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.     

Can sonographic measurements and changes in cervical length during pregnancy predict preterm labour in an asymptomatic low-risk population?

Objective: This study measured cervical length (CL) at 14–16 and 21–24 weeks of gestation and assessed whether the difference between the measurements is predictive of preterm delivery (PTD).

Methods: This retrospective, cohort study included patients with two consecutive CL measured with transvaginal sonography at 14–16 weeks of gestation (CL₁) and 21–24 weeks (CL₂). Electronic medical records were reviewed for demographic, medical and obstetric history; complications during the current pregnancy and delivery data. CL₁, CL₂ and the change between scans were evaluated and correlated to PTD prediction.

Results: Among the 216 patients, 196 (90.7%) delivered at term (≥37 weeks) and 20 (9.3%) preterm (<37 weeks). CL₁ was not a good predictor of PTD (p?=?.70). CL₂ was significantly shorter in the PTD group (p?p?=?.55). Perinatal outcomes between term and preterm deliveries were similar.

Conclusions: Sonographic measurement of CL at 14- to 16-week gestation and the difference between CL in the first and second scans are not reliable predictors of PTD. However, cervical length at 21–24 weeks in low-risk women is predictive of this complication.     

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.     

Does cervical cerclage decrease preterm birth in twin pregnancies with a short cervix?

Purpose: To determine if use of cerclage in twin gestations with mid-trimester short cervix is associated with decreased preterm birth rate.

Study design: This is a retrospective cohort of twin gestations identified with cervical length of ≤2.5?cm before 24 weeks of gestation through the perinatal ultrasound database of two institutions from 2008 to 2014. Patients with and without cerclage were compared for a primary outcome of preterm birth at <35 weeks. A pre-planned sub-group analysis of patients with cervical length ≤1.5?cm was also performed.

Results: Eighty-two patients were included; 43 received cerclage, 39 did not. Mean gestational age at cerclage placement was 20.8 weeks. There was no significant difference in rate of preterm birth <35 weeks between the groups (34.9% versus 48.7%, respectively). In the sub-group analysis of patients with cervical length ≤1.5?cm, there was a significant decreased risk of preterm birth <35 weeks [37% versus 71.4%; adjusted RR 0.49 (0.26–0.93)].

Conclusion: Cerclage placement for cervical length ≤2.5?cm in twin gestations did not decrease the rate of preterm birth at <35 weeks; however, cerclage placement for cervical length ≤1.5?cm was associated with a significantly decreased rate of preterm birth <35 weeks when compared to patients managed without cerclage.     

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.     

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.     

Positive vaginal culture at rescue cerclage predicts subsequent preterm delivery

Purpose: This retrospective case-control study is aimed to extract predictors of preterm delivery after rescue cerclage.

Materials and methods: We collected the data from all the pregnant women who underwent rescue cerclage before 26⁺⁰ gestational weeks at our facility between July 2006 and July 2016. These women were divided into “delivery at <34 weeks” group (n?=?12) and “delivery at ≥34 weeks” group (n?=?12). Multiple factors that had been detected at the time of cerclage were compared between these two groups.

Results: “Gestational weeks at cerclage ≥23” and “positive vaginal culture at cerclage” were significantly more prevalent in the “delivery at <34 weeks” group than in the “delivery at ≥34 weeks” group. “Prolapsed membranes at cerclage” tended to be more prevalent in the “delivery at <34 weeks” group than in the “delivery at ≥34 weeks” group. “Positive vaginal culture at cerclage” was the only independent risk factor associated with eventual preterm delivery before 34 gestational weeks.

Conclusions: Simple aerobic bacterial culture of the vaginal swab sampled at the time of cerclage could be used as a reliable test to predict subsequent preterm delivery before 34 gestational weeks.     

Risk factors for spontaneous preterm delivery after arrested episode of preterm labor

Introduction: We aimed to identify specific risk factors for spontaneous preterm delivery (PTD) among women with arrested preterm labor (PTL).

Method: A retrospective study of women admitted due to imminent PTL and intact membranes, which did not progress to PTD within 24?h from admission. Eligibility was limited to singleton gestations at 24?+?0/7–33?+?6/7 weeks of gestations with no known chromosomal or structural anomalies. All women were treated with corticosteroids and tocolysis. Comparison was made between those who delivered at <37?+?0/7 weeks of gestation (study group) to women who delivered at ≥37?+?0/7 weeks of gestation (controls).

