Fetal, Infant and Maternal Outcomes among Women with Prolapsed Membranes Admitted before 29 Weeks Gestation

Transvaginal Ultrasound Findings Predicting Prolonged Pregnancy in Cases of Prolapsed Fetal Membrane: A Retrospective Study

Background/Objectives: Fetal membrane prolapse can occur due to advanced cervical insufficiency. We investigated the yet unclear predictors of prolonged pregnancy in women with prolapsed fetal membranes. Methods: This retrospective observational study included 100 pregnant women with prolapsed fetal membranes between November 2017 and March 2023. We examined the correlation between transvaginal ultrasound findings at the time of admission and the duration of prolonged pregnancy, which was defined as the period from admission to delivery. We defined five transvaginal ultrasound indices: (1) width of the external os, (2) maximum width of the prolapsed fetal membrane, (3) distance from the external os to the presenting part of the fetus, (4) thickness of the posterior uterine lip, and (5) morphology of the prolapsed fetal membrane. Results: Women who underwent cervical cerclage comprised the cerclage group (n = 17), while those who underwent conservative management comprised the non-cerclage group (n = 83). The pregnancy period was significantly longer in the cerclage group than in the non-cerclage group (81.4 days vs. 9.1 days, p < 0.001). Multiple regression analysis revealed that type A morphology was a significant factor for prolonged pregnancy in the non-cerclage group (p < 0.05), which was significantly associated with a prolonged pregnancy period of over 7 days (p = 0.037). Conclusions: In cases of prolapsed fetal membranes, cerclage is challenging because of the high risk of iatrogenic preterm rupture of the membrane; however, if successful, a significant prolongation of the pregnancy period can be obtained. Morphological evaluation using ultrasonography is simple and easy to understand and correlates well with pregnancy outcomes, making it very useful.

Multimodal Management of Cervical Insufficiency Complicated by Intra-amniotic Candida albicans Infection

INTRODUCTION

Bacteria are the most common pathogens implicated in ascending infections in patients with cervical insufficiency. However, Candida albicans is a rare and serious cause of intra-amniotic infection that should be considered on the differential diagnosis. Upon diagnosis following cerclage placement, patients are generally advised to undergo immediate cerclage removal and discontinuation of the pregnancy due to the high risk of maternal and fetal morbidity. However, some patients decline and instead elect to continue the pregnancy with or without treatment. Limited data exist to guide management of these high-risk patients.

CASE PRESENTATION

We describe a case of previable intra-amniotic C. albicans infection diagnosed following physical examination-indicated cerclage placement. The patient declined pregnancy termination and subsequently underwent systemic antifungal therapy as well as serial intra-amniotic fluconazole instillations. Fetal blood sampling confirmed transplacental transfer of maternal systemic antifungal therapy. The fetus delivered preterm and without evidence of fungemia, despite persistently positive amniotic fluid cultures.

CONCLUSION

In a well-counseled patient with culture-proven intra-amniotic C. albicans infection declining termination of pregnancy, multimodal antifungal therapy in the form of systemic and intra-amniotic fluconazole administration may prevent subsequent fetal or neonatal fungemia and improve postnatal outcomes.

KEY POINTS

· Candida is an uncommon cause of intra-amniotic infection in the setting of cervical insufficiency.. · Multimodal antifungal therapy may prevent fetal fungemia related to intra-amniotic Candida infection.. · Fetal blood sampling confirmed transplacental passage of fluconazole after maternal administration..

Painless cervical dilation with "hourglass membranes". Conservative management: our experience

BACKGROUND

Cervical competence is currently conceived as a continuous biological process with progressive degrees of insufficiency, this substituting the traditional vision of cervical competence as being present or absent. The most extreme expression of cervical insufficiency is known as "hourglass membranes". Currently no consensus exists regarding the treatment of pregnancies complicated by the protrusion of amniotic membranes; however, the majority of authors agree on recommending bed rest and performing cervical cerclage, known as "emergent cerclage".

METHODS

We describe a series of clinical cases corresponding to second-trimester pregnancies with cervical dilation and prolapsed amniotic membranes that were admitted to our hospital,managed with conservative treatment. All patients received the same basic treatment: intravenous fluid therapy for hydration, a single-oral-dose of azithromycin and intravenous antibiotic therapy for 7 days, vaginal micronized progesterone and indomethacin administrated orally.

RESULTS

Mean gestational age at diagnosis was 22,5 weeks with an extension of pregnancy between 2.1 and 16 weeks, with eight patients (72.72%) who extended their pregnancy for more than 8 weeks. In all cases, live fetuses were obtained, with favourable evolution.

CONCLUSIONS

Despite our limited experience, resulting from the low number of cases presenting, our results encourage us to propose conservative management in pregnancies complicated with a dilated cervix and membranes protruding into the vagina, as a reasonable alternative to surgical emergency cervical cerclage, which is currently considered the therapy of choice when extreme cervical shortening occurs in the second trimester of pregnancy.

Intra-Amniotic Infection and Sterile Intra-Amniotic Inflammation in Cervical Insufficiency with Prolapsed Fetal Membranes: Clinical Implications

INTRODUCTION

The aim of this study was to identify the rates of 2 phenotypes of intra-amniotic inflammation: intra-amniotic infection (with microbial invasion of the amniotic cavity [MIAC]) and sterile intra-amniotic inflammation (without MIAC), and their outcomes, among women with cervical insufficiency with prolapsed fetal membranes.

METHODS OF STUDY

This is a retrospective study of women admitted to the Department of Obstetrics and Gynecology, University Hospital Hradec Kralove between January 2014 and May 2020. Transabdominal amniocentesis to evaluate intra-amniotic inflammation (amniotic fluid interleukin-6) and MIAC (culturing and molecular biology methods) was performed as part of standard clinical management.

RESULTS

In total, 37 women with cervical insufficiency and prolapsed fetal membranes were included; 11% (4/37) and 43% (16/37) of them had intra-amniotic infection and sterile intra-amniotic inflammation, respectively. In women with intra-amniotic infection and sterile intra-amniotic inflammation, we noted shorter intervals between admission and delivery (both p < 0.0001), and lower gestational age at delivery (p < 0.0001 and p = 0.004) and percentiles of birth/abortion weight (p = 0.03 and p = 0.009, respectively) than in those without intra-amniotic inflammation.

CONCLUSIONS

Both phenotypes of intra-amniotic inflammation, with sterile intra-amniotic inflammation being more frequent, are associated with worse outcomes in pregnancies with cervical insufficiency with prolapsed fetal membranes.

Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis

Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.