Twin transvaginal cervical length at 16–20 weeks and prediction of preterm birth*

Objective: Our objective was to determine if transvaginal cervical length at 16–20 weeks is predictive of preterm birth <34 weeks in a large cohort of twin pregnancies.

Study design: This is a secondary analysis from a randomized trial of 17 alpha-hydroxyprogesterone caproate in twins to prevent preterm birth. Transvaginal cervical length was performed at 16–20-week gestation. The inclusion criteria were non-anomalous twins with transvaginal cervical length at 16–20 weeks. Receiver-operating characteristic (ROC) curves were generated to determine the transvaginal cervical length associated with preterm birth.

Results: Of 655 pregnancies, 27% (N?=?178) women met our inclusion criteria. The rate of spontaneous preterm birth before 34 weeks was 16% (N?=?29). A receiver operator characteristic curve was generated for all preterm birth <34 weeks (spontaneous and indicated) which demonstrated an area under the curve of 0.51, 95% CI (0.41–0.61). When indicated preterm birth (n?=?15) were excluded, the area under the curve was 0.59 (95% CI 0.47–0.70), indicating that transvaginal cervical length values were not a clinically useful test for the prediction of spontaneous preterm birth. A transvaginal cervical length of 30?mm from this model would produce a sensitivity of detecting spontaneous preterm birth of 95% and a specificity of 14%.

Conclusion: In an asymptomatic twin population, a single transvaginal cervical length between 16 and 20 weeks was not predictive of spontaneous preterm birth before 34 weeks. Thus, our findings suggest that routine transvaginal cervical length screening of twins should not be performed between 16–20 weeks.     

The association between myometrial electrical activity and time to delivery in threatened preterm labor

Objective: To assess the association between myometrial electrical activity and time-to-delivery in preterm labor using uterine electromyography.

Methods: Myometrial electrical activity was measured via the electrical uterine monitor (EUM) device. Data was prospectively collected among women admitted due to suspected preterm labor, prior to 34 weeks of gestation. EUM-Index was defined as the mean electrical activity of the uterine muscle over a period of 10 minutes measured in units of microjoule (μJ, microwatt second). The association between the EUM-Index at admission to time-to-delivery and delivery prior to 34 weeks of gestation was calculated.

Results: Overall, 45 women were included in the study. EUM-Index combined with cervical dilatation, demonstrated significant correlation to time-to-delivery (R^2?=?0.49, p?=?0.005), which was strengthened for women presenting prior to 28 weeks of gestation. EUM-Index above the median (>3.05?MJ) was significantly associated with a shorter latency period for delivery (36.0?±?19.4 vs. 50.2?±?25.9 days, p?=?0.04). For delivery prior to 34 weeks, the EUM-Index showed an AUC?=?0.65 (95% CI 0.48–0.82), and a cutoff of 2.5?MJ provided 91.7% sensitivity and 93.3% negative predictive value.

Conclusion: EUM-Index at time of admission due to suspected preterm labor is inversely correlated with time-to-delivery and may effectively rule out preterm delivery prior to 34 weeks.     

The combination of short cervical length and phIGFBP-1 in the prediction of preterm delivery in symptomatic women

Objective.?To assess the combined use of cervical length and cervical phosphorylated insulin-like growth factor binding protein-1 (phIGFBP-1) in the prediction of preterm delivery in symptomatic women.

Methods.?Cervical length was prospectively measured in 102 consecutive singleton pregnancies with intact membranes and regular contractions at 24–32 weeks, and phIGFBP-1 was assessed in those with a cervix?≤30 mm.

Results.?Among women with a cervix?>30 mm (n?=?42), none delivered?<34 weeks or within 7 days. Among women with a cervical length?≤30 mm (n?=?60), eight delivered?<34 weeks, four of which within 7 days. A positive phIGFBP-1 conferred a significantly increased risk of delivery before 34 weeks in women with a cervix ≤30 mm (likelihood ratio 2.32, 95% confidence interval 1.15–4.67), and a significantly increased risk of delivering within 7 days in the subgroup of women with a cervical length of 20–30 mm (likelihood ratio 3.64, 95% confidence interval 2.20–6.01).

