in the normal/overweight group, and with area under the curve = 1.00 in the obese group (p = 0.08). Six patients in true preterm labor (delivering within 7 days from EMG measurement) had low EMG values (false negative group). There were no false positive results. No significant differences in patient's BMI were noted between false negative group patients and preterm labor patients with high EMG values (true positive group) and nonlabor patients with low EMG values (true negative group; p = 0.32). CONCLUSION: Accuracy of noninvasive uterine EMG monitoring and its predictive value for preterm delivery are not affected by obesity.

Identification of novel splice variants and exons of human endothelial cell-specific chemotaxic regulator (ECSCR) by bioinformatics analysis.

Recent discovery of biological function of endothelial cell-specific chemotaxic regulator (ECSCR), previously known as endothelial cell-specific molecule 2 (ECSM2), in modulating endothelial cell migration, apoptosis, and angiogenesis, has made it an attractive molecule in vascular research. Thus, identification of splice variants of ECSCR could provide new strategies for better understanding its roles in health and disease. In this study, we performed a series of blast searches on the human EST database with known ECSCR cDNA sequence (Variant 1), and identified additional three splice variants (Variants 2-4). When examining the ECSCR gene in the human genome assemblies, we found a large unknown region between Exons 9 and 11. By PCR amplification and sequencing, we partially mapped Exon 10 within this previously unknown region of the ECSCR gene. Taken together, in addition to previously reported human ECSCR, we identified three novel full-length splice variants potentially encoding different protein isoforms. We further defined a total of twelve exons and nearly all exon-intron boundaries of the gene, of which only eight are annotated in current public databases. Our work provides new information on gene structure and alternative splicing of the human ECSCR, which may imply its functional complexity. This undoubtedly opens new opportunities for future investigation of the biological and pathological significance of these ECSCR splice variants.

Structural and functional characterization of two alternative splicing variants of mouse Endothelial Cell-Specific Chemotaxis Regulator (ECSCR).

Endothelial cells (ECs) that line the lumen of blood vessels are important players in blood vessel formation, and EC migration is a key component of the angiogenic process. Thus, identification of genes that are specifically or preferentially expressed in vascular ECs and in-depth understanding of their biological functions may lead to discovery of new therapeutic targets. We have previously reported molecular characterization of human endothelial cell-specific molecule 2 (ECSM2)/endothelial cell-specific chemotaxis regulator (ECSCR). In the present study, we cloned two mouse full-length cDNAs by RT-PCR, which encode two putative ECSCR isoform precursors with considerable homology to the human ECSCR. Nucleotide sequence and exon-intron junction analyses suggested that they are alternative splicing variants (ECSCR isoform-1 and -2), differing from each other in the first and second exons. Quantitative RT-PCR results revealed that isoform-2 is the predominant form, which was most abundant in heart, lung, and muscles, and moderately abundant in uterus and testis. In contrast, the expression of isoform-1 seemed to be more enriched in testis. To further explore their potential cellular functions, we expressed GFP- and FLAG-tagged ECSCR isoforms, respectively, in an ECSCR deficient cell line (HEK293). Interestingly, the actual sizes of either ECSCR-GFP or -FLAG fusion proteins detected by immunoblotting are much larger than their predicted sizes, suggesting that both isoforms are glycoproteins. Fluorescence microscopy revealed that both ECSCR isoforms are localized at the cell surface, which is consistent with the structural prediction. Finally, we performed cell migration assays using mouse endothelial MS1 cells overexpressing GFP alone, isoform-1-GFP, and isoform-2-GFP, respectively. Our results showed that both isoforms significantly inhibited vascular epidermal growth factor (VEGF)-induced cell migration. Taken together, we have provided several lines of experimental evidence that two mouse ECSCR splicing variants/isoform precursors exist. They are differentially expressed in a variety of tissue types and likely involved in modulation of vascular EC migration. We have also defined the gene structure of mouse ECSCR using bioinformatics tools, which provides new information towards a better understanding of alternative splicing of ECSCR.

Repeat operation for treatment of persistent pudendal nerve entrapment after pudendal neurolysis.

