Efficacy of midtrimester short cervix interventions is conditional on intraamniotic inflammation.

BACKGROUND: Midtrimester ultrasound is a valuable method for identifying asymptomatic women at risk for spontaneous preterm delivery (PTD). However, response to various treatments (cerclage, progestogen) has been variable in the clinical setting. It remains unclear how other biomarkers may be used to guide intervention strategies. OBJECTIVE: We applied an amniotic fluid inflammatory scoring system to determine if the degree of inflammation is associated with intervention efficacy in patients with midtrimester short cervix. STUDY DESIGN: Women carrying a singleton fetus between 16-24 weeks' gestation with a short cervix (≤25 mm) on transvaginal ultrasound underwent amniocentesis and were assigned to McDonald cerclage, no cerclage, or weekly 17-alpha hydroxyprogesterone caproate (17OHP-C). Our previously described inflammatory risk score (comprised of 14 inflammatory markers) was used to classify patients as high (score ≥8) or low (score <8) risk for inflammation. Gestational age at delivery was compared for each intervention and risk score status. Risk of delivering as a function of the remaining gestation was evaluated using modified Cox proportional hazards models with incorporation of methods to account for both left and right truncation bias. RESULTS: Ninety patients were included: 24 were in the nonintervention control group, 51 received cerclage, and 15 received 17OHP-C. Inflammation status at time of sampling influenced the efficacy of the treatment (P < .001). Compared to the nonintervention control group, in patients with low inflammation (score < 8), both cerclage (adjusted hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.28-6.37) and 17OHP-C (HR, 3.11; 95% CI, 1.04-9.30) were associated with increased hazard of PTD. In contrast, in patients with high inflammation (score ≥8) both cerclage (HR, 0.22; 95% CI, 0.08-0.65) and 17OHP-C (HR, 0.20; 95% CI, 0.05-0.81) were associated with lower hazard of delivering preterm. CONCLUSION: Cerclage placement or administration of 17OHP-C therapy for midtrimester short cervix for PTD prevention appears beneficial only in the subset of patients with high inflammation. Knowledge of the amniotic fluid inflammatory status may aid in guiding the appropriate therapy for women presenting with midtrimester short cervix who are at increased risk of PTD.

Amniotic fluid inflammatory score is associated with pregnancy outcome in patients with mid trimester short cervix.

OBJECTIVE: We propose a novel amniotic fluid inflammatory score from a comprehensive cytokine analysis of patients with mid-trimester short cervix. STUDY DESIGN: Amniotic fluid from singleton gestations (n = 44) with a cervical length of ≤25 mm between 16-24 weeks was assayed for 25 inflammatory mediators. Patient data were stratified according to gestational age at delivery (<34 vs ≥34 weeks). Mediators that reached statistical significance were included in the amniotic fluid inflammatory score. Patients were assigned 1 point for each significant mediator if their level was in the upper quartile. The amniotic fluid inflammatory score was determined, and its relationship to other clinical characteristics was examined. RESULTS: Fourteen mediators met the criteria. A score of ≥8 was predictive of delivery at <34 weeks' gestation (sensitivity, 87.0%; specificity, 100%; positive predictive value, 100%; negative predictive value, 87.5%). Twenty patients had a high inflammatory score (≥8); 24 patients had a low score. All patients with a high inflammatory score delivered at <30 weeks' gestation. CONCLUSION: The amniotic fluid inflammatory score is related to delivery outcome and clinical characteristics.

Postpartum use of long-acting reversible contraception in a military treatment facility.

OBJECTIVE: To determine the rate at which long-acting reversible contraception (LARC) is desired immediately postpartum and utilized within 12 weeks of delivery at our institution. METHODS: This prospective cohort study analyzed 400 consecutive postpartum patients between January 2009 and March 2009. We followed contraceptive desire prior to discharge and actual contraception utilized within 12 weeks postpartum. Patient demographics and LARC utilization was analyzed to determine characteristics predictive of use. RESULTS: There was complete follow-up information on 329 (82.3%) of the studied women. Thirty-three percent (132/400) desired LARC immediately postpartum, and overall LARC utilization at 12 weeks was 31% (100/329). Demographic characteristics predictive of LARC desire and utilization included age <25 years (adjusted RR=1.53, 95% CI 1.17-1.92) and African-American ethnicity (adjusted RR=1.39, 95% CI 1.03-1.78). CONCLUSION: In our institution, LARC is highly desired and utilized within 12 weeks postpartum with African-American ethnicity and age <25 years predictive of use.

Controlled fine needle biopsy of the uterine cervix during pregnancy.

