Elevated vaginal pH in the absence of current vaginal infection,still a challenging obstetrical problem

Abstract

Objective: To assess the association of vaginal pH?≥?5 in the absence of vaginal infection with systemic inflammation and adverse pregnancy outcome.

Methods: Four-hundred sixty pregnant women completed the study, upon enrollment Vaginal pH was measured for all women, maternal and umbilical sera were obtained for determining C-reactive protein (CRP) and uric acid levels. Umbilical blood was tested for gas parameters, 1 and 5?min Apgar scores, the need for neonatal resuscitation and neonatal intensive care unit (NICU) admission were recorded.

Results: Elevated vaginal pH was significantly associated with preterm birth (odds ratio (OR), 2.23; 95% confidence interval (CI), 1.04–4.76), emergency cesarean section (OR 2.57; 95% CI 1.32–5), neonatal resuscitation in the delivery room (OR 2.85; 95% CI 1.1–7.38), elevated cord base deficit (OR 8.01; 95% CI 1.61–39.81), low cord bicarbonate (OR 4.16, 95% CI 1.33–12.92) and NICU admission (OR 2.02; 95% CI 1.12–3.66). Increased vaginal pH was also significantly associated with maternal leukocytosis, hyperuricemia and elevated CRP levels in maternal and umbilical sera.

Conclusions: Elevated vaginal pH in the absence of current vaginal infection still constitutes a risk for adverse pregnancy outcome which is mediated by systemic inflammatory response.     

The Effect of Second-Trimester Antibiotic Therapy on the Rate of Preterm Birth

ObjectiveAs many as 50% of spontaneous preterm births are infection-related, with Mycoplasma species being the most common microbial isolates from the amniotic cavity. The goal of our study was to evaluate the effect of macrolides, a specific group of antibiotics known to be effective against Mycoplasma species, on the rate of preterm births.MethodsWe performed a systematic review of the literature and a meta-analysis. We searched PubMed, Medline (1965–March 2006), Embase, and the Cochrane Library, using the key words “pregnancy,” “macrolides,” “erythromycin,” “azithromycin,” and “clarithromycin.” The research was limited to randomized controlled trials and to human females. Studies included for analysis were of women in the second trimester of pregnancy who received either macrolides or placebo (or no treatment) in order to prevent preterm delivery with at least 95% of patient follow-up. We excluded studies involving women with preterm premature rupture of membranes or regular uterine contractions. Meta-analysis of the retrieved data was performed using RevMan 4.2.8 (Cochrane Collaboration) with dichotomous analyses and delivery prior to 37 weeks’ gestation as the primary outcome. The analysis was subsequently repeated using the same methodology for clindamycin and metronidazole administered during the second trimester.ResultsOf the 61 articles yielded by our search, three original papers, investigating a total of 1807 women, examined macrolide utilization and met our criteria. Women included in our analysis were all considered to be at higher risk for preterm delivery (vaginal fetal fibronectin positivity, urogenital Mycoplasma infection, prior preterm delivery, and/or pregestational maternal weight < 50 kg). Compared with placebo, macrolides were associated with a lower rate of preterm births (odds ratio [OR] 0.72; 95% confidence intervals [CI] 0.56–0.93), as was clindamycin (OR 0.68; 95% CI 0.49–0.95). On the other hand, metronidazole (OR 1.10; 95% CI 0.95–1.29) was not linked with significant changes in the rate of preterm births. A higher rate of preterm delivery was found when mid-trimester metronidazole was the only antibiotic administered (OR 1.31; 95% CI 1.08–1.58).ConclusionMacrolides and clindamycin, given during the second trimester of pregnancy, are associated with a lower rate of preterm delivery, whereas second-trimester metronidazole used alone is linked with a greater risk of preterm delivery in a high-risk population. Use of metronidazole, a common treatment for bacterial vaginosis and Trichomonas vaginalis, should be avoided during the second trimester of pregnancy in this population.     

Perinatal outcomes and complications of pregnancy in women with immune thrombocytopenic purpura

Objective.?To investigate pregnancy and perinatal outcomes in women with immune thrombocytopenic purpura (ITP).

