The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization / 부인종양

OBJECTIVE: To evaluate pregnancy outcomes after electrosurgical conization. METHODS: We retrospectively analyzed the outcomes of 56 singleton pregnancies after electrosurgical conization of the uterine cervix. Of the 56 cases, 25 women underwent prophylactic cerclage with McDonald procedure (cerclage group), and 31 were managed expectantly (expectant group). Pregnancy outcomes including rate of preterm delivery were compared, and the effect of potential risk factors such as depth of cone, interval between conization and pregnancy, and cervical length on the risk of preterm delivery was assessed. RESULTS: The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization than those without (32.1% vs. 15.2%, p<0.001). However, preterm delivery rate was not different between the two groups (expectant group vs. cerclage group; <28 week, 6.5% vs. 8.0%, p=1.000; <34 week, 19.4% vs. 20.0%, p=1.000; <37 week, 29.0% vs. 36.0%, p=0.579). All obstetric and neonatal outcomes were similar in the two groups. Even when we confined the study subjects to 19 women (19/56, 33.9%) with cervical length less than 25 mm, the preterm delivery rate also was not significantly different between the expectant (n=7) and cerclage group (n=12). Finally, the potential risk factors for preterm delivery were not associated with risk of preterm delivery in patients with a history of electrosurgical conization. CONCLUSION: The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization before pregnancy. However, prophylactic cervical cerclage did not prevent preterm delivery in these patients.

Interpregnancy interval after a previous preterm birth and subsequent preterm birth risk / 대한산부인과학회지

OBJECTIVE: To investigate the recurrent preterm birth (PTB) risk in women with a history of previous PTB, and whether the interpregnancy interval or the indication for previous PTB is associated with the recurrent PTB risk. METHODS: A retrospective analysis was conducted on a group of 325 women whose first delivery ended at preterm and subsequently delivered their second birth. Data regarding delivery dates, gestational age at delivery and indication for PTB in the first and second pregnancies, respectively, were collected from medical records. Interpregnancy interval was defined as the period of time between the first PTB and subsequent conception. The patients were divided into six groups based on the interpregnancy intervals (48 months). RESULTS: The recurrent PTB rate in the study population was 24.3%, which was significantly higher than PTB rate in the control groups (primipara, 15.5%, P<0.001; multipara who delivered at term in their first pregnancy, 11.8%, P<0.001). The recurrent PTB rate was lowest in the 6-12 months interpregnancy interval group, and highest in the 36-48 months group. However, the rate of recurrent PTB was not significantly different among the six different interpregnancy interval groups (chi square test, P=0.394, linear-by-linear association test, P=0.343). In addition, there was no association between the indication for previous PTB and the recurrent PTB rate. CONCLUSION: Although the risk of PTB was increased in women with a history of PTB, the risk was not influenced by the interpregnancy interval or the indication for previous PTB.

Emergent hysterectomy and angiographic embolization for the management of obstetrical hemorrhage: 8-year experiences / 대한산부인과학회지

OBJECTIVE: To compare the clinical characteristics and outcome of hysterectomy and angiographic embolization in the management of obstetrical hemorrhage unresponsive to conservative management. METHODS: We retrospectively analyzed 88 patients who underwent hysterectomy and 53 patients who underwent angiographic embolization for the management of obstetrical hemorrhage from January 1999 to July 2007. We analyzed the maternal characteristics and outcomes by the review of medical records and telephone interview. Nonparametric test was performed for comparison of both groups. RESULTS: Angiographic embolization for the management of obstetrical hemorrhage is on the increase year by year, consisting of about three quarters of total cases in the last year. The most common indication of hysterectomy was abnormal placentation (68.2%) followed by uterine atony (25.0%). For the embolization, the most common indication was uterine atony (54.7%) followed by abnormal placentation (17%). The median pre-operative hemoglobin was significantly lower in embolization group than hysterectomy group [8.3 (3.8~12.7 g/dL) vs. 10.8 (2.4~13.7 g/dL), P<0.001]. There was no difference in the total transfusion amount of packed RBC between the two groups. The median hospital stay was shorter in embolization group [8 (5~57 days) vs. 6 (3~14 days), P<0.001]. Overall success rate of embolization was 89% and procedure-related acute complications were not occurred. Of the total population, there was one maternal death in the hysterectomy group. We found that most women who underwent the embolization resume normal menstruation. CONCLUSION: Angiographic embolization for the management of obstetrical hemorrhage is more commonly performed in recent years. Angiographic embolization was associated with shorter hospital stay, reasonable success rate, and minimal complication rate.

