1
|
Romero R, Meyyazhagan A, Hassan SS, Creasy GW, Conde-Agudelo A. Vaginal Progesterone to Prevent Spontaneous Preterm Birth in Women With a Sonographic Short Cervix: The Story of the PREGNANT Trial. Clin Obstet Gynecol 2024; 67:433-457. [PMID: 38576410 PMCID: PMC11047312 DOI: 10.1097/grf.0000000000000867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The PREGNANT trial was a randomized, placebo-controlled, multicenter trial designed to determine the efficacy and safety of vaginal progesterone (VP) to reduce the risk of birth < 33 weeks and of neonatal complications in women with a sonographic short cervix (10 to 20 mm) in the mid-trimester (19 to 23 6/7 wk). Patients allocated to receive VP had a 45% lower rate of preterm birth (8.9% vs 16.1%; relative risk = 0.55; 95% CI: 0.33-0.92). Neonates born to mothers allocated to VP had a 60% reduction in the rate of respiratory distress syndrome. This article reviews the background, design, execution, interpretation, and impact of the PREGNANT Trial.
Collapse
Affiliation(s)
- Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, Maryland
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan
| | - Arun Meyyazhagan
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, Maryland
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
- Office of Women’s Health, Integrative Biosciences Center, Wayne State University, Detroit, Michigan
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan
| | - George W. Creasy
- Center for Biomedical Research, Population Council, New York, New York
| | - Agustin Conde-Agudelo
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| |
Collapse
|
2
|
Liu J, Xu M, Zhou L, Yang L, Li H, Li X. Early Magnetic Resonance Imaging Measurements and Prediction of Second Trimester Pregnancy Loss: a Nomogram Model Analysis. Int J Womens Health 2024; 16:819-827. [PMID: 38765204 PMCID: PMC11102072 DOI: 10.2147/ijwh.s453867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/20/2024] [Indexed: 05/21/2024] Open
Abstract
Objective To investigate the magnetic resonance imaging (MRI) features of women with prior second-trimester pregnancy loss, and to establish a nomogram prediction model for subsequent miscarriage. Methods A retrospective cohort study of women with prior second-trimester pregnancy loss from January 2018 to December 2021 in Second Affiliated Hospital of Soochow University was performed. A total of 245 patients were included. Data from January 2018 to December 2019 were used to construct the model, and data from January 2020 to December 2021 were used to evaluate the model. Data on maternal demographic characteristics, MRI cervical measurements were extracted. The prediction model was constructed with independent variables determined by multivariate logistic regression analyses. Through receiver-operating characteristic (ROC) curve analysis, the predictive ability of the model for subsequent second trimester pregnancy loss in women was evaluated, and internal validation was performed through validation data. Results Thin cervix was observed in 77 (31.42%) women with prior second-trimester pregnancy loss, the mean longitudinal diameter of cervical canal on MRI was 11.76±2.75mm. The model reached a sensitivity of 80%, specificity of 75.90%, positive predictive value (PPV) of 55.80% and negative predictive value of 90.90%; ROC characteristics proved that the model was superior to any single parameter with an AUC of 0.826. Conclusion Our observations showed that thin cervix and longitudinal diameter of cervical canal reliably predicted second trimester pregnancy loss. We developed and validated a nomogram model to predict the individual probability of second trimester pregnancy loss in the next pregnancy and hopefully improve the prediction and indication of interventions.
Collapse
Affiliation(s)
- Juanjuan Liu
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
| | - Minqin Xu
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
| | - Ling Zhou
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
| | - Li Yang
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
| | - Hong Li
- Department of Radiology, Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
| | - Xue Li
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
| |
Collapse
|
3
|
Panagiotopoulos M, Pergialiotis V, Trimmi K, Varthaliti A, Koutras A, Antsaklis P, Daskalakis G. Differences in cervical length during the second trimester among normal weight, overweight and obese women: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2024; 21:100291. [PMID: 38419650 PMCID: PMC10900401 DOI: 10.1016/j.eurox.2024.100291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/02/2024] Open
Abstract
Objective Maternal obesity has been previously linked to increased risk of preterm birth; however, the actual pathophysiology behind this observation remains unknown. Cervical length seems to differentiate among overweight, obese and extremely obese patients, compared to normal weight women. However, to date the actual association between body mass index and cervical length remains unknown. In this systematic review, accumulated evidence is presented to help establish clinical implementations and research perspectives. Methods We searched Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar, and Clinicaltrials.gov databases from inception till February 2023. Observational studies that reported on women undergone ultrasound assessment of their cervical length during pregnancy were included, when there was data regarding their body mass index. Statistical meta-analysis was performed with RStudio. The quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS). Results Overall, 20 studies were included in this systematic review and 12 in the meta-analysis. Compared to women with normal weight, underweight women were not associated with increased risk of CL < 15 mm or < 30 mm and their mean CL was comparable (MD -1.51; 95% CI -3.07, 0.05). Overweight women were found to have greater cervical length compared to women with normal weight (MD 1.87; 95% CI 0.52, 3.23) and had a lower risk of CL < 30 mm (OR 0.65; 95% CI 0.47, 0.90). Conclusion Further research into whether BMI is associated with cervical length in pregnant women is deemed necessary, with large, well-designed, prospective cohort studies with matched control group.
Collapse
Affiliation(s)
- Michail Panagiotopoulos
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Vasilios Pergialiotis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Konstantina Trimmi
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Antonia Varthaliti
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Antonios Koutras
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Panagiotis Antsaklis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| |
Collapse
|
4
|
Yoshida K. Bioengineering and the cervix: The past, current, and future for addressing preterm birth. Curr Res Physiol 2023; 6:100107. [PMID: 38107784 PMCID: PMC10724223 DOI: 10.1016/j.crphys.2023.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/23/2023] [Accepted: 09/20/2023] [Indexed: 12/19/2023] Open
Abstract
The uterine cervix plays two important but opposing roles during pregnancy - as a mechanical barrier that maintains the fetus for nine months and as a compliant structure that dilates to allow for the delivery of a baby. In some pregnancies, however, the cervix softens and dilates prematurely, leading to preterm birth. Bioengineers have addressed and continue to address the lack of reduction in preterm birth rates by developing novel technologies to diagnose, prevent, and understand premature cervical remodeling. This article highlights these existing and emerging technologies and concludes with open areas of research related to the cervix and preterm birth that bioengineers are currently well-positioned to address.
Collapse
Affiliation(s)
- Kyoko Yoshida
- Department of Biomedical Engineering, University of Minnesota, 7-105 Nils Hasselmo Hall, 312 Church Street SE, Minneapolis, MN, 55455, USA
| |
Collapse
|
5
|
Hughes K, Ford H, Thangaratinam S, Brennecke S, Mol BW, Wang R. Diagnosis or prognosis? An umbrella review of mid-trimester cervical length and spontaneous preterm birth. BJOG 2023; 130:866-879. [PMID: 36871557 PMCID: PMC10953024 DOI: 10.1111/1471-0528.17443] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/04/2022] [Accepted: 01/16/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Cervical length is widely used to assess a woman's risk of spontaneous preterm birth (SPTB). OBJECTIVES To summarise and critically appraise the evidence from systematic reviews on the prognostic capacity of transvaginal sonographic cervical length in the second trimester in asymptomatic women with singleton or twin pregnancy. SEARCH STRATEGY Searches were performed in Medline, Embase, CINAHL and grey literature from 1 January 1995 to 6 July 2021, including keywords 'cervical length', 'preterm birth', 'obstetric labour, premature', 'review' and others, without language restriction. SELECTION CRITERIA We included systematic reviews including women who did not receive treatments to reduce SPTB risk. DATA COLLECTION AND ANALYSIS From 2472 articles, 14 systematic reviews were included. Summary statistics were independently extracted by two reviewers, tabulated and analysed descriptively. The ROBIS tool was used to evaluate risk of bias of included systematic reviews. MAIN RESULTS Twelve reviews performed meta-analyses: two were reported as systematic reviews of prognostic factor studies, ten used diagnostic test accuracy methodology. Ten systematic reviews were at high or unclear risk of bias. Meta-analyses reported up to 80 combinations of cervical length, gestational age at measurement and definition of preterm birth. Cervical length was consistently associated with SPTB, with a likelihood ratio for a positive test of 1.70-142. CONCLUSIONS The ability of cervical length to predict SPTB is a prognostic research question; systematic reviews typically analysed diagnostic test accuracy. Individual participant data meta-analysis using prognostic factor research methods is recommended to better quantify how well transvaginal ultrasonographic cervical length can predict SPTB.
Collapse
Affiliation(s)
- Kelly Hughes
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - Heather Ford
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Women's Health, Institute of Translational MedicineUniversity of BirminghamBirminghamUK
| | - Shaun Brennecke
- Department of Obstetrics and GynaecologyThe University of MelbourneMelbourneVictoriaAustralia
- Department of Maternal‐Fetal Medicine & Pregnancy Research CentreRoyal Women's HospitalMelbourneVictoriaAustralia
| | - Ben W. Mol
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Rui Wang
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| |
Collapse
|
6
|
Deffieux X, Rousset-Jablonski C, Gantois A, Brillac T, Maruani J, Maitrot-Mantelet L, Mignot S, Gaucher L, Athiel Y, Baffet H, Bailleul A, Bernard V, Bourdon M, Cardaillac C, Carneiro Y, Chariot P, Corroenne R, Dabi Y, Dahlem L, Frank S, Freyens A, Grouthier V, Hernandez I, Iraola E, Lambert M, Lauchet N, Legendre G, Le Lous M, Louis-Vahdat C, Martinat Sainte-Beuve A, Masson M, Matteo C, Pinton A, Sabbagh E, Sallee C, Thubert T, Heron I, Pizzoferrato AC, Artzner F, Tavenet A, Le Ray C, Fauconnier A. [Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:297-330. [PMID: 37258002 DOI: 10.1016/j.gofs.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To provide guidelines for the pelvic clinical exam in gynecology and obstetrics. MATERIAL AND METHODS A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature. CONCLUSIONS The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.
Collapse
Affiliation(s)
- Xavier Deffieux
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, université Paris-Saclay, AP-HP, 92140 Clamart, France.
| | - Christine Rousset-Jablonski
- Département de chirurgie, Centre Léon Bérard, 28, rue Laënnec, 69008 Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), université Claude-Bernard Lyon 1, 69008 Lyon, France; Service de Gynécologie-Obstétrique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Adrien Gantois
- Collège national des sages-femmes de France hébergé au Réseau de santé périnatal parisien (RSPP), 75010 Paris, France
| | | | - Julia Maruani
- Cabinet médical, 6, rue Docteur-Albert-Schweitzer, 13006 Marseille, France
| | - Lorraine Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris centre (HUPC), 75014 Paris, France
| | | | - Laurent Gaucher
- Collège national des sages-femmes de France, CNSF, 75010 Paris, France; Public Health Unit, hospices civils de Lyon, 69500 Bron, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), université Claude-Bernard Lyon 1, 69008 Lyon, France; Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, 1206 Genève, Suisse
| | - Yoann Athiel
- Maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, université Paris cité, FHU Prema, 75014 Paris, France
| | - Hortense Baffet
- Service de gynécologie médicale, orthogénie et sexologie, CHU de Lille, université de Lille, 59000 Lille, France
| | - Alexandre Bailleul
- Service de gynécologie-obstétrique, centre hospitalier de Poissy Saint-Germain-en-Laye, 78300 Poissy, France; Équipe RISCQ « Risques cliniques et sécurité en santé des femmes et en santé périnatale », université Paris-Saclay, UVSQ, 78180 Montigny-le-Bretonneux, France
| | - Valérie Bernard
- Service de chirurgie gynécologique, gynécologie médicale et médecine de la reproduction, centre Aliénor d'Aquitaine, centre hospitalo-universitaire Pellegrin, 33000 Bordeaux, France; Unité Inserm 1312, université de Bordeaux, Bordeaux Institute of Oncology, 33000 Bordeaux, France
| | - Mathilde Bourdon
- Service de gynécologie-obstétrique II et médecine de la reproduction, université Paris cité, AP-HP, centre hospitalier universitaire (CHU) Cochin Port-Royal, 75014 Paris, France
| | - Claire Cardaillac
- Service de gynécologie-obstétrique, CHU de Nantes, 44000 Nantes, France
| | | | - Patrick Chariot
- Département de médecine légale et sociale, Assistance publique-Hôpitaux de Paris, 93140 Bondy, France; Institut de recherche interdisciplinaire sur les enjeux sociaux, UMR 8156-997, UFR SMBH, université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Romain Corroenne
- Service de gynécologue-obstétrique, CHU d'Angers, 49000 Angers, France
| | - Yohann Dabi
- Service de gynécologie-obstétrique et médecine de la reproduction, Sorbonne université-AP-HP-hôpital Tenon, 75020 Paris, France
| | - Laurence Dahlem
- Département universitaire de médecine générale, faculté de médecine, université de Bordeaux, 146, rue Léo-Saignat, 33076 Bordeaux, France
| | - Sophie Frank
- Service d'oncogénétique, Institut Curie, 75005 Paris, France
| | - Anne Freyens
- Département universitaire de médecine générale (DUMG), université Paul-Sabatier, 31000 Toulouse, France
| | - Virginie Grouthier
- Service d'endocrinologie, diabétologie, nutrition et d'endocrinologie des gonades, Hôpital Haut Lévêque, Centre Hospitalo-universitaire régional de Bordeaux, 31000 Bordeaux, France; Université de Bordeaux, Inserm U1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Isabelle Hernandez
- Collège national des sages-femmes de France hébergé au Réseau de santé périnatal parisien (RSPP), 75010 Paris, France
| | - Elisabeth Iraola
- Institut de recherche interdisciplinaire sur les enjeux sociaux (IRIS), UMR 8156-997, CNRS U997 Inserm EHESS UP13 UFR SMBH, université Sorbonne Paris Nord, Paris, France; Direction de la protection maternelle et infantile et promotion de la santé, conseil départemental du Val-de-Marne, 94000 Créteil, France
| | - Marie Lambert
- Service de chirurgie gynécologique, gynécologie médicale et médecine de la reproduction, centre Aliénor d'Aquitaine, centre hospitalo-universitaire Pellegrin, 33000 Bordeaux, France
| | - Nadege Lauchet
- Groupe médical François-Perrin, 9, rue François-Perrin, 87000 Limoges, France
| | - Guillaume Legendre
- Service de gynécologue-obstétrique, CHU Angers, 49000 Angers, France; UMR_S1085, université d'Angers, CHU d'Angers, université de Rennes, Inserm, EHESP, Irset (institut de recherche en santé, environnement et travail), Angers, France
| | - Maela Le Lous
- Université de Rennes 1, Inserm, LTSI - UMR 1099, 35000 Rennes, France; Département de gynécologie et obstétrique, CHU de Rennes, 35000 Rennes, France
| | - Christine Louis-Vahdat
- Cabinet de gynécologie et obstétrique, 126, boulevard Saint-Germain, 75006 Paris, France
| | | | - Marine Masson
- Département de médecine générale, 86000 Poitiers, France
| | - Caroline Matteo
- Ecole de maïeutique, Aix Marseille Université, 13015 Marseille, France
| | - Anne Pinton
- Service de gynécologie-obstétrique, hôpital Trousseau, AP-HP, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Sorbonne université, 75013 Paris, France
| | - Emmanuelle Sabbagh
- Unité de gynécologie médicale, hôpital Port-Royal, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris centre (HUPC), 75014 Paris, France
| | - Camille Sallee
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU de Limoges, 87000 Limoges, France
| | - Thibault Thubert
- Service de gynecologie-obstétrique, CHU de Nantes, 44000 Nantes, France; EA 4334, laboratoire mouvement, interactions, performance (MIP), Nantes université, 44322 Nantes, France
| | - Isabelle Heron
- Service d'endocrinologie, université de Rouen, hôpital Charles-Nicolle, 76000 Rouen, France; Cabinet médical, Clinique Mathilde, 76100 Rouen, France
| | - Anne-Cécile Pizzoferrato
- Service de gynécologie-obstétrique, hôpital universitaire de La Miletrie, 86000 Poitiers, France; Inserm CIC 1402, université de Poitiers, 86000 Poitiers, France
| | - France Artzner
- Ciane, Collectif interassociatif autour de la naissance, c/o Anne Evrard, 101, rue Pierre-Corneille, 69003 Lyon, France
| | - Arounie Tavenet
- Endofrance, Association de lutte contre l'endométriose, 3, rue de la Gare, 70190 Tresilley, France
| | - Camille Le Ray
- Maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, université Paris cité, FHU Prema, 75014 Paris, France
| | - Arnaud Fauconnier
- Service de gynécologie-obstétrique, centre hospitalier de Poissy Saint-Germain-en-Laye, 78300 Poissy, France
| |
Collapse
|
7
|
Chen R, Huang X, Li N, Li B. Analysis of pregnancy outcomes in patients undergoing ultrasound-indicated cerclage and identification the influence factors for predicting preterm birth: A retrospective study of 87 cases. Taiwan J Obstet Gynecol 2023; 62:304-310. [PMID: 36965900 DOI: 10.1016/j.tjog.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 03/27/2023] Open
Abstract
OBJECTIVE To investigate the factors influencing preterm birth in patients after ultrasound-indicated cerclage with different cervical lengths (CL), and explore the optimal cut-off value of CL. MATERIALS AND METHODS The retrospective study included 87 pregnant women with a history of preterm birth and second-trimester loss that received ultrasound-indicated cerclage in our hospital between January 2004 and April 2021. Groups were divided by CL at the demarcation point of 1.0, 1.5 and 2.0 cm respectively. The pregnancy outcomes were compared. Logistic regression analysis was performed to assess the independent influence factors. Receiver-operating characteristic (ROC) curves were constructed and the area under the curve (AUC) was used to compare the prediction capability of the associated factors. RESULTS Significant difference was found in terms of patients delivered at ≥32 weeks of gestation (19 [55.9%]vs. 41 [77.4%], p < 0.05) and neonatal birth weight (2495 [1138,3185]vs. 2995 [2155,3235] g, p < 0.05), when the CL was categorized at the demarcation point of 1.5 cm. Body mass index (BMI) (odds ratio [OR] = 1.224, p < 0.05), a history of preterm birth and second-trimester loss (OR = 3.153, p < 0.05), and C-reactive protein (CRP) > 5 mg/L (OR = 8.097, p < 0.05) were independent risk factors for gestational age more than 28 weeks. The AUC of joint predictor A included those factors was 0.849 (95% CI: 0.701-0.998, p < 0.05). CRP>5 mg/L was found to be a significant independent risk factor for different gestational age at delivery. CONCLUSIONS A CL of 1.5 cm was the optimal cut-off value that could help women who underwent serial CL surveillance choose ultrasound-indicated cerclage at an appropriate time. High BMI, more history of preterm birth and second-trimester loss and abnormal CRP could be used as combined predictors to recognize the risk of preterm birth (<28 weeks) post-surgery.
