Outcomes following rescue cerclage in twin pregnancies*

Objective: Our aim was to compare perinatal outcomes in twin pregnancies complicated by premature asymptomatic cervical dilatation treated with rescue cerclage and expectant management.

Methods: A retrospective cohort study was conducted at a single tertiary referral center between 2003 and 2014 and included all women with twins found to have a dilated cervix with intact membranes before 25-week gestation. Pregnancy outcomes were compared between women with rescue cerclage and those managed expectantly. A total of 36 women were eligible for the study, 27 (75.0%) of whom had a rescue cerclage compared to 9 (25.0%) women managed expectantly. Student’s t-test was used to compare continuous variables between the groups and the chi-square and Fisher’s exact tests were used for categorical variables as appropriate. Statistical analysis was performed with the SPSS v21.0 software (IBM Corp; Armonk, NY). Differences were considered significant when the p value was less than .05.

Results: Among the 27 women with a rescue cerclage, the mean gestational age at time of cerclage insertion was 21.5?±?2.6 weeks. The intervention and control groups were similar with respect to the degree of cervical dilatation at presentation (2.6?±?1.3 versus 3.0?±?1.5?cm, p?=?.5). Women in the cerclage group gave birth at a more advanced gestation (28.9?±?6.1 versus 24.2?±?2.6?weeks, respectively, p?=?.03) and were less likely to give birth at <34 and <28?weeks (66.7 versus 100.0%, p?=?.046, and 59.3 versus 100.0%, p?=?.02, respectively). The mean latency from the placement of cerclage to delivery was 7.3?±?5.5 weeks. Similar findings were observed when analysis was limited to women with cervical dilatation of ≤3?cm at presentation.

Conclusions: In asymptomatic women with twin pregnancies and cervical dilatation before 25?weeks of gestation, rescue cerclage can prolong pregnancy and improve perinatal outcomes when compared to expectant management.     

Modification of cervical length after cervical pessary insertion: correlation weeks of gestation

Objectives: To observe the modifications in cervical length (CL) in patients with and without cervical pessary (Arabin® ASQ 65/25/32) and correlate these modifications with gestational age at delivery.

Study design: Prospective study of asymptomatic singleton pregnancies (PECEP-Trial) between weeks 20?+?0 and 23?+?6 with maternal short cervix (<25?mm) randomised into two groups: expectant management and cervical pessary.

Results: This study included 380 pregnant women: 190 with pessary and 190 without pessary. Mean CL in both groups at the time of randomisation showed no statistically-significant differences (pessary group: 19.0?mm and management group: 19.0?mm; p?=?0.9). Mean CL measured after randomisation was 15.4?mm in patients of the expectant management group and 21.5?mm in the pessary group. These differences were statistically significant (p?p?Conclusions: Insertion of an Arabin cervical pessary increased CL in asymptomatic patients with a short cervix, which correlated with shorter gestational age at delivery. The cervical pessary halted the progressive decrease in CL, which correlated with longer gestational age at delivery.     

McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes.

Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25?kg/m², overweight: 25–29?kg/m², obese: 30?kg/m² or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student’s t-test, and multivariable regression analysis.

Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0?±?0.3 weeks; overweight: 36.6?±?0.7 weeks; obese: 33.0?±?1.1 weeks; p?p?=?.02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6?±?1.0 weeks versus 28.8?±?0.9 weeks; p?p?=?.63).

Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.     

Targeted delivery at 34 versus 35 weeks in women with preterm prelabor rupture of membranes

Objective: To compare planned delivery at 34 versus 35 weeks for women with preterm prelabor rupture of membranes (PPROM).

Materials and methods: We performed a retrospective cohort study of singleton pregnancies with PPROM after 24 weeks delivered from 2006 to 2014. In 2009, an institutional practice change established 35 weeks as the target gestational age before induction of labor was initiated after PPROM. Demographic and outcome measures were compared for two cohorts: women delivered 2006–2008 – target 34 weeks (T34) and women delivered 2009–2014 – target 35 weeks (T35). The primary outcome was neonatal intensive care unit (NICU) admission.