Antenatal Predictors of Neonatal Outcome in Fetal Growth Restriction; Efficacy of Biophysical Score, Doppler Ultrasound, Fetal Heart Rate Monitoring / 대한주산의학회잡지

PURPOSE:To identify the antenatal variables predictive of neonatal outcome and to examine the relationship between biophysical score, multivessel Doppler ultrasound and fetal heart rate monitoring in fetal growth restriction (FGR). METHODS:We retrospectively analyzed the pregnancy and neonatal outcomes of 64 growth restricted fetuses delivered at less than 34 weeks of gestation at Samsung Medical Center, from May 2005 to May 2008. The result of Doppler velocimetry including umbilical artery, middle cerebral artery, and ductus venosus and biophysical score (BPS) and fetal heart rate (FHR) monitoring for each subject were reviewed. Adverse neonatal outcome was defined as bronchopulmonary dysplasia, periventricular leukomalacia, grade 3~4 intraventricular hemorrhage, grade 3~4 retinopathy of prematurity, necrotizing enterocolitis, neonatal sepsis, and perinatal mortality. We performed the univariate and multivariate analysis to determine which antenatal fetal surveillance test is the best to predict the adverse neonatal outcome in preterm FGR. We also assessed the degree of agreement of each antenatal test by the Cohens kappa test. RESULTS:By the univariate analysis, significant variables associated with adverse neonatal outcome were gestational age at delivery, oligohydramnios, and abnormal ductus venosus Doppler. However, in the multivariate analysis, gestational age at delivery and oligohydramnios remained as independent predictors of adverse neonatal outcome. Degree of agreement among the antenatal tests expressed by the Cohens kappa was only significant between BPS and FHR monitoring (kappa=0.303, P=0.019). CONCLUSION:Our data suggests that the timing of delivery of growth restricted fetuses less than 34 weeks of gestation should be determined by the gestational age and oligohydramnios, not by the one abnormal antenatal fetal surveillance result. We also confirmed that there are considerable amount of disagreements among BPS, mutivessel Doppler, and FHR monitoring.

Comparison of fetal magnetic resonance imaging and ultrasonography for the diagnosis of fetal anomalies / 대한주산의학회잡지

PURPOSE: To compare the accuracy of fetal magnetic resonance imaging (MRI) and prenatal ultrasonography (USG) with postnatal diagnosis for the diagnosis of fetal anomalies. METHODS: Retrospective analysis of 41 fetuses who underwent fetal MRI with prenatal USG from 2005 to 2008 was performed. In 28 cases of the total population, the final neonatal diagnosis was also analyzed for the consistency of pre- and postnatal diagnoses for each diagnostic tool. Postnatal diagnosis was confirmed by physical examination, radiographic studies (USG, MRI and/or computed tomography), surgery, and/or autopsy. RESULTS: Mean gestational age at the fetal MRI performed was 26.1+/-4.7 weeks. The most common indication of the fetal MRI was central nervous system (CNS) anomalies (n=12), followed by thoracic anomalies (n=5), abdominal anomalies (n=2), genitourinary anomalies (n=3), head and neck anomalies (n=4), and others (n=2). When compared with postnatal diagnosis, the accuracy of prental MRI was superior to prenatal USG (89% vs. 71%). The cases with additional accurate diagnosis with using fetal MRI were 4 CNS, 1 genitourinary, and 1 craniofacial anomaly. Of notes, there was a case of enlarged cisterna magna in which prenatal MRI missed the diagnosis. In 2 cases (7.1%), both imaging studies made an incorrect prenatal diagnoses. CONCLUSION: Fetal MRI could confirm the USG diagnosis in most cases and provided more accurate diagnosis in some cases of CNS and thoracic, genitourinary system abnormalities. MRI is expected to be a good adjunctive for USG to improve prenatal diagnosis of fetal anomalies.

A Comparison of Oral Misoprostol and Vaginal Dinoprostone Pessary in Induction of Labor at Term / 대한주산의학회잡지

OBJECTIVE: The aim of this study was to compare the efficacy and safety of oral prostaglandin (PG) E1, misoprostol, and vaginal PGE2, dinoprostone pessary, in the induction of labor at term. METHODS: From March 2004 to March 2006, we retrospectively analyzed 175 women who underwent labor induction at term with an unfavorable cervix (the Bishop score=4). Women in the misoprostol group (n=72) received 100 microgram oral misoprostol and the second dose could be repeated every 6 hours if the Bishop score remained at 4 or less. Women in the dinoprostone group (n=103) received 10 mg vaginal dinoprostone pessary. Intravenous oxytocin, if necessary, was administrated 6 hours after the last dose of oral misoprostol or removal of the dinoprostone pessary. RESULTS: Mode of delivery and indications for cesarean delivery were similar in the two groups. The interval from PG administration to active phase of labor (median [range], 9.6 [3.0~37.2] hr vs. 12.0 [1.8~41.7] hr, p<0.05) and vaginal delivery (median [range], 12.7 [3.2~38.4] hr vs. 15.5 [3.3~ 37.1] hr, p<0.05) were shorter in the misoprostol group than the dinoprostone group. However, delivery within 12 hours and within 24 hours after PG administration was similar in the two groups. Uterine hyperstimulation syndrome occurred in 5 (6.9%) women in the misoprostol group and in none in the dinoprostone group (p<0.05). The neonatal outcome was not different between the two groups. CONCLUSION: Overall, oral misoprostol is as effective as vaginal dinoprostone pessary for induction of labor at term, but it is associated with shorter labor induction time and higher risk of uterine hyperstimulation syndrome.

