The influence of uterine fibroids on adverse outcomes in pregnant women: a meta-analysis

OBJECTIVE

The objective of the meta-analysis was to determine the influence of uterine fibroids on adverse outcomes, with specific emphasis on multiple or large (≥ 5 cm in diameter) fibroids.

MATERIALS AND METHODS

We searched PubMed, Embase, Web of Science, ClinicalTrials.gov, China National Knowledge Infrastructure (CNKI), and SinoMed databases for eligible studies that investigated the influence of uterine fibroids on adverse outcomes in pregnancy. The pooled risk ratio (RR) of the variables was estimated with fixed effect or random effect models.

RESULTS

Twenty-four studies with 237 509 participants were included. The pooled results showed that fibroids elevated the risk of adverse outcomes, including preterm birth, cesarean delivery, placenta previa, miscarriage, preterm premature rupture of membranes (PPROM), placental abruption, postpartum hemorrhage (PPH), fetal distress, malposition, intrauterine fetal death, low birth weight, breech presentation, and preeclampsia. However, after adjusting for the potential factors, negative effects were only seen for preterm birth, cesarean delivery, placenta previa, placental abruption, PPH, intrauterine fetal death, breech presentation, and preeclampsia. Subgroup analysis showed an association between larger fibroids and significantly elevated risks of breech presentation, PPH, and placenta previa in comparison with small fibroids. Multiple fibroids did not increase the risk of breech presentation, placental abruption, cesarean delivery, PPH, placenta previa, PPROM, preterm birth, and intrauterine growth restriction. Meta-regression analyses indicated that maternal age only affected the relationship between uterine fibroids and preterm birth, and BMI influenced the relationship between uterine fibroids and intrauterine fetal death. Other potential confounding factors had no impact on malposition, fetal distress, PPROM, miscarriage, placenta previa, placental abruption, and PPH.

CONCLUSION

The presence of uterine fibroids poses increased risks of adverse pregnancy and obstetric outcomes. Fibroid size influenced the risk of breech presentation, PPH, and placenta previa, while fibroid numbers had no impact on the risk of these outcomes.

Frontiers in the Etiology and Treatment of Preterm Premature Rupture of Membrane: From Molecular Mechanisms to Innovative Therapeutic Strategies

Preterm premature rupture of membranes (pPROM) poses a significant threat to fetal viability and increases the risk for newborn morbidities. The perinatal period of preterm infants affected by pPROM is often characterized by higher rates of mortality and morbidity, with associated risks of cerebral palsy, developmental delays, compromised immune function, respiratory diseases, and sensory impairments. pPROM is believed to result from a variety of causes, including but not limited to microbially induced infections, stretching of fetal membranes, oxidative stress, inflammatory responses, and age-related changes in the fetal-placental interface. Maternal stress, nutritional deficiencies, and medically induced procedures such as fetoscopy are also considered potential contributing factors to pPROM. This comprehensive review explores the potential etiologies leading to pPROM, delves into the intricate molecular mechanisms through which these etiologies cause membrane ruptures, and provides a concise overview of diagnostic and treatment approaches for pPROM. Based on available therapeutic options, this review proposes and explores the possibilities of utilizing a novel composite hydrogel composed of amniotic membrane particles for repairing ruptured fetal membranes, thereby holding promise for its clinical application.

Factors contributing to preterm birth in patients presenting at tertiary care hospitals in Punjab

Objective

To determine the various causes and factors leading to preterm birth in women presenting at tertiary care hospitals.

METHODS

The cross-sectional, prospective study was conducted from June 19, 2021, to January 19, 2022, at the Central Park Teaching Hospital, Lahore, Pakistan, in collaboration with other tertiary care teaching hospitals in Lahore, and comprised pregnant women aged 15-45 years with preterm birth. Demographic and obstetric data was collected. Depending on the factors contributing to preterm birth, the subjects were categorised as spontaneous labour group A, preterm prelabour rupture of membrane group B, and iatrogenic preterm birth group C. Data was analysed using SPSS 25.

RESULTS

Of the 1,300 recorded births, 200(15.38%) were preterm. Group A had 86(43%) women with mean age 28.55±4.68 years, group B had 43(21,5%) women with mean age 27.14±3.25 years, and group C had 71(35.5%) women with mean age 28.28±3.74 years (p>0.05). There was significant difference among the groups with respect to body mass index (p=0.001) and parity (p=0.021). Vaginal and urinary tract infections were significantly higher in group A compared to the other groups (p<0.05). In group C, pre-eclampsia was the main reason for preterm birth 45(63.38%).

Conclusion

Medically indicated preterm birth rate was found to be high, and pre-eclampsia was noted as the main cause in iatrogenic preterm birth.

Accidental rupture of membranes and neonatal infection after labor induction with silicone or latex balloon catheters: A retrospective cohort study

OBJECTIVE(S)

Accidental rupture of membranes (acROM), an insertion-related complication of the balloon catheter for labor induction, may prolong the duration of ruptured membranes. Prolonged rupture of membranes is associated with an increased risk of intra-uterine infection with possibly neonatal infection as result. Little is known about safety profiles of different catheters regarding the occurrence of these complications. This study compares the incidence of neonatal early-onset sepsis (EOS) and acROM in women receiving either silicone or latex balloon catheters.

STUDY DESIGN

A retrospective cohort study was performed including 2200 women (silicone balloon catheter, n = 1100 vs. latex balloon catheter, n = 1100). The primary outcomes were the incidence of acROM, and suspected and proven neonatal EOS. Secondary outcomes were: prolonged rupture of membranes, intrapartum fever, pre- or postnatal neonatal exposure to antibiotics, and perinatal outcomes. A subgroup analysis was performed between women with and without acROM.

RESULTS

No statistically significant difference with regard to suspected or proven EOS was seen between the silicone and latex groups. The acROM rate was significantly higher in the silicone group compared to the latex group (2.9 % and 0.3 %, p < 0.01). Prolonged rupture of membranes was significantly more common in the silicone group compared to the latex group (5.0 % and 2.4 %, p < 0.01), as was the use of intrapartum antibiotics (12.7 % and 9.6 %, p = 0.02). Neonates were significantly more often exposed to pre- or postnatal antibiotics in the silicone group compared to the latex group (17.6 % and 13.6 %, p = 0.01). Subgroup analysis showed significantly more suspected and proven neonatal EOS when catheter-insertion was complicated with acROM (11.4 % and 20.0 %), compared to cases without acROM (3.8 % and 2.5 %), irrespective of the type of catheter used.

CONCLUSION(S)

The use of silicone balloon catheters for labor induction results in higher rates of acROM, prolonged rupture of membranes and use of intrapartum antibiotics, compared to latex balloon catheters. No statistically significant differences were found in the occurrence of suspected or proven neonatal EOS, however neonates from the silicone group were more often exposed to pre- or postnatal antibiotics. When acROM occurs, irrespective of type of catheter used, suspected and proven neonatal EOS was seen more often.

Obstetrical outcomes following amniocentesis performed after 24 weeks of gestation: A systematic review and meta-analysis

To evaluate obstetrical outcomes for women having late amniocentesis (on or after 24 weeks). Electronic databases were searched from inception to January 1st, 2023. The obstetrical outcomes evaluated were gestational age at delivery, preterm birth (PTB) < 37 weeks, PTB within 1 week from amniocentesis, premature prelabor rupture of membranes (pPROM), chorionamnionitis, placental abruption, intrauterine fetal demise (IUFD) and termination of pregnancy (TOP). The incidence of PTB <37 weeks was 4.85% (95% CI 3.48-6.56), while the incidence of PTB within 1 week was 1.42% (95% CI 0.66-2.45). The rate of pPROM was 2.85% (95% CI 1.21-3.32). The incidence of placental abruption was 0.91% (95% CI 0.16-2.25), while the rate of IUFD was 3.66% (95% CI 0.00-14.04). The rate of women who underwent TOP was 6.37% (95%CI 1.05-15.72). When comparing amniocentesis performed before or after 32 weeks, the incidence of PTB within 1 week was 1.48% (95% CI 0.42-3.19) and 2.38% (95% CI 0.40-5.95). Amniocentesis performed late after 24 weeks of gestation is an acceptable option for patients needing prenatal diagnosis in later gestation.

Association of amnioinfusion volume at the time of surgery for twin-twin transfusion syndrome and latency to delivery

OBJECTIVE

To evaluate the impact of amnioinfusion and other peri-operative factors on pregnancy outcomes in the setting of Twin-twin transfusion syndrome (TTTS) treated via fetoscopic laser photocoagulation (FLP).

METHODS

Retrospective study of TTTS treated via FLP from 2010 to 2019. Pregnancies were grouped by amnioinfusion volume during FLP (<1 L vs. ≥1 L). The primary outcome was latency from surgery to delivery. An amnioinfusion statistic (AIstat) was created for each surgery based on the volume of fluid infused and removed and the preoperative deepest vertical pocket. Regression analysis was planned to assess the association of AIstat with latency.