Results: Of the 382 women with PPROM, 153 (40%) comprized the T34 cohort and 229 (60%) comprized the T35 cohort. Demographic characteristics were similar between groups. There were no differences between groups in gestational age at PPROM (31.0?±?3.3 weeks versus 31.2?±?3.1 weeks; p?=?.50) or maternal complications. The mean gestational age at delivery was earlier in the T34 group (31.8?±?3.2 weeks versus 32.4?±?2.7 weeks; p?=?.04). The median predelivery maternal length of stay (LOS) was 1?day longer in the T35 group (p?=?.03); the total and postpartum LOS were similar between groups (p?>?.05). There were no differences in the rate of NICU admission (T34 89.5% versus T35 92.1%; p?=?.38) or median neonatal LOS (T34 14 days versus T35 17 days; p?=?.15). In those patients who reached their target gestational age, both maternal predelivery LOS and total LOS were longer in the T35 group (p?>?.05). The frequency of NICU admission in those reaching their target gestational age was similar between groups (T34 83.37% versus T35 76.19%; p?=?.46).

Conclusions: A 35-week target for delivery timing for women with PPROM does not decrease NICU admissions or neonatal LOS. This institutional change increased maternal predelivery LOS, but did not increase maternal or neonatal complications.     

Pregnancy outcomes following placement of elective,urgent and emergent cerclage

Objective.?To describe pregnancy outcomes following elective (history-indicated), urgent (ultrasound-indicated) or emergent (physical-exam indicated) cerclage placement.

Materials and Methods.?Study design was retrospective chart review. Women with singleton gestation and cervical cerclage were categorised into: elective, urgent and emergent group.

Results.?One hundred and thirty-three women were included; 89 in elective, 26 in urgent and 18 in emergent group. Difference was detected when elective and urgent groups were compared with emergent group for: gestation at delivery (35.9 ± 5.1 vs. 34.2 ± 5.9 vs. 29.3 ± 7.2 weeks, respectively, P < 0.05), delivery beyond 36 weeks, (73.9%, 57.7%vs. 23.5%, respectively, P < 0.05), neonatal death (6.8%, 9.5%vs. 43.8%, respectively, P < 0.05) and Apgar score <7 at 5 min (9.1%, 11.5%vs. 47.1%, respectively, P < 0.05). Difference was also detected between elective vs. urgent and emergent groups for: preterm premature rupture of membranes (PPROM) (19.3%vs. 38.5%vs. 64.7%, respectively, P < 0.05) and chorioamnionitis (1.4%vs. 18.2%vs. 42.9%, respectively, P < 0.05).

Conclusions.?Emergent cerclage group had the poorest obstetric outcomes. The urgent cerclage group reached similar gestational age at delivery as the elective group but is more likely to have PPROM and chorioamnionitis.     

Outcomes after periviable ultrasound-indicated cerclage

Background: Cerclage placed for a sonographically short cervix has been shown to reduce the risk of preterm delivery in women with a history of prior preterm birth. While short cervix is traditionally placed before viability, the threshold gestational age at which viability is achieved continues to decrease, and, as a result, a larger subset of women may be ineligible to receive this potentially beneficial procedure.

Objective: To evaluate the association between obstetric outcomes and perioperative complications after placement of an ultrasound-indicated cerclage at periviability compared to placement in the previable period.

Methods: This retrospective cohort study of patients who underwent ultrasound-indicated cerclage evaluated obstetric outcomes and perioperative complications based on gestational age at cerclage placement. Ultrasound-indicated cerclage was considered to have been placed at periviability if placed at 22 to <24 weeks (exposed) and at previability if placed at 16 to <22 weeks gestational age (unexposed). The primary outcome was preterm delivery <36 weeks. Secondary outcomes included mean gestational age at delivery, preterm delivery <32 weeks, <28, and <24 weeks, preterm premature rupture of membranes (PPROM), chorioamnionitis, and perioperative complications. Adjusted analyses were performed to account for demographic and obstetric factors.