Methods. A retrospective study comparing all singleton pregnancies of women with and without ITP was conducted. Deliveries occurred between the years 1988 and 2007. Multiple logistic regression models were performed to control for confounders.

Results.?During the study period, 186,602 deliveries were recorded, out of which 104 (0.06%) occurred in patients with ITP. In a multivariable analysis, we found the following conditions to be significantly and independently associated with ITP: hypertensive disorders, diabetes mellitus, and preterm delivery (<34 weeks gestation). Patients with ITP had significantly higher rates of preterm delivery (<34 weeks gestation; 6.7%vs. 2.2%; p < 0.001) and perinatal mortality (4.8%vs. 1.3%; p = 0.011) when compared with patients without ITP. Two multivariable logistic regression models were constructed with perinatal mortality and preterm delivery (<34 weeks gestation) as the outcome variables to control for possible confounders such as congenital malformations, hypertension, diabetes mellitus, and maternal age. In these models, ITP was found to be an independent risk factor for perinatal mortality (OR = 3.77; 95% CI 1.32–10.78, p = 0.013), as well as for preterm delivery before 34 weeks gestation (OR = 3.01; 95% CI 1.39–6.52, p = 0.005).

Conclusion.?ITP is significantly and independently associated with preterm delivery before 34 weeks gestation and with perinatal mortality.     

Assessing the relationship between preterm delivery and various microorganisms recovered from the lower genital tract

Objective.?To determine if the likelihood of preterm delivery is more dependent on the specific organisms present in the vagina than on the presence of bacterial vaginosis.

Methods.?We evaluated the vaginal fluid of a prospective cohort of women at 23–32 weeks of gestation with signs and symptoms of preterm labor and intact membranes. Forward stepwise logistic regression models were used to evaluate the relationship between preterm delivery and the presence of anaerobic bacteria, Gardnerella, ureaplasmas and mycoplasmas, and sialidase.

Results.?The cohort included 137 women, and complete delivery information was available for 134 of them. The rate of preterm delivery was 28% (37 of 134). Mycoplasma genitalium independently was associated with spontaneous preterm delivery (OR 3.48; 95% CI 1.41, 8.57). After controlling for this factor, none of the other variables were significantly prognostic for spontaneous preterm delivery (residual overall p = 0.19).

Conclusion.?The presence of Mycoplasma genitalium in the vagina of pregnant women is an independent risk factor for spontaneous preterm delivery.     

Is a cause of postpartum hemorrhage of using of tocolytic agents in preterm delivery?

Objective: Tocolytic agents are used to inhibit uterine contraction in preterm. The authors undertook this study to determine whether using of tocolytic agents before delivery is associated with increase postpartum hemorrhage in preterm delivered women.

Method: 296 singleton pregnancies delivered preterm from 24?+?1 to 37?+?0 weeks gestation were retrospectively reviewed. Hemoglobin (HB) and hematocrit (HCT) levels were checked before and after delivery to access postpartum blood loss. Multivariate logistic regression analysis was performed to determine whether delivery within the half-lives of tocolytic agents was associated with decreased HB and HCT levels.

Results: After adjusting for maternal age, parity, gestational age at delivery, birth weight, delivery method, and induction of labor, postpartum HB and HCT levels of those delivered within half-lives of tocolytic agents were found to be significantly diminished (HB: OR 3.306, 1.308–8.356 95% CI, p?=?0.011; HCT: OR 2.692, 1.077–6.726 95% CI, p?=?0.034). In addition, blood transfusion rates were elevated for deliveries made within the half-lives of tocolytic agents, (p?=?0.006).

Conclusions: Delivery within half-lives of tocolytic agents was found to be associated with low HB and HCT levels after delivery and higher blood transfusion rates in preterm delivered women.     