Conclusions.?In symptomatic women with a cervical length?>30 mm the risk of preterm delivery is very low. In women with a cervix ≤30 mm, adding phIGFBP-1 assessment may improve the risk assessment for preterm delivery, and help to plan subsequent pregnancy management.     

Loop electrosurgical excision of the cervix and the subsequent risk of preterm delivery

OBJECTIVES: To investigate the association between loop electrosurgical excision procedure (LEEP) and other potential risk factors, and subsequent preterm delivery (<37 weeks), using data from a large cohort study of Danish women. METHODS: The Danish prospective cohort study was initiated in 1991, with the original aim of investigating the role of human papillomavirus in the natural history of cervical neoplasia. The study included 11,088 women aged 20-29. The cohort was invited for 2 follow-up examinations in 1993-1995 and 1999-2000, respectively. At all 3 examinations, the women answered questions about a number of different lifestyle variables. We assessed the relationship between preterm delivery and potential risk factors, such as previous LEEP treatments, smoking during pregnancy, age, parity and previous preterm delivery. The cohort was followed until 2004, through linkages with the nationwide Pathology Data Bank and the Medical Birth Registry. RESULTS: Of the 14,982 deliveries in the cohort during follow up, 542 were preterm (21-37 weeks). Among deliveries with no previous LEEP, 3.5% ended as a preterm delivery, whereas this applied to 6.6% among deliveries following a LEEP, yielding a significantly increased risk of preterm birth after LEEP (OR=1.8; 95% CI: 1.1-2.9). The strongest risk factor for preterm delivery was a previous preterm delivery (OR=2.3; 95% CI: 1.4-3.7). Other significant risk factors were smoking during pregnancy and low educational status. CONCLUSION: Our study showed an almost 2-fold increase in the risk of preterm delivery after LEEP treatment. Thus, women in their reproductive age should be informed about the increased risk of preterm delivery, if treated with LEEP.     

Women with endometriosis at first pregnancy have an increased risk of adverse obstetric outcome

Objective: To evaluate pregnancy, delivery and neonatal outcome in singleton primiparous versus multiparous women with/without endometriosis.

Methods: Multicentric, observational and cohort study on a group of Caucasian pregnant women (n?=?2239) interviewed during their hospitalization for delivery in five Italian Gynecologic and Obstetric Units (Siena, Rome, Padua, Varese and Florence).

Results: Primiparous women with endometriosis (n?=?219) showed significantly higher risk of small for gestational age fetuses (OR: 2.72, 95% CI 1.46–5.06), gestational diabetes (OR: 2.13, 95% CI 1.32–3.44), preterm premature rupture of membranes (OR: 2.93, 95% CI 1.24–6.87) and preterm birth (OR: 2.24, 95% CI 1.46–3.44), and were hospitalized for a longer period of time (p?n?=?1331). Multiparous women with endometriosis (n?=?97) delivered significantly more often small for gestational age fetuses (OR: 2.93, 95% CI 1.28–6.67) than control group (n?=?592). Newborns of primiparous women with endometriosis needed more frequently intensive care (p?=?0.05) and were hospitalized for a longer period of time (p?Conclusions: Women with endometriosis at first pregnancy have an increased risk of impaired obstetric outcome, while a reduced number of complications occur in the successive gestation. Therefore, it is worthy for obstetricians to increase the surveillance in nulliparous women with endometriosis during pregnancy.     

The impact of loop electrosurgical excision procedure (LEEP) for CIN 2,3 on spontaneous preterm delivery in twin pregnancies by assisted reproductive technique: preliminary data

Abstract

The objective of this study was to compare the frequency of spontaneous preterm delivery before 35 weeks in 7 dichorionic twin pregnancies obtained after loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 2,3 with respect to 21 twin pregnancies without previous cervical treatment. All the pregnancies were obtained after assisted reproduction techniques (ART). Same age at delivery was observed between two groups (p?=?0.81) and none of our twin pregnancies after LEEP had a threatened preterm labor while four controls (19%) underwent a spontaneous preterm delivery (p?=?0.35). These preliminary data seem to indicate that LEEP may not be responsible of spontaneous preterm delivery in twin pregnancies subsequent to ART.     