Results: Of the 426 patients included in the analysis, 94 (22%) had cerclage placed between ≥22 weeks to <24 weeks, while 332 (78%) had cerclage placed at <22 weeks. On univariate analysis, women who had a periviable cerclage placed were less likely to have a recurrent preterm delivery <36 weeks compared to women with previable cerclage placement (26.6 versus 38.3%, respectively, p?=?.04). The adjusted model did not demonstrate a significant difference in risk for preterm delivery <36 weeks associated with periviable versus previable cerclage (odds ratio 0.66, 95%CI 0.37–1.17). Secondary outcomes were similar between the previable and periviable groups, including mean gestational age at delivery (35.1 versus 36.2 weeks, respectively, p?=?.08) and preterm delivery before 32-week gestation (20.7 versus 13.8%, respectively, p?=?.17). Intraoperative and postoperative complications were rare and rates were similar between groups.

Conclusions: Obstetric outcomes between patients receiving periviable and previable cerclage are similar. Ultrasound-indicated cerclage placement is associated with a relatively low rate of complications. Given the evidence supporting benefit of cerclage for women with short ultrasound cervical length and prior preterm birth, our findings demonstrate that benefits of placement at ≥22 weeks to <24 weeks may outweigh risks.     

Obstetrical outcomes of emergency compared with elective cervical cerclage

Objective: To study obstetric outcomes of emergency cerclage compared with elective cerclage.

Study design: Retrospective cohort study of pregnancy outcomes of patients who underwent cervical cerclage, performed according to ACOG guidelines, between January 2006 and December 2014. Patients who underwent emergency cerclage, due to cervical shortening or cervical dilation (emergency cerclage group) were compared with patients who underwent history-indicated cerclage (elective cerclage group). Emergency cerclage was not performed in patients with uterine contractions, vaginal bleeding, or signs of chorioamnionitis. Procedure-related complications were defined as rupture of membranes or chorioamnionitis occurring after cerclage placement and before 24 weeks of gestation.

Results: Overall, 154 patients with elective cerclage and 47 patients with emergency cerclage were included. Mean gestational age at cerclage operation was 13.1?±?1 and 20.2?±?3 weeks, respectively. There were no differences between the emergency cerclage group and the elective cerclage group regarding mean gestational age at delivery (36.1?±?3 versus 35.6?±?3, respectively, p?=?0.7), rate of deliveries beyond 34 weeks of gestation (81.81% versus 78.72%, respectively, p?=?0.67), rate of deliveries beyond 37 weeks of gestation (64.93% versus 59.57%, respectively, p?=?0.6), cesarean deliveries (33.11% versus 39.13%, p?=?0.48, respectively), or birthweight (2848 versus 2862 grams, respectively, p?=?0.9). Regarding procedure-related complications, there were no differences between the elective and the emergency cerclage groups in the rate of chorioamnionitis (1.29% versus 4.34%, respectively, p?=?0.22), or ruptured membranes (1.29% versus 4.34%, respectively, p?=?0.22).

Conclusion: Pregnancy outcomes of emergency cerclage are comparable with those of elective cerclage.     

The natural history of preterm premature rupture of membranes in twin pregnancies

Objective: To compare the characteristics of preterm premature rupture of membranes (PPROM) between twin and singleton pregnancies.

Methods: This was a retrospective study of all women with twin and singleton pregnancies admitted with PPROM between 24–34 weeks of gestation.

Results: Overall 698 women with PPROM were eligible for the study: 101 (14.5%) twins and 597 (85.5%) singletons. Twins presented with PPROM at a more advanced gestational age compared with singletons (29.1?±?2.7 vs. 28.5?±?2.8 weeks, p?=?0.03). The latency period was shorter in twins compared with singletons, especially for women presenting after 28 weeks of gestation (5.0?±?0.8 vs. 7.0?±?0.4 days, p?=?0.01). Women with twins were more likely to deliver within 48?h (OR:?2.7; 95%CI: 1.7–4.2) and were less likely to deliver within 2–7 days (OR: 0.5; 95%CI: 0.3–0.9) following PPROM. The rate of clinical chorioamnionitis or placental abruption following PPROM was lower in twins compared with singletons (15.8% vs. 26.0%, p?=?0.03).

Conclusions: PPROM in twin pregnancies tends to occur at a more advanced gestational age, is associated with a shorter latency period and is less likely to be complicated by chorioamnionitis or placental abruption compared with singletons. This information may be useful for counseling and management decisions in cases of PPROM in women with twins.     