Results: Overall, 301 women were recruited, of which 85 (28.2%) delivered before 37?+?0/7 weeks and 216 (71.8%) delivered at term. Advanced cervical dilatation was found to be an independent risk factor for PTD [for women with no past PTD: adjusted odds ratio (aOR) 1.66, 95% CI: 1.06–2.61 for each 1?cm dilatation; for women with past PTD: aOR 2.81, 95% CI: 1.02–7.73 for each 1?cm dilatation]. Among women without past PTD, additional independent risk factors for PTD were earlier gestational week at admission (OR: 1.20, 95% CI: 1.09–1.32 for each earlier week) and short cervical length (OR: 1.04, 95% CI: 1.01–1.08 for each decrease of 1?mm in cervical length).

Conclusion: Advanced cervical dilatation, earlier gestational age at the episode of arrested PTL, and short cervical length are specific risk factors for PTD in women with arrested PTL. These findings may assist in counseling women and direct further investigation.     

Medically indicated late preterm delivery and its impact on perinatal morbidity and mortality: a retrospective population-based cohort study

Objective: In the last few decades, attention has been focused on morbidity and mortality associated with late preterm delivery (34–36?+?6/7 weeks), accounting for 60–70% of all preterm births. This study is aimed to determine (1) the prevalence of late preterm deliveries (spontaneous and medically indicated) in our population; and (2) the rate of neonatal morbidity and mortality as well as maternal complications associated with the different phenotypes of late preterm deliveries.

Study design: This retrospective population-based cohort study, included 96,176 women who had 257,182 deliveries, occurred between 1988 and 2011, allocated into three groups: term (n?=?242,286), spontaneous (n?=?10,063), and medically indicated (n?=?4833) late preterm deliveries.

Results: (1) Medically indicated late preterm deliveries were associated with increased maternal morbidity, as well as neonatal morbidity and mortality, in comparison with other study groups (p?Conclusions: (1) Medically indicated late preterm deliveries were independently associated with adverse composite neonatal outcome; and (2) to benefit in term of neonatal outcome from the tool of medically indicated late preterm birth, their proportion should be kept below 35% of all late preterm deliveries, while exceeding this threshold increases the risk of neonatal mortality.     

Does the rate of cervical shortening after cerclage predict preterm birth?

Objective: The objective of this study is to evaluate whether the rate of cervical shortening after cerclage can predict spontaneous preterm birth (SPTB).

Methods: Women who had cervical length (CL) assessments after cerclage placement were identified. The rate of cervical shortening and its relationship with SPTB was established using a generalized linear regression model. Secondary outcomes included relationship between cervical shortening and risk of SPTB in those with a post-cerclage CL?<25?mm versus ≥25?mm at 18–20 weeks; and the rate of cervical shortening in women who delivered preterm compared with those who delivered at term.

Results: One hundred thirty-four patients were included and 30 (22.4%) delivered at <36 weeks. A rate of cervical shortening of 1?mm/week conferred a risk of SPTB of 22%. Among women with cerclage who had a CL?<25?mm at 18–20 weeks, 1?mm/week of cervical shortening was associated with a 59% risk of SPTB. Patients with cerclage who delivered at term had a slower rate of cervical shortening compared to those who delivered preterm (0.62?mm versus 1.40?mm per week, p?=?0.008).

Conclusions: The rate of cervical shortening after cerclage placement is associated with the risk of SPTB. Sonographic surveillance of the rate of cervical shortening may be useful in assessing risk for SPTB in patients with cerclage.     

Was the military operation “cast lead” a risk factor for preterm deliveries?

Objective: To investigate the influence of operation “Cast Lead” on rates of preterm delivery (PTD) and other adverse pregnancy outcomes at the main region under missile attack during the operation. Methods: A retrospective cohort study comparing pregnancy and delivery outcomes of women who gave birth at the time of the military operation “Cast Lead” with women who gave birth at the same time period 1 and 2 years before and after the war. Results: Out of 1272 women exposed to stress during the war, there were 126 preterm deliveries (9.9%) as compared with 381 preterm deliveries (9.6%) among the 3984 women of the control group (p = 0.719). The group exposed to stress of the military campaign had significantly more preterm deliveries at gestational age 32–34 weeks (1.6% vs. 0.8%; RR = 2.04, p = 0.011). Conclusion: Military operation period was adversely associated with an increase in the rate of early PTD (<34 weeks gestation). From a public health perspective, pregnant women should be considered a special population and should be taken into account in a preparedness program for an emergency crisis and must be an important part of the public agenda and the state’s infrastructure.     

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.     

Obstetric and neonatal outcome in patients with anxiety disorders

Abstract

Objective: To investigate whether a diagnosis of anxiety disorder is a risk factor for adverse obstetric and neonatal outcome.