Performance of cervicovaginal fetal fibronectin in a community hospital setting

Objective To assess the accuracy of vaginal fetal fibronectin (FFN) as a screening test for preterm delivery in a community hospital. Study design A prospective cohort of patients at high risk for preterm delivery at a community hospital underwent testing with FFN over a 15 month-period (March 2004–May 2005). Indications for testing were preterm labor, multiple pregnancies, cervical shortening, and cerclage. Pregnancy characteristics were retrieved on all women with positive FFN results and controls in a 1:2 ratio. Outcome variables included interval to delivery; length of hospital stay; and rates of preterm delivery <37 weeks. In the presence of serial FFN testing, only the initial result was used for calculation of diagnostic indices. Statistical analysis utilized t-test, Fisher’s exact test and logistic regression analyis to control for gestational age at testing, with P < 0.05 or odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. Results Two hundred and fifty seven FFN tests were performed in 230 women, of which 33 (14.3%) had positive FFN results. Duration of hospital stay was significantly shorter for patients with negative than positive results (8 h vs. 2.1 days, P = 0.011). Women with positive FFN were more likely to deliver within 14 days (OR = 6.5, 95% CI 1.4; 30.7), within 21 days (OR = 4.8; 95% CI 1.4; 16.6), before 34 weeks (OR = 5.0, 95% CI 1.7; 14.8) and before 37 weeks (OR = 3.1; 95% CI 1.3; 7.1) than women with negative results. Conclusion A negative FFN result provides enough reassurance to allow shorter hospital stay. In a real-world setting (a community hospital with a population heterogenous for risk factors for preterm delivery, and in a non-protocol setting) the performance of FFN testing closely mirrors that obtained in academic institutions, where the test was studied in more uniform populations under strict protocols. Summary The performance of vaginal fibronectin in patients with heterogeneous risk factors for preterm delivery closely mirrors that obtained in studies conducted in populations with homogeneous risk factors.     

Maternal risk factors for preterm birth: a country-based population analysis

Objective

The aim of this study was to identify maternal risk factors for spontaneous preterm birth (PTB) compared to delivery at term, in order to recognize high risk women and to provide a global overview of the Italian situation.

Study design

A multicenter, observational and retrospective, cross-sectional study was designed. The study population comprised 7634 women recruited in 9 different University Maternity Hospitals in Italy. The main criteria for inclusion were: women having had vaginal preterm or term spontaneous delivery in each participating centre during the study period. The records related to deliveries occurring between April and December 2008. A multivariable logistic regression was employed to identify independent predictors of spontaneous preterm birth. Odds ratios (ORs) and 95% confidence intervals (95% CI) were reported with two-tailed probability (p) values. Statistical calculations were carried out using SAS version 9.1. A two-tailed p-value of 0.05 was used to define statistical significant results.

Results

A significant increased risk of PTB was found in women with BMI > 25 (OR = 1.662; 95% CI = 1.033–2.676; p-value = 0.0365) and in women employed in heavy work (OR = 1.947; 95% CI = 1.182–3.207; p-value = 0.0089). Moreover there was a significant association between PTB and previous reproductive history. In fact a history of previous abortion (OR = 1.954; 95% CI = 1.162–3.285; p-value = 0.0116) or previous cesarean section (OR = 2.904; 95% CI = 1.066–7.910; p-value = 0.0371) was positively correlated to the increased risk of PTB and an important statistically significant association was calculated between PTB and previous pre-term delivery (OR = 3.412; 95% CI = 1.342–8.676; p-value = 0.0099). All the other covariates examined as potential risk factors for PTB were not found to be statistically significantly related (p-value > 0.05).

Conclusions

The present study, applied to a substantial sample of Italian population, demonstrates that there are peculiar risk factors for spontaneous PTB in the Italian population examined. It shows an association between preterm delivery and certain maternal factors as: BMI, employment, previous abortions, previous PTBs and previous cesarean section.     