Reinforcing cerclage for a short cervix at follow-up after the primary cerclage procedure

Objective: To determine whether a reinforcing cerclage (RC) for a short cervix measured after the primary cerclage procedure prolonged pregnancy.

Methods: We conducted a retrospective cohort study of 157 women with singleton gestations who underwent cerclage for standard indications. Women were grouped according to cervical length (CL) at the time of follow-up 1–2 weeks after the initial cerclage placement: ≥25?mm (106 women) and <25?mm with (20 women) or without RC (31 women). Gestational age (GA) at delivery was compared by ANOVA. Survival risk analysis was applied to model GA at delivery adjusted for indication and CL before and after the first cerclage.

Results: Women with CL?≥25mm delivered later than women with CL?<?25mm after the first cerclage (p?<?0.01). RC did not delay delivery for women with CL?<?25?mm (p?=?0.17) after the primary procedure. Indication for the primary cerclage (p?<?0.01) and CL (p?<?0.01) after the primary cerclage were the best predictors for GA at delivery.

Conclusion: Placement of RC for short cervix did not prolong duration of pregnancy, GA at delivery or modify the probability of preterm birth.     

Outcome of dichorionic diamniotic twin pregnancies with spontaneous PPROM before 24 weeks’ gestation

Objective: The objective of this study is to examine the outcome in dichorionic diamniotic twin pregnancies with rupture of membranes (PPROM) before 24 weeks’ gestation.

Material and methods: Retrospective analysis of fetal and neonatal outcomes in women with spontaneous PPROM before 24 weeks’ gestation that were treated at a single tertiary center.

Results: Twenty-nine pregnancies fulfilled the inclusion criteria. Mean gestational age at the time of PPROM was 20.4 weeks. Two women opted for termination. The remaining 27 (93.1%) women elected for expectant management. Ten (37.0%) of these delivered before 24?+?0 weeks’ gestation. The median gestational age at the time of delivery in the remaining 17 (63%) cases was 26.4 weeks. In those patients that did not deliver within the first 5 days of PPROM, the chance of reaching 24?+?0 weeks was 85%. Co-twins that had PPROM compared with those without PPROM suffered more often from several neonatal complications. Overall, about 40% of the fetuses in the PPROM group and 70% of the non-PPROM group survived without major complications.

Conclusion: Dichorionic diamniotic twin pregnancies with PPROM prior to 24?+?0 weeks’ gestation have a 60% chance of delivering at?>24 weeks. Survival rates without major complications in twins with and without PPROM are 40% and 70%, respectively.     

Comparison of two cervical cerclages for the prevention of preterm birth and neonatal complications

Objective: To investigate the outcomes of singleton pregnant women with cervical insufficiency undergoing two different cervical cerclages.

Methods: This is a retrospective cohort study of women who underwent a history- or ultrasound-indicated cerclage (either Shirodkar or McDonald) at a tertiary referral center from 2002 to 2014. Outcome parameters (delivery age, postoperative cervical length, preterm premature rupture of membranes, preterm delivery rate and neonatal complications) were compared between the two cerclage procedures. Multivariate logistic regression analysis was applied to control for significant variables of preterm birth. Kaplan–Meier survival analysis was used to demonstrate delivery age to percentage of term delivery by cerclage type.

Results: Ninety-four cases were initially included. After excluding cases not meeting the study criteria, 60 pregnancies (Shirodkar 36 and McDonald 24) were recruited for analysis. The mean delivery age in the Shirodkar group was more advanced than that in the McDonald group (37.1?±?3.3 versus 34.8?±?4.9 weeks, p?=?0.039). There were significantly fewer deliveries <37 gestational weeks in the Shirodkar group than in the McDonald group (30.6% versus 58.3%, p?=?0.033) but no significant differences in deliveries <28, 32 and 34 gestational weeks. No significant differences were found in neonatal complications except for respiratory distress syndrome (5.6% in Shirodkar versus 29.2% in McDonald, p?=?0.023).

