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.

Factors associated with the awareness and practice of evidence-based obstetric care in an African setting

OBJECTIVE

To identify the factors associated with important (> or =50%) variation in awareness and practice of evidence-based obstetric interventions in an African setting where we have previously reported poor awareness and use of evidence-based reproductive interventions.

DESIGN

Cross-sectional analysis of data from our Reproductive Health Interventions Study.

SETTING

North-west province, Cameroon, Africa.

POPULATION

Health workers including obstetricians, other physicians, midwives, nurses and other staff providing reproductive care.

MAIN OUTCOME MEASURES

Prevalence ratios (PR) of uniform awareness and practice of four key evidence-based obstetric interventions from the World Health Organization Reproductive Health Library (WHO RHL): antiretrovirals to prevent mother-to-child transmission of HIV/AIDS, antenatal corticosteroids for prematurity, uterotonics to prevent postpartum haemorrhage and magnesium sulphate for seizure prophylaxis.

METHODS

Comparisons of descriptive covariates, applying logistic regression to estimate independent relationships with awareness and use of evidence-based interventions.

RESULTS

A total of 15.5% (50/322) of health workers were aware of all the four interventions while only 3.8% (12/312) reported optimal practice. Evidence-based awareness was strongly associated with practice (PR = 15.4; 96% CI: 4.3-55.0). Factors significantly associated with awareness were: attending continuing education, access to the WHO RHL, employment as an obstetrician/gynaecologist and working in autonomous military or National Insurance Fund facilities. Controlling for potential confounding, working as an obstetrician was associated with increased awareness (adjusted prevalence odds ratio [aPOR] = 8.3; 95% CI: 1.3-53.8) as was median work experience of 5-15 years (aPOR = 2.0; 95% CI: 1.0-3.8). Internet access was associated with increased practice (aPOR = 3.4; 95% CI: 1.0-11.8). Other potentially important variations were observed, although they did not attain statistical significance.

CONCLUSIONS

Several factors including obstetric training and continuous education positively influence evidence-based awareness and practice of key obstetric interventions. Confirmation and application of this information may enhance the effectiveness of programmes to improve maternal and perinatal outcomes.

Rates of twinning before and after fortification of foods in the US with folic acid, Texas, 1996 to 1998

Several investigators have reported a 40% increase in the prevalence of twinning among women who have taken folic acid or multivitamins containing folic acid at the time of conception. Given that infant morbidity and mortality are greatly increased among twins, such a large increase in twinning could have serious implications. We undertook this study to determine if US fortification of enriched cereal-grain products with folic acid was associated with an unexpected increase in the prevalence of twinning in the state of Texas. We examined 1 003 207 deliveries conceived in Texas, between 1 January 1996 and 31 December 1998. We compared the prevalence of twin deliveries conceived before, during and after fortification with folic acid, mandated to begin on 1 January 1998. Comparing pregnancies conceived in 1997 with those conceived in 1996, we observed a 2.4% yearly increase in twinning, 1.024 [0.98, 1.07]. Comparing pregnancies conceived in 1998 with those conceived in 1997, we observed a 4.6% yearly increase in twinning, 1.046 [1.00, 1.09]. These increases were adjusted for maternal age, race, education, parity and season of conception. The size and pattern of these increases are consistent with the ongoing increase in twinning of 1-4% per year which began in the US prior to fortification.