Maternal rehospitalization after singleton term vaginal delivery

Objective: To determine risk factors for maternal rehospitalization after term vaginal delivery. Study design: The study group consisted of all women who were rehospitalized following singleton vaginal deliveries during 1996-1998 (n = 194). The control group consisted of 427 women who were not rehospitalized during the same period. Results: The incidence of rehospitalization was 0.75% (194/25 885). Maternal chronic diseases, preterm contractions and pre-eclampsia rates were significantly higher among the study group as compared to the controls (25.3% vs. 8.4%, p < 0.001; 6.7% vs. 2.8%, p = 0.022; 9.3% vs. 4.9%, p = 0.037, respectively). Duration of labor was significantly longer in the study group as opposed to the controls (379 ± 406 min vs. 259 ± 276 min, p < 0.001). The rates of postpartum hemorrhage, blood transfusion and antibiotic treatment during delivery hospitalization were significantly higher among the study group (1.5% vs. 0.2%, p = 0.021; 4.6% vs. 0.7%, p < 0.001; 26.8% vs. 14.1%, p < 0.001, respectively). Using a forward logistic regression analysis, prolonged labor and blood transfusion during labor were found as independent risk factors associated with rehospitalization (OR 1.001, 95% CI 1.001-1.002, p = 0.001; OR 4.751, 95% CI 1.698-13.292, p = 0.003). In contrast, vertex presentation had a protective effect against rehospitalization (p = 0.027, OR 0.084, 95% CI 0.009-0.758). Conclusions: Blood transfusion and prolonged labor are independent risk factors for rehospitalization after term vaginal delivery. Special attention should be given during the early postpartum period to patients receiving blood transfusions and those with prolonged deliveries, in order to reduce rehospitalization rates.     

Pregnancy outcome in women aged 40 years or more

Objective: The study aimed to analyze the pregnancy outcome of women aged 40 years or more. Methods: A matched retrospective cohort study comparing women aged 40 years or more with a control group aged 20 to 30 years is described. Multivariate logistic regression models were fitted for the prediction of preterm birth and cesarean delivery. Results: Pregnancy-induced hypertension, preeclampsia and placenta previa were similar in both groups, but a higher rate of gestational diabetes was found in elderly patients (odds ratio [OR] 3.820, 95% confidence interval [CI] = 1.400–10.400; p < 0.0001). Preterm delivery was significantly more frequent in elderly women (OR 1.847, 95% CI = 1.123–3.037; p = 0.020). Gestational diabetes and pregnancy-induced hypertension were strongly associated with preterm delivery and advanced maternal age was not an independent risk factor for preterm delivery. The cesarean delivery rate was significantly higher in the study group (OR 3.234, 95% CI = 2.266–4.617; p < 0.0001). The variables most influencing the cesarean delivery rate were maternal age, analgesia, parity, premature rupture of the membranes and gestational hypertension. No significant differences were detected in neonatal birth weight and Apgar score. Conclusions: Patients aged 40 years or more have been demonstrated to carry a favorable pregnancy and neonatal outcome, similar to younger patients. The risk of cesarean delivery was higher in patients with advanced maternal age, in nulliparous and in women with a previous cesarean section. The risk of preterm delivery was not related to age but it was strongly associated with gestational diabetes and pregnancy-induced hypertension.     

First trimester vaginal bleeding and adverse pregnancy outcomes among Chinese women: from a large cohort study in China

Objectives: To examine the effect of first trimester vaginal bleeding on adverse pregnancy outcomes including preterm delivery, low birth weight and small for gestational age. Methods: This is a prospective population-based cohort study. A questionnaire survey was conducted on 4342 singleton pregnancies by trained doctors. Binary logistic regression was used to estimate risk ratios (RRs) and 95% con?dence intervals (95% CI). Results: Vaginal bleeding occurred among 1050 pregnant women, the incidence of vaginal bleeding was 24.2%, 37.4% of whom didn’t see a doctor, 62.6% of whom saw a doctor for vaginal bleeding. Binary logistic regression demonstrated that bleeding with seeing a doctor was significantly associated with preterm birth (RR 1.84, 95% CI 1.25–2.69) and bleeding without seeing a doctor was related to increased of low birth weight (RR 2.52, 95% CI 1.34–4.75) and was 1.97-fold increased of small for gestational age (RR 1.97, 95% CI 1.19–3.25). Conclusions: These results suggest that first trimester vaginal bleeding is an increased risk of low birth weight, preterm delivery and small for gestational age. Find ways to reduce the risk of vaginal bleeding and lower vaginal bleeding rate may be helpful to reduce the incidence of preterm birth, low birth weight and small for gestational age.     

The association of different progesterone preparations with preterm birth prevention

Objective: We aimed to compare the efficacy of commonly available progesterone preparations for preterm birth prevention.

