Time required to complete transvaginal cervical length in women receiving universal cervical length screening for preterm birth prevention.

BACKGROUND: Preterm birth contributes to over one-third of infant deaths, and although there are several risk factors for preterm birth few tests predict this obstetric complication. Midtrimester transvaginal cervical length (TVCL) screening is currently the best clinical predictor of spontaneous preterm birth and has been suggested to be applied universally. Although several studies have examined the cost-efficacy of universal screening, the time consumption and resultant time management has not been examined. OBJECTIVE: We aim to quantitate the time requirement for transvaginal cervical length (TVCL) screening with the implementation of universal TVCL screening.Study design: This is a retrospective cohort study of women undergoing cervical length screening after implementation of universal Transvaginal Cervical Length (TVCL) screening at a university setting over a 1-year period. The primary outcome was time in minutes for TVCL screening from completion of transabdominal to completion of transvaginal ultrasound. RESULTS: This study included 2803 ultrasounds, 1673 of which involved completion of a TVCL after completion of abdominal imaging between 16 0/7 and 23 6/7 weeks of gestation. The mean duration of cervical length screening was 9.8 min (standard deviation [SD], 4.0 min). The time range was less than 1 min to 48 min. For women obtaining cervical lengths, 4.2% required less than 5 additional minutes to perform cervical length screening, 52.1% (872), required less than 10 additional minutes. The majority, 91.8%, of ultrasounds required less than 15 min to complete. Ultrasounds performed in private practice sites required less time compared to those at teaching sites (8.2 ± 3.1 min versus 10.2 ± 4.1 min, p < .001). No significant time improvement occurred after 6 months of universal TVCL screening, with the first 6 months average of 10.1 min versus 9.6 min in the later half, p = .61. CONCLUSION: Implementation of a universal TVCL program adds an average of 10 min to each ultrasound exam. This additional time does diminish with increasing experience with TVCL, but not to a significant degree.

Universal transvaginal cervical length screening during pregnancy increases the diagnostic incidence of low-lying placenta and placenta previa.

BACKGROUND: Universal transvaginal cervical length screening has been increasingly implemented with both positive and negative consequences. OBJECTIVE: In this study, we described the diagnostic incidence of low-lying placenta and placenta previa with the implementation of universal transvaginal cervical length screening. STUDY DESIGN: This is a retrospective cohort study of women undergoing midtrimester universal transvaginal cervical length screening. The primary outcome was the rate of transvaginal diagnosis of low-lying placenta or placenta previa using midtrimester universal transvaginal cervical length screening. RESULTS: This study included 1982 midtrimester ultrasounds, of which 211 indicated a low-lying placenta or placenta previa on either transabdominal or transvaginal ultrasound. With transvaginal ultrasound, a low-lying placenta or placenta previa was diagnosed in 211 women (10.6% of the study population). Of the 211 patients with a low-lying placenta or placenta previa, 90 (42.6%) had a false-negative result, diagnosed using only transvaginal ultrasound; 112 (53.1%) had a true-positive result; and 9 (4.3%) had a false-positive result. The relative risk of having an abnormal finding on ultrasound with the addition of universal transvaginal cervical length screening was 9.2 (95% confidence interval, 4.6-18.1). Of the low-lying placenta or placenta previa diagnosed using midtrimester universal transvaginal cervical length screening, 98.9% resolved (95% confidence interval, 93.7-99.97). CONCLUSION: Implementation of universal transvaginal cervical length screening increases the diagnostic incidence of low-lying placenta or placenta previa without an increase in the diagnoses that persist to term, which comes at the cost of increased follow-up ultrasounds and potentially increased anxiety for the patient.

Comparison of prostaglandin and mechanical cervical ripening in the setting of small for gestational age neonates.

Objective: The objective of this study is to determine whether cervical ripening with misoprostol (MP) is associated with higher rates of cesarean delivery (CD) compared with dinoprostone (DP) or Pitocin/Foley balloon (PFB) in infants found to be small for gestational age (SGA). Study design: Single center institution based cohort study of all inductions between 2008 and 2012 where birth weight was found to be as SGA (< 10th percentile). Maternal demographic, obstetric, and labor characteristics were compared between SGA births where cervical ripening with MP, DP, or PFB was used as the primary agent. The primary outcome was CD after attempted induction between the three study groups which included MP, DP, and PFB. Secondary outcomes included inability to achieve active labor (defined as cervical dilation of 6 cm or greater), cervical dilation at the time of CD, the incidence of CD for the indication of non-reassuring fetal status, and neonatal outcomes including Apgar scores and admission to neonatal intensive care unit. Multivariable logistic regression was performed to evaluate the association of these outcomes with MP as the induction agent versus the referent groups, PFB. Results: Of 260 inductions where the infant was found to be SGA by birth weight during the 5-year period, 172 (66.2%) patients were induced using MP, 38 (14.6%) with DP, and 50 (19.2%) with PFB. There were no differences in baseline characteristics between groups (age, race, BMI, parity, induction indication, birth weights, or maternal comorbidities). MP did not increase rate of CD which was 25.6%, 26.3%, and 22.0% in the MP, DP, and PFB groups, respectively (p = .86). There were also no differences in incidence of CD for non-reassuring fetal well-being (NRFWB), failure to attain active labor, or cervical dilation at time of CD between induction groups. NICU admission was 18%, 18%, and 16% (p = .94) between MP, DP, and PFB groups, respectively. MP was not associated with an increased rate of CD when compared with the other two agents combined, aOR 0.93 (0.67-1.30, 95% CI). Conclusion: MP appears to have similar efficacy and safety when compared with other cervical ripening agents in pregnancies complicated by SGA.