The effect of loop electrosurgical excision procedure on future pregnancy outcome

OBJECTIVE: To estimate whether the loop electrosurgical excision procedure (LEEP) is associated with an adverse effect on the outcome of subsequent pregnancies. METHODS: A retrospective cohort study was performed. The study group comprised women who had a LEEP in Halifax County between 1992 and 1999 and then had a subsequent singleton pregnancy of greater than 20 weeks of gestation with delivery at the IWK Health Centre in Halifax, Nova Scotia. The comparison group comprised women with no history of cervical surgery who were matched for age, parity, smoking status, and year of delivery. There were 571 women in each group. The primary outcome was rate of preterm delivery at less than 37 weeks of gestation. Secondary outcomes included delivery at less than 34 weeks and various neonatal and maternal outcomes. The effect of specific LEEP characteristics was analyzed separately. RESULTS: Women who had a LEEP were more likely to deliver preterm overall (7.9% versus 2.5%; odds ratio [OR] 3.50, 95% confidence interval [CI] 1.90-6.95; P < .001) and to deliver preterm after premature rupture of membranes (PROM) (3.5% versus 0.9%; OR 4.10, 95% CI 1.48-14.09). The increase in delivery at less than 34 weeks was not statistically significant (1.25% versus 0.36%; OR 3.50, 95% CI 0.85-23.49; P = .12). Women with LEEP also delivered more low birth weight (LBW) infants (5.4% versus 1.9%; OR 3.00, 95% CI 1.52-6.46; P = .003). There were no differences in other neonatal or maternal outcomes. No association was found between the characteristics of the LEEP, including depth, and the rate of preterm delivery. CONCLUSION: Loop electrosurgical excision procedure is associated with an increased risk of overall preterm delivery, preterm delivery after PROM, and LBW infants in subsequent pregnancies at greater than 20 weeks of gestation. Women who are considering future pregnancies should be counseled about these risks during informed consent for LEEP. LEVEL OF EVIDENCE: II-2.     

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.     

Transvaginal ultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia

OBJECTIVE: To estimate whether cervical length measured by transvaginal ultrasonography in women having had loop electrosurgical excision procedure (LEEP), cold knife conization, or cryotherapy predicts spontaneous preterm birth. METHODS: Women with a history of LEEP, cold knife conization, or cryotherapy and who were subsequently pregnant with singleton gestations were prospectively compared with both a low-risk control group and women with previous spontaneous preterm birth. A transvaginal ultrasonogram measuring cervical length was performed at 24 to 30 weeks of gestation. Primary outcomes included cervical length and spontaneous preterm birth less than 37 weeks. Secondary outcomes were spontaneous preterm birth less than 34 weeks, low birth weight, and maternal and neonatal outcomes. RESULTS: Women with previous LEEP (N = 75), cold knife conization (N = 21), and cryotherapy (N = 36) had shorter cervical lengths (3.54, 3.69, and 3.75 cm respectively) than the low-risk control group (N = 81, 4.21 cm) (P < .001, P = .03, P = .02 respectively) and similar lengths to women with a previous spontaneous preterm birth (N = 63, 3.78 cm). Loop electrosurgical excision procedure and cold knife conization, but not cryotherapy, were associated with spontaneous preterm birth less than 37 weeks (odds ratio 3.45, 95% confidence interval 1.28-10.00, P = .02; and odds ratio 2.63, 95% confidence interval 1.28-5.56, P = .009, respectively). Using a cutoff of 3.0 cm, transvaginal ultrasonography had a positive predictive value of 53.8% and negative predictive value of 95.2% for spontaneous preterm birth less than 37 weeks in women with LEEP. CONCLUSION: Women with a history of LEEP, cold knife conization, and cryotherapy all independently have shorter cervical lengths than low-risk controls and similar lengths to women with previous spontaneous preterm birth. Loop electrosurgical excision procedure and cold knife conization are associated with spontaneous preterm birth less than 37 weeks, and transvaginal ultrasonography predicts preterm birth in women who have had LEEP. LEVEL OF EVIDENCE: II-2.     