RESULTS

Patients with amnioinfusion of ≥1 L at the time of FLP had decreased latency from surgery to delivery (61 ± 29.4 vs. 73 ± 28.8 days with amnioinfusion <1 L, p < 0.001) and increased preterm prelabor rupture of membranes (PPROM) <34 weeks (44.7% vs. 33.5%, p = 0.042). Amnioinfusion ≥1 L was associated with an increased risk of delivery <32 weeks (aRR 2.6, 95% CI 1.5-4.5), 30 weeks (aRR 2.4, 95% CI 1.5-3.8), and 28 weeks (aRR 1.9, 95% CI 1.1-2.3). Cox-proportional regression revealed that AIstat was inversely associated with latency (HR 1.1, 95% CI 1.1-1.2).

CONCLUSION

Amnioinfusion ≥1 L during FLP was associated with decreased latency after surgery and increased PPROM <34 weeks.

Plugging membranes after fetoscopy in congenital diaphragmatic hernia: early cost-effectiveness analysis

OBJECTIVES

Fetal endoscopic tracheal occlusion (FETO) improves neonatal survival of fetuses with congenital diaphragmatic hernia (CDH). However, FETO also increases the risk of preterm prelabor rupture of membranes (PPROM) and preterm delivery (PTD), as fetal membrane defects after fetoscopy do not heal. To solve this issue, an advanced sealing plug for closing the membrane defect is being developed. Using early-stage health economic modeling, we aimed to estimate the potential value of this innovative plug in terms of costs and effects, and to determine the properties required for it to become cost-effective.

METHODS

Early-stage health economic modeling was applied to the case of performing FETO in women with a singleton pregnancy whose fetus is diagnosed prenatally with CDH. We simulated a cohort of patients using a state-transition model over a 45-year time horizon. In our best-case-scenario analysis, we compared the current-care strategy with the perfect-plug strategy, which reduces the risk of PPROM and PTD by 100%, to determine the maximum quality-adjusted life years (QALYs) gained and costs saved. Using threshold analysis, we determined the minimum percentage reduction in the risk of PPROM and PTD required for the plug to be considered cost-effective. The impact of model parameters on outcome was investigated using a sensitivity analysis.

RESULTS

Our model indicated that a perfect-plug strategy would yield on average an additional 1.94 QALYs at a cost decrease of €2554 per patient. These values were influenced strongly by the percentage of cases with early PTD (27-34 weeks). Threshold analysis showed that, for €500 per plug, the plug strategy needs a minimum percentage reduction of 1.83% in the risk of PPROM and PTD (i.e. reduction in the risk from 47.50% to 46.63% for PPROM and from 71.50% to 70.19% for PTD) to be cost-effective.

CONCLUSIONS

Our model-based approach showed clear potential of the plug strategy when applied in the context of FETO for CDH fetuses, as only a minor reduction in the risk of PPROM and PTD is needed for the plug to be cost-effective. Its value is expected to be even higher when used in conditions associated with a higher rate of early PTD. Continued investment in research and development of the plug strategy appears to provide value for money. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

In vivo Sealing of Fetoscopy-Induced Fetal Membrane Defects by Mussel Glue

INTRODUCTION

The benefits of fetal surgery are impaired by the high incidence of iatrogenic preterm prelabor rupture of the fetal membranes (iPPROM), for which chorioamniotic separation has been suggested as a potential initiator. Despite the urgent need to prevent iPPROM by sealing the fetoscopic puncture site after intervention, no approach has been clinically translated.

METHODS

A mussel-inspired biomimetic glue was tested in an ovine fetal membrane (FM) defect model. The gelation time of mussel glue (MG) was first optimized to make it technically compatible with fetal surgery. Then, the biomaterial was loaded in polytetrafluoroethylene-coated nitinol umbrella-shaped receptors and applied on ovine FM defects (N = 10) created with a 10 French trocar. Its sealing performance and tissue response were analyzed 10 days after implantation by amniotic fluid (AF) leakage and histological methods.

RESULTS

All ewes and fetuses recovered well after the surgery, and 100% ewe survival and 91% fetal survival were observed at explantation. All implants were tight at explantation, and no AF leakage was observed in any of them. Histological analysis revealed a mild tissue response to the implanted glue.

CONCLUSION

MG showed promising properties for the sealing of FM defects and thereby the prevention of preterm birth. Studies to analyze the long-term tissue response to the sealant should be performed.

Perinatal outcomes of iatrogenic chorioamniotic separation following fetoscopic surgery: systematic review and meta-analysis

OBJECTIVE

To compare the perinatal outcomes between pregnancies with and those without iatrogenic chorioamniotic separation (iCAS) following fetoscopic intervention.

METHODS

We performed a search in PubMed, EMBASE, Scopus, Web of Science and Google Scholar from inception up to December 2020 for studies comparing perinatal outcomes between pregnancies that developed and those that did not develop iCAS after fetoscopic intervention for twin-to-twin transfusion syndrome (TTTS), open neural tube defect (ONTD) or congenital diaphragmatic hernia. A random-effects model was used to pool the mean differences (MD) or odds ratios (OR) and the corresponding 95% CI. The primary outcome was neonatal survival. Secondary outcomes included gestational age (GA) at intervention and at delivery, interval from intervention to delivery and incidence of preterm prelabor rupture of membranes (PPROM) and preterm delivery. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa scale.

RESULTS

The search identified 348 records, of which seven studies (six on fetoscopic laser photocoagulation (FLP) for TTTS and one on fetoscopic repair for ONTD) assessed the perinatal outcomes of pregnancies that developed iCAS after fetoscopic intervention. Given that only one study reported on fetoscopic ONTD repair, the meta-analysis was limited to TTTS pregnancies and included six studies (total of 1881 pregnancies). Pregnancies that developed iCAS after FLP for TTTS, compared with those that did not, had significantly lower GA at the time of intervention (weeks) (MD, -1.07 (95% CI, -1.89 to -0.24); P = 0.01) and at delivery (weeks) (MD, -1.74 (95% CI, -3.13 to -0.34); P = 0.01) and significantly lower neonatal survival (OR, 0.41 (95% CI, 0.24-0.70); P = 0.001). In addition, development of iCAS after FLP for TTTS increased significantly the risk for PPROM < 34 weeks' gestation (OR, 3.98 (95% CI, 1.76-9.03); P < 0.001) and preterm delivery < 32 weeks (OR, 1.80 (95% CI, 1.16-2.80); P = 0.008).

CONCLUSIONS

iCAS is a common complication after FLP for TTTS. In patients undergoing FLP for TTTS, iCAS develops more often with earlier GA at intervention and is associated with earlier GA at delivery, higher risk of PPROM < 34 weeks' gestation and preterm delivery < 32 weeks and lower neonatal survival. Given the limitations of this meta-analysis and lack of literature reporting on other types of fetoscopic intervention, the presented findings should be interpreted with caution and should not be generalized to fetoscopic procedures used to treat other fetal conditions. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Study for risks of amniocentesis in anterior placenta compared to placenta of other locations

OBJECTIVE

This study aimed to compare the risks of amniocentesis between anteriorly located placentas and placentas in other locations and assess the factors that cause procedure-related complications.

MATERIALS AND METHODS

We prospectively studied women with singleton pregnancies who underwent amniocentesis between 2014 and 2020. The amniocentesis puncture sites were determined using ultrasonography. Women were classified into two groups according to their placental location. Medical records were retrospectively reviewed and characteristics and complications were compared between the groups of patients with different placental locations.

RESULTS

During the study period, 629 women underwent amniocentesis. Three cases (0.5%) of premature rupture of membranes and one case (0.3%) of fetal loss within four weeks of amniocentesis were found. Puncture failure was observed in 14 cases (2.2%). Puncture failure included procedures with failure to obtain an adequate sample and procedures requiring more than three needle insertions. There was no significant difference in the frequency of puncture failure between the two groups. Logistic regression analysis revealed that uterine myoma (odds ratio [OR] 11.92; 95% CI, 3.04-45.17) and tenting membrane (OR 33.57; 95% CI, 6.45-178.41) were associated with puncture failure.

CONCLUSION

Anteriorly located placenta is not a risk factor for amniocentesis-related adverse outcomes. Instead, puncture failure frequently occurs in case of uterine myoma and tenting membrane. If puncture failure occurs, or if the puncture is difficult to perform, then the procedure should be considered technically difficult and postponed until it can be more easily performed.

Disorders of placental villous maturation are present in one-third of cases with spontaneous preterm labor

OBJECTIVES

Spontaneous preterm labor is an obstetrical syndrome accounting for approximately 65-70% of preterm births, the latter being the most frequent cause of neonatal death and the second most frequent cause of death in children less than five years of age worldwide. The purpose of this study was to determine and compare to uncomplicated pregnancies (1) the frequency of placental disorders of villous maturation in spontaneous preterm labor; (2) the frequency of other placental morphologic characteristics associated with the preterm labor syndrome; and (3) the distribution of these lesions according to gestational age at delivery and their severity.

METHODS

A case-control study of singleton pregnant women was conducted that included (1) uncomplicated pregnancies (controls, n=944) and (2) pregnancies with spontaneous preterm labor (cases, n=438). All placentas underwent histopathologic examination. Patients with chronic maternal diseases (e.g., chronic hypertension, diabetes mellitus, renal disease, thyroid disease, asthma, autoimmune disease, and coagulopathies), fetal malformations, chromosomal abnormalities, multifetal gestation, preeclampsia, eclampsia, preterm prelabor rupture of the fetal membranes, gestational hypertension, gestational diabetes mellitus, and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome were excluded from the study.

