Term Labor Outcomes after Cerclage Placement in a Multi-institutional Cohort.

OBJECTIVE: The placement of a cervical cerclage in early pregnancy could influence subsequent labor outcomes at term. Prior studies have yielded conflicting results regarding the potential association with adverse labor outcomes such as cesarean delivery (CD), cervical laceration, and prolonged labor. Our objective was to evaluate rate of CD and adverse maternal outcomes in women who labored at term with and without a cerclage within the Consortium on Safe Labor (CSL) cohort. We hypothesize that women with a cerclage in the incident pregnancy will have an increased frequency of CD and other adverse term labor outcomes. STUDY DESIGN: A retrospective cohort study was performed using data from the CSL. Women with live nonanomalous singleton gestations≥ 37 weeks with induced or spontaneous labor were identified. The risk of CD and other maternal and neonatal outcomes were compared between women with and without cerclage placement during pregnancy. Univariable and multivariable analyses were performed with adjustment for confounding factors. Planned subgroup analysis by history of CD was performed. RESULTS: A total of 374 of the 147,463 patients who met study inclusion criteria in the CSL (0.25%) had a cerclage. In univariable analysis, cerclage placement was associated with a significant increase in the frequency of CD (17.1 vs. 12.8%, p = 0.016, odds ratio: 1.4, 95% CI: 1.07-1.84), cervical lacerations, infectious morbidity, and blood loss. The association with CD persisted in multivariable regression. Cerclage placement was not associated with an increased risk of neonatal morbidity. CONCLUSION: Cerclage placement in pregnancy is associated with an increased risk of CD, cervical laceration, and infectious morbidity among women delivering at term. These findings suggest that cerclage placement may impact labor progression and outcomes. However, the magnitude of the association may not alter clinical decisions regarding cerclage placement in appropriate candidates.

Cervical ripening balloon with and without oxytocin in multiparas: a randomized controlled trial.

BACKGROUND: The optimal method for induction of labor for multiparous women with an unfavorable cervix is unknown. OBJECTIVE: We sought to determine if induction of labor with simultaneous use of oxytocin and a cervical ripening balloon, compared with sequential use, increases the likelihood of delivery within 24 hours in multiparous women. STUDY DESIGN: We performed a randomized controlled trial from November 2014 through June 2017. Eligible participants were multiparous women with a vertex presenting, nonanomalous singleton gestation ≥34 weeks undergoing induction of labor. Women were excluded for admission cervical examination >2 cm, ruptured membranes, chorioamnionitis or evidence of systemic infection, placental abruption, low-lying placenta, >1 prior cesarean delivery, or contraindication to vaginal delivery. Patients were randomly allocated to the following cervical ripening groups: simultaneous (oxytocin with cervical ripening balloon) or sequential (oxytocin following cervical ripening balloon expulsion). The primary outcome was delivery within 24 hours of cervical ripening balloon placement. Secondary outcomes included induction-to-delivery interval, time to cervical ripening balloon expulsion, mode of delivery, and adverse maternal or neonatal outcomes. RESULTS: In all, 180 patients were randomized (90 simultaneous, 90 sequential). Baseline demographic and obstetric characteristics were similar between study groups. Women in the simultaneous group were significantly more likely to deliver within 24 hours of cervical ripening balloon placement compared to the sequential group (87.8% vs 73.3%, P = .02). The simultaneous group also had a significantly shorter induction-to-delivery interval and greater cervical dilation at cervical ripening balloon expulsion. There were no differences in mode of delivery, chorioamnionitis, or adverse maternal or neonatal outcomes. CONCLUSION: In multiparous women with an unfavorable cervix, the simultaneous use of cervical ripening balloon and oxytocin results in an increased frequency of delivery within 24 hours and a shorter induction-to-delivery interval.

Pregnancy Outcomes after Endometrial Ablation in a Multi-institutional Cohort.

OBJECTIVE: The objective of this study was to determine the incidence of morbidly adherent placenta in pregnancies after endometrial ablation. STUDY DESIGN: We performed a retrospective cohort analysis using a large, multiinstitutional deidentified clinical database, IBM EPM: Explore (IBM Corporation, Somers, NY). We identified women who underwent endometrial ablation and had a subsequent delivery between 1999 and 2016. Patients with a delivery and no prior ablation were used as controls. The association between morbidly adherent placenta, ablation, and other known risk factors for morbidly adherent placenta was analyzed using multivariable logistic regression. RESULTS: Of 162,100 reproductive-aged women who underwent endometrial ablation, 2,770 women (1.71%) subsequently had a delivery. The rate of morbidly adherent placenta was 1 in 13.9 pregnancies after ablation compared with 1 in 838.7 pregnancies in the control group (adjusted odds ratio [aOR], 20.22, p < 0.0001). CONCLUSION: Pregnancies that occurred after endometrial ablation were associated with increased rates of morbidly adherent placenta.