Methods: A retrospective population-based study was conducted comparing obstetric and neonatal complications in patients with and without a diagnosis of anxiety. Multivariable analysis was performed to control for confounders.

Results: During the study period 256?312 singleton deliveries have occurred, out of which 224 (0.09%) were in patients with a diagnosis of an anxiety disorder. Patients with anxiety disorders were older (32.17?±?5.1 versus 28.56?±?5.9), were more likely to be smokers (7.1% versus 1.1%) and had a higher rate of preterm deliveries (PTD; 15.2% versus 7.9%), as compared with the comparison group. Using a multiple logistic regression model, anxiety disorders were independently associated with advanced maternal age (OR 1.087; 95% CI 1.06–1.11; p?=?0.001), smoking (OR 4.51; 95% CI 2.6–7.29; p?=?0.001) and preterm labor (OR 1.92; 95% CI 1.32-–2.8; p?=?0.001). In addition, having a diagnosis of an anxiety disorder was found to be an independent risk factor for cesarean section (adjusted OR 2.5; 95% CI 1.82–3.46; p?<?0.001), using another multivariable model. No association was noted between anxiety disorders and adverse neonatal outcomes including small for gestational age, low Apgar scores and perinatal mortality.

Conclusion: Anxiety disorders are independent risk factors for spontaneous preterm delivery and cesarean section, but in our population it is not associated with adverse perinatal outcome.     

Association of adherence to guidelines for cervical cerclage with perinatal outcomes and placental inflammation in women with cervical length ≥2.0 cm

ObjectivesCerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines.Material and methodsThis study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology.ResultsAmong 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033).ConclusionCerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation.     

Trends,seasonality and effect of ambient temperature on preterm delivery

Purpose: To identify trends in preterm delivery (PTD) as well as seasonality, temporal variation and the effect of heat stress on its incidence.

Materials and methods: In this retrospective population-based study, we included all deliveries taking place at the Soroka University Medical Center between the years 1988–2012. A time series database was built including meteorological factors and the number of spontaneous versus induced PTDs for each day. Data were analyzed using time–series analyses.

Results: During the study period, 263 709 deliveries occurred, 7.9% of which were preterm. Spontaneous PTD rate steadily decreased, while induced PTD rate increased. A significant annual and seasonal variation was noted in PTD incidence. A significant higher incidence of spontaneous PTD was demonstrated during the summer period with an incidence rate ratio (IRR) of 4.1 (95%CI: 3.1–5.5; p?p?Conclusions: Spontaneous PTD is more common during the summer and its rate is declining steadily over the past decades. Increased outdoor temperature has a significant effect on the incidence of spontaneous, but not induced, PTD.     

Knot positioning during McDonald cervical cerclage,does it make a difference? A cohort study

Objective: To study the effect of McDonald cerclage knot position on the different maternal and neonatal outcomes.

Methods: This historical cohort study included women with singleton pregnancy who had a prophylactic McDonald cervical cerclage between 1 May 2010 and 31 September 2017. Maternal and neonatal outcome parameters were compared between the anterior and posterior knot cerclage procedures. The primary outcome measure was the rate of term birth.

Results: 550 Women had a prophylactic McDonald cervical cerclage, 306 with anterior knot (Group A) and 244 with posterior knot (Group B). There were no statistically significant differences regarding gestational age (GA) at delivery (36.3?±?4.2 versus 35.8?±?5.3 for groups A and B respectively), term birth rate, post-cerclage cervical length, symptomatic vaginitis, urinary tract infection, difficult cerclage removal and cervical lacerations. Similarly, there were no statistically significant differences as regards the studied neonatal outcomes including take home babies, neonatal intensive care admission, respiratory distress syndrome and neonatal sepsis. Survival analysis on GA at delivery demonstrated no statistically significant difference as regards the proportion of term deliveries in the anterior and posterior knot cerclage groups (log-rank test p-value?=?.478).

Conclusions: Knot positioning during McDonald cervical cerclage, anteriorly or posteriorly, didn’t significantly impact the studied maternal and neonatal outcomes.     

