Pre-pregnancy body mass index (BMI) and cerclage success.

OBJECTIVE: This study was performed to evaluate the effect of pre-pregnancy body mass index (BMI) on the success of cerclage. MATERIALS AND METHODS: A retrospective cohort study of women who had a history-indicated (HIC) or ultrasound-indicated cerclage (UIC) placed between 1994 and 2011. Based on pre-pregnancy BMI (World Health Organization criteria), three cohorts were defined: normal/overweight (BMI: 20.0-29.9 kg/m(2)), obese class I/II (BMI: 30.0-39.9 kg/m(2)) and obese class III (BMI ≥ 40.0 kg/m(2)). The primary outcome was spontaneous preterm birth (sPTB) <35 weeks. The secondary outcomes included but were not limited to gestational age of delivery, sPTB <37, <32 and <28 weeks, preterm premature rupture of membranes and birth weight. RESULTS: 375 women were included for analysis. Demographics were similar in the three BMI categories, except black race (p = 0.01). The rates of sPTB <35 weeks were similar between each cohort: 24.3%, 23.0% and 27.7%, respectively (p = 0.81). BMI was not a predictor of any of the secondary outcomes. A HIC was placed in 47.2% and an UIC was placed in 52.8% women. Both unadjusted and adjusted analysis showed no significant difference in sPTB <35 weeks between BMI categories overall or by cerclage type (HIC or UIC). CONCLUSIONS: Pre-pregnancy BMI is not a significant predictor of sPTB <35 weeks in women with HIC or UIC.

Prior Ultrasound-Indicated Cerclage: Comparison of Cervical Length Screening or History-Indicated Cerclage in the Next Pregnancy.

OBJECTIVE: To evaluate outcomes of women with prior ultrasound-indicated cerclage, who in their subsequent pregnancy were either followed by transvaginal ultrasound cervical length screening or received a planned history-indicated cerclage. METHODS: Multicenter cohort study of singleton gestations with a prior ultrasound-indicated cerclage performed from 1994 to 2014. We evaluated three pregnancies in the study participants: first pregnancy with prior spontaneous preterm birth at less than 37 weeks of gestation; second pregnancy with ultrasound-indicated cerclage for cervical length 25 mm or less; and the third index pregnancy managed with either transvaginal ultrasound cervical length screening with ultrasound-indicated cerclage for cervical length 25 mm or less or planned history-indicated cerclage. The primary outcome was incidence of spontaneous preterm birth at less than 37 weeks of gestation. We planned a subgroup analysis for women who delivered at less than 32 weeks of gestation compared with 32 weeks of gestation or greater in their prior ultrasound-indicated cerclage pregnancy. RESULTS: Of 102 singleton gestations included, 38 (37.3%) were followed with transvaginal ultrasound cervical length screening and 64 (62.7%) underwent history-indicated cerclage. Of 38 women in the transvaginal ultrasound group, 18 (47.4%) underwent ultrasound-indicated cerclage for cervical length 25 mm or less. After adjusting for confounders, the rate of spontaneous preterm birth at less than 37 weeks of gestation was similar between transvaginal ultrasound cervical length screening and history-indicated cerclage groups (36.8% compared with 43.8%; adjusted odds ratio 0.77, 95% confidence interval 0.47-1.45). Secondary outcomes were also similar in both groups. All women (n=7) who delivered at less than 32 weeks of gestation in their prior pregnancy and subsequently had transvaginal ultrasound screening received ultrasound-indicated cerclage in the index pregnancy compared with only 35.5% of women who delivered at 32 weeks of gestation or greater in their prior pregnancy. CONCLUSION: Women with prior ultrasound-indicated cerclage have similar outcomes if they receive either transvaginal ultrasound cervical length screening with ultrasound-indicated cerclage for cervical length 25 mm or less or planned history-indicated cerclage in the subsequent pregnancy. Less than 50% of the transvaginal ultrasound cervical length screening group require a repeat ultrasound-indicated cerclage in the subsequent pregnancy. LEVEL OF EVIDENCE: II.

Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage for preterm birth prevention.

OBJECTIVE: The objective of the study was to compare the efficacy and outcomes of 2 vs 1 stitch at the time of cervical cerclage placement for preterm birth prevention. STUDY DESIGN: This was a retrospective cohort study of women with singleton gestation undergoing history- or ultrasound-indicated transvaginal cervical cerclage prior to 24 weeks. The primary outcome was delivery at less than 37 weeks. The secondary outcomes included gestational age at delivery at less than 35, less than 34, less than 32, less than 28, and less than 24 weeks, perioperative details at the time of cerclage placement and removal, and maternal and neonatal outcomes. Comparison was made between patients with 2 vs 1 stitch at the time of cerclage placement. History- and ultrasound-indicated cerclages were analyzed separately. RESULTS: Four hundred forty-four patients met inclusion criteria, 237 being history indicated (2 stitches, n = 86, 1 stitch, n = 151), and 207 ultrasound indicated (2 stitches, n = 117, 1 stitch, n = 90). Gestational age at delivery at less than 37 weeks was not significantly different between the 2 groups for both history- and ultrasound-indicated cerclage, even after adjusting for demographic differences and suture type (39% vs 35%; adjusted odds ratio, 1.38; 95% confidence interval, 0.64-3.01; and 44% vs 49%; adjusted odds ratio, 0.66; 95% confidence interval, 0.27-1.61, respectively). CONCLUSION: Two stitches at the time of cerclage do not appear to improve pregnancy outcome either in the history- or the ultrasound-indicated procedures, compared with 1 stitch.

Cervical cerclage and preterm PROM.

Preterm premature rupture of membranes (PPROM) occurs in 38% of women with cerclage in place. Controversy exists on what to do with the cerclage in this clinical scenario. The objective was to review the literature addressing retention versus removal of cerclage after PPROM and present management recommendations. Retention of cerclage for more than 24 hours after PPROM was found to prolong pregnancy for more than 48 hours, but also to increase maternal chorioamnionitis and neonatal mortality from sepsis, making immediate cerclage removal as the usually preferred therapeutic approach. Steroids for fetal maturity before cerclage removal can be considered between 24 and 33 6/7 weeks gestation.

Postpartum endometritis caused by herpes and cytomegaloviruses.

BACKGROUND: Postpartum endometritis is usually a polymicrobial infection caused by organisms that are part of the normal vaginal flora. A pathologically confirmed case of postpartum endometritis secondary to herpes and cytomegalovirus in a human immunodeficiency virus (HIV)-positive patient is reported. CASE: A 29-year-old, HIV-positive woman presented 6 days postpartum with abdominal pain and foul-smelling vaginal discharge. Pelvic ultrasonography revealed retained products of conception. Dilation and evacuation was performed, and antibiotics were started. Despite adequate antibiotics and laparoscopic drainage of a pelvic collection, fevers and pain continued. A total abdominal hysterectomy, salpingectomy, and appendectomy were performed. Pathology reported herpes and cytomegalovirus infection of the uterus. CONCLUSION: Herpes simplex virus (HSV) and cytomegalovirus need to be considered as a potential cause of postpartum endometritis. When antibiotic therapy fails, an antiviral regimen should be considered.

Compliance with methotrexate therapy for presumed ectopic pregnancy in an inner-city population.

Fewer than 1 in 5 patients comply with the established follow-up protocol to treat presumed ectopic pregnancy medically in an urban clinic population. Institutions should consider tracking their patient compliance with follow-up to determine the efficacy of their treatment decisions.