STUDY OBJECTIVES: To describe a new approach to transgluteal pudendal neurolysis and transposition and to review the outcome in 10 patients who underwent repeat operation because of persistent pudendal neuralgia after failing to improve after initial surgical decompression. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Academic chronic pelvic pain practice at St. Joseph's Hospital and Medical Center in Phoenix, Arizona. PATIENTS: Women and men with persistent pudendal neuralgia after undergoing transgluteal pudendal neurolysis and transposition. INTERVENTION: Transgluteal decompression of the pudendal nerve was performed in all 10 patients. In brief, a transgluteal incision was made, and the pudendal nerve was identified via a nerve integrity monitoring system. Adhesiolysis was performed from the piriformis muscle to the distal Alcock canal using a Zeiss NC-4 surgical microscope. The nerve was then enclosed in NeuraWrap Nerve Protector and coated with activated platelet-rich plasma. An ON-Q PainBuster catheter was place along the nerve into the Alcock canal, and 0.5% bupivacaine was infused at 2 mL/hr. The sacrotuberous ligament was repaired using an Achilles or gracillis cadaver ligament. The overlying subcutaneous tissue and skin were then closed. MEASUREMENTS AND MAIN RESULTS: From June 2008 to March 2010, 10 consecutive patients (7 women and 3 men; age range, 29-81 years) underwent repeat operation with transgluteal decompression of the pudendal nerve. Neuropathic pain was unilateral (n = 8) or bilateral (n = 2), in the clitoris or penis (30%), vulva or scrotum (70%), perineum (40%), and rectum (50%). Of the 10 patients, 1 patient was lost to follow-up. Mean follow-up was 23 months. Eight of 9 patients reported global improvement, with 2 patients reporting complete resolution of symptoms. One patient reported no change. Pain, as measured using an 11-point numerical scale, improved from a mean of 7.2 to 4.0 (p = .02), with 5 patients reporting clinically significant improvement (change, ≥2). Comfortable sitting or maximum time that the patient was able to sit without exacerbation of pain improved in 8 patients, with a change in median time of 5 to 45 minutes (p = .008). Change in the ability to sit correlated well with patient-reported global improvement (correlation coefficient, 0.86). No patient experienced worsening of symptoms. CONCLUSION: Patients with persistent pudendal neuralgia after surgical decompression may benefit from repeat operation via our novel approach. Ability to sit correlates well with reported improvement due to surgery.

Inhibition of uterine contractility with various tocolytics with and without progesterone: in vitro studies.

OBJECTIVE: Various tocolytics are used to suppress uterine contractility in patients in preterm labor. Progesterone (P4) is used in patients at high risk for preterm delivery. In this study, we evaluated the effects of various tocolytics with and without P4 to examine effects on uterine contractility. STUDY DESIGN: Uterine tissues (n = 280) from women undergoing cesarean at term were exposed in vitro to various agents (vehicle, magnesium sulfate [MgSO(4)], nifedipine, indomethacin, or pinacidil-all with and without P4). Contractility was measured before and after addition of the various agents. RESULTS: P4 alone at 10(-5) mol/L concentration has little effect to inhibit contractility (P ≥ .05). MgSO(4) (2-8 × 10(-3) mol/L) inhibits uterine contractility (P < .05) but there is no change when combined with P4 (P > .05). Nifedipine (10(-8) mol/L) and indomethacin (10(-5) mol/L) inhibit contractions alone (P < .05) and to a greater extent when combined with P4 (P < .05). P4 significantly (P < .05) reduced the effects of pinacidil (10(-6.5) mol/L). CONCLUSION: Combinations of P4 with nifedipine or indomethacin, but not MgSO(4), might be used to effectively suppress preterm labor.

Signaling cross talk between growth hormone (GH) and insulin-like growth factor-I (IGF-I) in pancreatic islet ß-cells.

Dysfunction and destruction of pancreatic islet ß-cells is a hallmark of diabetes. Better understanding of cell signals regulating ß-cell growth and antiapoptosis will allow development of therapeutic strategies for diabetes by preservation and expansion of ß-cell mass. GH and IGF-I share a complicated physiological relationship and have both been implicated in ß-cell function. GH and IGF-I exert their biological effects through binding to respective receptors (GHR and IGF-IR) and subsequently engaging downstream signaling pathways. However, their collaborative roles in modulation of ß-cell mass and the underlying molecular mechanisms remain poorly understood. In this study, we demonstrate that cultured ß-cells are appealing systems for investigating potential GH-IGF-I signaling cross talk. We uncover that GH specifically promotes formation of a protein complex containing GHR, Janus kinase 2 (a nonreceptor kinase coupled to GH/GHR signaling), and IGF-IR. More importantly, GH and IGF-I synergistically activate both signal transducer and activator of transcription 5 and Akt pathways. Concomitantly, ß-cells proliferate more robustly and are better protected from serum deprivation-induced apoptosis when exposed to GH and IGF-I in combination vs. GH or IGF-I alone. The augmented proliferative effects by GH and IGF-I are confirmed in isolated islets. Taken together, our findings strongly suggest that there exists a novel signaling relationship between GH/GHR and IGF-I/IGF-IR systems in ß-cells, i.e. IGF-IR may serve as a proximal component of GH/GHR signaling, contributing to enhancement of ß-cell mass and function. In support of this, IGF-IR knockdown in ß-cells resulted in the desensitization of acute GH-induced signal transducer and activator of transcription 5 activation.

