Prediction and Prevention of Recurrent Spontaneous Preterm Birth

Placental histology for targeted risk assessment of recurrent spontaneous preterm birth

BACKGROUND

Spontaneous preterm birth significantly increases the risk for a recurrent preterm birth. Only a few identifiable clinical risk factors can be referenced in counseling for recurrent preterm birth. Furthermore, treatment using progesterone supplementation has not consistently prevented preterm birth among high-risk patients, but it may be effective in a subset of those patients. Placental pathology from a previous pregnancy may be used to predict which patients will experience a recurrent preterm birth or to identify a subset of patients more likely to respond to treatment with antenatal progesterone.

OBJECTIVE

This study aimed to determine if histologic patterns are associated with recurrent preterm birth among patients with an index spontaneous preterm birth. A secondary objective was to determine if placental histologic types and/or progesterone receptor density in the decidua are associated with the response to progesterone supplementation with intramuscular 17-hydroxyprogesterone caproate.

STUDY DESIGN

This was a retrospective cohort study at a single institution of women with singleton pregnancies with an index spontaneous preterm birth and a subsequent birth within the same hospital system between 2009 and 2019. Patients were included if placental pathology was available for the index spontaneous preterm birth. A logistic regression was used to determine if there were independent associations between 4 histologic types (acute inflammation, maternal vascular malperfusion, fetal vascular malperfusion, chronic inflammation) and recurrent preterm birth. For the secondary endpoint, 17-hydroxyprogesterone caproate response was defined as prolonging gestation by >3 weeks beyond the gestational age at delivery in the index pregnancy. Patients who delivered <3 weeks beyond the gestational age in the index pregnancy but at ≥39 weeks' gestation were excluded. A logistic regression was used to assess the independent association between placental histology and 17-hydroxyprogesterone caproate response. Sensitivity analyses were completed using only patients with an index birth <36 weeks' gestation, and then excluding those with medically indicated preterm birth in a subsequent pregnancy. A nested case-control immunohistochemical study was done among 20 patients with a subsequent term birth and 20 patients with a subsequent spontaneous preterm birth. The percentage of cells in the maternal decidua positive for progesterone receptors was correlated with the subsequent pregnancy outcome.

RESULTS

A total of 352 patients were included. Acute inflammation was the most common histologic type seen among patients with spontaneous preterm birth (44.1%), followed by chronic inflammation (40.9%) and maternal vascular malperfusion (31.3%). No histologic type was independently associated with recurrent preterm birth. A total of 155 patients received 17-hydroxyprogesterone caproate in a second pregnancy. Low-grade acute inflammation was significantly associated with a decreased likelihood of 17-hydroxyprogesterone caproate response. Low-grade maternal vascular malperfusion among those with an index pregnancy delivered at <36 weeks' gestation was significantly associated with a more than 4 times increased likelihood of 17-hydroxyprogesterone caproate response when excluding those with a subsequent iatrogenic preterm birth. Progesterone receptor staining was not associated with recurrent preterm birth.

CONCLUSION

Although acute inflammation was prevalent among spontaneous preterm births, more than half of the spontaneous preterm births were not associated with acute inflammation. Low-grade acute inflammation was associated with a significantly decreased response to 17-hydroxyprogesterone caproate supplementation. Low-grade maternal vascular malperfusion was associated with a 4-fold increased likelihood of 17-hydroxyprogesterone caproate response among those with index deliveries <36 weeks' gestation. Further work is needed to determine if placental pathologic examination can be used to target treatment in subsequent pregnancies to prevent recurrent preterm birth.

What now? A critical evaluation of over 20 years of clinical and research experience with 17-alpha hydroxyprogesterone caproate for recurrent preterm birth prevention

Spontaneous preterm birth is multifactorial, and underlying etiologies remain incompletely understood. Supplementation with progestogens, including 17-alpha hydroxyprogesterone caproate has been a mainstay of prematurity prevention strategies in the United States in the last 2 decades. Following a recent negative confirmatory trial, 17-alpha hydroxyprogesterone caproate was withdrawn from the US market and is currently available only through clinical research studies. This expert review summarized clinical and research data regarding the use of 17-alpha hydroxyprogesterone caproate in the United States from 2003 to 2023 for recurrent prematurity prevention. In 17-alpha hydroxyprogesterone caproate. The history of the use, mechanisms of action, clinical trial results, and efficacy by clinical and biologic criteria of 17-alpha hydroxyprogesterone caproate are presented. We report that disparate findings and conclusions between similarly designed rigorous studies may reflect differences in a priori risk and population incidence and extreme care should be taken in interpreting the studies and making decisions regarding efficacy of 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth. The likelihood of improved obstetrical outcomes after receiving 17-alpha hydroxyprogesterone caproate may vary by clinical factors (eg, body mass index), plasma drug concentrations, and genetic factors, although the identification of individuals most likely to benefit remains imperfect. It is crucial for the medical community to recognize the importance of preserving the decades-long efforts invested in preventing recurrent preterm birth in the United States. Moreover, it is important that we thoroughly and thoughtfully evaluate 17-alpha hydroxyprogesterone caproate as a promising contender for future well-executed prematurity studies.

Reduction in preterm birth among COVID-19-vaccinated pregnant individuals in the United States

BACKGROUND

Most studies investigating preterm birth and COVID-19 vaccination have suggested no difference in preterm birth rates between vaccinated and unvaccinated pregnant individuals; however, 1 recent study suggested a protective effect of COVID-19 vaccination on preterm birth rates in Australia.

OBJECTIVE

This study aimed to determine whether a similar association and protective effect of COVID-19 vaccination on preterm birth would be found in our multistate, US cohort.

STUDY DESIGN

A cohort study was conducted using the Vizient Clinical Database, which included data from 192 hospitals in 38 states. Pregnant individuals who delivered between January 2021 and April 2022 were included. Propensity score matching was used to match a "treated" group of pregnant individuals with any COVID-19 vaccination (incomplete or complete vaccination) to a group that had not received any COVID-19 vaccination (the "untreated" group). A complete vaccination series of ≥2 doses of the Moderna or Pfizer vaccines or at least 1 dose of the Johnson & Johnson vaccine was considered. An incomplete series was receipt of 1 dose of the Pfizer or Moderna vaccine. We examined the association between COVID-19 vaccination status and preterm birth at <28, <34, and <37 weeks of gestation. Multivariable logistic regression models were used to adjust for potential confounders, with adjusted odds ratios as the measure of treatment effect.

RESULTS

Matching with replacement was performed for 5749 treated participants. After propensity score matching, there was no difference in maternal demographics of age, race, insurance status, parity, or comorbid conditions. Vaccinated individuals were 26% less likely to deliver at <37 weeks of gestation (adjusted odds ratio, 0.74; 95% confidence interval, 0.73-0.75; P<.001), 37% less likely to deliver at <34 weeks of gestation (adjusted odds ratio, 0.63; 95% confidence interval, 0.61-0.64; P<.001), and 43% less likely to deliver at <28 weeks of gestation (adjusted odds ratio, 0.57; 95% confidence interval, 0.55-0.60; P<0.001) than unvaccinated individuals.

CONCLUSION

Vaccination against COVID-19 may be protective against preterm birth.

Reassessing Preterm Birth Prevention After the Withdrawal of 17-α Hydroxyprogesterone Caproate

The U.S. Food and Drug Administration has recently withdrawn approval for 17-α hydroxyprogesterone caproate for prevention of recurrent preterm birth, and recent studies have called into question benefits of the pessary in the setting of a short cervix. Obstetric health care professionals are once again left with limited remaining options for preterm birth prevention. This narrative review summarizes the best current evidence on the use of vaginal progesterone, low-dose aspirin, and cerclage for the prevention of preterm birth; attempts to distill possible lessons learned from studies of progesterone and pessary, as well as their implementation into practice; and highlights areas where inroads into preterm birth prevention may be possible outside of the progesterone-aspirin-cerclage paradigm.

Association between maternal benzodiazepine or Z-hypnotic use in early pregnancy and the risk of stillbirth, preterm birth, and small for gestational age: a nationwide, population-based cohort study in Taiwan

BACKGROUND

Benzodiazepines and Z-hypnotics are commonly prescribed for anxiety and insomnia during pregnancy, but the evidence regarding potential adverse neonatal outcomes is insufficient because of poor control for confounding factors in previous studies. We therefore aimed to evaluate the association between the use of benzodiazepines or Z-hypnotics during early pregnancy and adverse neonatal outcomes (stillbirth, preterm birth, and small for gestational age).

METHODS

We did a nationwide, population-based cohort study in Taiwan using three data sources: Taiwan's National Birth Certificate Application database, the National Health Insurance database, and the Maternal and Child Health Database. The study cohort included all singleton pregnancies of females aged 15-50 years who gave birth between Jan 1, 2004, and Dec 31, 2018. Pregnancies without valid information were excluded. Benzodiazepine and Z-hypnotic use was defined as at least one benzodiazepine or Z-hypnotic prescription during early pregnancy (the first 20 weeks of pregnancy). The primary outcomes were stillbirth (fetal death at or after 20 weeks' gestation), preterm birth (<37 weeks' gestation), and small for gestational age (birthweight below the 10th percentile for gestational age by sex). Logistic regression models with propensity score fine stratification weighting were used to control for potential confounders and examine the association between benzodiazepines or Z-hypnotics use during early pregnancy and the risk of adverse neonatal outcomes. Odds ratios (ORs) and 95% CIs were reported. We used confounding by indication control analyses, a sibling control study, and a paternal negative control design to account for unmeasured confounders. The risk associated with exposure during late pregnancy was also assessed.