Collapse
Affiliation(s)
- Ruizhe Chen
- Department of Diagnosis & Treatment Centre of Cervical Diseases, Women's Hospital, Zhejiang University School of Medicine, Xueshi Rd No. 1, Hangzhou, 310006, China
| | - Xiaoxiu Huang
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Xueshi Rd No. 1, Hangzhou, 310006, China
| | - Na Li
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Xueshi Rd No. 1, Hangzhou, 310006, China
| | - Baohua Li
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Xueshi Rd No. 1, Hangzhou, 310006, China.
| |
Collapse
|
8
|
Sanz Cortes M, Corroenne R, Johnson B, Sangi-Haghpeykar H, Mandy G, VanLoh S, Nassr A, Espinoza J, Donepudi R, Shamshirsaz AA, Whitehead WE, Belfort M. Effect of preoperative low-normal cervical length on perinatal outcome after laparotomy-assisted fetoscopic spina bifida repair. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:74-80. [PMID: 36099454 DOI: 10.1002/uog.26070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/26/2022] [Accepted: 09/01/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine if preoperative cervical length in the low-normal range increases the risk of adverse perinatal outcome in patients undergoing fetoscopic spina bifida repair. METHODS This was a retrospective cohort study of patients who underwent fetal spina bifida repair between September 2014 and May 2022 at a single center. Cervical length was measured on transvaginal ultrasound during the week before surgery. Eligibility for laparotomy-assisted fetoscopic spina bifida repair was as per the criteria of the Management of Myelomeningocele Study, although maternal body mass index (BMI) up to 40 kg/m2 was allowed. Laparotomy-assisted fetoscopic spina bifida repair was performed, with carbon dioxide insufflation via two 12-French ports in the exteriorized uterus. All patients received the same peri- and postoperative tocolysis regimen, including magnesium sulfate, nifedipine and indomethacin. Postoperative follow-up ultrasound scans were performed either weekly (< 32 weeks' gestation) or twice a week (≥ 32 weeks). Perinatal outcome was compared between patients with a preoperative cervical length of 25-30 mm vs those with a cervical length > 30 mm. Logistic regression analyses and generalized linear mixed regression analyses were used to predict delivery at less than 30, 34 and 37 weeks' gestation. RESULTS The study included 99 patients with a preoperative cervical length > 30 mm and 12 patients with a cervix 25-30 mm in length. One further case which underwent spina bifida repair was excluded because cervical length was measured > 1 week before surgery. No differences in maternal demographics, gestational age (GA) at surgery, duration of surgery or duration of carbon dioxide uterine insufflation were observed between groups. Cases with low-normal cervical length had an earlier GA at delivery (median (range), 35.2 (25.1-39.7) weeks vs 38.2 (26.0-40.9) weeks; P = 0.01), higher rates of delivery at < 34 weeks (41.7% vs 10.2%; P = 0.01) and < 30 weeks (25.0% vs 1.0%; P < 0.01) and a higher rate of preterm prelabor rupture of membranes (PPROM) (58.3% vs 26.3%; P = 0.04) at an earlier GA (mean ± SD, 29.3 ± 4.0 weeks vs 33.0 ± 2.4 weeks; P = 0.05) compared to those with a normal cervical length. Neonates of cases with low-normal cervical length had a longer stay in the neonatal intensive care unit (20 (7-162) days vs 9 (3-253) days; P = 0.02) and higher rates of respiratory distress syndrome (50.0% vs 14.4%; P < 0.01), sepsis (16.7% vs 1.0%; P = 0.03), necrotizing enterocolitis (16.7% vs 0%; P = 0.01) and retinopathy (33.3% vs 1.0%; P < 0.01). There was an association between preoperative cervical length and risk of delivery at < 30 weeks which was significant only for patients with a maternal BMI < 25 kg/m2 (odds ratio, 0.37 (95% CI, 0.07-0.81); P = 0.02). CONCLUSIONS Low-normal cervical length (25-30 mm) as measured before in-utero laparotomy-assisted fetoscopic spina bifida repair may increase the risk of adverse perinatal outcomes, including PPROM and preterm birth, leading to higher rates of neonatal complications. These data warrant further research and are of critical relevance for clinical teams considering the eligibility of patients for in-utero spina bifida repair. Based on this evidence, patients with a low-normal cervical length should be aware of their increased risk for adverse perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- M Sanz Cortes
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics, University Hospital of Angers, Angers, France
| | - B Johnson
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - H Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - G Mandy
- Department of Pediatrics, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - S VanLoh
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - A Nassr
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - W E Whitehead
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - M Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
9
|
Oh KJ, Romero R, Kim HJ, Lee J, Hong JS, Yoon BH. Preterm labor with intact membranes: a simple noninvasive method to identify patients at risk for intra-amniotic infection and/or inflammation. J Matern Fetal Neonatal Med 2022; 35:10514-10529. [PMID: 36229038 PMCID: PMC10544756 DOI: 10.1080/14767058.2022.2131388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/29/2022] [Accepted: 09/28/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To develop a noninvasive scoring system to identify patients at high risk for intra-amniotic infection and/or inflammation, which would reduce the need for amniocentesis. METHODS This prospective cohort study comprised patients admitted with preterm labor and intact membranes (20-34 weeks of gestation) who underwent a transabdominal amniocentesis and for whom concentrations of quantitative cervical fetal fibronectin and of maternal serum C-reactive protein (CRP) were determined. Intra-amniotic infection was defined as a positive amniotic fluid culture for microorganisms. Intra-amniotic inflammation was defined as an amniotic fluid matrix metalloproteinase-8 concentration >23 ng/mL. Multivariate logistic regression analysis was performed to identify intra-amniotic infection/inflammtion with noninvasive parameters that had a significant relationship with univariate analysis. With four parameters identified by multivariate analysis, we generated a noninvasive risk scoring system. RESULTS Of the study population consisting of 138 singleton pregnant women, (1) the overall rate of intra-amniotic infection/inflammation was 28.3% (39/138); (2) four parameters were used to develop a noninvasive risk scoring system [i.e. cervical fetal fibronectin concentration (score 0-2), maternal serum CRP concentration (score 0-2), cervical dilatation (score 0-2), and gestational age at presentation (score 0-1)]; the total score ranges from 0 to 7; 3) the area under the curve of the risk score was 0.96 (95% confidence interval (CI), 0.92-0.99), significantly higher than that of each predictor in the identification of intra-amniotic infection/inflammation (p < .001, for all); 4) the risk score with a cutoff of 4 had a sensitivity of 94.9% (37/39), a specificity of 90.9% (90/99), a positive predictive value of 80.4% (37/46), a negative predictive value of 97.8% (90/92), a positive likelihood ratio of 10.4 (95% CI, 5.6-19.5), and a negative likelihood ratio of 0.06 (95% CI, 0.15-0.22) in the identification of intra-amniotic infection/inflammation. CONCLUSIONS (1) The combination of four parameters (concentrations of cervical fetal fibronectin and maternal serum CRP, cervical dilatation, and gestational age) was independently associated with intra-amniotic infection and/or inflammation; and (2) the risk scoring system comprised of the combination of 4 noninvasive parameters was sensitive and specific to identify the patients at risk for intra-amniotic infection and/or inflammation.
Collapse
Affiliation(s)
- Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, USA, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
- Detroit Medical Center, Detroit, Michigan, USA
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - JoonHo Lee
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
10
|
A novel method for assessing the condition of the cervix before labor induction: Cervical length/thickness ratio. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.7357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Due to the increasing cesarean rates globally, new methods for supporting vaginal delivery and induction of successful vaginal delivery are still being developed. We aimed to obtain an easy-to-use method that can predict the effectiveness of cervical ripening agents before labor induction. So, we presented the effects on labor by measuring the thickness of the cervix and the cervical length/thickness ratio ultrasonographically.
Methods: In this prospective cohort study, we evaluated 183 pregnant between 37 and 41 weeks of gestational age and will apply vaginal delivery induction. Before oxytocin induction, we applied 10 mg dinoprostone vaginally to women whose cervix was stiff. We started labor induction with oxytocin when regular uterine contractions or dilatation occurred. We used the Bishop Scoring System for favorable cervix defining. Then, we compared the groups with successful and unsuccessful cervical ripening regarding cervical length and thickness parameters.
Results: The mean cervical thickness of the pregnant women with successful cervical ripening was 34.5 (7.5) mm before treatment, while the mean values of the unsuccessful group were 29.2 (9.1) mm (P < 0.001). The cervical length did not differ between the two groups (31.6 [8.2] vs. 32.5 [6.8], P = 0.44), while the cervical length/thickness ratio was lower in the group with successful ripening (0.9 [0.38–2], P < 0.001). Cervical length/thickness ratio was the highest predictor of the favorable cervix with dinoprostone. Each 1 unit decrease in the length/thickness ratio of the cervix increases the preparation of the cervix for induction by 0.25 times (P = 0.04). A successful response to dinoprostone can be obtained if the cervical length/thickness ratio is <1.06 mm (P < 0.001).
Conclusion: In conclusion, assessing the cervix’s condition before labor induction by measuring the cervical length/thickness ratio may be a good predictor of cervical ripening activity.
Collapse
|
11
|
Lee JY, Seo S, Shin B, Hong SH, Kwon E, Park S, Hur YM, Lee DK, Kim YJ, Han SB. Development of a New Biomarker Model for Predicting Preterm Birth in Cervicovaginal Fluid. Metabolites 2022; 12:metabo12080734. [PMID: 36005605 PMCID: PMC9416165 DOI: 10.3390/metabo12080734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/28/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Preterm birth (PTB) is a social problem that adversely affects not only the survival rate of the fetus, but also the premature babies and families, so there is an urgent need to find accurate biomarkers. We noted that among causes, eubiosis of the vaginal microbial community to dysbiosis leads to changes in metabolite composition. In this study, short chain fatty acids (SCFAs) representing dysbiosis were derivatized using (N-tert-butyldimethylsilyl-N-methyltrifluoroacetamide, MTBSTFA) and targeted analysis was conducted in extracted organic phases of cervicovaginal fluid (CVF). In residual aqueous CVF, polar metabolites produced biochemistry process were derivatized using methoxyamine and N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA), and non-targeted analysis were conducted. Nine SCFAs were quantified, and 58 polar metabolites were detected in 90 clinical samples using gas chromatography/mass spectrometry (GC/MS). The criteria of statistical analysis and detection rate of clinical sample for development of PTB biomarkers were presented, and 19 biomarkers were selected based on it, consisting of 1 SCFA, 2 organic acids, 4 amine compounds, and 12 amino acids. In addition, the model was evaluated as a suitable indicator for predicting PTB without distinction between sample collection time. We hope that the developed biomarkers based on microbiota-derived metabolites could provide useful diagnostic biomarkers for actual patients and pre-pregnancy.