Conclusion: In the setting of history-indicated or ultrasound-indicated cerclage, Shirodkar was superior to McDonald in the prevention of late preterm birth and neonatal respiratory distress syndrome.     

A systematic review of intentional delivery in women with preterm prelabor rupture of membranes

Objective.?To evaluate the effect of intentional delivery versus expectant management in women with preterm prelabor rupture of membranes (PPROM).

Methods.?We searched electronic databases and trials registries, contacted experts, and checked reference lists of relevant studies. Studies were included if they were randomized controlled trials comparing intentional delivery versus expectant management after PPROM, the gestational age of participants was between 30 and 36 weeks, and the study reported one of several pre-determined outcomes.

Results.?Four studies were included in the meta-analysis. No difference was found between intentional delivery and expectant management in neonatal intensive care unit (NICU) length of stay (LOS) (weighted mean difference (WMD) ?0.81 day, 95% confidence interval (CI) ?1.66, 0.04), respiratory distress syndrome (risk difference (RD) ?0.01, 95% CI ?0.07, 0.06), and confirmed neonatal sepsis (RD ?0.01, 95% CI ?0.05, 0.04). One study found a significantly lower incidence of suspected neonatal sepsis among the intentional delivery group (RD ?0.31, 95% CI ?0.50, ?0.12; number needed to treat (NNT) 3, 95% CI 2, 8). Maternal LOS was significantly shorter for the intentional delivery group (WMD ?1.39 day, 95% CI ?2.03, ?0.75). There was a significant difference in the incidence of clinical chorioamnionitis favoring intentional delivery (RD ?0.16, 95% CI ?0.23, ?0.10; NNT 6, 95% CI 5, 11). There was no significant difference in the incidence of other maternal outcomes, including cesarean section (RD 0.05, 95% CI ?0.01, 0.11).

Conclusions.?Intentional delivery may be favorable to expectant management for some maternal outcomes (chorioamnionitis and LOS). There is insufficient evidence to suggest that either strategy is beneficial or harmful for the baby. Large multicenter trials with primary neonatal outcomes are required to assess whether intentional delivery is associated with less neonatal morbidity.     

Obstetric outcome of second trimester antenatal bleeding

Objective: To evaluate the clinical significance of vaginal bleeding in pregnant women between 14th and 22th gestational weeks.

Methods: This retrospective case–control study was conducted between September 2010 and December 2013. Two-hundred nineteen pregnant women with vaginal bleeding between 14th and 22th gestational weeks were compared with 325 pregnant women without vaginal bleeding for their maternal and early neonatal outcomes.

Results: Mean gestational age and birth weight of study group were significantly different from those of the control group respectively (37.9?±?2.8 versus 38.9?±?1.4 and 3071?±?710 versus 3349?±?446 for groups p?<?0.001). Vaginal bleeding between 14th and 22th gestational weeks had increased risk of having preterm birth (PB) and preterm premature rupture of membranes (PPROM) (OR: 10.8, 95% CI: [4.5–26.1]; OR: 12.0, 95% CI: [3.5–40.6], respectively). Gestational diabetes mellitus (GDM) and polyhydramnios ratio in the study group was significantly higher than the control respectively (4.1% versus 1.2%, p?=?0.031; 1.9% versus 0%, p?=?0.025).

Conclusion: Pregnant women with vaginal bleeding was a significantly risk factor for PB, PPROM, GDM, and polyhydramnios. Consequently, these pregnancies should be closely followed up for maternal and fetus complications.     

Maternal serum interleukin 6 levels and fetomaternal outcomes in women with preterm premature rupture of membranes in Lagos,South-western Nigeria

Objective: This study was done to assess the relationship between maternal serum IL-6 levels and fetomaternal outcome following PPROM.

Methodology: This was a prospective cohort study comprising 45 cases of PPROM and 45 controls of similar age, parity, and gestational age. Five milliliters of maternal serum was collected after obtaining informed consent. They were followed up till delivery and records of the delivery and neonatal outcomes were obtained. Serum IL-6 levels were determined by standard enzyme-linked immunosorbent assay [ELISA]. PPROM patients were categorized into two groups using a threshold of 14?pg/ml. Chi-square (χ2) test was used to compare categorical outcomes. p values of?<?0.05 were taken as significant.