OBJECTIVE: Cervical sampling could furnish tissue-based information regarding premature cervical ripening and effacement. This report assesses the effect of cervical fine needle biopsy (FNB) in the evaluation of cervical shortening. METHODS: Retrospective cohort study evaluating adverse events during the first week following FNB in women with short cervix. Patients with a cervical length(CL) ≤25 mm had a cervical FNB between 16 and 24 weeks. The risk of FNB was compared to a control group that was similarly evaluated but did not undergo FNB. RESULTS: One hundred and thirty-two FNBs were performed in 94 participants. The mean gestational age and CL at enrollment were 20.4 ± 2.3 weeks and 15.7 ± 0.6 mm. Within 7 days of FNB, there were 3 adverse events (2.3%) in the study group compared to 5 in the control group (2.1%). CONCLUSIONS: FNB of the cervix in high risk gravidae is feasible in clinical situations. It did not increase the risk of adverse events compared to women studied under a similar protocol without FNB.

Complete trisomy 21 vs translocation Down syndrome: a comparison of modes of ascertainment.

OBJECTIVE: To compare the indications for invasive prenatal testing resulting in the detection of translocation Down syndrome and complete trisomy 21. STUDY DESIGN: This case control study was based on a large amniocentesis and chorionic villi samples database (n = 534,795). All specimens with translocation Down syndrome (n = 203) comprised the translocation group and were compared with a maternal age-matched group (4 to 1, n = 812) in which complete trisomy 21 was detected. Women with a normal karyotype were randomly selected (n = 812) and served as controls. Indications for invasive testing were compared among the 3 paired groups using χ(2) analysis. RESULTS: There were no differences in the incidence of abnormal first- and second-trimester screening tests between the translocation Down syndrome and the complete trisomy 21 groups. History of prior aneuploidy was significantly more frequent in the translocation Down syndrome group, as compared with either complete trisomy 21 fetuses or normal controls. CONCLUSION: Fetuses with translocation Down syndrome present with the same screening abnormalities as fetuses with complete trisomy 21.

A systematic technique using 3-dimensional ultrasound provides a simple and reproducible mode to evaluate the corpus callosum.

OBJECTIVE: The aim of this study was to evaluate a rapid 3-dimensional ultrasound-assisted technique for evaluation of the corpus callosum as an integral part of the anatomic survey. STUDY DESIGN: Transabdominal 3-dimensioal gray scale and power Doppler volumes of the fetal brain were acquired in 102 consecutive healthy fetuses at 20-23 postmenstrual weeks. Offline analysis was performed by 2 of the authors using a systematic approach of "volume manipulation." Diagnostic-quality visualization of the corpus callosum and the pericallosal arteries on the median plane was recorded by the 2 examiners independently. RESULTS: The median plane was easily obtained in all cases. Diagnostic-quality images of the corpus callosum were recorded in 93.1% and 99.0% and of the pericallosal arteries in 94.4% and 95.5% of the cases, by the 2 examiners, respectively. CONCLUSION: Three-dimensional ultrasound enables a rapid and easy evaluation of the corpus callosum that may facilitate its inclusion as an integral part of the routine anatomic survey.

Comprehensive amniotic fluid cytokine profile evaluation in women with a short cervix: which cytokine(s) correlates best with outcome?

OBJECTIVE: The objective of this study was to determine whether an expanded amniotic fluid cytokine profile predicts spontaneous preterm birth in patients with short cervix in the midtrimester. STUDY DESIGN: Amniocentesis was performed on singleton gestations between 16-24 weeks with a cervical length

A randomized trial of cerclage vs. 17 alpha-hydroxyprogesterone caproate for treatment of short cervix.

OBJECTIVE: To determine pregnancy outcome in patients with short cervix on transvaginal ultrasound between 16 and 24 weeks' gestation treated with McDonald cerclage compared to weekly intramuscular injections of 17 alpha-hydroxyprogesterone caproate (17OHP-C). METHODS: From November 2003 through December 2006, asymptomatic, singleton pregnancies were screened with transvaginal ultrasound between 16-24 weeks' gestation. Patients with a cervical length (CL) < or =25 mm were offered enrollment. Patients were randomly assigned to treatment with McDonald cerclage or weekly intramuscular injections of 17OHP-C. The primary outcome was spontaneous preterm birth (PTB) prior to 35 weeks' gestation. RESULTS: Seventy-nine patients met inclusion criteria; 42 were randomly assigned to the cerclage and 37 to 17OHP-C. Spontaneous PTB prior to 35 weeks' gestation occurred in 16/42 (38.1%) of the cerclage group and in 16/37 (43.2%) of the 17OHP-C group (relative risk, 1.14 95% CI, 0.67, 1.93). A post hoc analysis of patients with a prior PTB showed no difference in spontaneous PTB <35 weeks between groups. A similar analysis of patients with a CL< or =15 mm showed a reduction in spontaneous PTB <35 weeks in the cerclage group (relative risk 0.48, 0.24-0.97). CONCLUSION: Women with CL < or =25 mm in the second-trimester appear to have similar risks of delivering prior to 35 weeks' gestation when treated with 17OHP-C or McDonald cerclage. However, cerclage may be more effective in preventing spontaneous PTB in women with CL< or =15 mm.