FINDINGS

Between Oct 7, 2021, and June 10, 2022, we analysed the study data. The cohort included 2 882 292 singleton pregnancies; of which, 75 655 (2·6%) of the mothers were dispensed one or more benzodiazepines or Z-hypnotics during early pregnancy. Women exposed during pregnancy were older (mean age at delivery was 31·0 years [SD 5·3] for exposed women vs 30·6 years [4·9] for unexposed women), had a higher prevalence of psychiatric disorders, and were more likely to have unhealthy lifestyle behaviours than unexposed women. Information about ethnicity was not available. Early pregnancy exposure was associated with adverse neonatal outcomes compared with non-exposure. The propensity score-weighted OR was 1·19 (95% CI 1·10-1·28) for stillbirth, 1·19 (1·16-1·23) for preterm birth, and 1·16 (1·13-1·19) for small for gestational age. After controlling for confounding by indication, there was no significant association between drug exposure and stillbirth risk; however, this attenuation was not observed for preterm birth and small for gestational age. In models with sibling controls that accounted for familial confounding and genetic factors, early exposure to benzodiazepines or Z-hypnotics was not associated with an increased risk of stillbirth and preterm birth, but it remained significantly associated with small for gestational age. The paternal negative control analyses with point estimates close to the null indicated no strong evidence of unmeasured confounding shared by the mother and the father. Substantially increased risks of stillbirth and preterm birth were observed for late pregnancy exposure.

INTERPRETATION

Benzodiazepine or Z-hypnotic use in early pregnancy is not associated with a substantial increase in the risk of stillbirth and preterm birth after accounting for unmeasured confounding factors. Clinicians should be aware of the increased risk of small for gestational age and caution should be taken when prescribing these medications during late pregnancy.

FUNDING

National Science and Technology Council, Taiwan.

TRANSLATION

For the Taiwanese translation of the abstract see Supplementary Materials section.

Subsequent risk of stillbirth, preterm birth, and small for gestational age: A cross-outcome analysis of adverse birth outcomes

BACKGROUND

Stillbirth, preterm birth, and small for gestational age (SGA) birth have an increased recurrence risk. The occurrence of one of these biologically related outcomes could also increase the risk for another one of these outcomes in a subsequent pregnancy.

OBJECTIVES

We assessed cross-outcome risks for subsequent stillbirth, preterm birth, and SGA.

METHODS

We used live birth and fetal death records to identify singleton, sequential birth pairs in California (1997-2017). Stillbirth was defined as delivery at ≥20 weeks of gestation of a foetus that died in utero; preterm birth as live birth at 20-36 weeks; and small for gestational age as sex-specific birthweight <10th percentile for gestational age. Risk ratios (RR) were computed using modified Poisson regression and adjusted for potential confounders. Sensitivity analyses included analysing a cohort restricted to primiparous index births and using inverse-probability censoring weights.

RESULTS

Of 3,108,532 birth pairs, 16,668 (0.5%), 260,596 (8.4%) and 331,109 (10.7%) of index births were stillborn, preterm and SGA, respectively. Among individuals with an index stillbirth, the adjusted RRs were 1.90 (95% confidence interval [CI] 1.83, 1.98) for subsequent preterm and 1.35 (95% CI 1.28, 1.41) for subsequent SGA. Among those with index preterm birth, the adjusted RRs were 2.02 (95% CI 1.92, 2.13) for stillbirth and 1.42 (95% CI 1.41, 1.44) for SGA. Among those with index SGA, the adjusted RRs were 1.54 (95% CI 1.46, 1.63) for stillbirth and 1.45 (95% CI 1.44, 1.47) for preterm birth. Similar results were reported for sensitivity analyses.

CONCLUSIONS

Individuals experiencing stillbirth, preterm birth, or SGA in one pregnancy had an increased risk of one of these biologically related outcomes in a subsequent pregnancy. These findings could encourage enhanced surveillance for individuals who experience stillbirth, preterm birth, or SGA and desire a subsequent pregnancy.

Perinatal care for the extremely preterm infant

Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (20^0/7-25^6/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.

Evaluation of Uterocervical Angle and Cervical Length as Predictors of Spontaneous Preterm Birth

Aim The aim of this article was to evaluate uterocervical angle (UCA) and cervical length (CL) measured at 16 to 24 weeks of gestation using transvaginal sonography (TVS) as predictors of spontaneous preterm birth.

Methods In this prospective study, TVS was performed in 159 primigravidas with a singleton, uncomplicated pregnancy at 16 to 24 weeks of gestation to measure the anterior UCA and CL. All the cases were followed until labor to document gestational age at delivery.

Results The risk of spontaneous preterm birth was higher in women with obtuse UCA (>95 degrees) with sensitivity of 86.7%, specificity of 93.0%, positive predictive value of 83.0%, negative predictive value of 94.6%, and p-value of <0.001. The difference between the means was statistically significant (p-value < 0.001). UCAs ≥105degrees and 95 to 105 degrees were found to be significantly associated with spontaneous preterm births at <34 weeks and 34 to 37 weeks, respectively. CL <2.5 cm was found to predict spontaneous preterm births at <37 weeks with sensitivity of 31.1%, specificity of 95.6%, and p-value of <0.001. UCA was found to be a better predictor of spontaneous preterm birth with a higher coefficient of variation (56.4%) when compared with CL (16.9%).

Conclusions UCA proved to be a novel ultrasound parameter that can serve as a better predictor of spontaneous preterm births in comparison to CL. A strong correlation exists between obtuse UCA and a risk of spontaneous preterm birth.

Prevention of Preterm Birth with Progesterone

Gestational age at birth is a critical factor for perinatal and adulthood outcomes, and even for transgenerational conditions' effects. Preterm birth (PTB) (prematurity) is still the main determinant for infant mortality and morbidity leading cause of infant morbidity and mortality. Unfortunately, preterm birth (PTB) is a relevant public health issue worldwide and the global PTB rate is around 11%. The premature activation of labor is underlined by complex mechanisms, with a multifactorial origin influenced by numerous known and probably unknown triggers. The possible mechanisms involved in a too early labor activation have been partially explained, and involve chemokines, receptors, and imbalanced inflammatory paths. Strategies for the early detection and prevention of this obstetric condition were proposed in clinical settings with interesting results. Progesterone has been demonstrated to have a key role in PTB prevention, showing several positive effects, such as lower prostaglandin synthesis, the inhibition of cervical stromal degradation, modulating the inflammatory response, reducing gap junction formation, and decreasing myometrial activation. The available scientific knowledge, data and recommendations address multiple current areas of debate regarding the use of progesterone in multifetal gestation, including different formulations, doses and routes of administration and its safety profile in pregnancy.

Gestational age as a predictor for subsequent preterm birth in New South Wales, Australia

Background

There is no validated evidence base on predictive ability and absolute risk of preterm birth by gestational age of the previous pregnancy.

Methods

We conducted a retrospective cohort study of mothers who gave birth to their first two children in New South Wales, 1994–2016 (N = 517,558 mothers). For each week of final gestational age of the first birth, we calculated relative and absolute risks of subsequent preterm birth.

Results

For mothers whose first birth had a gestational age of 22 to 30 weeks the absolute risks of clinically significant preterm second birth (before 28, 32, and 34 weeks) were all less than 14%. For all gestational ages of the first child the median gestational ages of the second child were all at least 38 weeks. Sensitivity and positive predictive values were all below 30%.

Conclusion

Previous gestational age alone is a poor predictor of subsequent risk of preterm birth.

Using principal component analysis to examine associations of early pregnancy inflammatory biomarker profiles and adverse birth outcomes

OBJECTIVE

Inflammation as a risk factor for preterm birth is well-established. The primary objective of this analysis was to examine whether individual cytokines versus a composite indicator of mid-pregnancy inflammation are significantly associated with risk for adverse birth outcomes.

STUDY DESIGN

A multi-site prospective study was conducted in a socio-demographically diverse cohort of 610 pregnant participants. At a study visit between 12 and 20 6/7 weeks' gestation, low-grade inflammation was measured via log-transformed serum concentrations of the biomarkers IFN-γ, IL-10, IL-13, IL-6, IL-8, TNF-α, and CRP. Principal component analysis (PCA) was used to identify underlying dimensions of inflammatory activity from the seven biomarkers measured. Gestational age and birth weight at delivery were obtained from medical chart review. The associations between inflammatory profiles and birth outcomes were assessed via linear and logistic regression models. Results were compared with those from individual inflammatory biomarkers, and model fit was assessed using Akaike's Information Criterion (AIC).