Collapse
Affiliation(s)
- Ji-Youn Lee
- College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
| | - Sumin Seo
- College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
| | - Bohyun Shin
- College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
| | - Se Hee Hong
- College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
| | - Eunjin Kwon
- Department of Obstetrics and Gynecology and Ewha Medical Research Institute, College of Medicine, Ewha Womans University, Seoul 07984, Korea
| | - Sunwha Park
- Department of Obstetrics and Gynecology and Ewha Medical Research Institute, College of Medicine, Ewha Womans University, Seoul 07984, Korea
| | - Young Min Hur
- Department of Obstetrics and Gynecology and Ewha Medical Research Institute, College of Medicine, Ewha Womans University, Seoul 07984, Korea
| | - Dong-Kyu Lee
- College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
- Correspondence: (D.-K.L.); (Y.J.K.); (S.B.H.)
| | - Young Ju Kim
- Department of Obstetrics and Gynecology and Ewha Medical Research Institute, College of Medicine, Ewha Womans University, Seoul 07984, Korea
- Correspondence: (D.-K.L.); (Y.J.K.); (S.B.H.)
| | - Sang Beom Han
- College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
- Correspondence: (D.-K.L.); (Y.J.K.); (S.B.H.)
| |
Collapse
|
12
|
The amniotic fluid proteome predicts imminent preterm delivery in asymptomatic women with a short cervix. Sci Rep 2022; 12:11781. [PMID: 35821507 PMCID: PMC9276779 DOI: 10.1038/s41598-022-15392-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 06/23/2022] [Indexed: 11/09/2022] Open
Abstract
Preterm birth, the leading cause of perinatal morbidity and mortality, is associated with increased risk of short- and long-term adverse outcomes. For women identified as at risk for preterm birth attributable to a sonographic short cervix, the determination of imminent delivery is crucial for patient management. The current study aimed to identify amniotic fluid (AF) proteins that could predict imminent delivery in asymptomatic patients with a short cervix. This retrospective cohort study included women enrolled between May 2002 and September 2015 who were diagnosed with a sonographic short cervix (< 25 mm) at 16–32 weeks of gestation. Amniocenteses were performed to exclude intra-amniotic infection; none of the women included had clinical signs of infection or labor at the time of amniocentesis. An aptamer-based multiplex platform was used to profile 1310 AF proteins, and the differential protein abundance between women who delivered within two weeks from amniocentesis, and those who did not, was determined. The analysis included adjustment for quantitative cervical length and control of the false-positive rate at 10%. The area under the receiver operating characteristic curve was calculated to determine whether protein abundance in combination with cervical length improved the prediction of imminent preterm delivery as compared to cervical length alone. Of the 1,310 proteins profiled in AF, 17 were differentially abundant in women destined to deliver within two weeks of amniocentesis independently of the cervical length (adjusted p-value < 0.10). The decreased abundance of SNAP25 and the increased abundance of GPI, PTPN11, OLR1, ENO1, GAPDH, CHI3L1, RETN, CSF3, LCN2, CXCL1, CXCL8, PGLYRP1, LDHB, IL6, MMP8, and PRTN3 were associated with an increased risk of imminent delivery (odds ratio > 1.5 for each). The sensitivity at a 10% false-positive rate for the prediction of imminent delivery by a quantitative cervical length alone was 38%, yet it increased to 79% when combined with the abundance of four AF proteins (CXCL8, SNAP25, PTPN11, and MMP8). Neutrophil-mediated immunity, neutrophil activation, granulocyte activation, myeloid leukocyte activation, and myeloid leukocyte-mediated immunity were biological processes impacted by protein dysregulation in women destined to deliver within two weeks of diagnosis. The combination of AF protein abundance and quantitative cervical length improves prediction of the timing of delivery compared to cervical length alone, among women with a sonographic short cervix.
Collapse
|
13
|
Ortiz JU, Eixarch E, Micheletti T, Lobmaier SM, Bennasar M, Martinez JM, Gratacós E. Impact of Preoperative Cervical Length on Pregnancy Outcome in Twin-Twin Transfusion Syndrome. Z Geburtshilfe Neonatol 2022; 226:245-250. [PMID: 35545124 DOI: 10.1055/a-1812-5608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the impact of preoperative cervical length on pregnancy outcome in monochorionic diamniotic twin pregnancies complicated by twin-twin transfusion syndrome that underwent laser surgery or cord occlusion. MATERIALS AND METHODS Retrospective study of 330 patients stratified by preoperative cervical length (≥25 mm, 16-24 mm,≤15 mm). Maternal characteristics, operative data, and pregnancy outcomes were compared between the cervical length groups as well as between the subgroups of patients with a cervical length≤15 mm according to management (expectant vs. cerclage). RESULTS A preoperative cervical length≥25 mm was observed in 82% (n=271) of cases, 16-24 mm in 9% (n=29), and≤15 mm in 9% (n=30). Patients with a preoperative cervical length≤15 mm showed shorter median procedure-to-delivery interval (5.5 weeks vs. 11.6 (16-24 mm) vs. 13.0 (≥25 mm); p<0.001); lower median gestational age at delivery (29.5 weeks vs. 34.3 (16-24 mm) vs. 33.4 (≥25 mm); p<0.001); higher rate of preterm delivery<32 weeks (78 vs. 20% (16-24 mm) vs. 31% (≥25 mm); p<0.001); and lower neonatal survival rate of at least one twin (70 vs. 88% (16-24 mm) vs. 93% (≥25 mm); p<0.001). Outcome of patients with a preoperative cervical length≤15 mm was similar regardless of management. CONCLUSION Monochorionic diamniotic twin pregnancies complicated by twin-twin transfusion syndrome with a preoperative cervical length≤15 mm showed a higher rate of preterm delivery<32 weeks and lower neonatal survival. The role of a cervical cerclage remains unclear.
Collapse
Affiliation(s)
- Javier U Ortiz
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain.,University Hospital rechts der Isar, Technical University of Munich, Division of Obstetrics and Perinatal Medicine, Munich, Germany
| | - Elisenda Eixarch
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Talita Micheletti
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Silvia M Lobmaier
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain.,University Hospital rechts der Isar, Technical University of Munich, Division of Obstetrics and Perinatal Medicine, Munich, Germany
| | - Mar Bennasar
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Josep M Martinez
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Eduard Gratacós
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| |
Collapse
|
14
|
Woo J, Ge W, Mancheri J, Hyett J, Mogra R. Shear wave elastography: the relationship of the cervical stiffness with gestational age and cervical length- a feasibility study. J Matern Fetal Neonatal Med 2022; 35:9684-9693. [PMID: 35337244 DOI: 10.1080/14767058.2022.2050896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To standardize the measurement of shear wave elastography for assessment of cervical stiffness and its relationship with gestational age and cervical length. METHODS A prospective cross-sectional study was conducted from September 2017 to March 2019. Data from 125 unselected women (at 11-13 + 6, 18-22 and 24-28 weeks' gestation) and 55 high-risk women were analyzed for the study. Six regions of interest were evaluated for cervical elastography in the mid-sagittal position by transvaginal ultrasound. Statistical analyses were performed using R statistical language in R-studio. Delivery outcomes were recorded for each patient. RESULTS The shear wave elastography was feasible with good intraoperator and interoperator reproducibility. The endocervical canal and anterior lip internal position had the highest reproducibility (ICC-0.82, 0.75). Shear wave speed was significantly higher in all internal os regions than the external os. There was a statistically significant negative linear relationship of shear wave speed with the gestational age. There was a weak positive relationship between shear wave speed and cervical length. There was no difference between pregnancies with and without spontaneous preterm delivery in shear wave speed measurements and cervical length, although numbers were small for statistical analysis. The internal os of the large loop excision of the transformation zone group was stiffer than the normal population. CONCLUSION Cervical elastography is feasible and effectively evaluates the tensile properties of the cervix during pregnancy. The most reproducible measurements were obtained at the anterior lip of the internal cervical os. Combining evaluation of cervical elasticity and length might further improve the identification of women at risk of preterm delivery. Currently, technical issues hinder the practical application of shear wave elastography in the clinical setting and require further research and development of the imaging modality.
Collapse
Affiliation(s)
- Joyce Woo
- Sydney Institute for Women, Children and their Families, Sydney, Australia
| | - Weirong Ge
- Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Institute for Women, Children and their Families, Sydney, Australia
| | - Jyothi Mancheri
- Sydney Institute for Women, Children and their Families, Sydney, Australia
| | - Jon Hyett
- Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Institute for Women, Children and their Families, Sydney, Australia
| | - Ritu Mogra
- Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Institute for Women, Children and their Families, Sydney, Australia
| |
Collapse
|
15
|
Wolf HM, Romero R, Strauss JF, Hassan SS, Latendresse SJ, Webb BT, Tarca AL, Gomez-Lopez N, Hsu CD, York TP. Study protocol to quantify the genetic architecture of sonographic cervical length and its relationship to spontaneous preterm birth. BMJ Open 2022; 12:e053631. [PMID: 35301205 PMCID: PMC8932269 DOI: 10.1136/bmjopen-2021-053631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION A short cervix (cervical length <25 mm) in the midtrimester (18-24 weeks) of pregnancy is a powerful predictor of spontaneous preterm delivery. Although the biological mechanisms of cervical change during pregnancy have been the subject of extensive investigation, little is known about whether genes influence the length of the cervix, or the extent to which genetic factors contribute to premature cervical shortening. Defining the genetic architecture of cervical length is foundational to understanding the aetiology of a short cervix and its contribution to an increased risk of spontaneous preterm delivery. METHODS/ANALYSIS The proposed study is designed to characterise the genetic architecture of cervical length and its genetic relationship to gestational age at delivery in a large cohort of Black/African American women, who are at an increased risk of developing a short cervix and delivering preterm. Repeated measurements of cervical length will be modelled as a longitudinal growth curve, with parameters estimating the initial length of the cervix at the beginning of pregnancy, and its rate of change over time. Genome-wide complex trait analysis methods will be used to estimate the heritability of cervical length growth parameters and their bivariate genetic correlation with gestational age at delivery. Polygenic risk profiling will assess maternal genetic risk for developing a short cervix and subsequently delivering preterm and evaluate the role of cervical length in mediating the relationship between maternal genetic variation and gestational age at delivery. ETHICS/DISSEMINATION The proposed analyses will be conducted using deidentified data from participants in an IRB-approved study of longitudinal cervical length who provided blood samples and written informed consent for their use in future genetic research. These analyses are preregistered with the Center for Open Science using the AsPredicted format and the results and genomic summary statistics will be published in a peer-reviewed journal.
Collapse
Affiliation(s)
- Hope M Wolf
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Human and Molecular Genetics, Virginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
- Detroit Medical Center, Detroit, Michigan, USA
| | - Jerome F Strauss
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sonia S Hassan
- Office of Women's Health, Wayne State University, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Shawn J Latendresse
- Department of Psychology and Neuroscience, Baylor University, Waco, Texas, USA
| | - Bradley T Webb
- GenOmics, Bioinformatics, and Translational Research Center, Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina, USA
- Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA
| | - Adi L Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Timothy P York
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Human and Molecular Genetics, Virginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| |
Collapse
|
16
|
Evaluation of midtrimester cervical length thresholds for the prediction of spontaneous preterm birth. J Gynecol Obstet Hum Reprod 2021; 51:102287. [PMID: 34896642 DOI: 10.1016/j.jogoh.2021.102287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION To estimate the optimal midtrimester cervical length (CL) threshold for the prediction of spontaneous preterm birth (sPTB) in asymptomatic pregnant women. MATERIAL AND METHODS This is a prospective observational cohort study including asymptomatic women with singleton pregnancies who underwent CL measurement by transabdominal and/or transvaginal ultrasound between 19°/7 and 216/7 weeks of gestation. All CL ≤30 mm from transabdominal ultrasound were confirmed by transvaginal ultrasound. Primary outcomes were sPTB <35 and <37 weeks. RESULTS Out of 3,449 participants, 28 (0.8%) had a sPTB before 35 weeks and 99 (2.9%) had a sPTB before 37 weeks. Receiver operating characteristics (ROC) curves suggest that a cut-off of 30 mm was the optimal CL to predict sPTB before 35 weeks (sensitivity: 43%; specificity: 97%) and sPTB before 37 weeks (sensitivity: 21%; specificity: 97%). While a CL <25 mm was an important risk factor for sPTB before 35 weeks (relative risk: 31; 95% confidence interval: 13-73), women with a CL between 25 and 30 mm were also at greater risk (relative risk: 12; 95% confidence interval: 4 - 35) compared to women with CL ≥30 mm. DISCUSSION A midtrimester CL <30 mm should be considered to identify women at high-risk of sPTB.
Collapse
|
17
|
Olisova K, Sung CY, Lussier EC, Chang TY. Revisions to mid-pregnancy cervical length reference range for preterm birth screening among singleton pregnancies in Taiwan - 10 years' experiences. Taiwan J Obstet Gynecol 2021; 60:836-839. [PMID: 34507658 DOI: 10.1016/j.tjog.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2020] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Our study aimed to build a normal reference range for routine mid-pregnancy cervical length screening for preterm birth (PTB) based on a large cross-section of Taiwanese singleton pregnancies. Based on our reference range findings, we aim to develop a Z-score and centile calculator. MATERIALS AND METHODS We performed a retrospective analysis of the routine mid-trimester cervical length measurement in low-risk singleton pregnancies (without known abnormal growth or karyotype, congenital malformation, history of preterm birth due to preterm premature rupture of the membranes, or history of cervical cerclage treatment). From November 2008 to June 2018, the cervical lengths of 51,644 Taiwanese low-risk pregnant women were measured by experienced sonographers via transvaginal ultrasound during second trimester fetal anatomical screening at 20-24 weeks of gestation. Kolmogorov-Smirnov test was used to assess the normality of the distribution. Cole's lambda, mu, sigma (LMS) method was applied to build mid-pregnancy cervical length reference range and calculate Z-scores. Cut-off values of 2.5, 2.0 and 1.5 cm were used to evaluate the number of pregnancies considered high-risk for PTB. RESULTS Kolmogorov-Smirnov test showed that the cervical length measurements did not follow a normal distribution (<0.001). Reference range constructed by LMS method was presented in our study. Mean cervical length was 3.82 cm (SD = 0.62 cm). Overall, less than 0.3% of women had a cervical length shorter than 1.5 cm. CONCLUSION We are providing an open access calculator for z-score and centile calculation for use in clinical practice for assessing how CL measurement compares in normally developing singleton pregnancies. Further investigation is needed to determine if Z-scores can better assess risk for PTB compared to fixed cut-offs. Since Z-scores are used to assess large deviations from normal development, they may be a useful tool for risk assessment and can be the basis for future standardized screening protocol in Taiwan.