RESULTS

Compared to the controls, the most prevalent placental lesions among the cases were the disorders of villous maturation (31.8% [106/333] including delayed villous maturation 18.6% [62/333] vs. 1.4% [6/442], q<0.0001, prevalence ratio 13.7; and accelerated villous maturation 13.2% [44/333] vs. 0% [0/442], q<0.001). Other lesions in decreasing order of prevalence included hypercapillarized villi (15.6% [68/435] vs. 3.5% [33/938], q<0.001, prevalence ratio 4.4); nucleated red blood cells (1.1% [5/437] vs. 0% [0/938], q<0.01); chronic inflammatory lesions (47.9% [210/438] vs. 29.9% [282/944], q<0.0001, prevalence ratio 1.6); fetal inflammatory response (30.1% [132/438] vs. 23.2% [219/944], q<0.05, prevalence ratio 1.3); maternal inflammatory response (45.5% [195/438] vs. 36.1% [341/944], q<0.01, prevalence ratio 1.2); and maternal vascular malperfusion (44.5% [195/438] vs. 35.7% [337/944], q<0.01, prevalence ratio 1.2). Accelerated villous maturation did not show gestational age-dependent association with any other placental lesion while delayed villous maturation showed a gestational age-dependent association with acute placental inflammation (q-value=0.005).

CONCLUSIONS

Disorders of villous maturation are present in nearly one-third of the cases of spontaneous preterm labor.

Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial

BACKGROUND

Selective fetoscopic laser coagulation of the intertwin anastomotic chorionic vessels is the first-line treatment for twin-twin transfusion syndrome. However, in stage 1 twin-twin transfusion syndrome, the risks of intrauterine surgery may be higher than those of the natural progression of the condition.

OBJECTIVE

This study aimed to compare immediate surgery and expectant follow-up in stage 1 twin-twin transfusion syndrome.

STUDY DESIGN

We conducted a multicentric randomized trial, which recruited from 2011 to 2018 with a 6-month postnatal follow-up. The study was conducted in 9 fetal medicine centers in Europe and the Unites States. Asymptomatic women with stage 1 twin-twin transfusion syndrome between 16 and 26 weeks' gestation, a cervix of >15 mm, and access to a surgical center within 48 hours of diagnosis were randomized between expectant management and immediate surgery. In patients allocated to immediate laser treatment, percutaneous laser coagulation of anastomotic vessels was performed within 72 hours. In patients allocated to expectant management, a weekly ultrasound follow-up was planned. Rescue fetoscopic coagulation of anastomoses was offered if the syndrome worsened as seen during a follow-up, either because of progression to a higher Quintero stage or because of the maternal complications of polyhydramnios. The primary outcome was survival at 6 months without severe neurologic morbidity. Severe complications of prematurity and maternal morbidity were secondary outcomes.

RESULTS

The trial was stopped at 117 of 200 planned inclusions for slow accrual rate over 7 years: 58 women were allocated to expectant management and 59 to immediate laser treatment. Intact survival was seen in 84 of 109 (77%) expectant cases and in 89 of 114 (78%) (P=.88) immediate surgery cases, and severe neurologic morbidity occurred in 5 of 109 (4.6%) and 3 of 114 (2.6%) (P=.49) cases in the expectant and immediate surgery groups, respectively. In patients followed expectantly, 24 of 58 (41%) cases remained stable with dual intact survival in 36 of 44 (86%) cases at 6 months. Intact survival was lower following surgery than for the nonprogressive cases, although nonsignificantly (78% and 71% following immediate and rescue surgery, respectively).

CONCLUSION

It is unlikely that early fetal surgery is of benefit for stage 1 twin-twin transfusion syndrome in asymptomatic pregnant women with a long cervix. Although expectant management is reasonable for these cases, 60% of the cases will progress and require rapid transfer to a surgical center.

Incidence of and risk factors for thromboembolism during pregnancy and postpartum: A 10-year nationwide population-based study

OBJECTIVE

Knowledge of the incidence of pregnancy-related thromboembolism and its risk factors is clinically important because thromboembolism is the leading cause of maternal death. However, there are insufficient large population-based studies on this topic. The purpose of this study was to estimate the incidence of and identify the risk factors for thromboembolism during pregnancy and puerperium.

MATERIALS AND METHODS

We analyzed data from 2007 to 2016 using the Health Insurance Review and Assessment Service (HIRA) database. Women who gave birth in the Republic of Korea were identified. Thromboembolism was defined as the simultaneous presence of both the diagnostic and test codes. Risk factors for thromboembolism were identified using logistic regression.

RESULTS

A total of 1,188 delivery episodes with thromboembolism were extracted from 4,243,393 delivery episodes. The incidence of thromboembolism was 0.28 per 1,000 deliveries, and it increased over the 10-year period. The incidence of antepartum thromboembolism was 0.1 per 1,000 deliveries (418 cases), and the incidence of postpartum thromboembolism was 0.18 per 1,000 deliveries (770 cases). Thromboembolism was associated with ovarian hyperstimulation syndrome, low socioeconomic status, multiple birth, cesarean birth, preeclampsia, postpartum hemorrhage, placenta previa, advanced maternal age, hyperemesis and primiparity. The factors associated with mortality from thromboembolism were cesarean birth and preterm premature rupture of membranes.

CONCLUSION

The incidence of pregnancy-related thromboembolism increased over the 10-year study period. Low socioeconomic status, ovarian hyperstimulation syndrome, cesarean delivery and premature rupture of membranes were high-risk factors. This study provides an important reference for thromboprophylaxis for pregnancy-related thromboembolism.

Chorioamniotic membrane separation following fetal myelomeningocele repair: incidence, risk factors and impact on perinatal outcome

OBJECTIVES

Prenatal myelomeningocele (MMC) repair has been shown to provide significant benefits to the infant, decreasing the postnatal need for ventriculoperitoneal shunt and improving motor outcome. Chorioamniotic membrane separation (CAS) is a potential complication following prenatal MMC repair and may increase the risk of preterm prelabor rupture of membranes (PPROM) and preterm birth. The objectives of this study were: (1) to evaluate the incidence of CAS after prenatal MMC repair; (2) to determine risk factors associated with its occurrence; and (3) to assess its association with adverse perinatal outcomes.

METHODS

This was a retrospective cohort study of patients who underwent fetal MMC repair between November 2011 and December 2018. Surgery was performed using either a fetoscopic (laparotomy or exteriorized uterus) approach or an open-hysterotomy approach. Eligibility criteria were those reported in the Management of Myelomeningocele Study. If CAS was detected on ultrasound (US), its severity was graded as 'mild' if amnion detachment involved < 25% of the uterine cavity, 'moderate' if it involved 25-50% and 'severe' if it involved > 50%. Evolution of CAS was classified as stable, increasing or decreasing based on the difference in severity grading between the time at first diagnosis and the last US scan before delivery. Logistic regression analysis was performed to identify pre- or perisurgical factors associated with the development of CAS and to determine the risk of adverse perinatal outcome associated with CAS.

RESULTS

In total, 91 cases were included. Fetoscopic or open-hysterotomy repair of MMC was performed in 52/91 (57.1%) and 39/91 (42.9%) cases, at a median gestational age (GA) of 25.0 weeks (range, 22.9-26.0 weeks) and 25.0 weeks (range, 21.3-25.9 weeks), respectively. CAS was diagnosed in 31/91 (34.1%) patients, at a median GA of 28.1 weeks (range, 24.4-37.6 weeks). Anterior placenta was identified as a risk factor for the postoperative development of CAS (odds ratio (OR), 3.72 (95% CI, 1.46-9.5); P < 0.01). This risk was dependent on the repair technique. An anterior placenta significantly increased the risk of CAS after fetoscopic repair (OR, 3.94 (95% CI, 1.14-13.6); P = 0.03) but not after open repair (OR, 2.8 (95% CI, 0.6-12.5); P = 0.16). There was no significant difference in the rate of CAS after fetoscopic repair (21/52 (40.4%)) vs open-hysterotomy repair (10/39 (25.6%)) (P = 0.14), nor were there any differences in GA at diagnosis of CAS, interval between surgery and diagnosis, distribution of CAS severity or progression of CAS between the two groups. CAS increased the risk of PPROM (50% in those with vs 12% in those without CAS) (OR, 7.6 (95% CI, 2.5-21.9); P < 0.01) and preterm delivery (70% vs 38%) (OR, 3.2 (95% CI, 1.3-8.1); P < 0.01). Fetoscopically repaired cases with CAS had a higher rate of PPROM (12/20 (60.0%) vs 2/31 (6.5%); P < 0.01) and preterm delivery (13/20 (65.0%) vs 5/31 (16.1%); P < 0.01) than those that did not develop CAS, while the differences were not significant in cases with open-hysterotomy repair. Early detection of CAS (before 30 weeks' gestation) was a risk factor for preterm delivery (90% before 30 weeks vs 36% at or after 30 weeks) (OR, 15.7 (95% CI, 2.3-106.3); P < 0.01). There was no association between PPROM or preterm delivery and the severity or progression of CAS.