Automated auditory brainstem response in preterm newborns with histological chorioamnionitis

Objective: We investigated whether histological chorioamnionitis is associated with an adverse neonatal hearing outcome.

Methods: Two cohorts of very preterm newborns (n?=?548, gestational age ≤ 32.0 weeks) were linked to placental histology and automated auditory brainstem response (AABR) outcome.

Results: In multivariable analyses, an abnormal AABR was not predicted by the presence of histological chorioamnionitis, either with or without fetal involvement (OR 1.4, 95% CI 0.5 – 3.8, p?=?0.54 and OR 1.1, 95% CI 0.4–3.0, p?=?0.79, respectively). Significant predictors of abnormal AABR included, e.g. birth weight (per kg increase: OR 0.2, 95% CI 0.0–0.6, p?=?0.006), umbilical cord artery pH (per 0.1 increase: OR 0.7, 95% CI 0.5–0.9, p?=?0.005) and mechanical ventilation (OR 3.7, 95% CI 1.2–11.6, p?=?0.03).

Conclusions: Histological chorioamnionitis was not associated with an adverse neonatal hearing outcome in two cohorts of very preterm newborns. Indicators of a complicated neonatal clinical course were the most important predictors of an abnormal hearing screening.     

Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis

Objective

This study aimed at assessing the association of the relative risk (RR) of adverse pregnancy outcomes with previous treatment of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN).

Methods

Data sources were from MEDLINE, EMBASE, and SCI citation tracking. Selection criteria: The eligible studies had data on pregnancy outcomes of women with or without previous treatment for CIN. Considered outcomes were severe preterm delivery (<34/32 weeks), extreme preterm delivery (<28 weeks), low birth weight (<2,500 g), stillbirth, preterm spontaneous rupture of membranes, perinatal mortality, and neonatal mortality and induction.

Results

36,954 cases and 1,794,174 controls in 4 prospective cohort and 22 retrospective studies were included in this meta-analysis. LEEP was associated with a higher risk of severe preterm delivery (<32 weeks, relative risk 1.98, 95 % CI [1.31, 2.98] 159/11,337 vs. 7,830/860,883), extreme preterm delivery (<28 weeks, RR, 2.33, 95 % CI [1.84, 2.94] 97/9,611 vs. 1,559/618,332), preterm premature rupture of the membranes (RR, 1.88, 95 % CI [1.54, 2.29] 126/2,837 vs. 7,899/313,094), and low birth weight (<2,500 g, RR, 2.48, 95 % CI [1.75, 3.51] 110/1,451 vs. 55/1,742). A cervical length of less than 3 cm was significantly increased in LEEP as compared with that of control group (RR, 4.88, 95 % CI [1.56, 15.25]), but increasing LEEP volume or depth was not associated with an increased rate of preterm birth <37 weeks. And LEEP was not associated with a significantly increased risk of perinatal mortality, cesarean section, stillbirth mortality, neonatal mortality, induction, and neonatal intensive care unit admission.

Conclusions

LEEP is associated with an increased risk of subsequent preterm delivery (<32/34, <28 weeks) and other serious pregnancy outcomes. But increasing LEEP volume or depth is not associated with an increased rate of preterm birth.     

Inflammatory biomarkers and spontaneous preterm birth among obese women

Objective: To identify associations between second-trimester serum inflammatory biomarkers and preterm birth among obese women.

Methods: In this nested case-control study, we compared 65 serum inflammatory biomarkers in obese women whose pregnancies resulted in early spontaneous preterm birth (<32 weeks gestation, n?=?34) to obese women whose pregnancies resulted in term birth (n?=?34). These women were selected from a larger population-based California cohort. Random forest and classification and regression tree techniques were employed to identify biomarkers of importance, and adjusted odds ratios (aORs) and 95% confidence intervals (CI) were estimated using logistic regression.