Collapse
Affiliation(s)
- Ksenia Olisova
- Department of Research & Development, Taiji Clinic, Taipei, Taiwan
| | - Chan-Yu Sung
- Department of Research & Development, Taiji Clinic, Taipei, Taiwan
| | - Eric C Lussier
- Department of Research & Development, Taiji Clinic, Taipei, Taiwan
| | - Tung-Yao Chang
- Department of Research & Development, Taiji Clinic, Taipei, Taiwan.
| |
Collapse
|
18
|
Anumba DOC, Stern V, Healey JT, Dixon S, Brown BH. Value of cervical electrical impedance spectroscopy to predict spontaneous preterm delivery in asymptomatic women: the ECCLIPPx prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:293-302. [PMID: 32798253 DOI: 10.1002/uog.22180] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Preterm birth (PTB) accounts for two-thirds of deaths of structurally normal babies and is associated with substantial lifetime healthcare costs. Prevention of PTB remains limited by the modest accuracy of prediction methods, namely transvaginal ultrasound (TVS) cervical length (CL) measurement and quantitative cervicovaginal fetal fibronectin (FFN) estimation. We report the first substantive study detailing the predictive performance of a cervical probe device based on electrical impedance spectroscopy (EIS) for PTB - the EleCtriCaL Impedance Prediction of Preterm birth by spectroscopy of the cervix (ECCLIPPx) study. We aimed to compare the accuracy of cervical EIS-based prediction of spontaneous PTB with that of prediction using TVS-CL and FFN in asymptomatic women in the mid-trimester. METHODS We studied asymptomatic women with a singleton pregnancy at 20-22 weeks' and 26-28 weeks' gestation. EIS was performed using a Sheffield Mark 5.0 device that makes measurements in the frequency range 76 Hz to 625 kHz using a small probe housing tetrapolar electrodes. TVS-CL and FFN were also measured. The associations of cervical EIS, TVS-CL and FFN with spontaneous delivery before 37 weeks and before 32 weeks were determined by multivariate linear and non-linear logistic regression analysis. Areas under the receiver-operating-characteristics curves (AUC) plots of sensitivity against specificity were used to compare the predictive performance of all parameters, both in isolation and in combination. RESULTS Of the 365 asymptomatic women studied at 20-22 weeks who were not receiving treatment, 29 had spontaneous PTB, 14 had indicated PTB and 322 had term birth. At the higher frequencies assessed, cervical EIS predicted spontaneous PTB before 37 weeks with an AUC of 0.76 (95% CI, 0.71-0.81), compared with AUCs of 0.72 (95% CI, 0.66-0.76) for TVS-CL and 0.62 (95% CI, 0.56-0.72) for FFN. Combining all three assessments improved the prediction of spontaneous PTB before 37 weeks (AUC, 0.79 (95% CI, 0.74-0.83)) compared with TVS-CL and FFN alone. Incorporating a history of spontaneous PTB (defined as previous mid-trimester miscarriage or spontaneous PTB (14 to < 37 weeks)) into the cervical EIS prediction model improved the accuracy of prediction of spontaneous PTB before 37 weeks (AUC, 0.83 (95% CI, 0.78-0.87)) and before 32 weeks (AUC, 0.86 (95% CI, 0.82-0.90)). CONCLUSIONS Mid-trimester cervical EIS assessment predicts spontaneous PTB. Larger confirmatory studies investigating its potential clinical utility and to inform effective preventive interventions are required. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- D O C Anumba
- Academic Unit of Reproductive and Developmental Medicine, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - V Stern
- Academic Unit of Reproductive and Developmental Medicine, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - J T Healey
- Medical Physics and Clinical Engineering, University of Sheffield, Sheffield, UK
| | - S Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - B H Brown
- Medical Physics and Clinical Engineering, University of Sheffield, Sheffield, UK
| |
Collapse
|
19
|
Gulersen M, Bornstein E, Domney A, Blitz MJ, Rafael TJ, Li X, Krantz D, Rochelson B. Cerclage in singleton gestations with an extremely short cervix (≤10 mm) and no history of spontaneous preterm birth. Am J Obstet Gynecol MFM 2021; 3:100430. [PMID: 34271252 DOI: 10.1016/j.ajogmf.2021.100430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/20/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Data regarding the efficacy of a cervical cerclage for preterm birth prevention in patients with a short cervix and no history of spontaneous preterm birth are limited and inconclusive. OBJECTIVE This study aimed to determine whether cervical cerclage is associated with an increased time interval to delivery in asymptomatic patients with singleton pregnancies with an extremely short cervical length (≤10 mm) and no history of spontaneous preterm birth. STUDY DESIGN This was a multicenter retrospective cohort study of asymptomatic patients with singleton pregnancies with a cervical length of ≤10 mm between 16 and 23 weeks' gestation from January 2014 to December 2019. Patients with previous spontaneous preterm birth, symptoms of preterm labor, cervical dilation of >1 cm, pessary, major fetal structural malformations, or missing data were excluded from the study. The primary outcome of time interval from diagnosis to delivery was compared between those who had a cervical cerclage after diagnosis and those who did not. The secondary outcomes included gestational age at delivery and adverse neonatal outcomes. Moreover, a subgroup analysis of all outcomes in patients already being treated with vaginal progesterone in each group was performed. Statistical analysis included chi-square and Wilcoxon rank-sum tests and a multivariate Cox proportional hazard regression for time interval to delivery. RESULTS Of the 90 patients included in the study, 52 (57.8%) had cervical cerclage, of which 35 (67.3%) were already being treated with progesterone. Moreover, 38 patients (42.2%) did not have cervical cerclage, of which 21 (55.3%) were already being treated with progesterone. Patients in the cervical cerclage group had an earlier gestational age (21.0 vs 22.0 weeks' gestation; P≤.001) and shorter cervical length (5 vs 7 mm; P=.002) at the diagnosis of a short cervix (cervical length≤10 mm) than those who did not have a cerclage. Cervical cerclage was associated with a longer time interval to delivery (17.0 vs 15.0 weeks; P=.02) and lower hazard of earlier delivery after diagnosis (adjusted hazard ratio, 0.61; 95% confidence interval, 0.38-0.99; P=.04) than no cerclage, after accounting for gestational age and cervical length at diagnosis. In patients already treated with progesterone, cervical cerclage was also associated with a longer time interval to delivery (17.0 vs 13.1 weeks; P=.01) and a lower hazard of earlier delivery after diagnosis (adjusted hazard ratio, 0.49; 95% confidence interval, 0.27-0.87; P=.02) compared to those with no cerclage. Late preterm birth was less common in patients with a cervical cerclage compared with those with no cervical cerclage (11.5% vs 31.6%; P=.03). CONCLUSION Cervical cerclage should be considered in asymptomatic patients with an extremely short cervical length (≤10 mm) and no history of spontaneous preterm birth.
Collapse
Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson).
| | - Eran Bornstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY (Dr Bornstein)
| | - Alixandra Domney
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson)
| | - Matthew J Blitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Bay Shore, NY (Dr Blitz)
| | - Timothy J Rafael
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson)
| | - Xueying Li
- Eurofins NTD, Melville, NY (Ms Li and Mr Krantz)
| | - David Krantz
- Eurofins NTD, Melville, NY (Ms Li and Mr Krantz)
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson)
| |
Collapse
|
20
|
Almeida JPRFPD, Bartosch CMM, Macedo AMPCC. The Impact of Routine Transvaginal Ultrasound Measurement of the Cervical Length on the Prediction of Preterm Birth: A Retrospective Study in a Tertiary Hospital. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:264-274. [PMID: 33979887 PMCID: PMC10183866 DOI: 10.1055/s-0041-1726053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Preterm birth (PTB) is a major obstetric problem associated with high rates of neonatal morbidity and mortality. The prevalence of PTB has not changed in the last decade; thus, the establishment of a screening test and effective treatment are warranted. Transvaginal ultrasound measurement of the cervical length (TUCL) has been proposed as an effective method to screen pregnant women at a higher risk of experiencing PTB. OBJECTIVE To evaluate the applicability and usefulness of second-trimester TUCL to predict PTB in a cohort of Portuguese pregnant women. METHODS Retrospective cross-sectional cohort study including all singleton pregnant women who performed their second-trimester ultrasound (between weeks 18 and 22 + 6 days) from January 2013 to October 2017 at Centro Hospitalar Universitário São João. RESULTS Our cohort included 4,481 women. The prevalence of spontaneous PTB was of 4.0%, with 0.7% occurring before the 34th week of gestation. The mean TUCL was of 33.8 mm, and percentiles 3, 5 and 10 corresponded to TUCLs of 25.0 mm, 27.0 mm and 29.0 mm respectively. The multiple logistic regression analysis, including maternal age, previous PTB and cervical surgery showed a significant negative association between TUCL and PTB, with an odds ratio (OR) of 0.92 (95% confidence interval [95%CI]: 0.90-0.95; p < 0.001). The use of a TUCL of 20 mm is the best cut-off, when compared with the 25-mm cut-off, improving the prediction of risk. CONCLUSION The present study showed an inverse association between TUCL and PTB, and that the inclusion of other risk factors like maternal age, previous PTB and cervical surgery can improve the screening algorithm. Furthermore, it emphasizes that the TUCL cut-off that defines short cervix can differ according to the population.
Collapse
|
21
|
Schreiber H, Ovadia M, Gluska H, Sharon-Weiner M, Biron-Shental T, Markovitch O. Can sonographic changes in cervical length during pregnancy predict the need for cervical ripening in term pregnancies? Arch Gynecol Obstet 2021; 305:7-10. [PMID: 33978806 DOI: 10.1007/s00404-021-06089-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the effect of changes in sonographic cervical length (CL) measured at 14-16 and 21-24 weeks of gestation, on cervical ripening in term pregnancies. METHODS This retrospective, cohort study included term pregnancies with CL measured with transvaginal sonography (CL1 at 14-16 weeks gestation and CL2 at 21-24 weeks). History of preterm labor, multiple gestations, planned caesarean section, fetal anomalies and stillbirths were excluded. Participants were grouped based on ≥ 10% vs. < 10% CL shortening between measurements. The primary outcome was whether cervical shortening < 10% between CL1 and CL2 was associated with increased use of cervical ripening. Secondary outcomes were gestational age at delivery, delivery mode and birthweight. RESULTS Among 267 women who met the inclusion criteria, CL decreased ≥ 10% between scans in 70 (26.3%) and < 10% in 197 (73.7%). Baseline characteristics were similar between groups. Fewer women with ≥ 10% shortening between scans, underwent cervical ripening (7.1% vs. 16.8%, p < 0.05). In addition, in the ≥ 10% group, although CL2 was in the normal range, it was shorter than in the < 10% group (34.3 ± 6.7 mm vs. 40.1 ± 6.4 mm, p < 0.01). CONCLUSION Decrease in cervical length > 10% between 14-16 and 21-24-weeks' gestation is associated with lower use of cervical ripening at term.
Collapse
Affiliation(s)
- Hanoch Schreiber
- Department of Obstetrics and Gynecology, Meir Medical Center, Tchernichovsky 59, 44281, Kfar Saba, Israel
| | - Michal Ovadia
- Department of Obstetrics and Gynecology, Meir Medical Center, Tchernichovsky 59, 44281, Kfar Saba, Israel
| | - Hadar Gluska
- Department of Obstetrics and Gynecology, Meir Medical Center, Tchernichovsky 59, 44281, Kfar Saba, Israel
| | - Maya Sharon-Weiner
- Department of Obstetrics and Gynecology, Meir Medical Center, Tchernichovsky 59, 44281, Kfar Saba, Israel
| | - Tal Biron-Shental
- Department of Obstetrics and Gynecology, Meir Medical Center, Tchernichovsky 59, 44281, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Markovitch
- Department of Obstetrics and Gynecology, Meir Medical Center, Tchernichovsky 59, 44281, Kfar Saba, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
22
|
Gudicha DW, Romero R, Kabiri D, Hernandez-Andrade E, Pacora P, Erez O, Kusanovic JP, Jung E, Paredes C, Berry SM, Yeo L, Hassan SS, Hsu CD, Tarca AL. Personalized assessment of cervical length improves prediction of spontaneous preterm birth: a standard and a percentile calculator. Am J Obstet Gynecol 2021; 224:288.e1-288.e17. [PMID: 32918893 PMCID: PMC7914140 DOI: 10.1016/j.ajog.2020.09.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A sonographic short cervix (length <25 mm during midgestation) is the most powerful predictor of preterm birth. Current clinical practice assumes that the same cervical length cutoff value should apply to all women when screening for spontaneous preterm birth, yet this approach may be suboptimal. OBJECTIVE This study aimed to (1) create a customized cervical length standard that considers relevant maternal characteristics and gestational age at sonographic examination and (2) assess whether the customization of cervical length evaluation improves the prediction of spontaneous preterm birth. STUDY DESIGN This retrospective analysis comprises a cohort of 7826 pregnant women enrolled in a longitudinal protocol between January 2006 and April 2017 at the Detroit Medical Center. Study participants met the following inclusion criteria: singleton pregnancy, ≥1 transvaginal sonographic measurements of the cervix, delivery after 20 weeks of gestation, and available relevant demographics and obstetrical history information. Data from women without a history of preterm birth or cervical surgery who delivered at term without progesterone treatment (N=5188) were used to create a customized standard of cervical length. The prediction of the primary outcome, spontaneous preterm birth at <37 weeks of gestation, was assessed in a subset of pregnancies (N=7336) that excluded cases with induced labor before 37 weeks of gestation. Area under the receiver operating characteristic curve and sensitivity at a fixed false-positive rate were calculated for screening at 20 to 23 6/7, 24 to 27 6/7, 28 to 31 6/7, and 32 to 35 6/7 weeks of gestation in asymptomatic patients. Survival analysis was used to determine which method is better at predicting imminent delivery among symptomatic women. RESULTS The median cervical length remained fundamentally unchanged until 20 weeks of gestation and subsequently decreased nonlinearly with advancing gestational age among women who delivered at term. The effects of parity and maternal weight and height on the cervical length were dependent on the gestational age at ultrasound examination (interaction, P<.05 for all). Parous women had a longer cervix than nulliparous women, and the difference increased with advancing gestation after adjusting for maternal weight and height. Similarly, maternal weight was nonlinearly associated with a longer cervix, and the effect was greater later in gestation. The sensitivity at a 10% false-positive rate for prediction of spontaneous preterm birth at <37 weeks of gestation by a short cervix ranged from 29% to 40% throughout pregnancy, yet it increased to 50%, 50%, 53%, and 54% at 20 to 23 6/7, 24 to 27 6/7, 28 to 31 6/7, and 32 to 35 6/7 weeks of gestation, respectively, for a low, customized percentile (McNemar test, P<.001 for all). When a cervical length <25 mm was compared to the customized screening at 20 to 23 6/7 weeks of gestation by using a customized percentile cutoff value that ensured the same negative likelihood ratio for both screening methods, the customized approach had a significantly higher (about double) positive likelihood ratio in predicting spontaneous preterm birth at <33, <34, <35, <36, and <37 weeks of gestation. Among symptomatic women, the difference in survival between women with a customized cervical length percentile of ≥10th and those with a customized cervical length percentile of <10th was greater than the difference in survival between women with a cervical length ≥25 mm and those with a cervical length <25 mm. CONCLUSION Compared to the use of a cervical length <25 mm, a customized cervical length assessment (1) identifies more women at risk of spontaneous preterm birth and (2) improves the distinction between patients at risk for impending preterm birth in those who have an episode of preterm labor.