The effect of multiple courses of antenatal corticosteroid therapy on perinatal outcome of the preterm neonates / 대한산부인과학회지

OBJECTIVE: To investigate the effect of multiple courses of antenatal corticosteroid (ACS) therapy on perinatal outcomes, especially the respiratory distress syndrome (RDS), of the premature neonates. METHODS: We retrospectively evaluated the pregnancy and neonatal outcomes of 622 singleton pregnancies delivered at 24-34 weeks of gestation from January 1996 to December 2005. Subjects were categorized into three groups according to ACS exposure: (1) a non-user group (n=234), (2) a single-course group (n=299) and (3) a repeated-course group (n=89). Univariate and multiple logistic regression analyses were used for the incidences of RDS. RESULTS: Pregnancy outcomes including gestational age at delivery, occurrence of clinical and histological chorioamnionitis, birth weight, neonatal intensive care unit (NICU) admission rate, duration of NICU stay and neonatal mortality were similar in the three groups. The incidence of RDS was significantly lower in ACS user groups than the non-user group, with lowest incidence in multiple-course group (44.9% vs. 37.8% vs. 12.4%, p<0.001). The incidence of bronchopulmonary dysplasia and overall neonatal composite morbidity were also lowest in multiple-course group. Multivariate analysis showed that multiple courses of ACS were associated with reduced incidence of RDS (OR 0.100, 95% CI 0.042, 0.240, p<0.001) independently with gestational age at delivery, admission-to-delivery interval and premature rupture of membranes. CONCLUSION: Multiple courses of ACS administered to women with risk of preterm delivery were found to be associated with decreased incidence of RDS of the premature neonates.

Clinical outcomes of first trimester discordant twins / 대한산부인과학회지

OBJECTIVE: To compare the clinical outcomes of first trimester discordant twins with second or third trimester discordant twins and concordant twins. METHODS: Pregnancy outcomes of twin pregnancies delivered from October 1994 to February 2006 were analyzed retrospectively. Subjects were categorized into following three groups: 1) group 1, first trimester discordant twins defined as intertwin CRL difference > or =5 days at 10-14 weeks of gestation (n=32), 2) group 2, second or third trimester discordant twins defined as intertwin AC difference >20 mm at 20-28 weeks of gestation or intertwin fetal weight difference >25% beyond 29 weeks of gestation (n=42), 3) group 3, concordant twins with no discordancy throughout the whole gestation (n=723). Perinatal complications analyzed for were congenital anomaly, fetal growth restriction (FGR), fetal death in utero (FDIU). RESULTS: The three groups were similar with respect to maternal characteristics and chorionicity. Overall, the group 2 had higher perinatal complications compared to the group 3. Congenital anomaly was more common in the group 1 than the group 2 (21.9% vs. 11.9%, p<0.001). However, FGR rate was higher in the group 2 than the group 1 (32.3% vs. 71.8%, p<0.01). Congenital anomaly, FGR and FDIU were more common in the group 1 compared to the group 3 (21.9% vs. 3.5%, p<0.001, 32.3% vs. 9.1%, p<0.01, 6.3% vs. 1.0%, p<0.05, respectively). CONCLUSIONS: First trimester discordant twins have an increased risk of congenital anomaly, FGR and FDIU, and therefore, they should be regarded as a high-risk pregnancy likewise second or third trimester discordant twins.

Clinical outcome of preterm premature rupture of membranes in singleton versus twin pregnancy / 대한산부인과학회지

OBJECTIVE: To compare the latency period and perinatal outcome of singleton and twin pregnancies complicated by preterm premature rupture of the membranes (PPROM). METHODS: From January 1996 to December 2005, the medical records of women with singleton (n=345) and twin pregnancies (n=73) complicated by PPROM (24-34 weeks of gestation) were reviewed. Pregnancy and neonatal outcomes including the latency period, neonatal morbidity, and mortality were compared between the singleton and twin groups. RESULTS: No differences were noted with respect to gestational age at the time of membrane rupture and use of tocolytics, steroid and prophylactic antibiotics between the two groups. The latency period was significantly shorter in twins (median [range]; 4.0 [0-50] day vs. 1.0 [0-25] days, p<0.001), and significantly more twins were born within 48 hours and within 7 days after rupture of the membranes (within 48 hours, 33.0%vs. 65.8%, p<0.001; within 7 days, 67.5%vs. 87.7%, p<0.001). The latency period was longer when PPROM occurred before 30 weeks of gestation than after 30 weeks of gestation in both groups (median [range]; singleton, 11.5 [0-50] days vs. 3.0 [0-33] days, p<0.001; twin, 3.0 [0-25] days vs. 0 [0-6] day, p<0.001). Although gestational age at delivery was similar in singleton and twin groups, more twin infants had low birth weight, low Apgar score and neonatal morbidities. CONCLUSION: Twin pregnancy with PPROM, compared to singleton pregnancy with PPROM, had shorter latency period and worse perinatal outcome.