Methods: A retrospective cohort study of all women treated with progesterone to prevent preterm birth and delivered in a single university-affiliated tertiary medical-center. Four progesterone preparations were compared: vaginal Endometrin 100?mg twice daily, vaginal Crinone 8% gel 90?mg daily, vaginal Utrogestan 200?mg daily, and intramuscular 17α-hydroxyprogesterone caproate (17-OHPC) 250?mg weekly. All women were considered at risk for preterm birth according to: prior preterm birth or cervical length below 25?mm measured during the second trimester. Significant maternal morbidity, pregnancy achieved by artificial reproductive technique and cerclage placement were excluded. Primary outcome was the rate of preterm birth prior to 37 weeks of gestation.

Results: Overall, 422 women were allocated to four study groups according to progesterone preparation: Endometrin 175 (41.5%), Crinone 73 (17.3%), Utrogestan 154 (36.5%), and 17-OHPC 20 (4.7%). Rates of preterm birth prior to 37 gestational weeks were lowest on the Endometrin treatment group (12.6 versus 20.5, 17.5, and 35% in the rest, p?=?.05). Multivariate analysis revealed that the progesterone preparation was associated with preterm birth prior to 37 gestational weeks (LR?=?8.3, p?=?.004). The need for maternal red blood cells transfusion was significantly higher in the Endometrin subgroup (4% versus 0 in all others, p?=?.018). This finding remained significant after adjustment to potential confounders (LR 16.44, p?Conclusions: Different progesterone preparations prescribed to women at risk, may possess different efficacy in preventing preterm delivery prior to 37 weeks of gestation.     

Risk of preterm delivery in relation to vaginal bleeding in early pregnancy

OBJECTIVE: To examine the relationship between vaginal bleeding during early pregnancy and preterm delivery. METHODS: Study subjects (N=2678) provided information regarding socio-demographic, biomedical, and lifestyle characteristics. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: Any vaginal bleeding in early pregnancy was associated with a 1.57-fold increased risk of preterm delivery (95% CI: 1.16-2.11). Vaginal bleeding was most strongly related with spontaneous preterm labor (OR=2.10) and weakly associated with preterm premature rupture of membrane (OR=1.36) and medically induced preterm delivery (OR=1.32). As compared to women with no bleeding, those who bled during the first and second trimesters had a 6.24-fold increased risk of spontaneous preterm labor; and 2-3-fold increased risk of medically induced preterm delivery and preterm premature rupture of membrane, respectively. CONCLUSION: Vaginal bleeding, particularly bleeding that persists across the first two trimesters, is associated with an increased risk of preterm delivery.     

Bacterial vaginosis and group B streptococcal colonization and preterm delivery in a low-risk population

OBJECTIVE: To evaluate the relationship between bacterial vaginosis (BV) and group B streptococcal (GBS) colonization in the 2nd trimester of pregnancy and preterm delivery. METHODS: 1,197 pregnant women between 22 and 25 weeks' gestation had a high vaginal swab for assessment of BV and GBS. Exclusion criteria were: previous preterm delivery, or mid-trimester abortion or termination of pregnancy, multiple gestation, oligo- or polyhydramnios, placenta previa, fetal abnormalities, uterine malformations, cervical incompetence, cervical cerclage, or receipt of an antibiotic effective against BV or GBS following the screening. All women had no risk factors for preterm delivery. The primary outcome measure in this analysis was spontaneous preterm delivery before 37 weeks' gestation. RESULTS: The preterm delivery rate was 8.7%, while the maternal BV and GBS colonization rates were 7.9 and 12.5%, respectively. Following adjustment for potential confounders BV was associated with an increased risk of preterm delivery (RR 2.19; CI: 1.21-3.98) (p = 0.01). On the contrary, GBS colonization was found to have a negative correlation with preterm birth (RR 0.43; 95% CI: 0.19-1.00). CONCLUSIONS: Although BV is a risk factor for preterm delivery, GBS colonization in the 2nd trimester of pregnancy has an inverse correlation with preterm delivery.     

Adenomyosis and adverse perinatal outcomes: increased risk of second trimester miscarriage,preeclampsia, and placental malposition

Objective: To evaluate the potential impact of adenomyosis on the pregnancy outcomes by retrospectively investigating adenomyosis-complicated pregnancy cases.