Collapse
Affiliation(s)
- Dereje W Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Florida International University, Miami, FL
| | - Doron Kabiri
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Maternity Department "D," Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Beer-Sheva, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Center for Research and Innovation in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sótero del Río Hospital, Santiago, Chile; Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Carmen Paredes
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Stanley M Berry
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Sonia S Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Office of Women's Health, Integrative Biosciences Center, Wayne State University, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Adi L Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI.
| |
Collapse
|
23
|
Bortoletto TG, Silva TV, Borovac-Pinheiro A, Pereira CM, Silva AD, França MS, Hatanaka AR, Argenton JP, Passini R, Mol BW, Cecatti JG, Pacagnella RC. Cervical length varies considering different populations and gestational outcomes: Results from a systematic review and meta-analysis. PLoS One 2021; 16:e0245746. [PMID: 33592005 PMCID: PMC7886126 DOI: 10.1371/journal.pone.0245746] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The uterine cervical length is an important risk factor for preterm birth. The aim of this study was to assess cervical length distribution in women with singleton pregnancies, measured by transvaginal ultrasound between 16 and 24 weeks, and its association with population characteristics. MATERIALS AND METHODS We searched electronic databases and other sources for studies published from April 1, 1990 to July 21, 2020. Of the 2019 retrieved publications, full-text versions of 137 articles were considered. We included 77 original articles that reported cervical length measurements of 363,431 women. The main aim of this study was to identify the pattern of cervical length in different populations. We collected demographic and clinical data concerning the population, in addition to information regarding the ultrasound examination and cervical length measurement. Regarding study bias, 56 were at low risk of bias and 21 were at medium risk of bias. RESULTS The meta-analysis included 57 articles with data from 158,346 women. The mean cervical length was 37.96. mm (95% CI [36.68, 39.24]). Cervical length was shorter in women from Africa and Asia, in those from low-income countries, with a lower body weight, and in those who delivered before 37 gestational weeks. We found that the cervical length from pooled studies is longer than that usually discussed in the literature. Regarding limitations, we had difficulty assessing our main variable because there was no consistent pattern in the way authors reported cervical length measurement. Another limitation was the great heterogeneity between studies. CONCLUSIONS The use of a single cutoff value to define a short cervix diagnosis, an important risk factor for preterm birth, may not be correct and cervical length must be considered according to maternal population characteristics. Future studies should identify different specific curves and cutoff values for cervical length in different populations. This meta-analysis was registered in the PROSPERO database under CRD42017070246 at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=70246.
Collapse
Affiliation(s)
- T. G. Bortoletto
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - T. V. Silva
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- University of Pernambuco (UPE), Recife, Pernambuco, Brazil
| | - A. Borovac-Pinheiro
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - C. M. Pereira
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - A. D. Silva
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - M. S. França
- Department of Obstetrics and Gynaecology, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - A. R. Hatanaka
- Department of Obstetrics and Gynaecology, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - J. P. Argenton
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - R. Passini
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - B. W. Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - J. G. Cecatti
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - R. C. Pacagnella
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| |
Collapse
|
24
|
Wu Y, Liang X, Cai M, Gao L, Lan J, Yang X. Development and validation of a model for individualized prediction of cervical insufficiency risks in patients undergoing IVF/ICSI treatment. Reprod Biol Endocrinol 2021; 19:6. [PMID: 33413472 PMCID: PMC7789534 DOI: 10.1186/s12958-020-00693-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/26/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Women who conceived with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) are more likely to experience adverse pregnancy outcomes than women who conceived naturally. Cervical insufficiency (CI) is one of the important causes of miscarriage and premature birth, however there is no published data available focusing on the potential risk factors predicting CI occurrence in women who received IVF/ICSI treatment. This study aimed to identify the risk factors that could be integrated into a predictive model for CI, which could provide further personalized and clinically specific information related to the incidence of CI after IVF/ICSI treatment. PATIENTS AND METHODS This retrospective study included 4710 patients who conceived after IVF/ICSI treatment from Jan 2011 to Dec 2018 at a public university hospital. The patients were randomly divided into development (n = 3108) and validation (n = 1602) samples for the building and testing of the nomogram, respectively. Multivariate logistic regression was developed on the basis of pre-pregnancy clinical covariates assessed for their association with CI occurrence. RESULTS A total of 109 patients (2.31%) experienced CI among all the enrolled patients. Body mass index (BMI), basal serum testosterone (T), gravidity and uterine length were associated with CI occurrence. The statistical nomogram was built based on BMI, serum T, gravidity and uterine length, with an area under the curve (AUC) of 0.84 (95% confidence interval: 0.76-0.90) for the developing cohort. The AUC for the validation cohort was 0.71 (95% confidence interval: 0.69-0.83), showing a satisfactory goodness-of-fit and discrimination ability in this nomogram. CONCLUSION The user-friendly nomogram which graphically represents the risk factors and a pre-pregnancy predicted tool for the incidence of CI in patients undergoing IVF/ICSI treatment, provides a useful guide for medical staff on individualized decisions making, where preventive measures could be carried out during the IVF/ICSI procedure and subsequent pregnancy.
Collapse
Affiliation(s)
- Yaoqiu Wu
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, China
- Reproductive Medicine Center, The Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Xiaoyan Liang
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, China
| | - Meihong Cai
- Reproductive Medicine Centre, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 51000, Guangdong, China
| | - Linzhi Gao
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, China
| | - Jie Lan
- Reproductive Medicine Center, The Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Xing Yang
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, China.
| |
Collapse
|
25
|
Cervical Length at 28–32 Weeks of Gestation Predicts Preterm Birth. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
26
|
Motomura K, Romero R, Tarca AL, Galaz J, Bhatti G, Done B, Arenas-Hernandez M, Levenson D, Slutsky R, Hsu CD, Gomez-Lopez N. Pregnancy-specific transcriptional changes upon endotoxin exposure in mice. J Perinat Med 2020; 48:700-722. [PMID: 32866128 PMCID: PMC8258803 DOI: 10.1515/jpm-2020-0159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/27/2020] [Indexed: 12/26/2022]
Abstract
Objectives Pregnant women are more susceptible to certain infections; however, this increased susceptibility is not fully understood. Herein, systems biology approaches were utilized to elucidate how pregnancy modulates tissue-specific host responses to a bacterial product, endotoxin. Methods Pregnant and non-pregnant mice were injected with endotoxin or saline on 16.5 days post coitum (n=8-11 per group). The uterus, cervix, liver, adrenal gland, kidney, lung, and brain were collected 12 h after injection and transcriptomes were measured using microarrays. Heatmaps and principal component analysis were used for visualization. Differentially expressed genes between groups were assessed using linear models that included interaction terms to determine whether the effect of infection differed with pregnancy status. Pathway analysis was conducted to interpret gene expression changes. Results We report herein a multi-organ atlas of the transcript perturbations in pregnant and non-pregnant mice in response to endotoxin. Pregnancy strongly modified the host responses to endotoxin in the uterus, cervix, and liver. In contrast, pregnancy had a milder effect on the host response to endotoxin in the adrenal gland, lung, and kidney. However, pregnancy did not drastically affect the host response to endotoxin in the brain. Conclusions Pregnancy imprints organ-specific host immune responses upon endotoxin exposure. These findings provide insight into the host-response against microbes during pregnancy.
Collapse
Affiliation(s)
- Kenichiro Motomura
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan 48109, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan 48824, USA,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan 48201, USA,Detroit Medical Center, Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Florida International University, Miami, Florida, 33199, USA,Address correspondence to: Nardhy Gomez-Lopez, MSc, PhD, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Perinatology Research Branch, NICHD/NIH/DHHS, 275 E. Hancock, Detroit, Michigan 48201, USA, Tel (313) 577-8904, ; . Roberto Romero, MD, D. Med. Sci., Perinatology Research Branch, NICHD/NIH/DHHS, Wayne State University/Hutzel Women’s Hospital 3990 John R, Box 4, Detroit, Michigan 48201, USA, Telephone: (313) 993-2700, Fax: (313) 993-2694,
| | - Adi L. Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA,Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan 48201, USA
| | - Jose Galaz
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Gaurav Bhatti
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Bogdan Done
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Marcia Arenas-Hernandez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Dustyn Levenson
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Rebecca Slutsky
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS); Bethesda, Maryland, 20892 and Detroit, Michigan 48201, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA,Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan 48201, USA,Address correspondence to: Nardhy Gomez-Lopez, MSc, PhD, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Perinatology Research Branch, NICHD/NIH/DHHS, 275 E. Hancock, Detroit, Michigan 48201, USA, Tel (313) 577-8904, ; . Roberto Romero, MD, D. Med. Sci., Perinatology Research Branch, NICHD/NIH/DHHS, Wayne State University/Hutzel Women’s Hospital 3990 John R, Box 4, Detroit, Michigan 48201, USA, Telephone: (313) 993-2700, Fax: (313) 993-2694,
| |
Collapse
|
27
|
Galaz J, Romero R, Xu Y, Miller D, Levenson D, Para R, Varrey A, Hsu R, Tong A, Hassan SS, Hsu CD, Gomez-Lopez N. Cellular immune responses in amniotic fluid of women with a sonographic short cervix. J Perinat Med 2020; 48:665-676. [PMID: 32716907 PMCID: PMC8272936 DOI: 10.1515/jpm-2020-0037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/27/2020] [Indexed: 11/15/2022]
Abstract
Objectives A sonographic short cervix is one of the strongest predictors of preterm delivery. However, the cellular immune composition of amniotic fluid in women with a short cervix has not yet been described. Herein, we determined cellular and soluble immune responses in amniotic fluid from pregnant women with a mid-trimester asymptomatic short cervix. Methods Amniotic fluid samples (n=77) were collected from asymptomatic women with a cervical length between 15 and 25 mm (n=36, short cervix) or ≤15 mm (n=41, severely short cervix) diagnosed by ultrasound. Flow cytometry and multiplex measurement of cytokines/chemokines were performed. Results (1) The cellular immune composition of amniotic fluid did not differ between women with a severely short cervix (≤15 mm) and those with a short cervix 15-25 mm; (2) amniotic fluid concentrations of multiple cytokines/chemokines were higher in women with a severely short cervix (≤15 mm) than in those with a short cervix 15-25 mm; (3) the cellular immune composition of amniotic fluid did not differ between women with a severely short cervix (≤15 mm) who ultimately underwent preterm delivery and those who delivered at term; and (4) amniotic fluid concentrations of IL-2, but not other immune mediators, were increased in women with a severely short cervix (≤15 mm) who ultimately delivered preterm compared to those who delivered at term. Conclusions Women with a severely short cervix (≤15 mm) have increased concentrations of pro-inflammatory mediators in the amniotic cavity; yet, these do not translate to changes in the cellular immune response.
Collapse
Affiliation(s)
- Jose Galaz
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
- Detroit Medical Center, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Florida International University, Miami, FL, USA
| | - Yi Xu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Derek Miller
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Dustyn Levenson
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Robert Para
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Aneesha Varrey
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Richard Hsu
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Anna Tong
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Immunology, Microbiology, and Biochemistry, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
28
|
Cervical pessary for preterm twin pregnancy in women with a short cervix. Obstet Gynecol Sci 2020; 63:231-238. [PMID: 32489967 PMCID: PMC7231939 DOI: 10.5468/ogs.2020.63.3.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 11/08/2022] Open
Abstract
Objective We aimed to evaluate the effectiveness of cervical pessary for extending twin pregnancy in women with a short cervix. Methods Between January 2014 and March 2019, the use of a cervical pessary for twin pregnancy in women with a cervical length of ≤15 mm was investigated between 16 and 28 weeks of gestation. We included women with a shortened cervix after a cerclage procedure and visible fetal membranes and cervical dilatation. Thirteen patients underwent pessary insertion and were matched with a control group of 15 patients. Pregnancy and neonatal outcomes were compared between the groups. We excluded women with major fetal anomalies discovered before or after birth and known placenta previa. Results Women who underwent pessary insertion were diagnosed with a short cervix (0.65±0.47 vs. 0.66±0.51 cm in the pessary and control groups, respectively; P=0.957) at a gestational age similar to that of the controls (23.29 vs. 25.14 weeks, P=0.294). There was no significant difference in gestational age at delivery between them (33.29 vs. 27.29 weeks in the pessary and control groups, respectively, P=0.058). The pessary group had a longer interval between the diagnosis and delivery than the control group (60.7±28.3 vs. 22.6±24.5 days, P=0.001). The number of adverse neonatal outcomes was significantly lower in the pessary group (n=7; 28.0%) than in the control group (n=14; 58.3%; P=0.032). Conclusion The use of a cervical pessary may prolong gestation in twin pregnancies in women with an extremely short cervix until viable gestational age.
Collapse
|
29
|
Helmi H, Siddiqui A, Yan Y, Basij M, Hernandez-Andrade E, Gelovani J, Hsu CD, Hassan SS, Mehrmohammadi M. The role of noninvasive diagnostic imaging in monitoring pregnancy and detecting patients at risk for preterm birth: a review of quantitative approaches. J Matern Fetal Neonatal Med 2020; 35:568-591. [PMID: 32089024 DOI: 10.1080/14767058.2020.1722099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Preterm birth (PTB) is the leading cause of neonatal morbidity and mortality worldwide. The ability to predict patients at risk for preterm birth remains a major health challenge. The currently available clinical diagnostics such as cervical length and fetal fibronectin may detect only up to 30% of patients who eventually experience a spontaneous preterm birth. This paper reviews ongoing efforts to improve the ability to conduct a risk assessment for preterm birth. In particular, this work focuses on quantitative methods of imaging using ultrasound-based techniques, magnetic resonance imaging, and optical imaging modalities. While ultrasound imaging is the major modality for preterm birth risk assessment, a summary of efforts to adopt other imaging modalities is also discussed to identify the technical and diagnostic limits associated with adopting them in clinical settings. We conclude the review by proposing a new approach using combined photoacoustic, ultrasound, and elastography as a potential means to better assess cervical tissue remodeling, and thus improve the detection of patients at-risk of PTB.
Collapse
Affiliation(s)
- Hamid Helmi
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Adeel Siddiqui
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Yan Yan
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Maryam Basij
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI, USA
| | - Juri Gelovani
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Sonia S Hassan
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA.,Office of Women's Health, Wayne State University, Detroit, MI, USA
| | - Mohammad Mehrmohammadi
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA.,Department of Electrical and Computer Engineering, Wayne State University, Detroit, MI, USA
| |
Collapse
|
30
|
Schneider K, Fimmers R, Jörgens M, Peter S, Pelzer V, Redlich T. Emergency cerclage following a standardized protocol offers an effective and safe therapeutic option for women with high risk for prematurity - a retrospective monocentric cohort study on 130 pregnancies and 155 neonates. J Matern Fetal Neonatal Med 2019; 34:4053-4059. [PMID: 31852290 DOI: 10.1080/14767058.2019.1702960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: To present emergency cerclage (EC) as a safe and effective therapeutic option for prevention of prematurity in women with advanced cervical dilation in second-trimester pregnancy. It is focused on seemingly futile situations like cervical dilation >5 cm, bulging membranes and multifetal pregnancies. The outcomes of interest are the prolongation of pregnancy, gestational age at delivery and neonatal morbidity and mortality related to distinct risk factors.Study design: Retrospective monocentric cohort study involving 130 pregnancies (105 single and 25 twin pregnancies) and 155 neonates by using a standardized protocol. Women between 18 and 28 gestational weeks with cervical shortening of <10 mm + cervical dilation >2 cm and/or bulging membranes were included. Analyses of maternal and neonatal parameters were done by chart review.Results: The medium gestational age at delivery was 35 5/7 week with a medium interval from cerclage placement to delivery of 83 days. Overall, 46.5% (72/155) neonates were born beyond 37 weeks, extreme prematurity of less than 28 gestational weeks was observed in 14.8% (23/155), no miscarriage before 22 weeks was documented. The neonatal mortality was 1.9% (3/155). Neonatal deaths and morbidity was related to severe prematurity exclusively. The association of amnion-infection syndromes and failing therapy was significantly with respect to bulging membranes and advanced cervical dilation >5 cm.Conclusions: Even in futile cases EC can be an option to save the pregnancy and prevent severe prematurity. However, a standardized protocol is imminent for successful therapy and every indication has to be a case by case decision.