Endothelial cell-specific molecule 2 (ECSM2) localizes to cell-cell junctions and modulates bFGF-directed cell migration via the ERK-FAK pathway.

BACKGROUND: Despite its first discovery by in silico cloning of novel endothelial cell-specific genes a decade ago, the biological functions of endothelial cell-specific molecule 2 (ECSM2) have only recently begun to be understood. Limited data suggest its involvement in cell migration and apoptosis. However, the underlying signaling mechanisms and novel functions of ECSM2 remain to be explored. METHODOLOGY/PRINCIPAL FINDINGS: A rabbit anti-ECSM2 monoclonal antibody (RabMAb) was generated and used to characterize the endogenous ECSM2 protein. Immunoblotting, immunoprecipitation, deglycosylation, immunostaining and confocal microscopy validated that endogenous ECSM2 is a plasma membrane glycoprotein preferentially expressed in vascular endothelial cells (ECs). Expression patterns of heterologously expressed and endogenous ECSM2 identified that ECSM2 was particularly concentrated at cell-cell contacts. Cell aggregation and transwell assays showed that ECSM2 promoted cell-cell adhesion and attenuated basic fibroblast growth factor (bFGF)-driven EC migration. Gain or loss of function assays by overexpression or knockdown of ECSM2 in ECs demonstrated that ECSM2 modulated bFGF-directed EC motility via the FGF receptor (FGFR)-extracellular regulated kinase (ERK)-focal adhesion kinase (FAK) pathway. The counterbalance between FAK tyrosine phosphorylation (activation) and ERK-dependent serine phosphorylation of FAK was critically involved. A model of how ECSM2 signals to impact bFGF/FGFR-driven EC migration was proposed. CONCLUSIONS/SIGNIFICANCE: ECSM2 is likely a novel EC junctional protein. It can promote cell-cell adhesion and inhibit bFGF-mediated cell migration. Mechanistically, ECSM2 attenuates EC motility through the FGFR-ERK-FAK pathway. The findings suggest that ECSM2 could be a key player in coordinating receptor tyrosine kinase (RTK)-, integrin-, and EC junctional component-mediated signaling and may have important implications in disorders related to endothelial dysfunction and impaired EC junction signaling.

Progestin treatment for the prevention of preterm birth.

Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.

A novel optical method to assess cervical changes during pregnancy and use to evaluate the effects of progestins on term and preterm labor.

OBJECTIVE: The purpose of this study was to determine whether optical methods can estimate cervix function during pregnancy and whether progestins modify this process. STUDY DESIGN: Photos of the external cervix of timed-pregnant rats were taken every other day from day 13 until postpartum day 5 after daily treatments with vehicle (controls) or progestin treatments (progesterone, subcutaneously or vaginally; 17-alpha-hydroxyprogesterone caproate [17P] and RU-486 subcutaneously, once on day 16). The surface area of the cervix was estimated from photos. RESULTS: The surface area of cervix increases throughout pregnancy and reverses after delivery in controls. In the progesterone subcutaneously or 17P subcutaneously groups, increases in surface area are lower (17P group until day 19 only; P < .05). Vaginal progesterone does not prevent surface area increases. Only the progesterone subcutaneously blocked delivery. RU-486 increases the surface area of the cervix (P < .05) during preterm delivery. CONCLUSION: An optical method is useful for quantitative assessment of the cervix and evaluation of agents that modify cervical function.

Additive inhibitory effects of progesterone and sodium nitroprusside on uterine contractility during pregnancy.