Methods: We performed a retrospective case–control study. Forty-nine singleton pregnancy cases complicated with adenomyosis were included in this study. The controls (n?=?245) were singleton pregnant women without adenomyosis and were frequency matched to adenomyosis cases by age, parity, and the need for assisted reproductive technology for this conception. The incidence of obstetrical complications and delivery and neonatal outcomes were examined.

Results: Patients in the adenomyosis group were significantly more likely to have a second trimester miscarriage (12.2% versus 1.2%, odds ratio (OR): 11.2, 95% confidence interval (95% CI): 2.2–71.2), preeclampsia (18.3% versus 1.2%, OR: 21.0, 95% CI: 4.8–124.5), placental malposition (14.2% versus 3.2%, OR: 4.9, 95% CI: 1.4–16.3), and preterm delivery (24.4% versus 9.3%, OR: 3.1, 95% CI: 1.2–7.2), compared with the control group.

Conclusion: Adenomyosis was associated not only with an increased incidence of preterm delivery, as previously reported, but also with an increased risk of second trimester miscarriage, preeclampsia, and placental malposition, which could lead to poor perinatal outcomes.     

Pregnancy outcome of patients following deep venous thrombosis

Objective. To investigate pregnancy outcome of patients with a history of deep vein thrombosis (DVT).

Methods. A population-based study comparing all pregnancies of patients with and without a history of DVT was conducted. Deliveries occurred during the years 1988–2007 at a tertiary Medical Center. Stratified analyses were performed using multivariable logistic regression models and the Mantel-Haenszel technique.

Results. During the study there were 212,086 deliveries, of which 122 (0.06%) occurred in patients with a history of DVT. Using a multivariate analysis, with backward elimination, the following conditions were significantly associated with DVT: advanced maternal age (OR, 1.1; 95% CI, 1.02–1.1; p = 0.004), chronic hypertension (OR, 2.9; 95% CI, 1.4–6.0; p = 0.005) and previous caesarean delivery (OR, 2.8; 95% CI, 1.9–4.1; p < 0.001). Patients with a history of DVT were more likely to have caesarean deliveries (OR, 2.6; 95% CI, 1.8–3.8; p < 0.001) than non-DVT patients. After controlling for possible confounders, such as maternal age, hypertensive disorders, pregestational diabetes and multiple gestations, by using another multivariate analysis with preterm delivery (<37 weeks' gestation) as the outcome variable, DVT was found to be an independent risk factor for preterm birth (OR, 1.8; 95% CI, 1.1–2.9; p = 0.033). This association remained significant after controlling for labor induction, using the Mantel-Haenszel technique (OR, 1.8; 95% CI, 1.1–3.0; p = 0.011). No significant differences were noted between the groups regarding perinatal outcomes such as low Apgar scores, congenital malformations or perinatal mortality.

Conclusions. A history of DVT is an independent risk factor for spontaneous preterm delivery. Nevertheless, in our population it is not associated with adverse perinatal outcome.     

Vaginal Douching,Bacterial Vaginosis,and Spontaneous Preterm Birth

ObjectiveVaginal douching and bacterial vaginosis (BV) are independently associated with spontaneous preterm birth. Because the interrelationships among these variables remain unclear, we sought to examine the associations in a prospective study.MethodsWe conducted a nested case-control study within a prospectively recruited cohort of pregnant women. We prospectively collected demographic and health status data, data on pre-pregnancy vaginal douching, vaginal smears for bacterial vaginosis as defined by Nugent’s criteria, fetal fibronectin at 26 weeks of pregnancy, and placental pathology at delivery. Spontaneous preterm births before 37 weeks’ gestation were selected as cases. All spontaneous births occurring after 37 weeks were potential control subjects. To limit costs, some tests were performed only in selected control subjects.ResultsPreterm birth occurred in 207 of 5092 women (4.1%). In bivariate analysis, BV was not associated with preterm birth (OR 1.2; 95% CI 0.5 to 2.4). Vaginal douching was significantly associated with bacterial vaginosis (P < 0.05) and preterm birth (P < 0.05). On multivariate analysis, vaginal douching was no longer associated with preterm birth, buta significant association with early preterm birth < 34 weeks (OR, 6.9; 95% CI 1.7 to 28.2) and preterm birth due to preterm labour (OR 3.0; 95% CI 1.1 to 8.5) persisted after controlling for the presence of bacterial vaginosis and placental inflammation.ConclusionVaginal douching and bacterial vaginosis were not associated with spontaneous preterm birth overall. However, vaginal douching appears to be an independent and potentially modifiable risk factor for early preterm birth (32-34 weeks), although the mechanism remains unclear.     