Maternal Obesity Is an Independent Risk Factor for Intensive Care Unit Admission during Delivery Hospitalization.

OBJECTIVE: We aim to quantify the impact of obesity on maternal intensive care unit (ICU) admission. MATERIALS AND METHODS: This is a population-based, retrospective cohort study of Ohio live births from 2006 to 2012. The primary outcome was maternal ICU admission. The primary exposure was maternal body mass index (BMI). Relative risk (RR) of ICU admission was calculated by BMI category. Multivariate logistic regression quantified the risk of obesity on ICU admission after adjustment for coexisting factors. RESULTS: This study includes 999,437 births, with peripartum maternal ICU admission rate of 1.10 per 1,000. ICU admission rate for BMI 30 to 39.9 kg/m2 was 1.24 per 1,000, RR: 1.20 (95% confidence interval [CI]: 1.07, 1.35); BMI 40 to 49.9 kg/m2 had ICU admission rate of 1.80 per 1,000, RR: 1.73 (95% CI: 1.38, 2.17); and BMI ≥ 50 kg/m2 had ICU admission rate of 2.98 per 1,000, RR: 1.73 (95% CI: 1.77, 4.68). After adjustment, these increases persisted in women with BMI 40 to 49.9 kg/m2 with adjusted relative risk (adjRR) of 1.37 (95% CI: 1.05, 1.78) and in women with BMI ≥ 50 kg/m2, adjRR: 1.69 (95% CI: 1.01, 2.83). CONCLUSION: Obesity is a risk factor for maternal ICU admission. Risk increases with BMI. After adjustment, BMI ≥ 40 kg/m2 is an independent risk factor for ICU admission.

Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial.

Importance: The rate of obesity among US women has been increasing, and obesity is associated with increased risk of surgical site infection (SSI) following cesarean delivery. The optimal perioperative antibiotic prophylactic regimen in this high-risk population undergoing cesarean delivery is unknown. Objective: To determine rates of SSI among obese women who receive prophylactic oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery. Design, Setting, and Participants: Randomized, double-blind clinical trial comparing oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery for the prevention of SSI in obese women (prepregnancy BMI ≥30) who had received standard intravenous preoperative cephalosporin prophylaxis. Randomization was stratified by intact vs rupture of membranes prior to delivery. The study was conducted at the University of Cincinnati Medical Center, Cincinnati, Ohio, an academic and urban setting, between October 2010 and December 2015, with final follow-up through February 2016. Interventions: Participants were randomly assigned to receive oral cephalexin, 500 mg, and metronidazole, 500 mg (n = 202 participants), vs identical-appearing placebo (n = 201 participants) every 8 hours for a total of 48 hours following cesarean delivery. Main Outcomes and Measures: The primary outcome was SSI, defined as any superficial incisional, deep incisional, or organ/space infections within 30 days after cesarean delivery. Results: Among 403 randomized participants who were included (mean age, 28 [SD, 6] years; mean BMI, 39.7 [SD, 7.8]), 382 (94.6%) completed the trial. The overall rate of SSI was 10.9% (95% CI, 7.9%-14.0%). Surgical site infection was diagnosed in 13 women (6.4%) in the cephalexin-metronidazole group vs 31 women (15.4%) in the placebo group (difference, 9.0% [95% CI, 2.9%-15.0%]; relative risk, 0.41 [95% CI, 0.22-0.77]; P = .01). There were no serious adverse events, including allergic reaction, reported in either the antibiotic group or the placebo group. Conclusions and Relevance: Among obese women undergoing cesarean delivery who received the standard preoperative cephalosporin prophylaxis, a postoperative 48-hour course of oral cephalexin and metronidazole, compared with placebo, reduced the rate of SSI within 30 days after delivery. For prevention of SSI among obese women after cesarean delivery, prophylactic oral cephalexin and metronidazole may be warranted. Trial Registration: clinicaltrials.gov Identifier: NCT01194115.