CONCLUSIONS

The presence of an anterior placenta was the only factor that increased the risk for CAS after fetoscopic MMC repair. Detection of CAS after fetoscopic MMC repair significantly increases the risk for PPROM and preterm delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Alloscardovia omnicolens emerging presence in premature rupture of membranes

Alloscardovia omnicolens is a recently-reported microorganism with unknown pathogenic implications. It has been isolated in various clinical localizations but not in the endocervix. We isolated A. omnicolens in an endocervical sample from a 31-yr-old patient with preterm premature rupture of membranes (PPROM) in week 33+3 of pregnancy. The main risk of PPROM is prematurity and the possibility of developing infectious chorioamnionitis, which can be lethal for the mother and newborn. This is the first report of an association between A. omnicolens and PPROM, although its pathogenic role has not yet been elucidated.

Maternal and neonatal effects of Acinetobacter colonisation in preterm premature rupture of membrane and term labour

INTRODUCTION

Some anecdotal reports suggest that maternal colonisation with Acinetobacter baumannii during pregnancy is associated with adverse maternal and neonatal effects, including preterm premature rupture of membrane (PPROM). The objective of this study was to compare the maternal and neonatal effects of A. baumannii colonisation in cases with PPROM and those with spontaneous onset of labour at term.

METHODS

The recruitment of participants' was carried out at Selayang Hospital, Selangor, Malaysia. Vaginal swabs were prospectively taken from 104 patients of PPROM and 111 with spontaneous onset of labour at term. Swabs were also taken from the axillae and ears of their babies. These swabs were cultured to isolate A. baumannii. Maternal and neonatal adverse outcomes were documented.

RESULTS

Sixteen mothers were A. baumannii positive, eight from each group respectively. None of the cases developed chorioamnionitis or sepsis. Those positive were four cases of PPROM and two babies of term labour. None of the babies developed sepsis.

CONCLUSIONS

This study does not support the suggestion that A. baumannii colonisation during pregnancy is associated with adverse maternal and neonatal outcomes.

Fetal Survival Immediate after Fetoscopic Laser Ablation in Twin to Twin Transfusion Syndrome

BACKGROUND

The purpose of this study was to determine prognostic factors that can affect the fetal survival immediate after fetoscopic laser ablation.

METHODS

The study population consisted of consecutive twin pregnant women who underwent fetoscopic laser ablation with the diagnosis of twin to twin transfusion syndrome (TTTS) from 2011 to 2018 in Seoul National University Hospital. Fetal survival immediate after procedure was defined as survival to 48 hours after procedure and neonatal survival was defined as survival to 28 days of life. Clinical characteristics and ultrasound findings were compared according to the fetal survival immediate after procedure.

RESULTS

A total of 57 pregnant women with TTTS were included, and the overall fetal survival immediate after procedure was 71.1% (81/114) after fetoscopic laser ablation. Fetuses who survived immediate after procedure had higher gestational age at procedure and lower frequency of abnormal Doppler studies than those did not survive. However, the frequency of hydrops was not different between cases with fetal survival and those with fetal death. The earlier gestational age at procedure and the presence of abnormal Doppler studies were significant risk factors for fetal death even after adjustment.

CONCLUSION

Based on this data, the fetal survival immediate after procedure (fetoscopic laser treatment) in TTTS can be affected by the gestational age at procedure and the presence of abnormal Doppler studies.

Urinary vanadium concentration in relation to premature rupture of membranes: A birth cohort study

Heavy metal exposure has been indicated to be linked with reproductive and developmental toxicity. However, human studies on the association between heavy metal exposure and premature rupture of membranes (PROM) are limited. Thus, we aimed to evaluate the associations between urinary metal concentrations in pregnant women and the risk of PROM. The study was conducted among 7290 pregnant women from an ongoing cohort study in China. Levels of urinary metals were determined using an inductively coupled plasma-mass spectrometry and adjusted by creatinine concentration (μg/g creatinine). Adjusted odds ratios (OR) and 95% confidence intervals (CI) for PROM and preterm PROM were estimated using logistic regression models. Among 12 urinary metals detected, vanadium (V) have shown stable positive associations with PROM and preterm PROM. With one unit increase in natural logarithmically transformed urinary V concentration, adjusted OR of 1.57 (95% CI: 1.47, 1.66) for PROM was observed. Compared with the lowest tertile of urinary V, we also observed positive associations between V levels and PROM (for the medium tertile, adjusted OR = 1.66, 95% CI: 1.34, 2.05; for the highest tertile, adjusted OR = 3.75, 95% CI: 3.09, 4.54). In addition, higher adjusted ORs for preterm PROM were observed (for the highest tertile, adjusted OR = 8.14, 95% CI: 4.55, 14.55). Further stratified analysis suggested the associations were more pronounced among women delivering male infants than those with female infants. Our present epidemiological study indicated that pregnant women exposure to higher level of V might lead to an increased risk of PROM.

Risk factors of premature rupture of membranes in public hospitals at Mekele city, Tigray, a case control study

BACKGROUND

The incidence of premature rupture of membranes ranges from about 5% to 10% of all deliveries. A woman with premature rupture of membranes is at risk of intra-amniotic infection, postpartum infection, endometritis, and death. A neonate born from premature rupture of membranes mother is at high risk of respiratory distress syndrome, sepsis, intraventricular hemorrhage and death. Little is known regarding the risk factors in Ethiopia. Therefore, this study was conducted to identify risk factors of premature rupture of membranes among pregnant women admitted to public hospitals in Mekelle city, Tigray, Ethiopia.

METHODS

Hospital based unmatched case control study design was implemented on 240 samples (160 controls and 80 cases) from pregnant mothers admitted to public hospitals in Mekelle city from February - April/2016. Data was collected by interviewer administered Structured questionnaire and checklist. Binary logistic regression model was used to see the association between dependent and independent variables and multivariable logistic regression was used to identify the independent predictors of premature rupture of membranes.

RESULTS

A total of 160 controls and 80 cases were enrolled in the study. Multivariable logistic regression showed that history of abortion [AOR 3.06 (CI: 1.39, 6.71)], history of PROM [AOR 4.45 (CI: 1.87, 10.6)], history of caesarean section [AOR 3.15(CI: 1.05, 9.46)] and abnormal vaginal discharge in the index pregnancy [AOR 3.31(CI: 1.67, 6.56)] were positively associated with premature rupture of membranes.

CONCLUSIONS

Past obstetric history and risks in the index pregnancy have an association with premature rupture of membranes. The finding of the study suggests early identification and treatment of genitourinary infection.

Predictors of preterm birth

Cervical length (CL) measured by transvaginal ultrasound examination (TVUE) best identifies the risk for preterm birth (PTB). It identifies women at risk who can benefit from corticosteroids or in utero transfer. Early screening improves effectiveness of tocolysis. It reduces iatrogenicity and cost. In preterm premature rupture of membranes (PPROM), CL is devoid of infectious risk and predicts duration of the latency phase but not the risk of perinatal sepsis. Asymptomatic women at risk should be screened at a 2-week interval starting from 16 to 18 weeks, up to 24 weeks. CLs <10th centile are at risk of PTB, especially with decrease in CL after 16 weeks. Repeat ultrasound improves predictive values. Stable CL calls for term delivery. Funneling does not improve predictivity of CL. In twin pregnancies, CL reduces unnecessary interventions. In symptomatic women, fetal fibronectin performs less than CL. Its combination with inconclusive CL has not emerged productive through randomized controlled trials (RCTs), and studies with homogeneous management for preterm labor (PTL) suggest that up to 15% of unjustified hospitalizations and treatment could be avoided.

Prevalence and factors associated with preterm birth at kenyatta national hospital

BACKGROUND

The World Health Organization estimates the prevalence of preterm birth to be 5-18% across 184 countries of the world. Statistics from countries with reliable data show that preterm birth is on the rise. About a third of neonatal deaths are directly attributed to prematurity and this has hindered the achievement of Millennium Development Goal-4 target. Locally, few studies have looked at the prevalence of preterm delivery and factors associated with it. This study determined the prevalence of preterm birth and the factors associated with preterm delivery at Kenyatta National Hospital in Nairobi, Kenya.

METHODS

A cross-sectional descriptive study was conducted at the maternity unit of Kenyatta National Hospital in Nairobi, Kenya in December 2013. A total of 322 mothers who met the eligibility criteria and their babies were enrolled into the study. Mothers were interviewed using a standard pretested questionnaire and additional data extracted from medical records. The mothers' nutritional status was assessed using mid-upper arm circumference measured on the left. Gestational age was assessed clinically using the Finnstrom Score.

RESULTS

The prevalence of preterm birth was found to be 18.3%. Maternal age, parity, previous preterm birth, multiple gestation, pregnancy induced hypertension, antepartum hemorrhage, prolonged prelabor rupture of membranes and urinary tract infections were significantly associated with preterm birth (p = < 0.05) although maternal age less < 20 years appeared to be protective. Only pregnancy induced hypertension, antepartum hemorrhage and prolonged prelabor rupture of membranes remained significant after controlling for confounders. Marital status, level of education, smoking, alcohol use, antenatal clinic attendance, Human Immunodeficiency Virus status, anemia, maternal middle upper arm circumference and interpregnancy interval were not associated with preterm birth.

CONCLUSIONS

The prevalence of preterm birth in Kenyatta National Hospital was 18.3%. Maternal age ≤ 20 years, parity > 4, twin gestation, maternal urinary tract infections, pregnancy induced hypertension, antepartum hemorrhage and prolonged prelabor rupture of membranes were significantly associated with preterm birth. The latter 3 were independent determinants of preterm birth. At-risk mothers should receive intensified antenatal care to mitigate preterm birth.