RESULTS

Principal component analysis analysis yielded a two-factor solution, with the first factor (IF1) composed of IL-8, IL-10, IL-13, IFN-ɣ, and TNF-α, and the second factor (IF2) containing IL-6 and CRP. When adjusted for race, education, BMI, smoking status, gestational age at time of blood draw, and study site, a one standard deviation (SD) increase in IF1 remained significantly associated with a decrease in standardized gestational age (β = -.13, 95% CI: -.21, -.05) and an increase in odds of preterm delivery (OR = 1.46, 95% CI: 1.13, 1.88) (Table 3). A one SD increase in IF2 was similarly associated with a decrease in standardized gestational age at delivery (β = -.13, 95% CI: -.23, -.04) and an increase in odds of preterm delivery (OR: 1.46, 95% CI: 1.04, 2.05). Neither IF1 nor IF2 was associated with measures of fetal growth. AIC identified that IL-6 was a slightly better fit for length of gestation compared to either composite measure, though all performed similarly.

CONCLUSION

Independent of known sociodemographic risk factors, an elevated mid-pregnancy inflammatory profile was associated with a nearly 50% increase in odds of preterm delivery. The composite performed similarly to IL-6. These results suggest that maternal low-grade inflammation is a risk factor for preterm delivery, and that mid-pregnancy inflammatory biomarkers may be useful in predicting risk for preterm delivery.

The risk for recurrent preterm birth after prior preterm birth complicated by major fetal anomaly

Major fetal anomalies (MFA) are a known risk factor for preterm birth (PTB), though the etiology of this is not well-studied, making counseling of these patients difficult. Thus, we sought to describe the rate of recurrent PTB in a second-observed pregnancy among persons with a history of PTB of an infant with a MFA in a first observed pregnancy, and to assess the difference in delivery timing between the first- and second-observed pregnancy. This was a retrospective cohort study of patients with a first-observed pregnancy complicated by MFA and a second-observed pregnancy in single healthcare system between 2013 and 2017. The primary outcome was recurrent PTB (PTB in second-observed pregnancy) and secondary outcomes were recurrent spontaneous PTB (SPTB), delivery gestational age (GA) in second-observed pregnancy, and difference in delivery GA between the first- and second-observed pregnancy. Recurrent PTB in the setting of prior PTB complicated by an MFA is common (∼1/4 patients), though median delivery timing for individuals who delivered preterm in the first-observed pregnancy was 6 weeks later in the second-observed pregnancy. These data suggest that PTB in the setting of MFA is a comparable risk factor to PTB in the absence of MFA.

Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234

Preterm birth is among the most complex and important challenges in obstetrics. Despite decades of research and clinical advancement, approximately 1 in 10 newborns in the United States is born prematurely. These newborns account for approximately three-quarters of perinatal mortality and more than one half of long-term neonatal morbidity, at significant social and economic cost (1-3). Because preterm birth is the common endpoint for multiple pathophysiologic processes, detailed classification schemes for preterm birth phenotype and etiology have been proposed (4, 5). In general, approximately one half of preterm births follow spontaneous preterm labor, about a quarter follow preterm prelabor rupture of membranes (PPROM), and the remaining quarter of preterm births are intentional, medically indicated by maternal or fetal complications. There are pronounced racial disparities in the preterm birth rate in the United States. The purpose of this document is to describe the risk factors, screening methods, and treatments for preventing spontaneous preterm birth, and to review the evidence supporting their roles in clinical practice. This Practice Bulletin has been updated to include information on increasing rates of preterm birth in the United States, disparities in preterm birth rates, and approaches to screening and prevention strategies for patients at risk for spontaneous preterm birth.

Cervical length distribution and other sonographic ancillary findings of singleton nulliparous patients at midgestation

BACKGROUND

Short cervix at midgestation, the presence of intraamniotic debris, and cervical funneling are risk factors for preterm birth; however, cervical length measurements and cutoffs are not well documented among pregnant patients of different gestational ages and self-reported races and ethnicities.

OBJECTIVE

This study aimed to describe the distribution of cervical length and frequency of funneling and debris at midgestation in nulliparous women by gestational age and race/ethnicity.

STUDY DESIGN

This secondary analysis of screening data from a multicenter treatment trial of singleton nulliparous patients with short cervix was conducted at 14 geographically distributed, university-affiliated medical centers in the United States. Singleton nulliparous patients with no known risk factors for preterm birth were screened for trial participation and asked to undergo a transvaginal ultrasound to measure cervical length by a certified sonographer. The distribution of cervical length and the frequency of funneling and debris were assessed for each gestational age week (16-22 weeks) and stratified by self-reported race and ethnicity, which for this study were categorized as White, Black, Hispanic, and other. Patients enrolled in the randomized trial were excluded from this analysis.

RESULTS

A total of 12,407 nulliparous patients were included in this analysis. The racial or ethnic distribution of the study participants was as follows: White, 41.6%; Black, 29.6%; Hispanic, 24.2%; and others, 4.6%. The 10th percentile cervical length for the entire cohort was 31.1 mm and, when stratified by race and ethnicity, 31.9 mm for White, 30.2 mm for Black, 31.4 mm for Hispanic, and 31.2 mm for patients of other race and ethnicity (P<.001). At each gestational age, the cervical length corresponding to the tenth percentile was shorter in Black patients. The 25 mm value commonly used to define a short cervix and thought to represent the 10th percentile ranged from 1.3% to 5.4% across gestational age weeks and 1.0% to 3.8% across race and ethnicity groups. Black patients had the highest rate of funneling (2.6%), whereas Hispanic and Black patients had higher rates of intraamniotic debris than White and other patients (P<.001).

CONCLUSION

Black patients had shorter cervical length and higher rates of debris and funneling than White patients. The racial and ethnic disparities in sonographic midtrimester cervical findings may provide insight into the racial disparity in preterm birth rates in the United States.

Vancomycin-Resistant Enterococci and Extended-Spectrum β-Lactamase-Producing Bacterial Colonization of the Cervix after Emergency Cerclage: Is It Safe?

Antimicrobial resistance is currently becoming a global threat to human health. We performed a retrospective study on patients who underwent emergency cerclage between January 2016 and December 2018 at the Dongsan Medical Center. Cervical culture was first performed before surgery to confirm that there was no infection and was repeated on days 1, 4, and 7 after surgery. A total of 85 pregnant women underwent emergency cerclage. Among them, six patients had vancomycin-resistant enterococci (VRE) colonization in the cervix after cerclage, and 23 patients developed extended-spectrum β-lactamase (ESBL)-producing bacterial colonization in the cervix. The average gestational age at delivery was lower in the VRE group. Neonatal death was also significantly higher in the VRE group. The rate of occurrence of early-onset sepsis was also higher in the VRE group, and both VRE and ESBL-producing bacterial colonization cases in which early-onset sepsis occurred resulted in neonatal death. The prognosis of cervical VRE colonization after cervical surgery was poor, whereas the prognosis of ESBL-producing bacterial colonization in the cervix did not differ significantly from that of the control group. However, careful neonatal treatment is required considering that early-onset sepsis is fatal to the newborn.

Preventing recurrent preterm birth with 125 mg of 17-alpha-hydroxyprogesterone caproate

AIM

There is strong evidence that weekly intramuscular (IM) injections of 250 mg of 17-alpha-hydroxyprogesterone caproate (17-OHPC) reduce the risk of recurrent preterm birth (PTB); however, whether a lower dose of 17-OHPC could reduce the risk of recurrent PTB remains unclear. This study aimed to assess whether 125 mg of 17-OHPC reduces recurrent PTB among women with a prior singleton spontaneous PTB and cervical length >25 mm.

METHODS

This retrospective cohort study at a tertiary-care medical center in Japan included women with a prior singleton spontaneous PTB between 20 and 36 weeks' gestation and cervical length >25 mm, between 2008 and 2018. Primary outcomes were PTB <37 and <34 weeks' gestation. We calculated the adjusted odds ratio (aOR) and 95% confidence interval (CI) using a multiple logistic regression model. Gestational age at delivery was compared using the Kaplan-Meier survival curve and log-rank test.

RESULTS

Overall, 173 women met the inclusion criteria. Eighty-four women received weekly injections of 125 mg of 17-OHPC, and 89 did not. Treatment with 125 mg of 17-OHPC significantly reduced the risk of recurrent spontaneous PTB <37 (aOR: 0.156 [95% CI: 0.049-0.497]) and <34 weeks' gestation (aOR: 0.156 [95% CI: 0.049-0.497]). The mean delivery gestational age was also significantly longer in the 17-OHPC group (log-rank p = 0.005).

CONCLUSIONS

In this study population, weekly IM injections of 125 mg of 17-OHPC reduced the risk of recurrent PTB <37 and <34 weeks' gestation.