Results: Random forest and classification and regression tree techniques found that soluble vascular endothelial growth factor receptor-3 (sVEGFR3), soluble interleukin-2 receptor alpha-chain (sIL-2RA) and soluble tumor necrosis factor receptor-1 (sTNFR1) were related to preterm birth. Using multivariable logistic regression to compare preterm cases and term controls, decreased serum levels of sVEGFR3 and increased serum levels of sIL-2RA and sTNFR1 were associated with increased risk of preterm birth among obese women, aOR?=?3.2 (95% CI: 1.0–9.9), aOR?=?2.8 (95% CI: 0.9–9.0), and aOR?=?4.1 (95% CI: 1.2–14.1), respectively.

Conclusions: In this pilot study, we identified three serum biomarkers indicative of inflammation to be associated with spontaneous preterm birth among obese women: sVEGFR3, sIL-2RA and sTNFR1.     

The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks

Purpose: To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management.

Methods: This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5?cm, and cervical dilation ≥1.0?cm. The “cerclage” cohort received a cerclage from a single provider at a single institution from 2003–2016. The “no cerclage” group included all patients with similar indications that were expectantly managed from 2010–2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at <32 weeks, Results: In all, 135 women were included in two cohorts: cerclage (n?=?96) or no cerclage (n?=?39). The rates of spontaneous preterm birth <32 weeks were 10.4% (n?=?10) with cerclage versus 28.2% (n?=?11) without cerclage (OR 0.23, CI 0.08–0.70, p?=?.017). After adjusting for cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth <32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06–0.90, p?=?.035), spontaneous preterm birth <36 weeks (aOR 0.34, CI 0.04–0.81, p?=?.013) as well as in overall preterm birth <32 weeks (aOR 0.31, CI 0.1–0.86, p?=?.018), and overall preterm birth <36 weeks (aOR 0.37, CI 0.10–0.84, p?=?.030). When stratified by short cervix or cervical dilation in the cerclage versus no cerclage groups, there was a significant decrease in spontaneous preterm birth <32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p?=?.01) but not in the cerclage group with short cervix only, even for cervical length <1.5?cm. Pregnancy latency was 91 days in the cerclage group versus 57 days in the no cerclage group (p?=?.001), with a median gestational age at delivery of 35 versus 32 weeks (p?=?.002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665?g, p?p?=?.001).

Conclusions: Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth <32 weeks compared to expectant management. However, when stratified by cerclage indication, this decrease in primary outcome only remained significant in the group with cervical dilation.     

The postnatal morbidity associated with second-trimester miscarriage

Objective(s): To describe the complications, and their incidence, associated with the management and delivery of a distinct second-trimester miscarriage cohort.

Methods: A retrospective cohort study was undertaken in a large, tertiary-referral university hospital (8500 deliveries per annum). All cases of pregnancy loss occurring between 14⁺⁰ and 23⁺⁶ were identified from July 2009 to June 2013 (n?=?181). Medical notes were reviewed and the number of complications among this cohort was identified. Logistic regression was conducted to assess associations with clinical presentation and management.

Results: The mean gestation of loss was 18⁺² weeks (SD: 2⁺²). 64.6% (n?=?117) of the total losses were of intrauterine fetal demise (IUFD) with 17.7% (n?=?32) following preterm premature rupture of membranes (PPROM) and 17.7% (n?=?32) following preterm labour (PTL). All women required inpatient admission with 59.1% (n?=?107) undergoing medical induction of labour. PPROM cases, compared with cases of IUFD, had increased odds of requiring antibiotic therapy (OR 13.75, 95% CI: 4.88–38.72) and readmission (OR OR 4.15, 95% CI 1.12–15.36).

Conclusion: These women represent a small proportion of the obstetric population but remain a distinct cohort whose management is complicated by high rates of morbidity requiring medical intervention. An awareness of these risks should inform future clinical practice.     

Primiparity: An ‘intermediate’ risk group for spontaneous and medically indicated preterm birth

Objective.?Most women in their first pregnancy are at ‘unknown’ risk for preterm birth. We hypothesized that such women may be at an increased risk for preterm birth in comparison to those with a prior term birth.

Methods.?We used Missouri's maternally-linked data (1989–97), comprised of women delivering their first singleton live birth (N = 259 431) and women delivering their first two consecutive singleton live births (N = 154 810). We compared preterm birth (<37 weeks) rates among women with a previous term birth, women with no reproductive history (primiparous women), and in those with a previous preterm birth. Risks of spontaneous and medically indicated preterm birth were also examined after adjustments for confounders through multivariate log-binomial regression models.