Progesterone (P4) and nitric oxide (NO) suppress uterine contractility (CTX). This study compares the effects of P4 to sodium nitroprusside (SNP, an NO donor) and their combination on human CTX of term/preterm and labor/nonlabor tissues. Uterine tissues (n = 128) from women (n = 28) undergoing Cesarean were suspended in organ baths. Tissues (n ≥ 6/group) were treated with vehicle, P4, SNP, or combinations. A subset of tissues (n ≥ 2/group) from term/preterm ± labor and nonpregnant patients was analyzed with P4 alone. Analysis of variance (ANOVA) was used for statistical differences (P < .05). The combination of P4 with SNP significantly suppresses CTX (% inhibition of -127.1 ± 14.5) to the levels lower than with either P4 (-20.1 ± 8.6) or SNP alone (-72.0 ± 11.2). Suppression of P4 is similar in term, preterm, and nonpregnant tissues, with increased sensitivity in laboring tissues. This indicates that P4 or SNP alone may be used for preterm labor and their combination may be more successful.

Endometrial cancer surgery in Arizona: a statewide analysis of access to care.

OBJECTIVES: To investigate access to surgical care for endometrial cancer in Arizona. METHODS: The Arizona HealthQuery (AZHQ) data warehouse with claims information on over 7 million patients in Arizona was searched using the International Classification of Disease (ICD-9) codes and Current Procedural Terminology (CPT) codes for endometrial cancer surgery from 2005 to 2008. Coordinates were gathered for patients and hospital to determine the distance traveled, race, insurance and annual caseload per hospital/surgeon were collected. Distance traveled was local (< 50 miles) or distant (≥ 50 miles) and served as the primary independent variable. Secondary variables included age, race, insurance, surgeon annual volume, and hospital annual volume. Logistic regression for distance traveled was performed for insurance coverage, race, hospital volume, and surgeon volume and expressed as an odds ratio. RESULTS: There were 1532 endometrial cancer surgeries performed at 67 hospitals by 242 surgeons in 15 counties. Most (61%) were performed by high-volume surgeons. Approximately 1 in 5 (19%) of patients traveled greater than 50 miles. Medicare insured patients were twice (OR=2.07, 95% CI=1.38-3.13) and Medicaid patients were three times (OR=3.41, 95% CI=1.89-6.15) as likely to travel over 50 miles. No significant difference was found between uninsured and privately insured patients (OR=0.87, 95% CI=0.45-1.68). Patients were more likely to travel to a high volume facility (OR 2.39, 95% CI=1.26-4.51). Hispanics (OR=2.72, 95% CI=1.72-4.32) and Native Americans (OR=8.60, 95% CI=3.43-21.52) were more likely to travel compared to Caucasians. CONCLUSION: In Arizona significantly different patterns of care are seen for endometrial cancer surgery based upon insurance coverage, race, surgeon and hospital. Patients travel farther to a high-volume hospital and high-volume surgeon. Hispanics or Native Americans travel farther for care when compared with Caucasians. Patients on government funded insurance plans travel farther for care than patients covered by private insurance or those lacking insurance.

Use of uterine electromyography to diagnose term and preterm labor.

Current methodologies to assess the process of labor, such as tocodynamometry or intrauterine pressure catheters, fetal fibronectin, cervical length measurement and digital cervical examination, have several major drawbacks. They only measure the onset of labor indirectly and do not detect cellular changes characteristic of true labor. Consequently, their predictive values for term or preterm delivery are poor. Uterine contractions are a result of the electrical activity within the myometrium. Measurement of uterine electromyography (EMG) has been shown to detect contractions as accurately as the currently used methods. In addition, changes in cell excitability and coupling required for effective contractions that lead to delivery are reflected in changes of several EMG parameters. Use of uterine EMG can help to identify patients in true labor better than any other method presently employed in the clinic.

Noninvasive uterine electromyography for prediction of preterm delivery.

OBJECTIVE: Power spectrum (PS) of uterine electromyography (EMG) can identify true labor. EMG propagation velocity (PV) to diagnose labor has not been reported. The objective was to compare uterine EMG against current methods to predict preterm delivery. STUDY DESIGN: EMG was recorded in 116 patients (preterm labor, n = 20; preterm nonlabor, n = 68; term labor, n = 22; term nonlabor, n = 6). A Student t test was used to compare EMG values for labor vs nonlabor (P < .05, significant). Predictive values of EMG, Bishop score, contractions on tocogram, and transvaginal cervical length were calculated using receiver-operator characteristics analysis. RESULTS: PV was higher in preterm and term labor compared with nonlabor (P < .001). Combined PV and PS peak frequency predicted preterm delivery within 7 days with area under the curve (AUC) of 0.96. Bishop score, contractions, and cervical length had an AUC of 0.72, 0.67, and 0.54. CONCLUSION: Uterine EMG PV and PS peak frequency more accurately identify true preterm labor than clinical methods.