Acute Associations Between Outdoor Temperature and Premature Rupture of Membranes

BACKGROUND

Extreme ambient temperatures have been linked to preterm birth. Preterm premature rupture of membranes is a common precursor to preterm birth but is rarely studied in relation to temperature.

METHODS

We linked 15,381 singleton pregnancies with premature rupture of membranes from a nationwide US obstetrics cohort (2002-2008) to local temperature. Case-crossover analyses compared daily temperature during the week preceding delivery and the day of delivery to 2 control periods, before and after the case period. Conditional logistic regression models calculated the odds ratio (OR) and 95% confidence intervals (CIs) of preterm and term premature rupture of membranes for a 1°C increase in temperature during the warm (May-September) and cold (October-April) season separately after adjusting for humidity, barometric pressure, ozone, and particulate matter.

RESULTS

During the warm season, 1°C increase during the week before delivery was associated with a 5% (95% CI, 3%, 6%) increased preterm premature rupture of membranes risk, and a 4% (95% CI, 3%, 5%) increased term premature rupture of membranes risk. During the cold season, 1°C increase was associated with a 2% decreased risk for both preterm (95% CI, 1%, 3%) and term premature rupture of membranes (95% CI, 1%, 3%). The day-specific associations for the week before delivery were similar, but somewhat stronger for days closer to delivery.

CONCLUSIONS

Relatively small ambient temperature changes were associated with the risk of both preterm and term premature of membranes. Given the adverse consequences of premature rupture of membranes and concerns over global climate change, these findings merit further investigation. See video abstract at, http://links.lww.com/EDE/B312.

Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data

OBJECTIVE

The aim of this systematic review and meta-analysis was to quantify the efficacy of cervical cerclage in preventing preterm birth (PTB) in asymptomatic singleton pregnancies with a short mid-trimester cervical length (CL) on transvaginal sonography (TVS) and without prior spontaneous PTB.

METHODS

Electronic databases were searched from inception of each database until February 2017. No language restrictions were applied. All randomized controlled trials (RCTs) of asymptomatic singleton pregnancies without prior spontaneous PTB, found to have short CL < 25 mm on mid-trimester TVS and then randomized to management with either cerclage or no cerclage, were included. Corresponding authors of all the included trials were contacted to obtain access to the data and perform a meta-analysis of individual patient-level data. Data provided by the investigators were merged into a master database constructed specifically for the review. Primary outcome was PTB < 35 weeks. Summary measures were reported as relative risk (RR) with 95% CI. The quality of the evidence was assessed using the GRADE approach.

RESULTS

Five RCTs, including 419 asymptomatic singleton gestations with TVS-CL < 25 mm and without prior spontaneous PTB, were analyzed. In women who were randomized to the cerclage group compared with those in the control group, no statistically significant differences were found in PTB < 35 (21.9% vs 27.7%; RR, 0.88 (95% CI 0.63-1.23); I²  = 0%; five studies, 419 participants), < 34, < 32, < 28 and < 24 weeks, gestational age at delivery, preterm prelabor rupture of membranes (PPROM) and neonatal outcomes. In women who received cerclage compared with those who did not, planned subgroup analyses revealed a significantly lower rate of PTB < 35 weeks in women with TVS-CL < 10 mm (39.5% vs 58.0%; RR, 0.68 (95% CI, 0.47-0.98); I²  = 0%; five studies; 126 participants) and in women who received tocolytics (17.5% vs 32.7%; RR, 0.54 (95% CI, 0.31-0.93); I²  = 0%; four studies; 169 participants) or antibiotics (18.3% vs 31.5%; RR, 0.58 (95% CI, 0.33-0.98); I²  = 0%; three studies; 163 participants) as additional therapy to cerclage. The quality of evidence was downgraded two levels because of serious imprecision and indirectness, and therefore was judged as low.

CONCLUSIONS

In singleton gestations without prior spontaneous PTB but with TVS-CL < 25 mm in the second trimester, cerclage does not seem to prevent preterm delivery or improve neonatal outcome. However, in these pregnancies, cerclage seems to be efficacious at lower CLs, such as < 10 mm, and when tocolytics or antibiotics are used as additional therapy, requiring further studies in these subgroups. Given the low quality of evidence, further well-designed RCTs are needed to confirm the findings of this study. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Mutations in fetal genes involved in innate immunity and host defense against microbes increase risk of preterm premature rupture of membranes (PPROM)

BACKGROUND

Twin studies have revealed a significant contribution of the fetal genome to risk of preterm birth. Preterm premature rupture of membranes (PPROM) is the leading identifiable cause of preterm delivery. Infection and inflammation of the fetal membranes is commonly found associated with PPROM.

METHODS

We carried out whole exome sequencing (WES) of genomic DNA from neonates born of African-American mothers whose pregnancies were complicated by PPROM (76) or were normal term pregnancies (N = 43) to identify mutations in 35 candidate genes involved in innate immunity and host defenses against microbes. Targeted genotyping of mutations in the candidates discovered by WES was conducted on an additional 188 PPROM cases and 175 controls.

RESULTS

We identified rare heterozygous nonsense and frameshift mutations in several of the candidate genes, including CARD6, CARD8, DEFB1, FUT2, MBL2, NLP10, NLRP12, and NOD2. We discovered that some mutations (CARD6, DEFB1, FUT2, MBL2, NLRP10, NOD2) were present only in PPROM cases.

CONCLUSIONS

We conclude that rare damaging mutations in innate immunity and host defense genes, the majority being heterozygous, are more frequent in neonates born of pregnancies complicated by PPROM. These findings suggest that the risk of preterm birth in African-Americans may be conferred by mutations in multiple genes encoding proteins involved in dampening the innate immune response or protecting the host against microbial infection and microbial products.

Cigarette smoke condensate affects the retinoid pathway in human amnion

INTRODUCTION

The preterm premature rupture of membranes (PPROM) is a frequent pathology responsible of more than 30% of preterm births. Tobacco smoking is one of the most frequently described risk factors identified and contributes to the pre term weakening of fetal membranes. As previously demonstrated, all-trans retinoic acid (atRA) regulates several genes involved in the extracellular matrix dynamics, an essential actor in fetal membrane ruptures. We hypothesized that cigarette smoke may affect this pathway in human amnion.

METHODS

Amnion was obtained from full-term fetal membranes collected from non-smoking women after cesarean births and used either as explants or for the isolation of derived epithelial cells. The pro-healing and transcriptomic effects of atRA were studied by a scratch assay experiment and quantitative RT-PCR, respectively, after treatment with dimethyl sulfoxyde (DMSO), atRA, DMSO + cigarette smoke condensate (CSC), or atRA + CSC.

RESULTS

Our results show a strong alteration of the retinoid pathway after CSC treatment on amnion-derived epithelial cells and explants. We first demonstrated that CSC inhibits the activity of the RARE reporter gene in amnion-derived epithelial cells. Then, atRA's effects on both the transcription of its target genes and wound healing were demonstrated to be inhibited or at least decreased by the CSC in human amnion epithelial cells.

DISCUSSION

Here, we demonstrated that CSC altered the retinoid signal, already known to have roles in fetal membrane physiopathology. These results highlight a potential negative action of maternal smoking on the retinoid pathway in human amnion and more generally on pregnancy.

Maternal serum C-reactive protein concentration and intra-amniotic inflammation in women with preterm prelabor rupture of membranes

Objective

To evaluate maternal serum C-reactive protein (CRP) concentrations in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) in relation to the presence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI).

Methods

Two hundred and eighty-seven women with singleton pregnancies complicated by PPROM between 2014 and 2016 were included in this study. Maternal blood and amniotic fluid samples were collected at the time of admission. Maternal serum CRP concentration was measured using a high-sensitivity immunoturbidimetric assay. Interleukin-6 (IL-6) concentration was measured using a point-of-care test. MIAC was diagnosed based on a positive polymerase chain reaction result for Ureaplasma species, Mycoplasma hominis, and/or Chlamydia trachomatis and for the 16S rRNA gene. IAI was characterized by an amniotic fluid IL-6 concentration of ≥ 745 pg/mL.

Result

Women with MIAC and IAI had higher maternal serum CRP concentrations than did women without (with MIAC: median 6.9 mg/L vs. without MIAC: median 4.9 mg/L; p = 0.02; with IAI: median 8.6 mg/L vs. without IAI: median 4.7 mg/L; p < 0.0001). When women were split into four subgroups based on the presence of MIAC and/or IAI, women with the presence of both MIAC and IAI had higher maternal serum CRP than did women with IAI alone, with MIAC alone, and women without MIAC and IAI (both MIAC and IAI: median: 13.1 mg/L; IAI alone: 6.0 mg/L; MIAC alone: 3.9 mg/L; and without MIAC and IAI: median 4.8 mg/L; p < 0.0001). The maternal serum CRP cutoff value of 17.5 mg/L was the best level to identify the presence of both MIAC and IAI, with sensitivity of 47%, specificity of 96%, positive predictive value of 42%, negative predictive value of 96%, and the positive likelihood ratio of 10.9.