Results: The mean serum IL-6 level for the women with PPROM was (20.2?±?11.0?pg/ml), which was significantly greater than for the control subjects (13.9?±?5.8?pg/ml, p?<?0.001). Fetomaternal outcomes were all worse in those with IL-6?≥?14?pg/ml. Nevertheless, only the difference in early neonatal deaths was statistically significant.

Conclusion: Measurement of maternal serum IL-6 can help to indicate hostile intrauterine environments to the fetus as well as identify patients who may benefit from pregnancy prolongation or intervention.     

The maternal thiol/disulfide homeostasis does not change in pregnancies complicated by preterm prelabor rupture of membranes

Purpose: To evaluate the maternal thiol/disulfide homeostasis in pregnant women complicated by preterm prelabor rupture of membranes (PPROM) and to compare the results with healthy pregnancies.

Materials and methods: This cohort study consisted of thirty-nine pregnancies complicated by PPROM and 44 gestational age-matched healthy pregnancies in the third trimester of gestation. Maternal serum samples were obtained at the day of diagnosis, and thiol/disulfide profiles were measured by using an automated assay method. The patients were followed till delivery, and perinatal outcomes were noted.

Results: The maternal native thiol (319.9?±?30.5?μmol/L versus 305.1?±?49.2?μmol/L, p: .100), total thiol (379.2?±?38.8?μmol/L versus 363.6?±?56.4?μmol/L, p: .142) and disulfide (29.7?±?11.7?μmol/L versus 29.3?±?10.1?μmol/L, p: .864) levels were similar between the groups. Maternal disulfide/native thiol, disulfide/total thiol and native thiol/total thiol ratios were similar between the groups (p: .610, p: .565 and .562, respectively). The maternal serum thiol/disulfide profiles were not significantly correlated with maternal serum C-reactive protein, white blood cell count values and ongoing pregnancy outcomes (p?>?.05).

Conclusions: The current study demonstrated that there was not any disturbance in maternal thiol/disulfide homeostasis in pregnancies complicated by PPROM at the time of initial diagnosis. Follow-up studies with larger sample size are needed to confirm our results.     

Effectiveness and safety of late midtrimester cervical cerclage

Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications.

Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean?±?standard deviation. Categorical variables were expressed as proportions.

Results: The average gestational age at birth was 35?±?5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17?±?5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%).

Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.     

Maternal serum concentrations of s-Endoglin and IL-6 in pregnancy complicated by preterm premature membrane rupture

Objective: This study aimed to investigate maternal serum concentrations of s-Endoglin and compare s-Endoglin with other inflammatory markers in prediction of time to delivery, in pregnancies complicated by preterm premature rupture of membranes (PPROM).

Materials and methods: Fifty five patients complicated by PPROM whose gestational age were between 2433 weeks and 44 matched healthy pregnant women were included in present study. Maternal concentrations of s-Endoglin concentrations were measured by an enzyme-linked immunosorbent assay (ELISA) and compared with maternal inflammatory markers including interleukin-6 (IL-6), white blood cell (WBC) count and serum C-reactive protein (CRP). The best variable for prediction of preterm birth was computed.

Results: Mean s-Endoglin levels in PPROM were lower than control groups (0.24?±?0.12?pg/ml and 0.69?±?0.25?pg/ml, respectively, p?<?0.01). Besides IL-6 (p?<?0.01), WBC (p?=?0.016) and CRP (p?=?0.010) levels were higher in PPROM group. In PPROM group, ROC analysis results of s-Endoglin for prediction of preterm delivery <48 h, <7 days, <32 weeks were not different (p?>?0.05). For predicting preterm birth before 48 h and 7 days, only IL-6 at cut off value >0.70 (pg/ml) and >0.55 (pg/ml) had area under curve (AUC); 0.871 (0.7750.965), p?<?0.01, AUC; 0.925 (0.8560.993), p?<?0.001, respectively.

Conclusion: s-Endoglin as an anti-angiogenic marker seemed to have a role in pathogenesis but results of present study showed that, unlike IL-6, it was unsatisfactory for estimating time to delivery in PPROM.     