Pharmacologic actions of progestins to inhibit cervical ripening and prevent delivery depend on their properties, the route of administration, and the vehicle.

OBJECTIVE: The purpose of this study was to evaluate cervical changes and delivery at term during pregnancy in rats after various progestin treatments. STUDY DESIGN: Pregnant rats were treated by various routes and vehicles with progesterone, 17-alpha-hydroxyprogesterone caproate (17P), R5020, and RU-486. Delivery time was determined and cervical ripening was assessed in vivo by collagen light-induced fluorescence. RESULTS: The cervix is rigid in the progesterone injection, 17P, and vaginal R5020 groups vs controls. Vaginal progesterone had no effect. RU-486 treatment softened the cervix during preterm delivery. Only subcutaneous injected progesterone, R5020 (subcutaneous and vaginal), and topical progesterone in sesame and fish oil inhibits delivery. Delivery is not changed by subcutaneous injection of 17P, vaginal progesterone, oral progesterone, and topical progesterone in Replens (Crinone; Columbia Labs, Livingston, NJ). CONCLUSION: Inhibition of cervical ripening and delivery by progestins depends on many factors that include their properties, the route of administration, and the vehicle. This study suggests reasons that the present treatments for preterm labor are not efficacious.

Endothelial cell-specific molecule 2 (ECSM2) modulates actin remodeling and epidermal growth factor receptor signaling.

Endothelial cell-specific molecules (ECSMs) play a pivotal role in the pathogenesis of many angiogenesis-related diseases. Since its initial discovery, the exact function of human ECSM2 has not been defined. In this study, by database mining, we identified a number of hypothetical proteins across species exhibiting substantial sequence homology to the human ECSM2. We showed that ECSM2 is preferentially expressed in endothelial cells and blood vessels. Their characteristic structures and unique expression patterns suggest that ECSM2 is an evolutionarily conserved gene and may have important functions. We further explored the potential roles of human ECSM2 at the molecular and cellular level. Using a reconstitution mammalian cell system, we demonstrated that ECSM2 mainly resides at the cell membrane, is critically involved in cell-shape changes and actin cytoskeletal rearrangement, and suppresses tyrosine phosphorylation signaling. More importantly, we uncovered that ECSM2 can cross-talk with epidermal growth factor receptor (EGFR) to attenuate the EGF-induced cell migration, possibly via inhibiting the Shc-Ras-ERK (MAP kinase) pathway. Given the importance of growth factor and receptor tyrosine kinase-mediated signaling and cell migration in angiogenesis-related diseases, our findings regarding the inhibitory effects of ECSM2 on EGF-mediated signaling and cell motility may have important therapeutic implications.

Risk factors for preterm delivery in patients demonstrating sonographic evidence of premature dilation of the internal os, prolapse of the membranes in the endocervical canal and shortening of the distal cervical segment by second trimester ultrasound.

OBJECTIVE: To investigate the outcomes and risk factors associated with the second trimester sonographic findings of premature dilation of the internal cervical os, prolapse of the membranes into the endocervical canal and shortening of the distal segment. STUDY DESIGN: Retrospective chart review to identify patients who met the following criteria: (i) gestational age between 16 and 24 weeks; (ii) a vaginal probe ultrasound documenting dilatation of the internal os, prolapsed membranes into the endocervical canal but not extending beyond the external os, and a shortened distal cervix; and (iii) no evidence of increased uterine activity METHODS: Sonographic measurements obtained included: (i) the width of the internal os dilation; (ii) the depth of membranes prolapsed into endocervix (funneling); (iii) the distal cervical length; and (iv) the total cervical length. Patients were stratified into two groups according to gestational age at delivery: the preterm group (< 34 weeks) and the near-term group (> or = 34 weeks). RESULTS: Thirty-seven patients had complete records for analysis and their pregnancies resulted in 47 live births. Eighteen patients were stratified to the near term group and 19 were stratified to the preterm group. There were no stillborn infants and 10 neonatal deaths. Ten patients received cerclage and seven patients delivered at < 34 weeks gestational age. Risk factors found to be significant for preterm delivery included a gestational age at diagnosis of < or = 20 weeks gestation (p = 0.03), dilatation of the internal os > 1.3 cm (p = 0.04), and a composite Benham score > or = 1.0 (p = 0.02). CONCLUSIONS: The sonographic findings of premature dilatation of the internal os, prolapse of the membranes into the endocervical canal and shortening of the distal cervix are associated with a high rate of delivery < 34 weeks (51%) and neonatal death (27%).