Results.?Preterm birth rates were 8.1%, 9.6%, and 23.3% among women with a previous term birth, among primiparous women, and among those with a previous preterm birth, respectively. In comparison to women with a prior term birth, risks of spontaneous preterm birth among primiparous women and among women with a prior preterm birth were 1.1-fold (95% confidence interval (CI) 1.0, 1.2) and 2.5-fold (95% CI 2.4, 2.6) higher, respectively. These risks were higher for medically indicated preterm birth among both primiparous women (RR 1.3, 95% CI 1.2, 1.4) and those with a prior preterm birth (RR 3.2, 95% CI 3.0, 3.5) than for spontaneous preterm births.

Conclusions.?Primiparous women are at increased risk of both medically indicated and spontaneous preterm birth. The findings suggest that studies on preterm birth should consider a risk assignment to include three groups: low-risk (prior term birth), intermediate risk (primiparity), and high-risk (prior preterm birth). This strategy will be informative for the identification of women with impending risk of delivering preterm, and complications associated with prematurity.     

Peripartum cesarean hysterectomy: critical analysis of risk factors and trends over the years

Objective.?To investigate time trends and risk factors for peripartum cesarean hysterectomy.

Methods.?A population-based study comparing all deliveries that were complicated with peripartum hysterectomy to deliveries without this complication was conducted. Deliveries occurred during the years 1988–2007 at a tertiary medical center. A multiple logistic regression model was constructed to find independent risk factors associated with peripartum hysterectomy.

Results.?Emergency peripartum cesarean hysterectomy complicated 0.06% (n?=?125) of all deliveries in the study period (n?=?211,815). The incidence of peripartum hysterectomy increased over time (1988–1994, 0.04%; 1995–2000, 0.05%; 2001–2007, 0.095%). Independent risk factors for emergency peripratum hysterectomy from a backward, stepwise, multivariable logistic regression model were: uterine rupture (OR?=?487; 95% CI 257.8–919.8, p?<?0.001), placenta previa (OR?=?66.4; 95% CI 39.8–111, p?<?0.001), postpartum hemorrhage (PPH) (OR?=?40.8; 95% CI 22.4–74.6, p?<?0.001), cervical tears (OR?=?22.3; 95% CI 10.4–48.1, p?<?0.001), second trimester bleeding (OR?=?6; 95% CI 1.8–20, p?=?0.003), previous cesarean delivery (OR?=?5.4; 95% CI 3.5–8.4, p?<?0.001), placenta accreta (OR?=?4.7; 95% CI 1.9–11.7, p?=?0.001), and grand multiparity (above five deliveries, OR?=?4.1; 95% CI 2.5–6.6, p?<?0.001). Newborns of these women had lower Apgar scores (<7) at 1 and 5?min (32.7% vs.4.4%; p?<?0.001, and 10.5% vs. 0.6%; p?<?0.001, respectively), and higher rates of perinatal mortality (18.4% vs. 1.4%; p?<?0.001) as compared to the comparison group.

Conclusion.?Significant risk factors for peripartum hysterectomy are uterine rupture, placenta previa, PPH, cervical tears, previous cesarean delivery, placenta accreta, and grand multiparity. Since the incidence rates are increasing over time, careful surveillance is warranted. Cesarean deliveries in patients with placenta previa-accreta, specifically those performed in women with a previous cesarean delivery, should involve specially trained obstetricians, following informed consent regarding the possibility of peripartum hysterectomy.     

Adipokinins in pregnancies at risk of preterm delivery

Objective: To compare adipokinins between women experiencing preterm labor (PTL) and prior preterm deliveries (PTD).

Study design: In this prospective observational cohort, 110 women with a singleton <35 weeks at increased risk of PTD were studied. Serum leptin, adiponectin, and resistin were obtained at three times (23–34 weeks, 35–36 weeks, at delivery) and analyzed via enzyme-linked immunosorbent assay. The adipokinins were compared across time and between PTL (n?=?59) and prior PTD (n?=?51) groups using generalized estimated equation models.