Collapse
Affiliation(s)
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Jörgens
- Gynecology and Obstetrics, Kaiserswerther Diakonie, Düsseldorf, Germany
| | | | | | | |
Collapse
|
31
|
Gulersen M, Divon MY, Krantz D, Chervenak FA, Bornstein E. The risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23-28 weeks' gestation. Am J Obstet Gynecol MFM 2019; 2:100059. [PMID: 33345952 DOI: 10.1016/j.ajogmf.2019.100059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asymptomatic short cervical length is an independent risk factor for spontaneous preterm birth. However, most studies have focused on the associated risk of a short cervical length when encountered between 16 and 23 weeks' gestation. The relationship between cervical length and risk of spontaneous preterm birth after 23 weeks is not well known. OBJECTIVE To evaluate the risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23-28 weeks' gestation. MATERIALS AND METHODS A retrospective cohort study of women with asymptomatic short cervix (cervical length ≤25 mm) at extreme prematurity, defined as 23-28 weeks' gestation, was performed at a single center from January 2015 to March 2018. Women with symptoms of preterm labor, multiple gestations, fetal or uterine anomalies, cervical cerclage, or those with incomplete data were excluded from the study. Demographic information as well as data on risk factors for spontaneous preterm birth were collected. Patients were divided into 4 groups based on the cervical length measurement (≤10 mm, 11-15 mm, 16-20 mm, and 21-25 mm). The primary outcome was time interval from enrollment to delivery. Secondary outcomes included delivery within 1 and 2 weeks of enrollment, gestational age at delivery, and delivery prior to 32, 34, and 37 weeks, respectively. Continuous variables were compared using Kruskal-Wallis test, whereas categorical variables were compared using the χ2 or Fisher exact test as appropriate. The Wilcoxon test for difference in survival time was used to compare gestational age at delivery among the 4 cervical length groups, with data stratified based on gestational age at enrollment. RESULTS Of the 126 pregnancies that met inclusion criteria, 22 (17.4%) had a cervical length of ≤10 mm, 23 (18.3%) had a cervical length of 11-15 mm, 37 (29.4%) had a cervical length of 16-20 mm, and 44 (34.9%) had a cervical length of 21-25 mm. Baseline characteristics were similar among all 4 groups. The shorter cervical length group was associated with a shorter time interval from enrollment to delivery (cervical length ≤10 mm, 10 weeks; cervical length 11-15 mm, 12.7 weeks; cervical length of 16-20 mm, 13 weeks; cervical length of 21-25 mm, 13.2 weeks; P = .006). Regardless of the cervical length measurement, delivery within 2 weeks was extremely uncommon (1 patient; 0.8%). The prevalence of spontaneous preterm birth at <32 weeks or <34 weeks was higher in women with a cervical length of ≤10 mm compared to those with a longer cervical length (P < .001). CONCLUSIONS The risk of spontaneous preterm birth in asymptomatic women with a sonographic short cervix increases as cervical length decreases. The risk is substantially higher in women with a cervical length of ≤10 mm. Women with a cervical length of ≤10 mm also had the shortest time interval to delivery. Nevertheless, delivery within 1 or 2 weeks is highly unlikely, regardless of the cervical length at the time of enrollment. Therefore, based on our data, we suggest that management decisions such as timing of administration of antenatal corticosteroids in asymptomatic patients with a cervical length of ≤25 mm at 23-28 weeks' gestation may be delayed until additional indications are present.
Collapse
Affiliation(s)
- Moti Gulersen
- Department of Obstetrics and Gynecology, Lenox Hill Hospital-Northwell Health, New York, NY.
| | - Michael Y Divon
- Department of Obstetrics and Gynecology, Lenox Hill Hospital-Northwell Health, New York, NY
| | | | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Lenox Hill Hospital-Northwell Health, New York, NY
| | - Eran Bornstein
- Department of Obstetrics and Gynecology, Lenox Hill Hospital-Northwell Health, New York, NY
| |
Collapse
|
32
|
Yoshida K, Jayyosi C, Lee N, Mahendroo M, Myers KM. Mechanics of cervical remodelling: insights from rodent models of pregnancy. Interface Focus 2019; 9:20190026. [PMID: 31485313 PMCID: PMC6710664 DOI: 10.1098/rsfs.2019.0026] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2019] [Indexed: 01/01/2023] Open
Abstract
The uterine cervix undergoes a complex remodelling process during pregnancy, characterized by dramatic changes in both extracellular matrix (ECM) structure and mechanical properties. Understanding the cervical remodelling process in a term or preterm birth will aid efforts for the prevention of preterm births (PTBs), which currently affect 14.8 million babies annually worldwide. Animal models of pregnancy, particularly rodents, continue to provide valuable insights into the cervical remodelling process, through the study of changes in ECM structure and mechanical properties at defined gestation time points. Currently, there is a lack of a collective, quantitative framework to relate the complex, nonlinear mechanical behaviour of the rodent cervix to changes in ECM structure. This review aims to fill this gap in knowledge by outlining the current understanding of cervical remodelling during pregnancy in rodent models in the context of solid biomechanics. Here we highlight the collective contribution of multiple mechanical studies which give evidence that cervical softening coincides with known ECM changes throughout pregnancy. Taken together, mechanical tests on tissue from pregnant rodents reveal the cervix's remarkable ability to soften dramatically during gestation to allow for a compliant tissue that can withstand damage and can dissipate mechanical loads.
Collapse
Affiliation(s)
- Kyoko Yoshida
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - Charles Jayyosi
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - Nicole Lee
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - Mala Mahendroo
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristin M. Myers
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| |
Collapse
|
33
|
Bachkangi P, Taylor AH, Bari M, Maccarrone M, Konje JC. Prediction of preterm labour from a single blood test: The role of the endocannabinoid system in predicting preterm birth in high-risk women. Eur J Obstet Gynecol Reprod Biol 2019; 243:1-6. [PMID: 31618675 DOI: 10.1016/j.ejogrb.2019.09.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine if plasma concentrations of the N-acylethanolamines (NAEs) N-arachidonoylethanolamine (AEA), N-oleoylethanolamide (OEA) and N-palmitoylethanolamide (PEA) increase in women at high risk for preterm birth (PTB) and whether these could be used to predict preterm delivery and if so, how they compare with current methods. DESIGN Prospective cohort study. SETTING A large UK teaching hospital. POPULATION 217 pregnant women were recruited between 24 and 34 gestational weeks at 'high-risk' for PTB, recruited from a prematurity prevention clinic or antenatal wards. METHODS Plasma AEA, OEA, and PEA concentrations were measured using ultra-high performance liquid chromatography-tandem mass spectrometry whilst FAAH enzyme activity was measured by fluorometric radiometric assay and CL by ultrasound scan. The clinical usefulness of these measurements were determined by ROC and multivariate analyses. RESULTS AEA and PEA concentrations were significantly higher in women who delivered prematurely. An AEA concentration >1.095 nM predicted PTB, the gestational age at delivery and the recruitment to delivery interval (RTDI). A PEA concentration >17.50 nM only predicted PTB; FAAH enzyme activity was not related to these changes. Multivariate analysis (all variables) generated an equation to accurately predict the RTDI. CONCLUSIONS A single plasma AEA or PEA measurement can predict PTB. A single AEA measurement predicts the gestational age of delivery and the remaining period of pregnancy with reasonable accuracy and better than existing conventional tests thus offering a better window for primary prevention of PTB.
Collapse
Affiliation(s)
- P Bachkangi
- Endocannabinoid Research Group, Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
| | - A H Taylor
- Endocannabinoid Research Group, Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK; Department of Molecular and Cell Biology, University of Leicester, Leicester, Department of Medicine, UK
| | | | | | - Justin C Konje
- Endocannabinoid Research Group, Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK; Department of Obstetrics and Gynaecology, Sidra Medicine, Doha and Wellness Women's Research Center, HMC, Doha, Qatar.
| |
Collapse
|
34
|
Yan Y, Gomez-Lopez N, Basij M, Shahvari AV, Vadillo-Ortega F, Hernandez-Andrade E, Hassan SS, Romero R, MehrMohammadi M. Photoacoustic imaging of the uterine cervix to assess collagen and water content changes in murine pregnancy. BIOMEDICAL OPTICS EXPRESS 2019; 10:4643-4655. [PMID: 31565515 PMCID: PMC6757472 DOI: 10.1364/boe.10.004643] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/03/2019] [Accepted: 08/03/2019] [Indexed: 05/11/2023]
Abstract
The uterine cervix plays a central role in the maintenance of pregnancy and in the process of parturition. Cervical remodeling involves dramatic changes in extracellular matrix composition and, in particular, of collagen and water content during cervical ripening (a term that describes the anatomical, biochemical, and physiologic changes in preparation for labor). Untimely cervical ripening in early gestation predisposes to preterm labor and delivery, the leading cause of infant death worldwide. Inadequate ripening of the cervix is associated with failure of induction or prolonged labor. The current approach to evaluate the state of the cervix relies on digital examination and sonographic examination. Herein, we present a novel imaging method that combines ultrasound (US) and photoacoustic (PA) techniques to evaluate cervical remodeling by assessing the relative collagen and water content of this organ. The method was tested in vitro in extracted collagen phantoms and ex vivo in murine cervical tissues that were collected in mid-pregnancy and at term. We report, for the first time, that our imaging approach provides information about the molecular changes in the cervix at different gestational ages. There was a strong correlation between the results of PA imaging and the histological assessment of the uterine cervix over the course of gestation. These findings suggest that PA imaging is a powerful method to assess the biochemical composition of the cervix and open avenues to non-invasively investigate the composition of this organ, which is essential for reproductive success.
Collapse
Affiliation(s)
- Yan Yan
- Department of Biomedical Engineering, Wayne State University, Detroit, MI 48202, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Department of Biochemistry, Immunology, and, Microbiology, Wayne State University School of Medicine, Detroit, MI 48201, USA
- C.S. Mott Center for Human Growth and Development, Wayne State University, Detroit, MI 48201, USA
| | - Maryam Basij
- Department of Biomedical Engineering, Wayne State University, Detroit, MI 48202, USA
| | | | - Felipe Vadillo-Ortega
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI 48201, USA
- Unidad de Vinculación de la Facultad de Medicina,UNAM y Dirección de Investigación, Instituto Nacional de Medicina Genómica, CDMX, Mexico
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, MI 48201, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI 48824, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI 48201, USA
- Detroit Medical Center, Detroit, MI 48201, USA
- Department of Obstetrics and Gynecology, Florida International University, Miami, FL 33199, USA
| | - Mohammad MehrMohammadi
- Department of Biomedical Engineering, Wayne State University, Detroit, MI 48202, USA
- Department of Electrical and Computer Engineering, Wayne State University, Detroit, MI 48202, USA
| |
Collapse
|
35
|
OH KJ, ROMERO R, PARK JY, HONG JS, YOON BH. The earlier the gestational age, the greater the intensity of the intra-amniotic inflammatory response in women with preterm premature rupture of membranes and amniotic fluid infection by Ureaplasma species. J Perinat Med 2019; 47:516-527. [PMID: 31141489 PMCID: PMC6656366 DOI: 10.1515/jpm-2019-0003] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/21/2019] [Indexed: 01/13/2023]
Abstract
Objectives To determine the relationship between the intensity of the intra-amniotic inflammatory response and the gestational age at the time of diagnosis in cases with preterm premature rupture of membranes (PROM) and intra-amniotic infection caused by Ureaplasma spp. Methods A retrospective cohort study was conducted which included 71 women with preterm PROM and a positive amniotic fluid culture with Ureaplasma spp. Women with mixed intra-amniotic infections were excluded. The study population was classified into three groups according to gestational age: group 1, <26 weeks (extreme preterm PROM, n = 17); group 2, 26.0-33.9 weeks (moderate preterm PROM, n = 39); group 3, 34.0-36.9 weeks (late preterm PROM, n = 15). The intensity of the intra-amniotic and maternal inflammatory response was compared among the three groups. The intensity of the intra-amniotic inflammatory response was assessed by the concentration of amniotic fluid matrix metalloproteinase-8 (MMP-8) and white blood cell (WBC) count. The maternal inflammatory response was assessed by the concentration of C-reactive protein (CRP) and WBC count in maternal blood at the time of amniocentesis. Results (1) The median values of amniotic fluid MMP-8 concentration and WBC count were the highest in the extreme preterm PROM group and the lowest in the late preterm PROM group (P < 0.001 and P = 0.01, respectively); (2) the intensity of the maternal inflammatory response measured by maternal blood WBC count and CRP concentration was not significantly associated with gestational age at the time of diagnosis. Conclusion The earlier the gestational age at the time of PROM, the higher the intensity of the intra-amniotic inflammatory response in women with preterm PROM and intra-amniotic infection caused by Ureaplasma spp.
Collapse
Affiliation(s)
- Kyung Joon OH
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea;,Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Roberto ROMERO
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, USA, and Detroit, Michigan, USA;,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA;,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA;,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Jee Yoon PARK
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea;,Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Joon-Seok HONG
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea;,Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Bo Hyun YOON
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
36
|
Price JT, Vwalika B, Winston J, Kumwenda A, Lubeya MK, Rittenhouse KJ, Stringer E, Kasaro MP, Stringer JSA. HIV serostatus, viral load, and midtrimester cervical length in a Zambian prenatal cohort. Int J Gynaecol Obstet 2019; 146:206-211. [PMID: 30973655 DOI: 10.1002/ijgo.12823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/12/2018] [Accepted: 04/10/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate whether maternal HIV serostatus and plasma viral load (VL) are associated with midtrimester cervical length (CL). METHODS The Zambian Preterm Birth Prevention Study (ZAPPS) is an ongoing prospective cohort that began enrolling in Lusaka in August 2015. Pregnant women undergo ultrasound to determine gestational age and return for CL measurement at 16-28 weeks. We evaluated crude and adjusted associations between dichotomous indicators and short cervix (≤2.5 cm) via logistic regression, and between VL and CL as a continuous variable via linear regression. RESULTS This analysis includes 1171 women enrolled between August 2015 and September 2017. Of 294 (25.1%) HIV-positive women, 275 (93.5%) had viral load performed close to CL measurement; of these, 148 (53.8%) had undetectable virus. Median CL was 3.6 cm (IQR 3.5-4.0) and was similar in HIV-infected (3.7 cm, IQR 3.5-4.0) versus uninfected (3.6 cm, IQR 3.5-4.0) participants (P=0.273). The odds of short CL were similar by HIV serostatus (OR 0.64; P=0.298) and detectable VL among those infected (OR 2.37, P=0.323). We observed no association between log VL and CL via linear regression (-0.12 cm; P=0.732). CONCLUSION We found no evidence of association between HIV infection and short CL.