Évaluation du cerclage isthmique par voie cœlioscopique

ObjectiveThe transabdominal cervico-isthmic cerclage could to be proposed in case of failure of vaginal cerclage, 2nd trimester fetal losses and cervical defects. The efficiency of the laparoscopic approach, more recently described, has to be demonstrated for the prevention of obstetrical accident.Patients and methodsThis study is a retrospective monocentric evaluation of 14 laparoscopic cervico-isthmic cerclages performed with Benson modified technique before pregnancy between 2005 and 2007. Previous obstetrical accidents, etiology of cervical incompetence and patient outcome after cerclage were compared.ResultsMedian age of the patients was 33.5 years; 93% had previous fetal losses or preterm delivery and 42.9% had failure of Mac Donald cerclages. The indication of laparoscopic cervico-isthmic cerclage was Mac Donald cerclage failure (six cases), and eight cases of anatomic incompatibility of Mac Donald cerclage. Mean duration of laparoscopic cervico-isthmic cerclage was 45 minutes. All patients were hospitalized on an outpatient basis. No operative complication was reported. Six women were pregnant after cerclage: five deliveries by caesarean section at term, and one first trimester foetal loss.Discussion and conclusionThe cervico-isthmic cerclage can be easily performed by laparoscopy. The indications are strictly the same as cervico-isthmic cerclages by laparotomy. Increasing the number of term deliveries and the obstetrical outcome of these patients, the efficiency of the cervico-isthmic cerclage by laparoscopy is demonstrated.     

The role of cervical length measurement at 11–14 weeks for the prediction of preterm delivery

Objective.?To determine whether cervical length (CL) measurement at 11–14 weeks is predictive of preterm delivery (PTD).

Methods.?This was a prospective study of a low-risk population of 1113 women, who underwent CL measurement at 11–14 weeks. Mean CL was calculated for deliveries at >37, <37 and <34 weeks. Cut-off limits of 27?mm and 30?mm were used to examine the predictive value of CL.

Results.?Mean?±?SD CL for the entire study population was 40.6?±?5.5?mm. CL was analyzed for term and PTD (<37 weeks) and further analyzed for deliveries at 34–37 and <34 weeks. Mean CL was 38.9?±?5.5?mm for PTD and 40.8?±?5.5?mm for deliveries >37 weeks (p?=?0.001). Receiver operating characteristic analysis showed small predictive value of CL for PTD <37 weeks (sensitivity?=?63.3% and specificity?=?51.1%, area under the curve (AUC)?=?0.60, 95% CI: 0.54–0.66) (p?=?0.001) and did not show any predictive value for PTD <35 weeks (AUC?=?0.55, 95% CI: 0.43–0.67, p?=?0.355) or PTD <32 weeks (AUC?=?0.51, 95% CI: 0.30–0.74, p?=?0.851).

Conclusion.?CL at 11–14 weeks does not appear to be predictive of PTD. Statistical analysis of CL did not show any predictive value for PTD <35 weeks, or <32 weeks and although it showed a predictive value for PTD at <37 weeks, the sensitivity was very low.     

The clinical utility of sonographic cervical length in the management of preterm parturition at 28–32 weeks of gestation

Objectives: The aim of this study was to evaluate the role of cervical length measurement in early third trimester (28–32 weeks) as a predictor of preterm delivery (PTD), in women presenting with preterm parturition.

Methods: Cervical length was measured prospectively, in singleton pregnancies at 28–32 weeks with preterm contractions (PTC). A multivariate linear regression model was performed to assess the association between cervical length and gestational age at delivery. Logistic regression analysis with PTD before 34 and 37 weeks of gestation as the outcome variable was performed to control for confounders.

Results: Fifty-six women were included, mean gestational week at presentation and at delivery were 29.88?±?1.13 and 37.05?±?2.86, respectively. There was a direct association between short cervical length at admission and gestational week at delivery (p?=?0.027). This association remained significant even after controlling for confounders. Short cervical length was significantly associated with PTD before 34 (p?=?0.045) or 37 (p?=?0.046) weeks of gestation.

Conclusions: Third trimester cervical length measurement in patients with PTC is associated with gestational week at delivery, as well as PTD prior to 34 and 37 weeks of gestation. Therefore, examining cervical length is clinically valuable and probably cost-effective during early third trimester.     

Is preterm delivery an independent risk factor for long-term maternal kidney disease?*

Objective: To investigate whether women who had a preterm delivery (PTD) are at an increased risk of subsequent long term maternal kidney disease.

Study design: A population-based study compared the incidence of long-term maternal kidney disease in a cohort of women with and without previous PTD. Deliveries occurred during a 25 years period, with a mean follow-up duration of 11.2 years.

Results: Of 99 338 deliveries of women, 16 364 (16.4%) occurred in patients who had at least one PTD. A significant dose response was found between the number of previous PTDs and the gestational age at birth of the PTDs and future risk for renal-related hospitalizations. Patients with either spontaneous or indicated PTD had higher rates of renal-related hospitalizations (0.2% versus 0.1% OR=?2.6; 95%CI: 1.7–3.9, p ?<0.001 and 0.5% versus 0.2% OR 3.41; 95%CI: 1.7–6.5, p Conclusions: PTD is an independent risk factor for long-term maternal kidney disease.