Noninvasive cerclage for the management of cervical incompetence: a prospective study

Objective: The aim of this study was to evaluate the efficacy and safety of a noninvasive cerclage pessary in the management of cervical incompetence. Methods: This is a prospective cohort study of all pregnant women treated for cervical incompetence during a 4-year period. Women with known risk factors for preterm delivery had transvaginal ultrasonography every 2–3 weeks after 17–19 weeks of gestation. Those with progressive shortening of cervix diagnosed before 30 weeks were treated with a cerclage pessary when the cervical length was ≤25 mm. The pessary was electively removed at 34–36 weeks. The course and outcome of pregnancy were recorded. Results: Thirty-two women were treated with a cerclage pessary. There were nine twin and two triplet pregnancies. Fifteen (47%) had two or more risk factors for preterm delivery. The mean gestational age at cerclage was 23 (17–29) weeks, cervical length 17 (5–25) mm. Two women required delivery before the onset of labor due to severe intrauterine growth restriction and one due to HELLP syndrome. These were excluded from further analysis. In the remaining 29 women, the interval between cerclage and delivery was 10.4 (2–19) weeks, mean gestational age at delivery 34 (22–42) weeks, and birth weight 2,255 (410–4,045) g. Thirteen (45%) women delivered before 34 weeks. There were a total of 35 live-born infants and four intrapartum fetal deaths (all between 22 and 25 weeks gestation). All women complained of increased vaginal discharge, but no other significant complications were observed that could be attributed to the use of pessary. Conclusion : Cerclage pessary may be useful in the management of cervical incompetence. Whether it can be a noninvasive alternative to surgical cerclage merits further investigation.     

Pregnancy outcomes after cerclage placement in nulliparous women with a short cervix on transvaginal ultrasonography

Objective: Little is known about pregnancy outcomes associated with a short cervix and cerclage placement in nulliparous women.

Methods: An electronic query of our ultrasound database was used to identify patients whose cervical length measured <?25?mm between 16–24 weeks of gestation. Any nulliparous women, with no prior pregnancy lasting beyond 13 weeks 6 d gestational age, were included in the analysis. The primary outcome was the interval of time from the diagnosis of a short cervix (<25?mm) to the time of delivery.

Results: Our query identified 70 patients for analysis. The interval of time from diagnosis of a short cervix to delivery was observed to be 85 d (12.1 weeks) in the cerclage group and 116 d (16.6 weeks) in the expectantly managed group (p?=?0.02). In those women receiving a cerclage, there was a statistically significant risk of spontaneous preterm birth <32 weeks gestational age (R.R. 6.7 [95% CI 1.45–30.6]).

Conclusions: The impact of a short cervix is largely unknown in patients with an uncomplicated obstetrical history. Our investigation would suggest that in this subset of patients, cerclage would not be beneficial in preventing preterm delivery.     

Maternal and neonatal outcomes after antenatal corticosteroid administration for PPROM at 32 to 33 6/7 weeks gestational age*

Background: Preterm Premature Rupture of Membranes (PPROM) precedes many deliveries and experts agree with expectant management until 34 weeks gestation. However, there is controversy regarding the gestational age (GA) for administration of corticosteroids.

Study design: We performed a retrospective cohort study in the University of California Fetal Consortium (UCfC). We searched available charts of singleton pregnancies with PPROM between 32 and 33 6/7 weeks GA. Outcomes from the groups were analyzed.

Results: Of 191 women with PPROM at 32 to 33 6/7 weeks, 150 received corticosteroids. The median GA at admission was earlier for the exposed versus unexposed group (32 4/7 versus 33 0/7 weeks, respectively, p?=?0.001). The mean GA at delivery in the exposed was 33 2/7 (32 0/7 to 35 0/7) weeks versus 33 5/7 (32 0/7 to 36 1/7) weeks in the unexposed (p?=?0.001). There was no difference in chorioamnionitis or RDS.

Conclusion: In women with PPROM at 32 to 33 6/7 weeks, our data suggests that corticosteroids are associated with similar outcomes despite earlier GA at delivery and no differences in major morbidities. A larger prospective study is needed to determine if the benefit of corticosteroids outweighs the potential risks in PPROM.