Collapse
Affiliation(s)
- Joan T Price
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,University of North Carolina Global Projects Zambia, Lusaka, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jennifer Winston
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Kumwenda
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Mwansa K Lubeya
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Elizabeth Stringer
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jeffrey S A Stringer
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
37
|
Oh KJ, Romero R, Park JY, Kang J, Hong JS, Yoon BH. A high concentration of fetal fibronectin in cervical secretions increases the risk of intra-amniotic infection and inflammation in patients with preterm labor and intact membranes. J Perinat Med 2019; 47:288-303. [PMID: 30763270 PMCID: PMC6497400 DOI: 10.1515/jpm-2018-0351] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/08/2019] [Indexed: 01/07/2023]
Abstract
Objective To determine whether the risk of intra-amniotic infection/inflammation and spontaneous preterm delivery (SPTD) varies as a function of the concentration of cervical fetal fibronectin (fFN) in patients with preterm labor and intact membranes. Methods This prospective study included 180 patients with preterm labor and intact membranes who had a sample collected for quantitative fFN measurement and underwent amniocentesis. Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas. Intra-amniotic inflammation was defined as an amniotic fluid matrix metalloproteinase-8 concentration >23 ng/mL. Results (1) The prevalence of intra-amniotic infection/inflammation and SPTD within 7 days was 32.2% (58/180) and 33.9% (61/178), respectively; (2) The higher the fFN concentration, the greater the risk of intra-amniotic infection/inflammation and SPTD within 7 days (P<0.001, respectively); (3) An fFN concentration 150 ng/mL had a better diagnostic performance than an fFN 50 ng/mL in the identification of intra-amniotic infection/inflammation and SPTD within 7 days; (4) Among the patients with an fFN <50 ng/mL, intra-amniotic infection/inflammation was identified in 7.6% (6/79) of patients and 66.7% (4/6) delivered within 7 days. Conclusion The higher the concentration of fFN, the greater the risk of intra-amniotic infection/inflammation and SPTD in patients with preterm labor and intact membranes.
Collapse
Affiliation(s)
- Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, USA, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Jihyun Kang
- Department of Obstetrics and Gynecology, Veterans Health Service Medical Center, Seoul, Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
38
|
McCurdy RJ, Baxter JK. Universal cervical length screening with a cervicometer to prevent preterm birth <34 weeks: a decision and economic analysis. J Matern Fetal Neonatal Med 2019; 33:3670-3679. [PMID: 30760059 DOI: 10.1080/14767058.2019.1583202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Preterm birth is a leading cause of neonatal morbidity and mortality worldwide; evidence-based strategies to decrease preterm birth are desperately needed.Objective: The purpose of this study was to estimate which of three strategies for screening for shortened cervix in asymptomatic low-risk women is the most cost-effective in terms of prevention of preterm birth and associated morbidity.Study design: A decision analysis model was developed from available published evidence comparing three strategies in screening asymptomatic low-risk women for shortened cervix: (1) cervicometer with subsequent referral for transvaginal ultrasound, (2) transvaginal ultrasound screening, and (3) no screening. The cost and effectiveness of each strategy was assessed in terms of quality-adjusted life-years (QALYs), and cost in US dollars.Results: Screening with a cervicometer with referral was the most cost-effective strategy and represented a savings of $999.65 ($11,617.28 versus $12,616.93) over screening with ultrasound, and a savings of $15,601.62 ($11,617.28 versus $27,218.90) over no screening. Costs for outcomes ranged from $3528 for a healthy neonate ≥34 weeks to $717,467.5 for a neonate <34 weeks with severe morbidity. The cervicometer strategy avoided 11.68 neonatal deaths per 1000 deliveries (3.59 deaths versus 15.27 deaths) compared with no screening, and avoided 0.73 neonatal deaths per 1000 deliveries (3.59 deaths versus 4.32 deaths) compared with ultrasound strategy. The cervicometer strategy prevented 82.44 preterm births per 1000 deliveries (22.56 versus 105.00) compared with no screening, and 5.10 preterm births per 1000 deliveries (22.56 versus 27.66) compared with ultrasound strategy. Per QALY, cervicometer screening cost $386.57, transvaginal ultrasound cost $420.31, and no screening cost $922.73. Sensitivity analyses confirmed the robustness of these findings, including evaluation across the range of quoted transvaginal ultrasound costs ($43-$300).Conclusion: A simulation of universal screening of asymptomatic low-risk women with a cervicometer with subsequent referral for ultrasound for those with a cervix <25 mm is cost-effective and yields the greatest reduction in preterm births at <34 weeks. A risk simulation trial noted that a cervicometer strategy may be more expensive than a universal transvaginal ultrasound strategy, but both are less expensive than a no screening strategy.
Collapse
Affiliation(s)
- Rebekah J McCurdy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jason K Baxter
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
39
|
Development of a mucoinert progesterone nanosuspension for safer and more effective prevention of preterm birth. J Control Release 2019; 295:74-86. [PMID: 30597245 PMCID: PMC6398330 DOI: 10.1016/j.jconrel.2018.12.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/19/2018] [Accepted: 12/27/2018] [Indexed: 02/03/2023]
Abstract
Preterm birth (PTB) is a significant global problem, but few therapeutic options exist. Vaginal progesterone supplementation has been demonstrated to reduce PTB rates in women with a sonographic short cervix, yet there has been little investigation into the most effective dose or delivery form. Further, vaginal products like progesterone gel often contain excipients that cause local toxicity, irritation, and leakage. Here, we describe the development and characterization of a mucoinert vaginal progesterone nanosuspension formulation for improved drug delivery to the female reproductive tract. We compare the pharmacokinetics and pharmacodynamics to the clinical comparator progesterone gel in pregnant mice and demonstrate increased vaginal absorption and biodistribution via the uterine first-pass effect. Importantly, the unique plasma progesterone double peak observed in humans, reflecting recirculation from the uterus, was also observed in pregnant mice with vaginal dosing. We adapted a mouse model of progesterone withdrawal that was previously believed to be incompatible with testing the efficacy of exogenous progestins, and are first to demonstrate efficacy in preventing preterm birth with vaginal progesterone in this model. Further, improved vaginal progesterone delivery by the nanosuspension led to increased efficacy in PTB prevention. Additionally, we identified histological and transcriptional evidence of cervical and uterine toxicity with a single vaginal administration of the clinical gel that are absent after dosing with the mucoinert nanosuspension formulation. We demonstrate that a progesterone formulation that is designed for improved vaginal progesterone absorption and vaginal biocompatibility could be more effective for PTB prevention.
Collapse
|
40
|
Basbug A, Bayrak M, Doğan O, Ellibeş Kaya A, Goynumer G. McDonald versus modified Shirodkar rescue cerclage in women with prolapsed fetal membranes. J Matern Fetal Neonatal Med 2018; 33:1075-1079. [PMID: 30122099 DOI: 10.1080/14767058.2018.1514378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose: We compared the efficacy of modified Shirodkar and McDonald rescue cerclage techniques in women with singleton pregnancies.Methods: The study sample included 47 women who presented at two tertiary hospitals in Turkey from 2008 to 2017 and underwent rescue cerclage due to cervical incompetence and cervical dilatation with fetal membranes prolapsed into the vagina. The outcomes were compared by cerclage technique used, Shirodkar or McDonald.Results: The McDonald cerclage was applied in 27 cases, and modified Shirodkar cerclage in 20 cases. A longer cerclage-to-birth interval (83.8 ± 37.6 vs. 63.7 ± 38.9 days) and later gestational age at delivery (33 vs. 31 weeks) were observed with the Shirodkar cerclage, although these differences were not statistically significant (p = .08 and .63, respectively). Both groups had similar delivery rates after 28, 32, and 37 weeks (p = .20, .15, and .25, respectively), whereas the modified Shirodkar technique resulted in a higher rate of live births although these differences were not statistically significant (85% vs. 63%, p = .09).Conclusion: The effects of the McDonald and modified Shirodkar cerclage procedures on prolonging pregnancy and improving the live birth rate were similar. Therefore, either technique can be applied to prevent neonatal loss due to advanced prematurity.
Collapse
Affiliation(s)
- Alper Basbug
- Department of Obstetrics and Gynecology, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Mehmet Bayrak
- Obstetrics and Gynecology, Istanbul Medeniyet University Goztepe Education and Research Hospital, İstanbul, Turkey
| | - Ozan Doğan
- Obstetrics and Gynecology, Health Sciences University, Sisli Hamidiye Etfal Research and Training Hospital, İstanbul, Turkey
| | - Aşkı Ellibeş Kaya
- Department of Obstetrics and Gynecology, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Gokhan Goynumer
- Department of Obstetrics and Gynecology, Faculty of Medicine, Duzce University, Duzce, Turkey
| |
Collapse
|
41
|
Tsunoda Y, Fukami T, Yoneyama K, Kawabata I, Takeshita T. The presence of amniotic fluid sludge in pregnant women with a short cervix: an independent risk of preterm delivery. J Matern Fetal Neonatal Med 2018; 33:920-923. [PMID: 30081692 DOI: 10.1080/14767058.2018.1509309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: To examine whether the presence of amniotic fluid sludge (AFS) could increase the risk of preterm delivery in women with a cervical length (CL) of less than 25 mm.Materials and methods: This is a retrospective cohort study of 110 women who were 14-30 weeks pregnant with a singleton gestation and a CL of less than 25 mm. The primary outcomes were defined as preterm delivery before 34 weeks and preterm delivery before 37 weeks. The secondary outcome was defined as preterm premature rupture of membranes (PPROM) prior to preterm delivery. Risk factors for preterm delivery were defined as AFS, subchorionic hematoma (SCH), history of preterm delivery, CL of less than 20 mm, and CL of less than 15 mm. A univariate analysis was performed to assess the primary and secondary outcomes according to the presence or absence of each risk factor. A multiple logistic regression analysis was performed to evaluate the parameters, using a significance of p < .05 on the univariate analysis to examine whether they were independent risk factors.Results: A significantly increased risk of preterm delivery was found in the group of women with AFS who actually did deliver prior to 34 weeks (p < .001; odds ratio [OR] 6.44; 95% confidence interval [CI] 2.51-16.5), prior to 37 weeks (p = .001; OR 4.46; 95% CI 1.76-11.3), and who had PPROM (p < .001; OR 4.96; 95% CI 2.00-12.3). A multivariate logistic regression analysis was performed in the women with AFS who experienced preterm delivery before 34 weeks, in the women with a CL less than 20 mm, and in the women with a CL less than 15 mm. The results showed that AFS was an independent risk factor for preterm delivery before 34 weeks (p = .001; OR 5.86; 95% CI 2.11-16.3).Conclusion: The presence of AFS was an independent risk factor for preterm delivery before 34 weeks in women with a CL less than 25 mm.
Collapse
Affiliation(s)
- Youhei Tsunoda
- Department of Obstetrics and Gynecology, Nippon Medical School, Musashi Kosugi Hospital, Kanagawa, Japan
| | - Takehiko Fukami
- Department of Obstetrics and Gynecology, Nippon Medical School, Musashi Kosugi Hospital, Kanagawa, Japan
| | - Koichi Yoneyama
- Department of Obstetrics and Gynecology, Nippon Medical School, Musashi Kosugi Hospital, Kanagawa, Japan
| | - Ikuno Kawabata
- Department of Obstetrics and Gynecology, Nippon Medical School, Musashi Kosugi Hospital, Kanagawa, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School Hospital, Tokyo, Japan
| |
Collapse
|
42
|
Otsuki K, Kawabata I, Matsuda Y, Nakai A, Shinozuka N, Makino Y, Kamei Y, Iwashita M, Okai T. Randomized trial of the efficacy of intravaginal ulinastatin administration for the prevention of preterm birth in women with a singleton pregnancy and both cervical shortening and inflammation of lower genital tract. J Obstet Gynaecol Res 2018; 45:86-95. [PMID: 30277627 DOI: 10.1111/jog.13796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/01/2018] [Indexed: 01/28/2023]
Abstract
AIM To assess the preventive effect on preterm birth of intravaginal ulinastatin (urinary trypsin inhibitor; UTI) administration during the mid-trimester in women with singleton pregnancy and both cervical shortening and lower genital infections. METHODS Pregnant women with a short cervical length < 25 mm between 16 and 26 weeks of gestation and who had been diagnosed with a lower genital infection were randomly assigned for intravaginal UTI administration or placebo. All of the women were screened for infection or inflammation of the lower genital tract, and women with negative results were excluded. RESULTS Of the 92 patients with a short cervical length who were assessed for eligibility for this study, 86 singleton patients were enrolled. All patients were randomized to one of two treatment groups: patients administered UTI (n = 35) and placebo (n = 35). There were no differences between the two groups in the incidence of preterm delivery before 28, 30, 32, 34 and 37 weeks of gestation and in perinatal outcomes. CONCLUSION For women diagnosed with a short cervical length < 25 mm) between 16 and 26 weeks of gestation and lower genital infection, who were at risk of preterm birth, administration of transvaginal UTI with vaginal irrigation showed no apparent benefit. Future research on the efficacy of UTI should evaluate modified modes of UTI application.