Preterm Labor Using Tocolysis as a Possible Risk Factor for Postpartum Depression: A 14-Year Population-Based Study in Taiwan

Postpartum depression (PPD) is associated with negative physical and mental health outcomes for the mother and infant. Women often experience elevated symptoms of PPD, and the incidence of PPD has increased in recent years. There were lack of studies to investigate the effects of medications during pregnancy. Herein, we focused on the most common obstetric medical therapies used in labor and determined whether the medical therapies cause mental stress in pregnant women. This 14-year retrospective population-based nationwide study was based on the National Health Insurance Research Database. Univariate and multivariate logistic regression analyses were used to evaluate unadjusted and adjusted odds ratios and 95% confidence intervals for each tocolytic and uterotonic treatments during pregnancy and common medical illnesses. In comparing the effects of tocolytic and uterotonic medications on maternal PPD, tocolysis with the injection form of ritodrine resulted in a significantly higher risk of PPD based on multivariate analysis. This study supports existing research demonstrating an association between tocolysis with ritodrine and PPD. Ritodrine treatment for preterm labor was a significant risk factor for PPD, especially the injection form. This information provides obstetricians and health policy providers to pay attention to maternal mental health outcomes among high-risk pregnant women.

Supplementation of Omega 3 during Pregnancy and the Risk of Preterm Birth: A Systematic Review and Meta-Analysis

Preterm birth (PTB) is a major cause of neonatal death and long-term consequences for the newborn. This review aims to update the evidence about the potential benefit of pharmacological supplementation with omega 3 fatty acids during pregnancy on the incidence of PTB. The Medline, Embase, Cochrane Library and Central databases were searched until 28 June 2020 for RCTs in which omega 3 supplementation was used versus placebo to reduce PTB risk. Data from 37 trials were analyzed. We found an 11% reduction in PTB risk (RR(risk ratios), 0.89; 95% CI (confidence intervals), 0.82 to 0.97) in trials using omega 3 supplements versus placebo. Regarding early PTB (ePTB), there was a 27% reduction in the risk of ePTB (RR, 0.73; 95% CI, 0.58 to 0.92). However, after sensitivity analyses, there were no significant differences in PTB and ePTB risk (PTB RR, 0.92; 95% CI, 0.83 to 1.01, ePTB RR, 0.82; 95% CI, 0.61 to 1.09). We conclude that omega 3 supplementation during pregnancy does not reduce the risk of PTB and ePTB. More studies are required to determine the effect of omega 3 supplementations during pregnancy and the risk of detrimental fetal outcomes.

The Importance of Clinical Presentation in Risk and Management of Recurrent Preterm Birth

OBJECTIVE

This study aimed to compare the risk of recurrent spontaneous preterm birth (sPTB), as well as cerclage efficacy, between groups stratified by phenotype of the index sPTB.

STUDY DESIGN

This is a retrospective cohort study of women with a history of sPTB. Included were women with a history of singleton sPTB who received progesterone in a subsequent pregnancy. Multifetal gestations and abdominal cerclage were excluded. Exposure groups were based upon the presenting symptom that preceded their first sPTB and included painless cervical dilation (PCD), preterm premature rupture of membranes (PPROM), and painful dilation (preterm labor [PTL]). Primary outcome was delivery <34 weeks in a subsequent pregnancy. Secondary outcomes included delivery <28 and <37 weeks. Rates were compared using the Chi-square test. Multivariable Poisson regression was used to adjust for confounders.

RESULTS

A total of 723 women were included. A total of 114 (16%) presented with PCD, 305 (42%) with PPROM, and 304 (42%) with PTL in their first sPTB. Cerclage in subsequent pregnancy was highest in the PCD group (42%) when compared with the PPROM (16%) and PTL (12%) groups. Rates of sPTB <34 and 37 weeks were similar among the groups. After adjusting for confounders, PCD was found to significantly increase the risk of recurrent sPTB <28 weeks (incidence rate ratio: 3.46 [1.09-11.0]; p = 0.04). Of the 121 women who underwent cerclage, there were no significant differences in rates of sPTB between the clinical presentation groups.

CONCLUSION

PCD as a specific phenotype of sPTB impacts recurrence of delivery before 28 weeks, but not at later gestational ages. In contrast, there was no significant association between clinical presentation of index sPTB and gestational latency in women who also underwent cerclage placement in a subsequent pregnancy. Our data suggest that clinical presentation is important with regards to recurrence of early sPTB, but not sPTB at later gestational ages.

KEY POINTS

· Phenotype is critical to understanding PTB.. · Phenotype is associated with recurrent PTB.. · Painless dilation is associated with recurrent PTB..

Evaluation of trappin-2 in cervicovaginal secretions as predictor of spontaneous preterm birth in asymptomatic high-risk women: Nested case-control study

OBJECTIVE

To evaluate trappin-2 levels in cervicovaginal secretions for prediction of spontaneous preterm birth (sPTB) and compare it with transvaginal sonography (TVS) cervical length in asymptomatic women at risk of PTB.

METHODS

Trappin-2 levels assessed in cervicovaginal secretions collected from 80 asymptomatic pregnant women at high risk for preterm delivery and cervical length measured by TVS, first at 14-20 weeks of pregnancy and repeated 8 weeks later. On the basis of delivery outcomes, participants were divided into cases (delivery <37 weeks) and controls (delivery at 37-41 weeks).

RESULTS

The mean value of cervicovaginal trappin-2 was significantly higher in women who delivered preterm (n = 40), compared with the term group (n = 40: P < 0.001) both at 14-20 weeks and at 22-28 weeks. The critical cut-off value for cervicovaginal trappin-2 at 14-20 weeks was 4620 pg/mL, above which participants delivered prematurely with sensitivity, specificity, and positive and negative predictive values of 82.5%, 71.0%, 78.5%, and 81.5% respectively, whereas TVS cervical length in this window period was not significantly associated with preterm birth. At 22-28 weeks a trappin-2 value of 6900 pg/mL had similar predictive accuracy.

CONCLUSION

Raised cervicovaginal trappin-2 levels can be used as an early tool for prediction of PTB as early as 14-20 weeks (earlier than TVS) in asymptomatic high-risk women.

Risk factors for spontaneous preterm delivery

BACKGROUND

There is a substantial variation in rates of preterm delivery between different parts of the world. The understanding of these variations, as well as the biological mechanisms behind spontaneous preterm delivery, is limited. Although the benefit of antenatal interventions has been shown to be limited, using well-known risk factors for spontaneous preterm delivery to select the correct pregnant women for targeted interventions is important from both a medical and caregiving perspective.

OBJECTIVE

To provide an introduction to a substantial research area dealing with risk factors of spontaneous preterm delivery.

METHODS

Risk factors in this review were classified as demographical, obstetrical, and gynecological and those related to the current pregnancy according to high-quality evidence of recent literature.

RESULTS AND CONCLUSION

An introduction to a substantial research area in maternal and fetal medicine was provided that might help clinicians to better understand the risk factors related to preterm delivery and select the correct pregnant women for targeted interventions.

Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies

BACKGROUND

Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments.

OBJECTIVES

To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout.

MAIN RESULTS

We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.

Preterm Birth Prevention in Appalachian Kentucky: Understanding Barriers and Facilitators Related to Transvaginal Ultrasound Cervical Length Surveillance Among Prenatal Care Providers

Background: Appalachian Kentucky has higher-than-average rates of preterm birth (PTB)-a health disparity associated with increased maternal and fetal/neonatal morbidity and neonatal mortality. Transvaginal ultrasound (TVU) cervical length measurement is the best predictor of PTB risk, but is underutilized in Appalachia. This study explores prenatal care providers' TVU-related knowledge and practices, and identifies barriers and facilitators, which impact the adoption of this evidence-based technology. Materials and Methods: This study recruited providers from three Appalachian Kentucky health care sites. Prenatal care providers took part in semistructured interviews and completed brief survey scales. Questions focused on PTB knowledge, TVU-related barriers, and suggestions for clinician and/or patient-focused interventions. Transcripts were coded using a multistage process based in grounded theory. Descriptive statistics were calculated. Results: Eleven physicians, one nurse practitioner, one physician assistant, and one midwife completed interviews. Average participant age was 44 years with 17 years in practice; 43% of providers were female. Practitioners described the sociodemographic characteristics, health behaviors (e.g., smoking, opioid abuse), and comorbid conditions (e.g., obesity, hypertension, and diabetes) endemic in Appalachia that heightened their patients' PTB risk. TVU use was reported as important by all respondents, but not all were satisfied with their level of training. The most commonly identified barriers to TVU were patient access to transportation and social support. Participants stressed a need for changing community perceptions regarding consequences of PTB. Conclusions: Providers identified multiple TVU-related barriers and facilitators. These data will inform the design of a multifaceted dissemination and implementation strategy targeting PTB prevention in Appalachia.

Prior surgical uterine evacuation of pregnancy and infertility: protocol for systematic review and meta-analysis

INTRODUCTION

Prior surgical uterine evacuation is associated with an increased risk of infertility. However, findings are inconsistent, highlighting the need for a clear consensus on the effect of prior surgical uterine evacuation on the risk of infertility. Therefore, the aim of this systematic review and meta-analysis is to summarise the available evidence examining the association between prior surgical uterine evacuation and the risk of infertility.

METHODS AND ANALYSIS

A systematic search of electronic databases (ie, PubMed, Scopus, ClinicalTrials.gov, EMBASE and ScienceDirect) will be conducted since their inception until October 2019 with no limit for language using a detailed prespecified search strategy. Both the authors will independently screen titles and abstracts and select full-text articles, perform data extraction and appraise the quality of included studies using a bias classification tool. Meta-analyses will be performed to calculate the overall pooled estimates using the generic inverse variance method. This systematic review and meta-analysis will follow the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines.