Conclusion

The presence of both MIAC and IAI was associated with the highest maternal serum CRP concentrations. Maternal serum CRP concentration in women with PPROM at the time of admission can rule out the presence of the combined condition of both MIAC and IAI, therefore, it may serve as a non-invasive screening tool to distinguish between women with PPROM who are at high or at low risk for the presence of both MIAC and IAI.

Preterm prelabor rupture of membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

OBJECTIVE

To assess the incidence, clinical course, risk factors and outcomes of preterm prelabor rupture of membranes (PPROM) after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS).

METHODS

This was a prospective observational cohort study of 154 consecutive cases of TTTS. PPROM was defined as rupture of membranes before 34 weeks' gestation. Procedure-to-PPROM and PPROM-to-delivery intervals were determined. Relevant preoperative and intraoperative variables were analyzed by univariate and multivariate logistic regression to determine their impact on PPROM after FLS.

RESULTS

The incidence of PPROM was 39% (n = 60), occurring at a mean gestational age of 27.2 ± 4.6 weeks. Median procedure-to-PPROM interval was 46 (range, 1-105; interquartile range (IQR), 13-66) days and median PPROM-to-delivery interval was 1 (range, 0-93; IQR, 0-13) day. Mean gestational age at delivery in cases with PPROM was 29.0 ± 4.5 weeks compared with 32.6 ± 3.9 weeks in cases without PPROM (P < 0.0001). Insertion of a collagen plug was the only significant factor found on both univariate and multivariate analysis to be associated with an increased rate of PPROM (odds ratio, 3.1 (95% CI, 1.2-8.0); P = 0.006). There was no statistically significant difference in fetal (P = 0.07) or neonatal (P = 0.08) survival between those with and those without PPROM.

CONCLUSIONS

PPROM after FLS increases prematurity by 3.6 weeks. The latency period after PPROM was 2 weeks; 50% of patients delivered within 24 h. No variable thought to be associated with PPROM after FLS was found to be significantly associated with this complication. Other etiologies and mechanisms for PPROM after FLS should be explored. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Preterm delivery after fetoscopic laser surgery for twin-twin transfusion syndrome: etiology and risk factors

OBJECTIVE

Preterm delivery after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) is a major complication. The causative factors leading to preterm delivery continue to be elusive and a better understanding of the risk factors could reduce complications. The objective of this study was to determine the etiology of preterm delivery after FLS for TTTS and its associated risk factors.

METHODS

This was a secondary analysis of a prospective study of 203 patients with TTTS who underwent FLS at a single center between September 2011 and December 2014. Preoperative, operative, postoperative, delivery and neonatal data were reviewed. Preterm delivery was categorized according to etiology into three groups: spontaneous (SPT), indicated (IND) and elective (ELC). Comparisons between groups were performed by ANOVA. Kaplan-Meier survival analysis was performed to compare the procedure-to-delivery interval between groups. To identify risk factors for preterm delivery, logistic regression, with calculation of relative risks (RR), was performed, with P < 0.05 considered statistically significant.

RESULTS

Mean gestational age at time of FLS was 20.6 ± 2.4 weeks and mean gestational age at delivery was 30.9 ± 4.7 weeks. Iatrogenic preterm prelabor rupture of membranes (iPPROM) occurred in 39% of cases. SPT preterm delivery occurred in 97 (48%) patients, IND preterm delivery in 65 (32%) and ELC preterm delivery in 41 (20%). In the IND group, 30 (46%) patients delivered for fetal indications, 31 (48%) for maternal indications and four (6%) for combined fetal and maternal indications. The overall chorioamnionitis rate was 6.4%; of these, nine (9%) were in the SPT group and four (6%) were in the IND group, with no case occurring in the ELC group. There was a significant difference in procedure-to-delivery interval between groups (P < 0.0001). Using variables from the ELC group as a baseline, significant risk factors for SPT preterm delivery were iPPROM (RR, 16.2 (95% CI, 4.5-57.7)), preoperative cervical length (RR, 0.96 (95% CI, 0.92-0.998)) and number of anastomoses (RR, 1.14 (95% CI, 1.02-1.27)). Significant risk factors for IND preterm delivery were iPPROM (RR, 9.6 (95% CI, 2.6-35.0)) and number of ablated anastomoses (RR, 1.13 (95% CI, 1.02-1.30)).

CONCLUSION

iPPROM and an increased number of ablated placental anastomoses were associated independently with SPT and IND preterm deliveries. A shorter preoperative cervical length was associated with SPT preterm delivery. Strategies to prevent iPPROM and for management of cervical length shortening are needed urgently in these pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Effect of suppressive acyclovir administered to HSV-2 positive mothers from week 28 to 36 weeks of pregnancy on adverse obstetric outcomes: a double-blind randomised placebo-controlled trial

BACKGROUND

Acyclovir (ACV) given to HSV-2 positive women after 36 weeks reduces adverse outcomes but its benefit at lower gestation was undocumented. We determined the effect of oral acyclovir administered from 28 to 36 weeks on premature rupture of membranes (PROM) primarily and preterm delivery risk.

METHODS

This was a randomized, double-blind placebo-controlled trial among 200 HSV-2 positive pregnant women at 28 weeks of gestation at Mulago Hospital, Uganda. Participants were assigned randomly (1:1) to take either acyclovir 400 mg orally twice daily (intervention) or placebo (control) from 28 to 36 weeks. Both arms received acyclovir after 36 weeks until delivery. Development of Pre-PROM by 36 weeks and preterm delivery were outcomes.

RESULTS

One hundred women were randomised to acyclovir and 100 to placebo arms between January 2014 and February 2015. There was tendency towards reduction of incidence of PROM at 36 weeks but this was not statistically significant (4.0% versus 10.0%; RR 0.35; 95% 0.11-1.10) in the acyclovir and placebo arms respectively. However, there was a significant reduction in the incidence of preterm delivery (11.1% versus 23.5%; RR 0.41; 95% 0.20-0.85) in the acyclovir and placebo arms respectively.

CONCLUSIONS

Oral acyclovir given to HSV-2 positive pregnant women from 28 to 36 weeks reduced incidence of preterm delivery but did not significantly reduce incidence of pre-PROM.

TRIAL REGISTRATION

www.pactr.org, PACTR201311000558197 .

Obstructive sleep apnea and the risk of preterm delivery

OBJECTIVE

The aim of this study was to evaluate the risk of obstructive sleep apnea (OSA) to preterm delivery (PTD), using the Berlin Questionnaire (BQ).

METHODS

This was a large, prospective cohort study among pregnant Thai women. The BQ was employed for symptom-based OSA screening during the second trimester, and PTD was recorded in 1345 pregnant women. Multivariate models were applied in controlling for potential confounders.

RESULTS

The overall prevalence of the high risk of OSA was 10.1 %, and it was significantly associated with pre-pregnancy body mass index and score on the Perceived Stress Scale. An adjusted odds ratio for PTD in women with a high risk of OSA was 2.00 (95 % confidence intervals (CIs) = 1.20, 3.34). Stratified analyses, after adjusting for confounding factors, indicated that a high risk of OSA was associated with an increased risk of spontaneous preterm delivery (odds ratio (OR) = 2.45, 95 % CI = 1.20, 5.02), but not with preterm premature rupture of membranes (OR = 1.61, 95 % CI = 0.61, 4.26), and medically indicated preterm delivery (OR = 1.83, 95 % CI = 0.72, 4.64).

CONCLUSION

Pregnant women with a high risk of OSA are at an increased risk of having PTD, compared with pregnant women with a low risk of OSA.

Chorioamniotic membrane separation after fetoscopy in monochorionic twin pregnancy: incidence and impact on perinatal outcome

OBJECTIVE

To evaluate the incidence of chorioamniotic membrane separation (CMS) after fetoscopy in monochorionic diamniotic (MCDA) twins and its impact on pregnancy outcome.

METHODS

The study group comprised a consecutive series of 338 women with an MCDA pregnancy complicated by twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR) treated with selective laser photocoagulation of communicating vessels (SLPCV) or cord occlusion (CO). Data obtained included cervical length, gestational age at procedure, type and duration of surgery and placental location. The incidence of CMS, the rates of miscarriage and preterm prelabor rupture of membranes (PPROM), gestational age at delivery and neonatal survival were recorded.

RESULTS

Of the study population of MCDA pregnancies, 270 (79.9%) had TTTS and 68 (20.1%) had sIUGR. SLPCV was performed in 252 (74.6%) cases and CO in 86 (25.4%). Postoperative CMS was observed in 70 (20.7%) cases. Patients with CMS had higher rates of miscarriage (14.3% vs 7.1%; P = 0.049), PPROM before 32 weeks (43.3% vs 13.7%; P < 0.001) and preterm delivery before 32 weeks (53.3% vs 26.1%; P < 0.001) and a lower rate of neonatal survival of at least one twin (81.7% vs 93.6%; P = 0.003). Multivariate analysis showed that gestational age at surgery was the only independent predictor, with the highest proportion of CMS occurring in cases that underwent surgery before 18 weeks' gestation (odds ratio, 2.941 (95% CI, 1.640-5.275); P < 0.001). There was no influence of cervical length, placental location, duration of surgery or type of surgery on the risk of CMS.