Models for the prediction of successful induction of labor based on pre-induction sonographic measurement of cervical length

Objective.?To examine the effect of pre-induction cervical length, parity, gestational age at induction, maternal age and body mass index (BMI) on the possibility of successful delivery in women undergoing induction of labor.

Methods.?In 822 singleton pregnancies, induction of labor was carried out at 35 to 42^?+?6 weeks of gestation. The cervical length was measured by transvaginal sonography before induction. The effect of cervical length, parity, gestational age, maternal age and BMI on the interval between induction and vaginal delivery within 24?hours was investigated using Cox's proportional hazard model. The likelihood of vaginal delivery within 24?hours and risk for cesarean section overall and for failure to progress was investigated using logistic regression analysis.

Results.?Successful vaginal delivery within 24?hours of induction occurred in 530 (64.5%) of the 822 women. Cesarean sections were performed in 161 (19.6%) cases, 70 for fetal distress and 91 for failure to progress. Cox's proportional hazard model indicated that significant prediction of the induction-to-delivery interval was provided by the pre-induction cervical length (HR?=?0.89, 95 % CI 0.88–0.90, p?<?0.0001), parity (HR?=?2.39, 95% CI 1.98–2.88, p?<?0.0001), gestational age (HR?=?1.13, 95% CI 1.07–1.2, p?= <?0.0001) and birth weight percentile (HR?=?0.995, 95% CI 0.99?– 0.995, p?=?0.001), but not by maternal age or BMI. Logistic regression analysis indicated that significant prediction of the likelihood of vaginal delivery within 24?hours was provided by pre-induction cervical length (OR?=?0.86, 95% CI 0.84–0.88, p?<?0.0001), parity (OR?=?3.59, 95% CI 2.47–5.22, p?<?0.0001) and gestational age (OR =?1.19, 95% CI 1.07–1.32, p?= <?0.0001) but not by BMI or maternal age. The risk of cesarean section overall was significantly associated with all the variables under consideration, i.e., pre-induction cervical length (OR?=?1.09, 95% CI 1.06–1.11, p?<?0.0001), parity (OR?=?0.25, 95% CI 0.17–0.38, p?<?0.0001), BMI (OR?=?1.85, 95% CI 1.24–2.74, p?=?0.0024), gestational age (OR?=?0.88, 95% CI 0.78–0.98, p?=?0.0215) and maternal age (OR?=?1.04, 95% CI 1.01–1.07, p?=?0.0192). The risk of cesarean section for failure to progress was also significantly associated with pre-induction cervical length (OR?=?1.11, 95% CI 1.07–1.14, p?<?0.0001), parity (OR?=?0.26, 95% CI 0.15–0.43, p?<?0.0001), gestational age (OR?=?0.83, 95% CI 0.73–0.96, p?=?0.0097) and BMI (OR?=?2.07, 95% CI 1.27–3.37, p?=?0.0036).

Conclusion.?In women undergoing induction of labor, pre-induction cervical length, parity, gestational age at induction, maternal age and BMI have a significant effect on the interval between induction and delivery within 24?hours, likelihood of vaginal delivery within 24?hours and the risk of cesarean section.     