Universal tuberculosis screening in pregnancy.

We reviewed our practice of universal tuberculosis (TB) screening in an at-risk pregnant population with regards to utility and patient compliance. The Gouverneur Healthcare Services prenatal database was analyzed for compliance with TB screening. Age, ethnicity, country of origin, and education level were also analyzed. Of 4049 patients, 95.0% were compliant with their purified protein derivative (PPD) testing. Universal screening identified 1935 (50.4%) PPD+ patients, with chest X-rays (CXR) available for 95.1%. Only one patient had a CXR consistent with active TB, although sputum testing was negative for acid-fast bacilli. Asian women were more likely to be PPD-compliant (adjusted odds ratio [aOR]: 4.94, 95% confidence interval [CI]: 2.34 to 10.45). Similarly, PPD+ Asian women were more likely to be compliant with CXR (aOR: 12.67, 95% CI: 3.44 to 46.7). U.S.-born women were significantly less likely to be compliant with PPD (aOR: 0.44, 95% CI: 0.30 to 0.64) or with CXR (aOR: 0.22, 95% CI: 0.08 to 0.61). Universal prenatal TB screening is associated with excellent compliance rates and is an effective way to identify a high prevalence of latent TB, but not active disease.

Is midtrimester short cervix a sign of intraamniotic inflammation?

OBJECTIVE: We sought to determine the relationship between the degree of cervical shortening and intraamniotic inflammation in patients presenting with a midtrimester short cervix. STUDY DESIGN: Amniocentesis was performed on singleton pregnancies between 16-24 weeks' gestation with a sonographic cervical length (CL) 1500 pg/mL, CL of 5 mm had an 86% sensitivity, 85% specificity, 58% positive predictive value, and 96% negative predictive value to predict elevated MCP-1 levels. After excluding patients with intraamniotic infection or labor, findings were similar. CONCLUSION: CL

Comparison of modes of ascertainment for mosaic vs complete trisomy 21.

OBJECTIVE: We sought to compare the indications for amniocentesis leading to the detection of either mosaicism of trisomy 21 (mosaic-T21) or complete trisomy 21 (T21). STUDY DESIGN: A retrospective review of a large amniocentesis database (n = 494,163) was conducted. All specimens with mosaic-T21 (n = 124) were compared with a maternal age-matched group of T21 fetuses (n = 496). Samples with normal karyotypes were matched for maternal age and served as normal controls (n = 496). The chi(2) testing was used for statistical analysis. RESULTS: The presence of an abnormal first-trimester screen, abnormal sonographic findings, and specifically the single sonographic abnormalities of either a cystic hygroma or a cardiac anomaly were significantly less common in the mosaic-T21 as compared with the T21 group. There were no such differences between the mosaic-T21 and the normal control group. CONCLUSION: Fetuses with mosaic-T21, similar to those with normal karyotype, do not present with the same abnormal screening tests as fetuses with T21.

Fetal fibronectin testing in patients with short cervix in the midtrimester: can it identify optimal candidates for ultrasound-indicated cerclage?

OBJECTIVE: The objective of the study was to determine the relationship between fetal fibronectin (fFN) testing prior to ultrasound-indicated cerclage and obstetric outcome. STUDY DESIGN: Singleton pregnancies between 18 and 24 weeks' gestation with an ultrasound-diagnosed short cervix (< 25 mm) and funneling (> 25%) of the chorioamniotic membranes into the endocervical canal were analyzed. The fFN testing was performed and patients were randomized to cerclage or no-cerclage. Groups were stratified by fFN result. Cerclage patients were compared with no-cerclage patients. The primary outcome was delivery prior to 35 weeks' gestation. RESULTS: Spontaneous preterm birth prior to 35 weeks' gestation occurred in 15 (44.1%) fFN-positive-cerclage patients and 16 (55.2%) fFN-positive no-cerclage patients (P = .45). Similarly, it occurred in 16 (17.8%) fFN-negative cerclage patients and 11 (17%) fFN-no-cerclage patients (P = .99). CONCLUSION: fFN did not identify optimal candidates for cerclage. However, fFN testing before an ultrasound-indicated cerclage aids in counseling patients, anticipating the outcome of pregnancies complicated by cervical shortening.