CONCLUSIONS

CMS complicated one-fifth of all MCDA pregnancies that underwent fetoscopy. It appeared to be more common in those who underwent surgery before 18 weeks' gestation and was associated with poorer outcomes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Development and validation of a tool incorporating quantitative fetal fibronectin to predict spontaneous preterm birth in symptomatic women

OBJECTIVE

To develop a reliable and validated tool for prediction of spontaneous preterm birth (sPTB) in symptomatic women that incorporates quantitative measurements of fetal fibronectin (qfFN) and other relevant risk factors.

METHODS

Data were analyzed that had been collected prospectively from 382 women who presented at an emergency assessment unit between 22 + 0 and 35 + 6 weeks' gestation with symptoms of preterm labor. Clinicians were blinded to qfFN although they were aware of qualitative fFN results. Parametric survival models for sPTB, with time-updated covariates, were developed for combinations of predictors and the best was selected using the Akaike and Bayesian information criteria. The model was developed on the first 190 consecutive women and validated on the subsequent 192. The estimated probability of delivery before 30, 34 or 37 weeks' gestation and within 2 or 4 weeks of testing was calculated for each patient and was compared to actual event rates. Predictive statistics were calculated to compare training and validation sets.

RESULTS

The final model that was selected used qfFN and previous sPTB/preterm prelabor rupture of membranes (PPROM) as predictors. Predictive statistics were similar for training and validation sets and there was good agreement between expected and observed sPTB for all outcomes. Areas under the receiver-operating characteristics curves ranged from 0.77 to 0.88, indicating accurate prediction across all five delivery outcomes.

CONCLUSIONS

sPTB in symptomatic women can be predicted accurately using a model combining qfFN and previous sPTB/PPROM. Clinicians can use this model, which has been incorporated into an App (QUiPP), to determine accurately a woman's risk of sPTB and potentially tailor management decisions appropriately.

Anterior placental location influences onset and progress of labor and postpartum outcome

INTRODUCTION

The aim of the study is to evaluate whether placental location at term is associated with delivery outcome.

METHODS

A prospective study including 2354 patients with singleton pregnancy at term admitted for vaginal delivery was conducted. Placental position was determined before delivery by ultrasonographic examination performed transabdominally with women in the supine position. Maternal characteristics and delivery outcome such as premature rupture of membranes, induction of labor, mode and gestational age at delivery, indication for cesarean section, duration of the third stage, postpartum hemorrhage (PPH) and manual removal of placenta were correlated with anterior, posterior or fundal placental locations.

RESULTS

Among women enrolled: i) 1164 had an anterior placenta, ii) 1087 a posterior placenta, iii) 103 a fundal placenta. Women with anterior placenta showed: i) a higher incidence of induction of labor (p = 0.0001), especially for postdate pregnancies and prolonged prelabor rupture of membranes (p < 0.0001), ii) a higher rate of cesarean section rate for failure to progress in labor (p = 0.02), iii) a prolonged third stage (p = 0.01), iv) a higher incidence of manual removal of placenta (p = 0.003) and a higher rate of PPH in vaginal deliveries (p = 0.02).

DISCUSSION

The present study showed the influence of anterior placental location on the course of labor, with a later onset of labor, a higher rate of induction and cesarean section and postpartum complications. The reason for this influence on labor and delivery complications remains to be elucidated.

Iatrogenic perforation of intertwin membrane after laser surgery for twin-to-twin transfusion syndrome

OBJECTIVE

To evaluate management and outcome of iatrogenic monoamniotic twins (iMAT) compared with twins with intact intertwin dividing membranes after laser surgery for twin-to-twin transfusion syndrome (TTTS).

METHODS

This was a retrospective analysis of twins with and without iatrogenic rupture of the intertwin membranes that had been treated for TTTS with laser surgery at our center between 2004 and 2012. Primary outcomes were perinatal survival and severe neonatal morbidity. Secondary outcomes were mode of delivery, gestational age at birth and cord entanglement.

RESULTS

In total, 338 pregnancies were included. In 67/338 (20%) pregnancies, iMAT was suspected antenatally. In 47 of these 67 (70%), a preterm Cesarean section was performed for monoamnionicity. Perinatal survival was 108/134 (81%) vs 396/542 (73%) in twins with intact intertwin membranes (P = 0.13). Mean gestational age at birth in iMAT was 31 completed weeks, compared to 33 weeks in twins with intact membranes (P < 0.01). At birth, cord entanglement was present in 8/67 (12%) iMAT pregnancies. Severe neonatal morbidity was assessed in 106/110 (96%) in iMAT cases and 392/416 (94%) in controls. The incidence of severe neonatal morbidity was 28/106 (26%) in iMAT vs 72/392 (18%) in controls (P = 0.25). Severe cerebral injury was significantly increased in the iMAT group as compared with controls, at 16/106 (15%) vs 18/392 (5%) (P < 0.01).

CONCLUSIONS

Iatrogenic rupture of intertwin membranes was suspected in 20% of pregnancies treated with laser therapy for TTTS and was associated with a lower gestational age at birth and increased neonatal morbidity.

Collagen plug sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia

OBJECTIVES

To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH).

METHODS

This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as 'latency'. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM.

RESULTS

Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76-2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups.

CONCLUSIONS

No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH.

Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome

OBJECTIVE

Despite improved perinatal survival following fetoscopic laser ablation (FLA) for twin-twin transfusion syndrome (TTTS), prematurity remains an important contributor to perinatal mortality and morbidity. The objective of the study was to identify risk factors for complicated preterm delivery after FLA.

METHODS

Retrospective cohort study of prospectively collected data on maternal/fetal demographics and pre-operative, operative and postoperative variables of 459 patients treated with FLA in three USA fetal centers. Multivariate linear regression was performed to identify significant risk factors associated with preterm delivery, which were cross-validated using the k-fold method. Multivariate logistic regression was performed to identify risk factors for early compared with late preterm delivery based on median gestational age at delivery of 32 weeks.

RESULTS

There were significant differences in case selection and outcomes between the centers. After controlling for the center of surgery, multivariate analysis indicated that a lower maternal age at procedure, a history of previous prematurity, shortened cervical length, use of amnioinfusion, a cannula diameter of 12 French (Fr), lack of a collagen plug placement and iatrogenic preterm premature rupture of membranes (iPPROM) were significantly associated with a lower gestational age at delivery.

CONCLUSIONS

Specific fetal/maternal and operative variables are associated with preterm delivery after FLA for the treatment of TTTS. Further studies to modify some of these variables may decrease the perinatal morbidity after laser therapy.

Pregnancy outcomes after cold knife conization related to excised cone dimensions. A retrospective cohort study

OBJECTIVE

To analyze the perinatal outcome of pregnancies following cold knife conization and investigate its relationship, if any, with the amount of tissue removed, and to assess risk factors of perinatal complications.

STUDY DESIGN

A retrospective cohort study was designed to compare perinatal outcomes between a group of patients who had prior conization operation (study group) and a group of patients who did not have a conization operation (control group).

RESULTS

The preterm delivery rate and preterm premature rupture of membranes (PPROM) rate were significantly higher in the study group as compared with the control group. The mean cone volume was significantly higher in the group of patients who delivered at <37 weeks as compared with the group of patients who delivered at >37 weeks. For the patients who were diagnosed with PPROM, the mean excised volume and height were higher than those of the group of patients who were not diagnosed with PPROM. In cases with preterm delivery the cutoff value of excised cervix tissue volume was measured as 2.27 cm3, and in cases with PPROM the cutoff value of excised cervix tissue volume was measured as 3.99 cm3.

CONCLUSION

The perinatal complication frequency was higher for the group of patients who had undergone conization procedure. We found that the volume of excised cervix tissue is more important than the height of the excised cervix tissue in regards to the assessment of perinatal complications. Colposcopy and conization procedure must be performed by the same, experienced specialist. During the procedure unnecessary tissue excision must be avoided.

[Management of preterm prelabor rupture of membranes with respect to the inflammatory complications - our experiences]

OBJECTIVE

Preterm prelabor rupture of membranes is responsible for approximately one third of all preterm deliveries. The most common complications associated with this pregnancy pathology are microbial invasion of the amniotic cavity, intraamniotic inflammation, intraamniotic infection and histological chorioamnionitis. This article explains these complicatioss and their relation to the optimal management of preterm prelabor rupture of membranes.

DESIGN

Overview study.

SETTING

Department of Obstetrics and Gynecology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove.

METHODS

To analyze current knowledge and our own experiences regarding inflammatory complications of preterm prelabor rupture of membranes.

CONCLUSION

Inflammatory complications of preterm prelabor rupture of membranes are associated with risk of development of early onset sepsis. Nevertheless, gestational age is a main confounder affecting neonatal morbidity and mortality.

Management of prelabour rupture of membranes (PROM) at term

Over a 20-month period we identified several cases of neonatal pneumonia associated with prelabour rupture of membranes (PROM) at term. PROM complicates 8%-10% of all pregnancies, yet 60% of cases occur at term. Ascending infection is a contributing factor and the incidence of chorioamnionitis in these patients is relatively high, especially with prolonged membrane rupture. The signs and symptoms NICE recommends patients look out for are not always present as the majority of infections are subclinical, yet associated maternal and neonatal morbidity of chorioamnionitis is potentially devastating. A survey of maternity units in the West Midlands reveals significant variance in management of these cases. Given the lack of consensus and clear evidence on optimal management of PROM at term, we believe early detection of developing infections could be enhanced by using a combination of investigations (at presentation, 12 and 24 h), as well as current advice to self-monitor temperature and vaginal loss.