ETHICS AND DISSEMINATION

Given that this is a protocol based on published data, there is no requirement for ethics approval. It is anticipated that the dissemination of results will be reported according to the PRISMA statement. The results will be published in peer-reviewed journals and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42019117266.

SMFM Statement: Use of 17-alpha hydroxyprogesterone caproate for prevention of recurrent preterm birth

In late 2019, results from the Progestin's Role in Optimizing Neonatal Gestation (PROLONG) trial were published showing no benefit of weekly injections of 17-alpha hydroxyprogesterone caproate (17-)HPC) from 16-20 weeks of gestation in women with a history of a singleton PTB in reducing the rates of subsequent PTB and neonatal morbidity. The Society for Maternal-Fetal Medicine believes that the differences in these results from the earlier Meis, et al trial, which did show a benefit of 17-OHPC in reducing the rate of spontaneous PTB (sPTB), may be at least partially explained by differences in study populations. SMFM concludes that it is reasonable for providers to use 17-OHPC in women with a profile more representative of the very-high-risk population reported in the Meis trial. For all women at risk of recurrent sPTB, the risk/benefit discussion should incorporate a shared decision-making approach, taking into account the lack of short-term safety concerns but uncertainty regarding benefit.

Postal recruitment for genetic studies of preterm birth: A feasibility study

Background: Preterm birth (PTB) represents the leading cause of neonatal death. Large-scale genetic studies are necessary to determine genetic influences on PTB risk, but prospective cohort studies are expensive and time-consuming. We investigated the feasibility of retrospective recruitment of post-partum women for efficient collection of genetic samples, with self-collected saliva for DNA extraction from themselves and their babies, alongside self-recollection of pregnancy and birth details to phenotype PTB.

Methods: 708 women who had participated in the OPPTIMUM trial (a randomised trial of progesterone pessaries to prevent PTB [ISRCTN14568373]) and consented to further contact were invited to provide self-collected saliva from themselves and their babies. DNA was extracted from Oragene OG-500 (adults) and OG-575 (babies) saliva kits and the yield measured by Qubit. Samples were analysed using a panel of Taqman single nucleotide polymorphism (SNP) assays. A questionnaire designed to meet the minimum data set required for phenotyping PTB was included. Questionnaire responses were transcribed and analysed for concordance with prospective trial data using Cohen’s kappa ( k).

Results: Recruitment rate was 162/708 (23%) for self-collected saliva samples and 157/708 (22%) for questionnaire responses. 161 samples from the mother provided DNA with median yield 59.0µg (0.4-148.9µg). 156 samples were successfully genotyped (96.9%). 136 baby samples had a median yield 11.5µg (0.1-102.7µg); two samples failed DNA extraction. 131 baby samples (96.3%) were successfully genotyped. Concordance between self-recalled birth details and prospective birth details was excellent ( k>0.75) in 4 out of 10 key fields for phenotyping PTB (mode of delivery, labour onset, ethnicity and maternal age at birth).

Conclusion: This feasibility study demonstrates that self-collected DNA samples from mothers and babies were sufficient for genetic analysis but yields were variable. Self-recollection of pregnancy and birth details was inadequate for accurately phenotyping PTB, highlighting the need for alternative strategies for investigating genetic links with PTB.

Adherence rates and outcomes for 17-hydroxyprogesterone caproate use in women with a previous history of preterm birth

BACKGROUND

Progesterone has been used for preventing preterm birth with mixed results. The American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine recommended the use of 17-hydroxyprogesterone caproate for risk reduction of recurrent spontaneous preterm birth based on the results of a multicenter, randomized trial in the United States. However, recent literature lacks consensus for efficacy in the American population. In addition, partial adherence and outcomes thereof are underreported. Hence, the relationship between practical adherence to 17-hydroxyprogesterone caproate and outcomes were evaluated.

OBJECTIVE

The objective of this study was to evaluate the adherence to 17-hydroxyprogesterone caproate, defined as receipt of greater than 80% of intended injections, at an outpatient maternal-fetal medicine center and its effect on maternal and neonatal outcomes.

STUDY DESIGN

This retrospective cohort study included women older than 18 years with a singleton gestation, history of spontaneous preterm birth who initiated 17-hydroxyprogesterone caproate weekly injections between 16 and 20 weeks' gestational age and delivered between the years 2014 and 2017. Women receiving 17-hydroxyprogesterone caproate injections outside of the clinic were excluded. The primary outcome of adherence and secondary outcomes of gestational age at delivery, birthweight, and neonatal outcomes were analyzed using descriptive data, independent t-test, Mann-Whitney U test, chi-square test, and Fisher exact test, where appropriate, with a P value <.05 being considered significant.

RESULTS

Adherence to 17-hydroxyprogesterone caproate occurred in 38 of 92 (41.3%) women included in the study. At baseline, there was a difference in age between groups of adherent and nonadherent women (adherent: 30.8 years; nonadherent: 27.4 years; P=.002). The rate of spontaneous preterm birth less than 37, 35, and 32 weeks were not significantly different in those who were adherent vs nonadherent to 17-hydroxyprogesterone caproate. There were no differences in gestational age at delivery (adherent: 36.8±2.6 weeks; nonadherent: 36.5±3.8 weeks; P=.66), birthweight (adherent: 2776 g; nonadherent: 2709 g; P=.68), or composite neonatal morbidity (adherent: 18.4%; nonadherent: 20.4%; P=.86) between the adherent and nonadherent groups. Neonatal intensive care unit length of stay was 15.5 days in the adherent group compared with 15 days in the nonadherent group (P=.72).

CONCLUSION

Real-world adherence to 17-hydroxyprogesterone caproate is suboptimal with less than half of women adherent to in-clinic administration. Adherence to 17-hydroxyprogesterone caproate was not associated with a difference in gestational age at delivery or birthweight compared with nonadherence. Further studies are needed to assess the outpatient administration and benefit of 17-hydroxyprogesterone caproate therapy.

Increased incidence of hypertensive disorders of pregnancy in women with a history of spontaneous preterm birth: A longitudinal linked national cohort study

OBJECTIVE

Determine the risk of hypertensive disorders of pregnancy (HD) in women with a history of spontaneous preterm birth (SPTB).

STUDY DESIGN

Longitudinal linked national cohort study within the Dutch Perinatal Registry (1999-2009) on linked data among 349,291 women with a first and second singleton pregnancy in the Netherlands.

MAIN OUTCOME MEASURES

The incidence of HD, small for gestational age (SGA) and placental abruption in the second pregnancy.

RESULTS

Out of 349,291 women with a singleton first pregnancy, 19,991 (5.7%) had a SPTB. The incidence of HD in the second pregnancy was 8.1% in women with a previous SPTB, as compared to 5.6% in women with a previous term birth (aOR 1.49 (CI 1.41-1.57)). Also after excluding HD, SGA and/or placental abruption in the first pregnancy, women with a history of SPTB had a higher risk of HD in their second pregnancy compared to women with a previous term birth (4.6% versus 2.7%, aOR 1.77 (CI 1.64-191)). Similarly, the incidence of SGA and placental abruption was higher in the second pregnancy in women with a history of SPTB compared to term birth in the first pregnancy.

CONCLUSIONS

Women with a history of SPTB are at elevated risk of HD in the subsequent pregnancy. These results support shared pathophysiology between SPTB and HD.

Postal recruitment for genetic studies of preterm birth: A feasibility study

Background: Preterm birth (PTB) represents the leading cause of neonatal death. Large-scale genetic studies are necessary to determine genetic influences on PTB risk, but prospective cohort studies are expensive and time-consuming. We investigated the feasibility of retrospective recruitment of post-partum women for efficient collection of genetic samples, with self-collected saliva for DNA extraction from themselves and their babies, alongside self-recollection of pregnancy and birth details to phenotype PTB. Methods: 708 women who had participated in the OPPTIMUM trial (a randomised trial of progesterone pessaries to prevent PTB [ISRCTN14568373]) and consented to further contact were invited to provide self-collected saliva from themselves and their babies. DNA was extracted from Oragene OG-500 (adults) and OG-575 (babies) saliva kits and the yield measured by Qubit. Samples were analysed using a panel of Taqman single nucleotide polymorphism (SNP) assays. A questionnaire designed to meet the minimum data set required for phenotyping PTB was included. Questionnaire responses were transcribed and analysed for concordance with prospective trial data. Results: Recruitment rate was 162/708 (23%) for self-collected saliva samples and 157/708 (22%) for questionnaire responses. 161 samples from the mother provided DNA with median yield 59.0µg (0.4-148.9µg). 156 samples were successfully genotyped (96.9%). 136 baby samples had a median yield 11.5µg (0.1-102.7µg); two samples failed DNA extraction. 131 baby samples (96.3%) were successfully genotyped. Concordance between self-recalled birth details and prospective birth details ranged from 55 – 99%, median 86%. The highest rates of concordance were found for mode of birth (154/156 [99%]), smoking status (151/157 [96%]) and ethnicity (149/156 [96%]). Conclusion: This feasibility study demonstrates that self-collected DNA samples from mothers and babies were sufficient for genetic analysis but yields were variable. Self-recollection of pregnancy and birth details was inadequate for accurately phenotyping PTB, highlighting the need for alternative strategies for investigating genetic links with PTB.