Results: There were no differences in leptin, adiponectin, or resistin levels over the three times between the PTL and PTD groups. There was a trend toward higher leptin levels (p?=?0.06 unadjusted analysis, p?=?0.09 adjusted analysis) at 23–34 weeks. When stratified by body mass index (BMI), there were differences in leptin (p?p?=?0.77 for BMI?≥?30) and adiponectin (p?=?0.04 for BMI?p?=?0.09 for BMI?≥?30), but not in resistin over the three times between the PTL and prior PTD groups.

Conclusion: There were no significant differences in adipokinins in women with PTL and a prior PTD. The trends toward higher leptin levels at 23–34 weeks in women with PTL may represent a compensatory response and require further evaluation in the study of treatments for PTL.     

Group B streptococci cultured in urine during pregnancy associated with preterm delivery: a selection problem?

Objective: To investigate an association between Group B streptococci (GBS) in urine culture during pregnancy and preterm delivery.

Methods: A population-based cohort consisted of all the pregnant women (n?=?36,097) from the catchment area of Lillebaelt Hospital, Denmark, during the period January 2002 –December 2012. The cohort of 34,285 singleton pregnancies used in this study was divided into three groups. Group I (N?=?249) included women whose urine culture was positive for GBS; group II (N?=?5765) included women whose urine culture was negative for GBS; and group III (N?=?28 271) included women whose urine had not been cultured during pregnancy. Primary outcome was preterm delivery before 37 weeks’ gestation (PTD).

Results: We did not find an association between PTD and GBS bacteriuria in the cultured groups (odds ratios (OR)?=?0.89; 95% CI: 0.5–1.4) (Table 1). After controlling for potential confounders, the PTD remained not associated with GBS bacteriuria (adjusted OR?=?0.99; 95% CI: 0.6–1.6). Combined, the cultured groups (I and II) were associated with a statistically significant higher risk for PTD, when compared with the group with no urine specimens taken for culture (OR?=?1.96; 95% CI: 1.8–2.2 and adjusted or 1.80; 95% CI 1.6–2.0). The cultured group of women differed considerably from the group of women with no urine specimens taken for culture on the vast majority of variables examined.

Conclusions: No association between asymptomatic GBS bacteriuria and preterm delivery among women with singleton pregnancy and urine specimens cultured during pregnancy was found. Previous suggestions of such association may have been compromised by a selection problem for testing due to a high-risk profile of pregnancy complications in pregnant women selected for urine culture.     

Number and size of uterine fibroids and obstetric outcomes

Objective: Estimating the impact of sonographically identified multiple or large (≥5?cm in diameter) fibroids on obstetric outcomes.

Methods: Retrospective cohort study of 219 women with uterine fibroids (identified on a routine second-trimester ultrasound survey over a 3-year period, 2010–2012) and their age-matched controls. Inclusion criteria were singleton pregnancy, delivery at >24 weeks of gestation and no pathological conditions (chronic hypertension, gestational diabetes or pre-existing diabetes mellitus, uterine anomalies or fetal malformations).

Results: Compared to women with no fibroids, women with multiple fibroids (n?=?34) had a significantly higher rate of preterm birth (29.4% versus 5%, p?<?0.001), cesarean section (73.5% versus 37%, p?<?0.001) and breech presentation (11.8% versus 2.7%, p?=?0.04). Women with large fibroids (n?=?48) had a higher rate of preterm birth (16.7% versus 5%, p?=?0.01) and pPROM (10.4% versus 0.5%, p?<?0.001). By multivariate analysis, only multiple fibroids and previous preterm birth showed an independent significant association with preterm birth (OR?=?7.37, 95% CI 2.50–21.68 and OR?=?13.01, 95% CI 3.56–47.52, respectively).

Conclusions: Women with uterine fibroids are at an increased risk of obstetric complications. In particular, multiple rather than large fibroids are associated with a significantly increased risk of preterm birth and cesarean delivery while large fibroids are associated with a higher risk of pPROM. No correlation with IUGR, placenta previa or placental abruption was found.