Absorbable gelatin plug does not prevent iatrogenic preterm premature rupture of membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

OBJECTIVE

Despite fetoscopic laser ablation (FLA) having emerged as an effective treatment for twin-twin transfusion syndrome (TTTS), major postintervention challenges, such as iatrogenic preterm premature rupture of membranes (iPPROM), remain. A chorioamniotic plug (CAP) made of absorbable gelatin sponge has been used to seal the trocar entry site in the chorioamniotic layers to promote healing and prevent iPPROM, yet the results have been equivocal. Our objective was to test the hypothesis that, following FLA for TTTS, iPPROM may be prevented by placement of an absorbable gelatin CAP.

METHODS

A retrospective cohort study was performed on prospectively collected data from 134 consecutive patients who underwent FLA for TTTS. The decision for CAP placement was at the discretion of the physician. Preoperative, operative and postoperative variables were collected and analyzed. The primary outcome was the incidence of iPPROM, and the secondary outcomes were procedure-to-delivery interval and gestational age at delivery. Comparative statistical analysis was performed as appropriate.

RESULTS

A CAP was placed in 72 (54%) of 134 patients. Factors significantly associated with CAP placement were higher gravidity (P = 0.03), anterior placentation (P = 0.04), general endotracheal intubation (P = 0.02) and a cannula diameter of 12-Fr (P = 0.003). There were no differences between CAP and no-CAP groups in the rate of iPPROM (39% vs 34%, respectively; P = 0.42) or in the procedure-to-delivery interval (65.3 ± 34.7 days vs 58.2 ± 30.8 days, respectively; P = 0.21). The gestational age at delivery was later in the CAP group compared with the no-CAP group (30.7 ± 4.5 weeks vs 28.9 ± 3.9 weeks, respectively; P = 0.02).

CONCLUSIONS

CAP did not reduce the overall risk for iPPROM and did not increase the procedure-to-delivery interval. Further research is needed to identify other methods to prevent iPPROM and prolong pregnancy after laser therapy.

Mussel mimetic tissue adhesive for fetal membrane repair: initial in vivo investigation in rabbits

OBJECTIVE

Iatrogenic preterm prelabour rupture of fetal membranes (iPPROM) remains the main complication after invasive interventions into the intrauterine cavity. The aim of this study was to evaluate the sealing capability and tissue interaction of mussel-mimetic tissue adhesive (mussel glue) in comparison to fibrin glue on punctured fetal membranes in vivo.

STUDY DESIGN

A mid-gestational rabbit model was used for testing the materials. The fetal sacs of pregnant rabbits at day 23 were randomly assigned into experimental groups: unoperated (negative control), unclosed puncture (positive control), commercially available fibrin glue (FG) with decellularized amnion scaffold (DAM), mussel glue (MG) with DAM, or mussel glue alone. Evaluation was done at term (30 days' gestation) assessing fetal survival, fetal membrane integrity and histology of the membranes.

RESULTS

Fetal survival was not significantly lower in any of the treatment groups compared to the negative control. All plugging materials could be found at the end of the pregnancy and no adverse effects on the fetus or the pregnant does could be observed. Sac integrity was higher in all treatment groups compared to the positive control group but significant only in the FG+DAM group. Cellular infiltration could be seen in fibrin glue and DAM in contrast to mussel glue which was only tightly adhering to the surrounding tissue. These cells were mostly of mesenchymal phenotype staining positive for vimentin. CD68 positive macrophages were found clustered around all the plugging materials, but their numbers were only significantly increased for the mussel glue alone group compared to negative controls.

CONCLUSIONS

Mussel glues performance in sealing fetal membranes in the rabbit model was comparable to that of fibrin glue. Taking into account its other favorable properties, it is a noteworthy candidate for a clinically applicable fetal membrane sealant.

Procedure-related complications after genetic amniocentesis and chorionic villus sampling

PURPOSE

Amniocentesis (AC) and chorionic villus sampling (CVS) play an important role in the diagnosis of genetic anomalies. The aim of this study was to evaluate presentable numbers of procedure-related complications of genetic interventions in a tertiary referral hospital.

MATERIALS AND METHODS

The pregnancy outcome of women who underwent genetic AC or CVS during 2003-2010 at the Department of Obstetrics and Gynecology, Medical University of Graz, Austria, was analyzed retrospectively. The primary outcome was miscarriage or membrane rupture after an invasive procedure. Only singleton gestations were included.

RESULTS

1,569 AC procedures and 334 CVS procedures (234 transabdominal, 99 transcervical, 1 with undocumented route) were performed. Of these, 57 cases were excluded from further analysis because of severe anomalies. Complete outcome data were available for 93.17% of cases. In 164 (8.89%) cases the pregnancy was terminated due to genetic anomalies or severe malformations. In the remaining collective 10 of 1,342 (0.75%) AC procedures, 3 of 150 (2.00%) transabdominal CVS procedures and 2 of 64 (3.13%) transcervical CVS procedures lead to complications resulting in miscarriage < 24 weeks (n = 13) or rupture of membranes (n = 2) within 2 weeks after procedure. Complication rates were significantly higher after CVS than after AC (OR 3.19).

CONCLUSION

Over an observation period of seven years, the complication rates after AC, transabdominal CVS and transcervical CVS were 0.75%, 2.00% and 3.13%, respectively. These results are comparable to recent international investigations.

Perinatal outcome after selective feticide in monochorionic twin pregnancies

OBJECTIVE

To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide.

METHODS

This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity.

RESULTS

Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23-38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001).

CONCLUSIONS

The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required.

Prediction of preterm birth

Preterm delivery is birth occurring before 37 completed weeks of gestation. Preterm birth is the primary cause of morbidity and mortality in children especially if this occurs before 34 weeks of gestation. If preterm birth could be predicted and treated accordingly, this would greatly reduce mortality, morbidity and associated costs. There have been many attempts to develop an accurate and efficient method to predict preterm premature rupture of membranes (PPROM) and preterm labor that leads to spontaneous preterm birth (SPB). However, the initial signs and symptoms are most often mild and may even occur in normal pregnancies, making early detection rather difficult. The aim of this paper is to provide an overview of the current methods employed in predicting preterm birth occurring due to preterm labor and PPROM. Among these methods are risk scoring systems, cervical/vaginal screening for fetal fibronectin, cervical assessment by ultrasonography, uterine activity monitoring, biomarkers such as endocrine factors, cytokines and enzymes, fetal DNA and genetic polymorphism. SPB is multifactorial, and so it is highly unlikely that a single test can accurately predict SPB. A combination of biological markers is also reviewed in the estimation of the risk of preterm delivery.

[Thrombocytopenia during pregnancy]

Thrombocytopenia during pregnancy can be caused by a broad variety of disorders. An early diagnosis is essential for timely and adequate therapy. In cases of severe thrombocytopenia, a multidisciplinary approach by a team of obstetricians, haematologists and anaesthesiologists is needed. We describe a 30-year-old patient at a gestational age of 35 weeks who presented with preterm rupture of membranes. Coincidentally, she also had severe thrombocytopenia that proved to be due to immune thrombocytopenia (ITP). The severe thrombocytopenia persisted despite standard first-line treatment with corticosteroids and intravenous immunoglobulins. Based on this case report we discuss the differential diagnosis of thrombocytopenia during pregnancy with a focus on the management of ITP in pregnant women.

Adverse outcomes in twin pregnancies complicated by early vaginal bleeding

OBJECTIVE

We sought to estimate the risks of adverse pregnancy outcomes associated with early vaginal bleeding in twin pregnancies.

STUDY DESIGN

In a retrospective cohort study of consecutive twin pregnancies undergoing anatomic survey, we compared women who reported vaginal bleeding at <22 weeks to those who did not. Exclusion criteria included monoamniotic pregnancies, twin-to-twin transfusion syndrome, and placenta previa. Primary outcomes included preeclampsia, abruption, preterm premature rupture of membranes (PPROM), preterm birth <34 weeks, and intrauterine growth restriction.

RESULTS

Of 2106 pregnancies meeting inclusion criteria, 175 reported vaginal bleeding. Twin pregnancies with early vaginal bleeding had significantly higher risks of abruption, PPROM, and preterm birth compared to twin pregnancies without bleeding. The findings were similar when twin pairs were stratified by parity or maternal comorbidities.

CONCLUSION

Twin pregnancies complicated by vaginal bleeding in early pregnancy have an increased risk of abruption, PPROM, and preterm birth <34 weeks.

Morbidities of cervical cerclage: experience at a tertiary referral center

The Perinatal morbidity and mortality associated with pre-term delivery is well known. Cervical incompetence or short cervix is a risk factor for the condition and cervical cerclage is the management option for such cases. The objective of the study was to determine the frequency of operative morbidities of cervical cerclage. All women undergoing cervical cerclage from April 2007 to December 2009 at the Aga Khan University Hospital served as the study subjects. Findings suggested that the risk of developing ruptured membranes after cervical cerclage was 10% and that of pregnancy loss was 8.6%. The risk of cerclage-associated complications like rupture of membranes, bleeding and chorioamnionitis was small. The risk of delivery before 34 weeks of gestation was 15.7%.