Does the presence of a funnel increase the risk of adverse perinatal outcome in a patient with a short cervix?

OBJECTIVE: This study was undertaken to determine whether the presence of a dilated internal os (funneling or beaking) alters the outcome of patients with a short cervix documented by transvaginal ultrasound in the second trimester. STUDY DESIGN: Between January 1998 and May 2004, all singleton pregnancies with a short cervix (< or =2.5 cm) and no funnel between 16 and 24 weeks' gestational age were identified by query and review of the Lehigh Valley Perinatal Ultrasound Database. These no funnel patients were compared with patients with a short cervix and funnel matched in accordance with cervical length and risk factors. Multiple variables of perinatal outcome were identified and compared between the Funnel and No Funnel groups. Correlations between cervical measurements and gestational age at birth were analyzed. RESULTS: Of the 279 patients with a short cervix identified, 82 were singleton with a T-shaped cervix and no funnel and 82 patients matched with a typical Y-shaped funnel. There was no difference between groups with respect to maternal demographics, previous preterm birth (28.1% No Funnel group vs 36.5% Funnel group, P = .3), prior cervical surgery (24.3% vs 22.0 %, P = .8), gestational age at entry (20.5 +/- 2.1 vs 21.1 +/- 2.4 weeks, P = .1), and cervical length (1.9 +/- 0.4 vs 1.8 +/- 0.5 cm , P = .1). The No Funnel group had significantly less readmissions for preterm labor (43.2% vs 67.1 %, P = .004), chorioamnionitis (2.4% vs 23.2 %, P = .0002), abruption (1.2% vs 13.4 %, P = .007), preterm rupture of membranes (6.1% vs 23.4%, P = .002), and cerclage placement (23.2% vs 43 %, P = .008). The neonates in the no funnel group delivered later (36.2% +/- 4.6 vs 33.8 +/- 5.4 weeks , P = .003), and had less morbidity and mortality (17.1% vs 37.8 %, P = .02) compared with the Funnel group. The width and depth of the funnel did not correlate with perinatal outcome. Cervical length ( R(2) = 0.07, P = .02) and cervical funneling as a categorical variable ( r = 0.3, P = .0002) did correlate with earlier delivery. CONCLUSION: The disruption of the internal os, as documented by funneling, is a significant risk factor for adverse perinatal outcome (ie, preterm labor, chorioamnionitis, abruption, rupture of the membranes, and serious neonatal morbidity and mortality). Cervical funneling is best measured as a categorical variable (present or absent).     

Does apoptotic activity have a role in the development of the placental abruption?

Objective: The purpose of the present study is to analyses the role of apoptotic activity in placental abruption (PA) development by evaluating the level of plasma M30–M65.

Methods: The study group included 46 pregnant women who underwent caesarean sections (CS) because of PA, and the control group included 48 pregnant women who underwent CS because of obstetric causes. Venous blood samples were received from all expectants before starting the CS for the purpose of evaluating the M30–M65 levels, which are indicators of apoptotic activity in maternal plasma.

Results: The plasma M30–M65 levels were determined to be statistically significantly higher in with PA group. The sensitivity and specificity of the test were determined to be 71.7% and 64.6%, respectively in identifying the expectants with PA when the cut-off value was taken as 163.50?U/L for the plasma M30 value. The sensitivity and specificity of the test were determined to be 76.1% and 66.7%, respectively in identifying the PA when the cut-off value was taken as 295.50?U/L for the M65 value.

Conclusions: The increase of apoptotic activity induced by thrombin resulting from decidual bleeding may have a role in the development of PA.     

Is there a relationship between uterine activity and the length of the cervix in the second trimester?

OBJECTIVE: The purpose of this study was to determine if a relationship could be detected between uterine activity and cervical change in the second trimester. METHODS: Ten women with evidence of cervical change and 10 women with no cervical change (controls) were studied between 20 and 28 weeks gestation. Uterine activity was recorded using home uterine activity monitoring units. Cervical assessment was performed using transvaginal ultrasound. RESULTS: There was no statistically significant difference in the contractions per hour in the cervical change group (1.26 +/- 0.38; mean +/- SEM) compared to the controls (1.13 +/- 0.48) (p 0.48; Mann-Whitney U test). There were significant differences in closed endocervical length (p < 0.001) and internal os dilatation (p 0.004), the cervical change group demonstrating a shorter closed endocervical length and greater internal os dilatation. CONCLUSIONS: This preliminary study shows no evidence of a relationship between uterine activity and endocervical canal length in the second trimester.     