Collapse
Affiliation(s)
- Katsufumi Otsuki
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ikuno Kawabata
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, International University of Health and Welfare, Tochigi, Japan
| | - Yoshio Matsuda
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, Nippon Medical School, Tama-nagayama Hospital, Tokyo, Japan
| | - Akihito Nakai
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, International University of Health and Welfare, Tochigi, Japan
| | - Norio Shinozuka
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Fetal Medicine Research Unit, Kanagawa, Hiratsuka, Kanagawa, Japan
| | - Yasuo Makino
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshimasa Kamei
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, Tokyo University, Tokyo, Japan
| | - Mitsutoshi Iwashita
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, Kyorin University, Tokyo, Japan
| | - Takashi Okai
- Japanese Organization of Prevention of Preterm Delivery (JOPP) Tokyo, Tokyo, Japan.,Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| |
Collapse
|
43
|
Hernandez-Andrade E, Maymon E, Luewan S, Bhatti G, Mehrmohammadi M, Erez O, Pacora P, Done B, Hassan SS, Romero R. A soft cervix, categorized by shear-wave elastography, in women with short or with normal cervical length at 18-24 weeks is associated with a higher prevalence of spontaneous preterm delivery. J Perinat Med 2018; 46:489-501. [PMID: 29813033 PMCID: PMC6105276 DOI: 10.1515/jpm-2018-0062] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/27/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether a soft cervix identified by shear-wave elastography between 18 and 24 weeks of gestation is associated with increased frequency of spontaneous preterm delivery (sPTD). MATERIALS AND METHODS This prospective cohort study included 628 consecutive women with a singleton pregnancy. Cervical length (mm) and softness [shear-wave speed: (SWS) meters per second (m/s)] of the internal cervical os were measured at 18-24 weeks of gestation. Frequency of sPTD <37 (sPTD<37) and <34 (sPTD<34) weeks of gestation was compared among women with and without a short (≤25 mm) and/or a soft cervix (SWS <25th percentile). RESULTS There were 31/628 (4.9%) sPTD<37 and 12/628 (1.9%) sPTD<34 deliveries. The combination of a soft and a short cervix increased the risk of sPTD<37 by 18-fold [relative risk (RR) 18.0 (95% confidence interval [CI], 7.7-43.9); P<0.0001] and the risk of sPTD<34 by 120-fold [RR 120.0 (95% CI 12.3-1009.9); P<0.0001] compared to women with normal cervical length. A soft-only cervix increased the risk of sPTD<37 by 4.5-fold [RR 4.5 (95% CI 2.1-9.8); P=0.0002] and of sPTD<34 by 21-fold [RR 21.0 (95% CI 2.6-169.3); P=0.0003] compared to a non-soft cervix. CONCLUSIONS A soft cervix at 18-24 weeks of gestation increases the risk of sPTD <37 and <34 weeks of gestation independently of cervical length.
Collapse
Affiliation(s)
- Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Eli Maymon
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Suchaya Luewan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Gaurav Bhatti
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
| | | | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bogdan Done
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine,, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Service, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| |
Collapse
|
44
|
Ville Y, Rozenberg P. Predictors of preterm birth. Best Pract Res Clin Obstet Gynaecol 2018; 52:23-32. [PMID: 30309793 DOI: 10.1016/j.bpobgyn.2018.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/04/2018] [Indexed: 11/16/2022]
Abstract
Cervical length (CL) measured by transvaginal ultrasound examination (TVUE) best identifies the risk for preterm birth (PTB). It identifies women at risk who can benefit from corticosteroids or in utero transfer. Early screening improves effectiveness of tocolysis. It reduces iatrogenicity and cost. In preterm premature rupture of membranes (PPROM), CL is devoid of infectious risk and predicts duration of the latency phase but not the risk of perinatal sepsis. Asymptomatic women at risk should be screened at a 2-week interval starting from 16 to 18 weeks, up to 24 weeks. CLs <10th centile are at risk of PTB, especially with decrease in CL after 16 weeks. Repeat ultrasound improves predictive values. Stable CL calls for term delivery. Funneling does not improve predictivity of CL. In twin pregnancies, CL reduces unnecessary interventions. In symptomatic women, fetal fibronectin performs less than CL. Its combination with inconclusive CL has not emerged productive through randomized controlled trials (RCTs), and studies with homogeneous management for preterm labor (PTL) suggest that up to 15% of unjustified hospitalizations and treatment could be avoided.
Collapse
Affiliation(s)
- Yves Ville
- Université Paris Descartes, EHU-PACT, Department of Obstetrics and Fetal Medicine, Hôpital Necker Enfants-Malades, 149 rue de Sèvres, 75015, Paris, France.
| | - Patrick Rozenberg
- Université Versailles Saint-Quentin, Department of Obstetrics and Gynecology, Hôpital Intercommunal de Poissy, France
| |
Collapse
|
45
|
Vaginal progesterone is an alternative to cervical cerclage in women with a short cervix and a history of preterm birth. Am J Obstet Gynecol 2018; 219:5-9. [PMID: 29941278 DOI: 10.1016/j.ajog.2018.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 01/09/2023]
|
46
|
Conde-Agudelo A, Romero R, Da Fonseca E, O'Brien JM, Cetingoz E, Creasy GW, Hassan SS, Erez O, Pacora P, Nicolaides KH. Vaginal progesterone is as effective as cervical cerclage to prevent preterm birth in women with a singleton gestation, previous spontaneous preterm birth, and a short cervix: updated indirect comparison meta-analysis. Am J Obstet Gynecol 2018; 219:10-25. [PMID: 29630885 DOI: 10.1016/j.ajog.2018.03.028] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND An indirect comparison meta-analysis published in 2013 reported that both vaginal progesterone and cerclage are equally efficacious for preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic short cervix. The efficacy of vaginal progesterone has been challenged after publication of the OPPTIMUM study. However, this has been resolved by an individual patient-data meta-analysis (Am J Obstet Gynecol. 2018;218:161-180). OBJECTIVE To compare the efficacy of vaginal progesterone and cerclage in preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix. DATA SOURCES MEDLINE, EMBASE, LILACS, and CINAHL (from their inception to March 2018); Cochrane databases, bibliographies, and conference proceedings. STUDY ELIGIBILITY CRITERIA Randomized controlled trials comparing vaginal progesterone to placebo/no treatment or cerclage to no cerclage in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic cervical length <25 mm. STUDY APPRAISAL AND SYNTHESIS METHODS Updated systematic review and adjusted indirect comparison meta-analysis of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. The primary outcomes were preterm birth <35 weeks of gestation and perinatal mortality. Pooled relative risks (RRs) with 95% confidence intervals were calculated. RESULTS Five trials comparing vaginal progesterone vs placebo (265 women) and 5 comparing cerclage vs no cerclage (504 women) were included. Vaginal progesterone, compared to placebo, significantly reduced the risk of preterm birth <35 and <32 weeks of gestation, composite perinatal morbidity/mortality, neonatal sepsis, composite neonatal morbidity, and admission to the neonatal intensive care unit (RRs from 0.29 to 0.68). Cerclage, compared to no cerclage, significantly decreased the risk of preterm birth <37, <35, <32, and <28 weeks of gestation, composite perinatal morbidity/mortality, and birthweight <1500 g (RRs from 0.64 to 0.70). Adjusted indirect comparison meta-analyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Vaginal progesterone and cerclage are equally effective for preventing preterm birth and improving perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix. The choice of treatment will depend on adverse events and cost-effectiveness of interventions and patient/physician's preferences.
Collapse
Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Eduardo Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual "Francisco Morato de Oliveira" and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - John M O'Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
| | - Elcin Cetingoz
- Department of Obstetrics and Gynecology, Turkish Red Crescent Altintepe Medical Center, Maltepe, Istanbul, Turkey
| | - George W Creasy
- Center for Biomedical Research, Population Council, New York, NY
| | - Sonia S Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences. Ben-Gurion University of the Negev, Beersheba, Israel
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Kypros H Nicolaides
- Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, United Kingdom
| |
Collapse
|
47
|
Glover AV, Manuck TA. Screening for spontaneous preterm birth and resultant therapies to reduce neonatal morbidity and mortality: A review. Semin Fetal Neonatal Med 2018; 23:126-132. [PMID: 29229486 PMCID: PMC6381594 DOI: 10.1016/j.siny.2017.11.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Despite considerable effort aimed at decreasing the incidence of spontaneous preterm birth, it remains the leading cause of perinatal morbidity and mortality. Screening strategies are imperfect. Approaches used to identify women considered by historical factors to be low risk for preterm delivery (generally considered to be women with singleton pregnancies without a history of a previous preterm birth) as well as those at high risk for preterm birth (those with a previous preterm birth, short cervix, or multiple gestation) continue to evolve. Herein, we review the current evidence and approaches to screening women for preterm birth, and examine future directions for clinical practice. Further research is necessary to better identify at-risk women and provide evidence-based management.
Collapse
Affiliation(s)
- Angelica V Glover
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tracy A Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| |
Collapse
|
48
|
Mishra S, Bagga R, Kalra J, Jain V, Dutta S. Routine second trimester cervical length screening in low risk women identified women at risk of a 'very' preterm birth but did not reduce the preterm birth rate: a randomised study from India. J OBSTET GYNAECOL 2018. [PMID: 29537316 DOI: 10.1080/01443615.2017.1419461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Women (n = 300) at 'low risk' for a preterm birth (PTB), a singleton pregnancy and for a 16-24 week period of gestation (POG) were randomised to undergo cervical length (CL) measurement by transvaginal sonography (TVS) or not. The aim was to see if routine CL measurement and treatment of a short CL reduced the PTB rate. 'Low risk' was defined by an absence of a prior abortion or PTB of a singleton infant (>16 to <37 weeks) due to a spontaneous preterm labour (PTL) or a preterm pre-labour rupture of membranes (pPROM). The PTB rate was similar in the screened and unscreened group (10.3 and 8%, respectively, p = .433). In the screened group, women who delivered at 'term' or 'moderate to late' preterm (32 to <37 weeks) had a significantly higher mean CL (3.46 ± 0.41 and 3.48 ± 0.65 cm, respectively) than the women who delivered 'very' preterm (28 to 31 + 6 weeks; 2.05 ± 0.5 cm; p = .01). A short CL ≤2.5 cm was observed in two primigravidas (2/147 or 1.3%). They delivered at 28 + 3 and 30 + 6 weeks POG, respectively, despite treatment with vaginal progesterone and rescue cerclage in one. Their neonates were discharged in a good condition. In our low risk cohort, a routine second trimester CL measurement did not reduce the overall PTB rate. However, it identified two primigravidas at risk of having a 'very' PTB.Clinical Trials Registry (CTRI), India: Registration number CTRI/2016/01/010438 Impact statement What is already known on this subject? In women with a singleton pregnancy who are at a 'low risk' for preterm birth (PTB), a short cervical length (CL) at mid trimester measured by transvaginal sonography (TVS) identifies those at risk for a PTB. This risk may be reduced by the treatment with vaginal progesterone. At present, though evidence in favour of CL measurement in low-risk women exists, it is not established as a part of antenatal care. What do the results of this study add? A routine second trimester CL measurement in low risk women did not reduce the PTB rate. However, screening for a short CL helped to identify two primigravidas at risk for a 'very' PTB. It may be possible that detection and treatment of a short CL averted an 'extremely' PTB (<28 weeks) in these two women. What are the implications of these findings for clinical practice and/or further research? Future studies should assess the outcome of women with a short mid-trimester CL to see whether its treatment resulted in pregnancy prolongation and an improved neonatal outcome.
Collapse
Affiliation(s)
- Siddhidatri Mishra
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Rashmi Bagga
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Jasvinder Kalra
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Vanita Jain
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Sourabh Dutta
- b Department of Paediatrics, Division of Neonatology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| |
Collapse
|
49
|
O’Connell JS, Sakowicz A, Miller ES. Is Midtrimester Cervical Length Associated with Preterm Birth in Women Evaluated for Preterm Labor? Am J Perinatol 2018; 35:220-224. [PMID: 28910849 PMCID: PMC6033513 DOI: 10.1055/s-0037-1606608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This article aims to evaluate whether midtrimester cervical length (CL) is associated with improved prediction of preterm delivery in women presenting with preterm labor. STUDY DESIGN This is a retrospective cohort study of women with a singleton gestation who underwent routine CL screening between 18 and 24 weeks of gestation between 2010 and 2014 who were later evaluated for preterm labor. Women were stratified by midtrimester CL quartile. Bivariable and multivariable analyses were performed to identify factors independently associated with preterm birth <37 weeks, <34 weeks, and delivery within 7 days of evaluation. Receiver operating characteristic (ROC) curves were created for multivariable equations with and without CL quartile to determine whether addition of CL improved the predictive capacity of the model for predicting preterm birth. RESULTS A total of 460 women were evaluated for preterm labor and had midtrimester CL measurements available. When CL quartile was incorporated into a regression model including demographic and clinical characteristics associated with preterm birth, the area under the ROC curve was not improved (0.775 vs. 0.786, p = 0.20). CONCLUSION While a shorter midtrimester CL quartile is associated with an increased incidence of preterm delivery in women evaluated for preterm labor, the addition of this variable to an existing model does not improve prediction of preterm birth.
Collapse
Affiliation(s)
- Jessica S. O’Connell
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Allie Sakowicz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emily S. Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
50
|
Romero R, Conde-Agudelo A, Da Fonseca E, O'Brien JM, Cetingoz E, Creasy GW, Hassan SS, Nicolaides KH. Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix: a meta-analysis of individual patient data. Am J Obstet Gynecol 2018; 218:161-180. [PMID: 29157866 PMCID: PMC5987201 DOI: 10.1016/j.ajog.2017.11.576] [Citation(s) in RCA: 281] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/13/2017] [Accepted: 11/13/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The efficacy of vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix has been questioned after publication of the OPPTIMUM study. OBJECTIVE To determine whether vaginal progesterone prevents preterm birth and improves perinatal outcomes in asymptomatic women with a singleton gestation and a midtrimester sonographic short cervix. STUDY DESIGN We searched MEDLINE, EMBASE, LILACS, and CINAHL (from their inception to September 2017); Cochrane databases; bibliographies; and conference proceedings for randomized controlled trials comparing vaginal progesterone vs placebo/no treatment in women with a singleton gestation and a midtrimester sonographic cervical length ≤25 mm. This was a systematic review and meta-analysis of individual patient data. The primary outcome was preterm birth <33 weeks of gestation. Secondary outcomes included adverse perinatal outcomes and neurodevelopmental and health outcomes at 2 years of age. Individual patient data were analyzed using a 2-stage approach. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology. RESULTS Data were available from 974 women (498 allocated to vaginal progesterone, 476 allocated to placebo) with a cervical length ≤25 mm participating in 5 high-quality trials. Vaginal progesterone was associated with a significant reduction in the risk of preterm birth <33 weeks of gestation (relative risk, 0.62; 95% confidence interval, 0.47-0.81; P = .0006; high-quality evidence). Moreover, vaginal progesterone significantly decreased the risk of preterm birth <36, <35, <34, <32, <30, and <28 weeks of gestation; spontaneous preterm birth <33 and <34 weeks of gestation; respiratory distress syndrome; composite neonatal morbidity and mortality; birthweight <1500 and <2500 g; and admission to the neonatal intensive care unit (relative risks from 0.47-0.82; high-quality evidence for all). There were 7 (1.4%) neonatal deaths in the vaginal progesterone group and 15 (3.2%) in the placebo group (relative risk, 0.44; 95% confidence interval, 0.18-1.07; P = .07; low-quality evidence). Maternal adverse events, congenital anomalies, and adverse neurodevelopmental and health outcomes at 2 years of age did not differ between groups. CONCLUSION Vaginal progesterone decreases the risk of preterm birth and improves perinatal outcomes in singleton gestations with a midtrimester sonographic short cervix, without any demonstrable deleterious effects on childhood neurodevelopment.
Collapse
Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eduardo Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual "Francisco Morato de Oliveira" and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - John M O'Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
| | - Elcin Cetingoz
- Department of Obstetrics and Gynecology, Turkish Red Crescent Altintepe Medical Center, Maltepe, Istanbul, Turkey
| | - George W Creasy
- Center for Biomedical Research, Population Council, New York, NY
| | - Sonia S Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Kypros H Nicolaides
- Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, United Kingdom
| |
Collapse
|