Early universal use of oral progesterone for prevention of preterm births in singleton pregnancy (SINPRO study): protocol of a multicenter, randomized, double-blind, placebo-controlled trial

Background

Preterm birth accounts for 75% of perinatal deaths and more than 50% of long-term neurological disabilities. For a singleton pregnancy, progesterone treatment is effective in prevention of preterm birth in women with an asymptomatic short cervix or a history of preterm birth. However, a large proportion of preterm births still is not currently preventable. The aim of this study is to determine whether early universal use of oral progesterone before 14 + 0 weeks of gestation can prevent preterm birth better than universal screening of cervical length at 18 + 0 to 23 + 6 weeks of gestation, followed by progesterone treatment in those with a short cervix in singleton pregnancy.

Methods

This is a multicenter, randomized, double-blind, placebo-controlled trial registered with ClinicalTrials.gov on 12 February 2018. Eligible consecutive pregnant women with singleton gestation attending antenatal outpatient clinics will be recruited after receiving counseling and signing the written consent form. Transvaginal cervical length measurement will be performed at recruitment (before 14 + 0 weeks of gestation) and between 18 + 0 and 23 + 6 weeks of gestation. After randomization, women will be randomly assigned to either the treatment group (oral dydrogesterone 10 mg three times daily) or the placebo group, and medication will be started before 14 + 0 weeks of gestation. Assigned groups will be unblinded if the cervical length is ≤ 25 mm between 18 + 0 and 23 + 6 weeks of gestation, and the management option for short cervix will be discussed (oral progesterone, vaginal progesterone, or cervical cerclage). The primary outcome is preterm birth before 37 + 0 weeks of gestation.

Discussion

Progesterone is used extensively in part of the in vitro fertilization program as luteal phase support, and it is not associated with teratogenicity. Universal progesterone supplementation may be a better approach to prevent preterm birth. This large, multicenter, randomized, double-blind, placebo-controlled trial will provide the best evidence, leading to the best strategy for the prevention of preterm birth.

Trial registration

ClinicalTrials.gov, NCT03428685. Registered on 12 February 2018.

Improving Uptake and Adherence to 17-Hydroxyprogesterone Caproate in Non-Hispanic Black Women: A Mixed Methods Study of Potential Interventions from the Patient Perspective

Women with a history of a preterm birth (PTB) are at high risk for recurrence. Weekly 17-hydroxyprogestrone caproate (17-P) injections can reduce the risk of recurrence in women with prior spontaneous PTB. PTB occurs disproportionately in non-Hispanic black (NHB) women, and uptake and adherence to 17-P among NHB women are lower compared to women in other racial/ethnic groups. Evidence-based interventions to improve 17-P uptake and adherence that incorporate women's perceptions and preferences are needed. Our objective was to identify women's perspectives and preferences for interventions to promote uptake of and adherence to 17-P, particularly among NHB women. We conducted an exploratory sequential mixed methods study using focus group discussions (FGDs), a survey, and in-depth interviews (IDIs). We recruited women with a history of PTB who self-identified as NHB for the FGDs and IDIs. Survey participation was open to any woman with a history of PTB regardless of their race and ethnicity. Women could only participate in one of the three data collection activities. Transcripts from the qualitative focus groups and in-depth interviews were analyzed using applied thematic analysis. Descriptive statistics was used to analyze the quantitative survey. Eighty-two women participated in the study (FGDs [n = 7], surveys [n = 60], and IDIs [n = 15]). Suggested interventions were separated into two categories: (1) clinic-based interventions (i.e., interventions delivered during the clinical encounter) and (2) community-based interventions (i.e., interventions delivered outside of the clinical encounter). Clinic level interventions included improved clinic access and scheduling, same-day appointments, appointment reminders, making the clinic experience more comfortable for patients, and encouragement from providers. Interventions at the community level included increased 17-P awareness among support persons, employers, and community members and administration of 17-P outside the clinic setting. Our findings offer multiple potential interventions that could improve uptake of and adherence to 17-P for PTB prevention among NHB women. These proposed interventions have the potential to mitigate barriers to 17-P and narrow the disparity in PTB rates. Given the alarming and increasing rates of prematurity and PTB disparities, it is imperative to test, refine, and incorporate effective interventions into clinical practice. Our findings provide insights from patients that can help shape such interventions.

Utility of cervical length and quantitative fetal fibronectin for predicting spontaneous preterm delivery among symptomatic nulliparous women

OBJECTIVE

To validate the utility of fetal fibronectin (fFN) and cervical length (CL) in predicting preterm delivery among symptomatic nulliparous women.

METHODS

A retrospective cohort study of nulliparous women who presented with uterine contractions, abdominal pain, or cervical change at 21-34 gestational weeks at Fukushima Medical University Hospital, Japan, between 2008 and 2017. fFN (categorized as <50 ng/dL, 50-199 ng/dL, >200 ng/dL) and CL (≥15 mm or <15 mm) were evaluated simultaneously. Adjusted odds ratios (aORs) and confidence intervals (CIs) for preterm delivery before 37 or 34 weeks, and delivery within 28 or 14 days were calculated (references: fFN, <50 ng/dL; CL, ≥15 mm).

RESULT

Among 285 women who met the study criteria, CL less than 15 mm was a risk factor for preterm delivery before 37 (aOR, 4.1; 95% CI, 1.1-6.7) and 34 (aOR, 6.8; 95% CI, 2.3-20.2) weeks. fFN of 200 ng/dL or higher was a risk factor for delivery within 28 (aOR, 19.8; 95% CI, 4.3-90.2) and 14 (aOR, 10.8; 95% CI, 1.7-67.6) days.

CONCLUSION

Among symptomatic nulliparous women, short CL was found to be a risk factor for preterm delivery and higher fFN levels were related to short gestational latency.

SKA2 gene - A novel biomarker for latent anxiety and preterm birth prediction

BACKGROUND

There is a relationship between preterm birth (PTB) and anxiety. Spindle and Kinetochore Associated Complex Subunit 2 (SKA2) gene polymorphism (NC_000017.11: g.59110368 G > A) has also been associated with the development of anxiety. The current study was designed to evaluate the relationship between SKA2 gene SNP (NC_000017.11: g.59110368 G > A) with the occurrence of anxiety and PTB which might be considered a predictive biomarker for the prediction of preterm delivery.

METHODS

SKA2 gene (SNP rs7208505) genotyping was performed in 300 women with term birth (TB) and 293 women with PTB using PCR-RFLP method and then followed by DNA sequencing. Cortisol level was analyzed with ELISA method and the presence of anxiety was detected using Spielberg Inventory.

RESULTS

The AA genotype of SKA2 gene significantly increased the risk of PTB compared to the GG genotype by 9.6 fold ([CI] 4.5-20.2, P < 0.001) according to codominant model. Also, the frequency of A allele was significantly higher in PTB group (χ2 = 20.4, df = 1, P < 0.001) in comparison with the control group that increased the risk of PTB by 1.703 fold ([CI] 1.39-2.23, P < 0.001). Women with higher cortisol level with average 343.7 ± 3 nmol/L had AA genotype, while, the concentrations of cortisol in women with AG, and GG genotypes were 244.2 ± 3.1 nmol/L and 192.6 ± 2.5 nmol/L, respectively (P < 0.001). The score of apparent and latent anxiety in women with the AA genotype was higher compared to the AG and GG genotypes and also this score in women with the AG genotype was higher than the GG genotypes (P < 0.001). The history of preterm delivery was higher in women with the AA genotype (42.1%) in comparison with the GG (14.9%) and AG (22%) genotypes (P < 0.05).

CONCLUSION

The results of the current study suggest that prognosis of women with the AA genotype are more susceptible to be spontaneous preterm birth. Therefore, the A allele of SKA2 gene (NC_000017.11:g.59110368 G > A) could be as a predictive biomarker for the risk of PTB.

Correlation between lower uterine wall thickness measured by transabdominal ultrasonography and cervical length measured by transvaginal ultrasonography in Thai pregnant women

BACKGROUND

Preterm labor is one of major obstetric challenges and can be predicted by cervical length at mid-trimester. In some settings, transvaginal ultrasound is not available and the screening and prevention of preterm labor will be suboptimal. We hope to find a correlation between other marker i.e. lower uterine wall thickness measured by transabdominal ultrasonography and cervical length measured by transvaginal ultrasonography in Thai pregnant women during 16-32 weeks of gestation.

METHODS

This study was a cross-sectional study. 166 singleton pregnant women were invited to participate in the study between June 2015 and December 2015. Transabdominal ultrasonography was performed to measure the lower uterine wall thickness and transvaginal ultrasonography was performed to measure the cervical length. The Spearman's rank correlation was used to evaluate the correlation between the two parameters. The inter-observer variation was assessed by using Bland-Altman plot. The outcomes of all pregnancies were followed and only those who delivered at term were included for the calculation of normal value of lower uterine wall thickness.