History of cervical insufficiency increases the risk of pelvic organ prolapse and stress urinary incontinence in parous women.

OBJECTIVE: A likely contributor to pelvic floor disorders is injury and degradation of connective tissue components such as collagen and elastin, leading to weakening of the pelvic floor. Prior studies have found similar connective tissue component changes in women with cervical insufficiency (CI). However, the connection between pelvic floor disorders and cervical insufficiency has not previously been evaluated. Our objective was to determine whether a history of cervical insufficiency is associated with an increased risk of pelvic organ prolapse and stress urinary incontinence after controlling for confounders. STUDY DESIGN: The study used de-identified clinical data from a large multi-institution electronic health records HIPAA-compliant data web application, Explorys Inc. (Cleveland, Ohio, USA). Women with a history of at least one prior delivery after at least 20 weeks' gestation between the years 1999 and 2016 were identified. Logistic regression models were used to identify risk factors and adjust for confounders. MAIN OUTCOME MEASURES: The primary outcome was subsequent development of either stress incontinence or pelvic organ prolapse. RESULTS: A total of 1,182,650 women were identified, of whom 30,890 (2.6%) had a history of cervical cerclage or insufficiency. A history of cervical insufficiency was associated with an increased risk of either pelvic organ prolapse or stress urinary incontinence (aOR=1.93, 95%CI: 1.84-2.02). A history of cervical insufficiency was more strongly associated with an increased risk of pelvic organ prolapse (aOR=2.06, 95%CI: 1.91-2.21) than with stress urinary incontinence (aOR=1.91, 95%CI: 1.80-2.02). CONCLUSION: A history of cervical insufficiency is associated with an increased risk of development of pelvic organ prolapse and stress urinary incontinence.

Interactions between mecamylamine and alcohol in Long-Evans rats: flash-evoked potentials, body temperature, behavior, and blood alcohol concentration.

Mecamylamine, a noncompetitive antagonist of nicotinic acetylcholine receptors, has many potential clinical applications, including treating alcohol dependency. However, little is known about the combined effects of mecamylamine and alcohol on visual system electrophysiology. We examined the separate and combined effects of mecamylamine (4.0mg/kg, ip) and alcohol (2.0 g/kg, ip) on flash-evoked potentials (FEPs) recorded from the visual cortex (VC) and superior colliculus (SC) of chronically implanted adult male Long-Evans rats. On separate days, either saline or mecamylamine was given 10 min prior to either saline or ethanol. FEPs were recorded 15 and 30 min after the second injection. In the VC, alcohol significantly decreased the amplitudes of components P23, N29, N39, P89, N143, and P237, but increased P46. N63 amplitude was not significantly altered. In contrast, mecamylamine increased the amplitude of P23, P46, and N63, but reduced the amplitude of N29 and P237. The combination of mecamylamine and alcohol resulted in amplitudes very similar to alcohol alone for components P23, N29, N63, P89, N143, and P237. However, mecamylamine pretreatment reduced the effects of alcohol on components N39 and P46. In the SC, FEP component amplitudes were generally decreased by alcohol but not significantly altered by mecamylamine. Mecamylamine pretreatment did not significantly alter the effects of alcohol on SC amplitudes. Latencies of nearly all components in both structures were significantly increased by all drug treatments, with the greatest increase produced by the combination treatment. Hypothermia was also produced by all drug treatments, with the greatest hypothermia (2.25 °C) produced by the combination treatment, most likely accounting for much of the drug-induced increase in latencies. All drug treatments reduced movement during FEP testing, but later in an open field alcohol increased ambulation while mecamylamine reduced movement. Separate groups of experimentally naïve adult male Holtzman albino and Long-Evans hooded rats were given (ip) either alcohol or mecamylamine plus alcohol. Tail vein samples were taken 30 min later. For both rat strains, blood alcohol concentration in the mecamylamine pretreatment group was significantly less at this time interval by about 50-60 mg/dL, suggesting a mechanism whereby mecamylamine can mitigate some of the acute effects of alcohol (e.g., on VC components N39 and P46).