Is the occurrence of the empty follicle syndrome a predictor that a subsequent stimulated cycle will be an unfavourable one?

Several hypotheses have been advanced to explain empty follicle syndrome (EFS) but it remains a controversial topic. This paper reports experience with three IVF cycles in which no oocytes were collected. In all cases, an additional IVF cycle was performed. The ovarian stimulation protocol, ultrasound and hormonal surveillance methods, human chorionic gonadotrophin timing and oocyte retrieval technique were similar in all patients. The assessment of additional cycles demonstrated a poor response in terms of oocyte quality, since the number of mature oocytes was low despite the high number of oocytes collected. Thus, the data suggest that in these patients, EFS should be considered as a borderline form of poor response to ovarian stimulation. If this is confirmed, EFS should be a recurrent event and an empty cycle could be a good predictor that a subsequent stimulated cycle will be an unfavourable.     

Gynecologists' attitudes toward hysterectomy: is the sex of the clinician a factor?

OBJECTIVE: To assess the effect of gynecologists' sex on their clinical opinions of hysterectomy. STUDY DESIGN: A survey presenting a case of symptomatic uterine leiomyomas was randomly mailed to the fellows of the American College of Obstetricians and Gynecologists, who were asked to choose either hysterectomy or any uterus-sparing modality for the treatment of the presented case. The effects of gynecologists' sex, age, race, type and year of training, practice type, location and region on their clinical opinions were evaluated with univariate and multivariate logistic regression analysis. RESULTS: Among the 500 potential respondents, 245 (49.0%) responses were complete for analysis. One hundred forty-seven (60.0%) were males, and 98 (40.0%) were females. Hysterectomy choice was not significantly influenced by the gynecologist's sex (77.6% vs. 87.1%; OR 0.51; 95% CI 0.26, 1.01). Univariate logistic regression analysis indicated that only younger age and being in an academic practice significantly decreased the hysterectomy choice among the participants. In the multivariate model, both age (OR 1.66; 95% CI 1.27, 2.19) and academic practice type (OR 0.37; 95% CI 0.14, 0.94) remained independently significant. CONCLUSION: When presented with a case involving symptomatic leiomyomas, gynecologists' sex did not significantly affect their opinion for or against hysterectomy. Only age and practice type were independently significant in this decision making.     

Drug-induced labour--more than just a decision by the obstetrician?

The induction of labour ist the most frequently indicated measure in obstetrics. In this way a better perinatal result for both mother and infant should be expected than from a wait-and-see policy. In addition, the induction of labour should make vaginal delivery possible and thus spare the mother from the trauma of a Caesarean section. Today obstetrics is positioned in a field of tension between medical indications, the maternal wish for recognition of her sovereign right of decision, confirmed knowledge from evidence-based medicine and other paramedical influences. From the point of view of the clinical obstetrician the individual medical situation is all important, whereby the dynamics of the primary pathology, possibilities for its treatment, particular risks of induction of labour, and the success of a vaginal delivery have to be taken into consideration. A main principle is the more elective ist the induction of labour the more comprehensively must the patient be informed about the risks and benefits of the procedure. Current results about the most frequent indications for the induction of labour reveal a low strength of evidence. This is particularly valid for the increasingly more frequent problem of induction of labour after a previous Caesarean section. In the author's opinion the obstetrician should employ all his/her clinical skill and experience (in the sense of good clinical practice) in the risk-adapted decision making with regard to the induction of labour, especially in cases of previous Caesarean operations and not--a priori--follow the mode to "trendy Caesareanism". In this way, obstetrics will remain a domain demanding individual skill and ability from the future generations of responsible obstetrician and will not degenerate to solely a "surgical performance".