RESULTS

There was a highly positive correlation between lower uterine wall thickness and cervical length (rs = 0.767, n = 166, p < 0.001). For those who had short cervical length (defined as less than 30 mm) at GA 16-24 weeks (n = 10), the mean corresponding lower uterine wall thickness was 4.4 mm (SD 0.50). The inter-observer variation of the measurement of lower uterine wall thickness and cervical length were small. The lower uterine wall thickness tended to be slightly thinner when the gestation advanced. (mean 5.4 mm at 16-20 weeks and 5.1 mm at 28-32 weeks).

CONCLUSION

There was a highly positive correlation between lower uterine wall thickness measured by transabdominal ultrasonography and cervical length measured by transvaginal ultrasonography in Thai pregnant women.

Cervical funneling or intra-amniotic debris and preterm birth in nulliparous women with midtrimester cervical length less than 30 mm

OBJECTIVE

To evaluate whether the presence of cervical funneling or intra-amniotic debris identified in the second trimester is associated with a higher rate of preterm birth (PTB) in asymptomatic nulliparous pregnant women with a midtrimester cervical length (CL) less than 30 mm (i.e. below the 10th percentile).

METHODS

This was a secondary cohort analysis of data from a multicenter trial in nulliparous women between 16 and 22 weeks' gestation with a singleton gestation and CL less than 30 mm on transvaginal ultrasound, randomized to treatment with either 17-alpha-hydroxyprogesterone caproate or placebo. Sonographers were centrally certified in CL measurement, as well as in identification of intra-amniotic debris and cervical funneling. Univariable and multivariable analysis was performed to assess the associations of cervical funneling and intra-amniotic debris with PTB.

RESULTS

Of the 657 women randomized, 112 (17%) had cervical funneling only, 33 (5%) had intra-amniotic debris only and 45 (7%) had both on second-trimester ultrasound. Women with either of these findings had a shorter median CL than those without (21.0 mm vs 26.4 mm; P < 0.001). PTB prior to 37 weeks was more likely in women with cervical funneling (37% vs 21%; odds ratio (OR), 2.2 (95% CI, 1.5-3.3)) or intra-amniotic debris (35% vs 23%; OR, 1.7 (95% CI, 1.1-2.9)). Results were similar for PTB before 34 and before 32 weeks' gestation. After multivariable adjustment that included CL, PTB < 34 and < 32 weeks continued to be associated with the presence of intra-amniotic debris (adjusted OR (aOR), 1.85 (95% CI, 1.00-3.44) and aOR, 2.78 (95% CI, 1.42-5.45), respectively), but not cervical funneling (aOR, 1.17 (95% CI, 0.63-2.17) and aOR, 1.45 (95% CI, 0.71-2.96), respectively).

CONCLUSIONS

Among asymptomatic nulliparous women with midtrimester CL less than 30 mm, the presence of intra-amniotic debris, but not cervical funneling, is associated with an increased risk for PTB before 34 and 32 weeks' gestation, independently of CL. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Müllerian-Inhibiting Substance/Anti-Müllerian Hormone as a Predictor of Preterm Birth in Polycystic Ovary Syndrome

CONTEXT

There is increasing evidence for Müllerian-inhibiting substance (MIS)/anti-Müllerian hormone (AMH) physiologic activity in the human uterus, so it is relevant to study how MIS/AMH levels impact pregnancy.

OBJECTIVE

To investigate the association of MIS/AMH levels with the risk of adverse obstetric outcomes.

DESIGN

Retrospective cohort study.

SETTING

Academic fertility center.

PATIENTS

Women who became pregnant through in vitro fertilization between January 2012 and October 2016. Exclusion criteria were: oocyte donation, gestational carrier, multiple gestations, miscarriage before 20 weeks, or medically indicated preterm deliveries.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

There were two primary outcomes, preterm birth and cesarean delivery for arrest of labor. Because MIS/AMH level is highly skewed by certain infertility diagnoses, the preterm birth analysis was stratified by polycystic ovary syndrome (PCOS) diagnosis, and the cesarean delivery for arrest of labor analysis was stratified by diminished ovarian reserve diagnosis. χ2, Mann-Whitney, and t tests were used as appropriate. A P value of <0.05 was considered statistically significant.

RESULTS

Among women with PCOS, those who delivered prematurely had substantially higher MIS/AMH levels (18 vs 6.4 ng/mL, P = 0.003) than did those who delivered at term. At the highest MIS/AMH values, preterm deliveries predominated; above the 90th percentile in women with PCOS, all deliveries were premature. No effect of MIS/AMH level was observed in women without PCOS. We found no association between MIS/AMH values and cesarean delivery for labor arrest.

CONCLUSION

In women with PCOS, substantially elevated MIS/AMH levels are significantly associated with preterm birth, suggesting closer follow-up and further studies to elucidate the underlying mechanisms.

Racial Disparities in Adverse Pregnancy Outcomes and Psychosocial Stress

OBJECTIVE

To assess the relationships between self-reported psychosocial stress and preterm birth, hypertensive disease of pregnancy, and small-for-gestational-age (SGA) birth and to assess the extent to which these relationships account for racial and ethnic disparities in these adverse outcomes.

METHODS

Self-reported measures of psychosocial stress (perceived stress, depression, racism, anxiety, resilience, and social support) were collected during pregnancy among a racially and ethnically diverse cohort of women enrolled in a prospective observational study of nulliparous women with singleton pregnancies, from eight clinical sites across the United States, between October 2010 and May 2014. The associations of preterm birth, hypertensive disease of pregnancy, and SGA birth with the self-reported measures of psychosocial stress as well as with race and ethnicity were evaluated.

RESULTS

The study included 9,470 women (60.4% non-Hispanic white, 13.8% non-Hispanic black, 16.7% Hispanic, 4.0% Asian, and 5.0% other). Non-Hispanic black women were significantly more likely to experience any preterm birth, hypertensive disease of pregnancy, and SGA birth than were non-Hispanic white women (12.2% vs 8.0%, 16.7% vs 13.4%, and 17.2% vs 8.6%, respectively; P<.05 for all). After adjusting for potentially confounding factors, including the six different psychosocial factors singly and in combination, non-Hispanic black women continued to be at greater risk of any preterm birth and SGA birth compared with non-Hispanic white women.

CONCLUSION

Among a large and geographically diverse cohort of nulliparous women with singleton gestations, non-Hispanic black women are most likely to experience preterm birth, hypertensive disease of pregnancy, and SGA birth. These disparities were not materially altered for preterm birth or SGA birth by adjustment for demographic differences and did not appear to be explained by differences in self-reported psychosocial factors.

The Effect of Maternal Age at the First Childbirth on Gestational Age and Birth Weight: The Japan Environment and Children's Study (JECS)

BACKGROUND

In Japan, mean maternal age at first childbirth is increasing. The aim of this study was to investigate whether maternal age at the first childbirth is a risk factor for preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA).

METHODS

We used the results of Japan Environment and Children's Study (JECS) who gave birth in 2011-2014. Cases of primiparous singleton pregnancies where the subject was ≥20 years and delivered after 22 weeks were included. All subjects were categorized into five groups according to maternal age: 20-24, 25-29, 30-34, 35-39, and ≥40 years. Adjusted odds ratios (aORs) for PTB (before 37 and 34 weeks), LBW (<2,500 g and <1,500 g), and SGA were calculated using a logistic regression model, with the 20-24-year age group as reference.

RESULTS

We analyzed 38,412 singleton primiparous pregnancies. The aORs of all outcomes increased in parallel with each maternal age group >30 years. The aORs of PTB before 37 and 34 weeks, LBW <2,500 g, LBW <1,500 g, and SGA in the 30-34-year age group were 1.39 (95% confidence interval [CI], 1.16-1.67), 2.23 (95% CI, 1.45-3.41), 1.34 (95% CI, 1.18-1.53), 2.30 (95% CI, 1.35-3.94), and 1.24 (95% CI, 1.05-1.46), respectively.

CONCLUSION

The present study showed that higher maternal age (>30 years) at the first childbirth was an independent risk factor for PTB, LBW, and SGA.

Utilization of progesterone and cervical length screening for prevention of recurrent preterm birth

Objective: To assess utilization of progesterone and cervical length (CL) screening among women with prior spontaneous preterm birth (sPTB).Methods: This is a retrospective cohort study of women with prior sPTB. Primary outcomes were the use of progesterone and CL screening. Secondary outcomes were reasons for failure to utilize interventions and factors associated with use of recommended interventions.Results: 180 women had a prior sPTB. Of 171 women eligible for progesterone, 125 (74%) utilized it. Women who utilized progesterone were more likely to have a prior sPTB <28 weeks (50% vs 26%, OR 2.54 (1.18-5.42) p = .006) and a higher number of prior sPTB (1.5 ± 0.9 vs 1.2 ± 0.5, p = .02), and less likely to have a prior full term delivery (54% vs 72%, OR 0.47 (0.22-0.99), p = .04). Of 176 women eligible for CL screening, 157 (89%) utilized it. Women who utilized CL screening were less likely to have a prior full term delivery (59% vs 84%, OR 0.27 (0.07-0.95, p = .01)). The most frequent reason for lack of progesterone and CL screening was patient declining.Conclusion: Most women with prior sPTB received progesterone and CL screening. Those at highest risk for PTB based on obstetric history are more likely to utilize recommended interventions.