Risk of preterm delivery in relation to maternal low birth weight

OBJECTIVE: We examined the relationship between maternal low birth weight and preterm delivery risk. METHODS: Information concerning maternal birth weight was collected during in-person interviews. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI). Preterm delivery cases were studied in aggregate, in subgroups (spontaneous preterm labor, preterm premature rupture of membranes, medically induced preterm delivery, moderate preterm delivery [gestational age at delivery 34-36 weeks], and early preterm delivery [gestational age at delivery<34 weeks]). RESULTS: After adjusting for confounders, women weighing<2,500 g at birth had a 1.54-fold increased risk of preterm delivery versus women weighing=2,500 g (95% CI 0.97-2.44). Maternal low birth weight was associated with a 2-fold increased risk of spontaneous preterm delivery (95% CI 1.03-3.89), but weakly associated with preterm premature rupture of membranes (OR=1.44; 95% CI 0.67-3.09) and medically induced preterm delivery (OR=1.10; 95% CI 0.43-2.82). Maternal low birth weight was more strongly associated with early preterm delivery (OR=1.94) than with moderate preterm delivery (OR=1.46). Women weighing<2,500 g at birth and who became obese (pre-pregnancy body mass index, =30 kg/m2) before pregnancy had a 3.65-fold increased risk of preterm delivery (95% CI 1.33-10.02) versus women weighing=2,500 g at birth and who were not obese prior to pregnancy (<30 kg/m2). CONCLUSIONS: Results confirm earlier findings linking maternal low birth weight with future risk of preterm delivery.     

Adverse fetal outcome: is first trimester ultrasound and Doppler better predictor than biomarkers?

Aims and objectives: To evaluate the predictive value of first trimester biomarkers and ultrasound in determining adverse fetal outcomes in a low risk Asian population.

Material and method: All low risk, singleton pregnancies between 11 and 14 weeks gestation underwent ultrasound with uterine artery Doppler along with PAPP-A and free β-hCG estimation, and were followed till delivery to observe the outcome. The adverse fetal outcomes detected were structural anomaly, aneuploidy, intrauterine growth restriction, preterm birth and stillbirth (SB).

Results: Out of 3500 women screened, 417 cases had adverse fetal outcome in the absence of maternal complication, 2151 had normal outcome. Major structural anomaly was detected in first trimester in 17/28 (60.7%) cases. The most important markers for adverse fetal outcome were increased uterine artery pulsatility index (UPI) (p?=?0.028, OR 1.5, 95% CI: 1.05–2.38, AUC 0.56) for IUGR, nuchal translucency (p?=?0.001, OR 1.7, 95% CI: 1.11–2.77, AUC 0.60) for major anomaly and low PAPP-A (p?=?0.017, OR ?0.075, 95% CI: 0.87–0.98, AUC 0.621) for SB.

Conclusion: UPI, NT and PAPP-A in the first trimester are significant markers of adverse fetal outcome, although the sensitivity and specificity are not high they have a high negative predictive value.     

Second Trimester Placental Growth Factor Levels and Placental Histopathology in Low-Risk Nulliparous Pregnancies

ObjectivePlacental growth factor (PlGF) levels are lower at delivery in pregnancies with preeclampsia or fetuses small for gestational age (SGA). These obstetrical complications are typically mediated by placental dysfunction, most commonly related to the specific placental phenotype termed placental maternal vascular malperfusion (MVM). The objective of this study was to determine the relationship between PlGF levels in the second trimester and the development of placental diseases that underlie adverse perinatal outcomes.MethodsWe performed a secondary analysis of the prospective Placental Health Study in unselected healthy nulliparous women (n = 773). Maternal demographic data, Doppler ultrasound measurements, and plasma PlGF levels at 15 to 18 weeks gestation were analyzed for association with pregnancy outcomes and placental pathology following delivery.ResultsLow PlGF levels in the second trimester (<10th percentile; <72 pg/mL) was associated with preterm delivery (<37 weeks; 26% vs. 6%, P < 0.001; unadjusted odds ratio (OR) 5.75, 95% CI 3.2–10.5), reduced mean birth weight (2998 vs. 3320 g, P < 0.001), SGA deliveries (25% vs. 11%, P = 0.001; OR 2.6, 95% CI 1.5–4.6), and preeclampsia (7% vs. 2%, P = 0.02; OR 4.3, 95% CI 1.5-12.8) relative to normal PlGF levels (≥10th percentile; ≥72 pg/mL). Low PlGF was associated with lower mean placental weight (447 vs. 471 g, P = 0.01), aberrant cord insertion (25% vs. 12%, P = 0.001) and a pathologic diagnosis of MVM (18% vs. 11%, P = 0.04; OR 1.9, 95% CI 1.01–3.55) but not with other placental pathologies.ConclusionMVM placental pathology and related adverse perinatal outcomes are associated with low PlGF in the early second trimester for healthy nulliparous women.