Mid-trimester sonographic cervical consistency index to predict spontaneous preterm birth in a low-risk population

OBJECTIVES

To investigate the effectiveness of mid-trimester sonographic cervical consistency index (CCI) for the prediction of spontaneous preterm birth (sPTB) in low-risk pregnancies and to compare its performance with that of mid-trimester sonographic cervical-length (CL) measurement.

METHODS

This was a prospective cohort study of women with a singleton pregnancy examined by ultrasound at 19 + 0 to 24 + 6 weeks' gestation. All women underwent transvaginal ultrasound examination of the cervix, but CCI and CL were measured, offline, only in women without a risk factor for sPTB. Staff and participants were blinded to CL and CCI results. CCI was obtained by calculating the ratio between the anteroposterior diameter of the uterine cervix at maximum compression and at rest. The primary outcome was prediction of sPTB before 37 + 0 weeks. Receiver-operating characteristics (ROC) curves were produced and sensitivity and specificity were calculated for the optimal cut-off based on the ROC curve and for the 1^st , 5^th and 10^th centiles of CCI and CL. Intraclass correlation coefficients (ICC) and Bland-Altman plots were used to estimate intra- and interobserver agreement and reliability for measurement of CCI and CL.

RESULTS

Of the 749 women who underwent ultrasound examination of the cervix, 532 were included for analysis. The rates of sPTB before 37 + 0 and before 34 + 0 weeks were 4.1% (22/532) and 1.3% (7/532), respectively. The rates of short cervix < 25 mm and ≤ 20 mm were 0.9% (5/532) and 0.4% (2/532), respectively. The area under the ROC curve (AUC) with regard to predicting sPTB before 37 + 0 weeks was 0.84 (95% CI, 0.75-0.93) for CCI compared with 0.68 (95% CI, 0.56-0.81) for CL (P = 0.03). The optimal cut-off based on the ROC curve was 64.6% for CCI (sensitivity, 77.3%; specificity, 82.7%) and that for CL was 37.9 mm (sensitivity, 72.7%; specificity, 61.2%). The AUC with regard to predicting sPTB before 34 + 0 weeks was 0.87 (95% CI, 0.71-1.0) for CCI compared with 0.71 (95% CI, 0.47-0.94) for CL (P = 0.25). The optimal cut-off based on the ROC curve was 63.6% for CCI (sensitivity, 85.7%; specificity, 84.0%) and that for CL was 37.9 mm (sensitivity, 85.7%; specificity, 61.3%). Intraobserver ICC was > 0.90 both for CCI and CL, while interobserver ICC was 0.89 for CCI and 0.90 for CL.

CONCLUSIONS

Second-trimester CCI is a better predictor of sPTB < 37 weeks in low-risk pregnancies than is CL. External validation is needed as well as studies assessing the value of CCI as a screening tool in unselected and high-risk populations. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Comparative Evaluation of Arabin Pessary and Cervical Cerclage for the Prevention of Preterm Labor in Asymptomatic Women with High Risk Factors

Objective: Preterm labor is one of the most significant obstetric problems associated with high rate of actual and long-term perinatal complications. Despite the creation of scoring systems, uterine activity monitoring, cervical ultrasound and several biochemical markers, the prediction and prevention of preterm labor is still a matter of concern. The aim of this study was to examine cervical findings for the prediction and the comparative use of Arabin pessary or cerclage for the prevention of preterm birth in asymptomatic women with high risk factors for preterm labor. Material and methods: The study group was composed of singleton pregnancies (spontaneously conceived) with high risk factors for preterm labor. Cervical length, dilatation of the internal cervical os and funneling, were estimated with transvaginal ultrasound during the first and the second trimesters of pregnancy. Results: Cervical funneling, during the second trimester of pregnancy, was the most significant factor for the prediction of preterm labor. The use of Arabin cervical pessary was found to be more effective than cerclage in the prolongation of pregnancy. Conclusion: In women at risk for preterm labor, the detection of cervical funneling in the second trimester of pregnancy may help to predict preterm labor and to apply the appropriate treatment for its prevention. Although the use of cervical pessary was found to be more effective than cerclage, more studies are needed to classify the effectiveness of different methods for such prevention.

The Risk of Spontaneous Preterm Birth according to Maternal Pre-pregnancy Body Mass Index in Twin Gestations

BACKGROUND

Maternal obesity is a well-known risk factor for both total preterm birth (PTB) and spontaneous PTB in singleton gestation, whereas this association is not well determined in multiple pregnancy. The objective of this study was to determine the risk of spontaneous PTB according to the pre-pregnancy body mass index (BMI) in twin gestations.

METHODS

The association between the risk of PTB and pre-pregnancy BMI was determined in women pregnant with twins between 2004 and 2014. Pre-pregnancy BMI values were divided into three groups (underweight/normal/overweight and obese). PTB was classified as spontaneous PTB (following preterm premature rupture of membranes, preterm labor, or cervical insufficiency) or medically indicated PTB (cesarean section or induction of labor because of maternal/fetal indications).

RESULTS

A total of 1,959 women were included in the analysis, and the percentages of total PTB and spontaneous PTB were 13.1% and 9.3%. The percentages of total PTB and spontaneous PTB in three groups were 14.1%, 11.9%, 16.3%, respectively, and 11.0%, 8.0%, 12.5% (P < 0.05 between normal and overweight/obese women). The risks of total and spontaneous PTB in overweight/obese women were higher than those in women with normal weight, even after adjustment for prior history of PTB, age, maternal height, parity, in vitro fertilization-embryo transfer (IVF-ET) (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.01-2.03; OR, 1.58; 95% CI, 1.05-2.36).

CONCLUSION

The risks of both total and spontaneous PTB were significantly greater in the overweight/obese group than in the normal BMI group.

Fetal adrenal gland biometry and cervical elastography as predictors of preterm birth: A comparative study

Background

Preterm birth is a major health problem in developing and developed countries leading to rising health care costs and long-term neurodevelopmental disability. The study aims to evaluate the role of new quantitative markers, like the elastography of cervix (shear wave speed estimation), fetal adrenal zone enlargement, and corrected fetal adrenal gland volume; in preterm birth prediction and analyze their relative importance. Thus, these markers may be beneficial in early preterm birth detection and prevent the related morbidities.

Methods

Thirty pregnant females (from 28 to 37 weeks of gestational age), showing clinical signs and delivery outcome of preterm birth were included in the study with an equal number of not-in-labor antenatal females at ≥37 weeks as controls. These patients were categorized as preterm and term groups. Both the groups were subjected to trans-abdominal ultrasonography where cervical length, cervical shear wave speed (dynamic elastography) and fetal adrenal gland parameters were measured.

Results

Shear wave speed estimation of the antenatal cervix showed the highest sensitivity and specificity (96.7% and 87% respectively) in the prediction of preterm birth and also showed a strong correlation with fetal adrenal gland enlargement. Fetal adrenal zone enlargement was also shown to be a reliable marker of preterm birth, however, with reduced sensitivity and specificity than shear wave speed.

Conclusion

The elastographic advancement and fetal adrenal biometry derived quantitative markers can be used as an objective and standard criterion for accurate prediction of preterm birth.

Disparities in Postpartum Contraceptive Counseling and Provision Among Mothers of Preterm Infants

OBJECTIVE

Use of effective contraception could be one method to decrease recurrent preterm birth by increasing intervals between pregnancies. We assessed correlates of contraceptive counseling and uptake among women who delivered preterm.

MATERIALS AND METHODS

This is a retrospective cohort study of women who delivered live-born singletons or twins before 32 weeks' gestation. We assessed documented contraceptive counseling and method uptake by postpartum discharge, using inpatient medical records, and correlates of highly effective contraception uptake by the postpartum visit using outpatient records.

RESULTS

Of 594 eligible women, 44.6% (n = 265) had documented inpatient contraceptive counseling, but only 21.4% (n = 127) left the hospital using a World Health Organization (WHO) tier 1 or 2 method. Women who were younger, non-Hispanic black, multiparous, and delivered at earlier gestational ages were more likely to have inpatient counseling documented. Compared with women with private insurance, women with public insurance were more likely to have documented counseling (22.8% vs. 87.5%, p < 0.001; adjusted odds ratio [aOR] 9.55, 95% confidence interval [CI] 5.31-17.2) and to uptake a WHO tier 1 or 2 method as an inpatient (5.8% vs. 52.0%, p < 0.001; aOR 9.51, 95% CI 4.78-18.9). Of the 175 women with outpatient records available who attended a postpartum visit, only 54.9% (n = 96) adopted a WHO tier 1 or tier 2 method.

CONCLUSION

Although all women in this cohort were at risk of recurrent preterm birth, counseling about contraception after a preterm birth (<32 weeks) was not universal. Women with multiple risk factors for recurrent preterm birth, such as multiparity and public insurance, were more likely to have received documented contraceptive counseling and highly effective contraceptives.