Although observational studies have often claimed high success rates in women undergoing cervical cerclage for an incompetent cervix, randomized trials have not consistently favored this procedure. This multicenter, randomized, controlled trial sought to determine whether patient selection for cerclage could be improved by transvaginal sonographic measurements of cervical length. More than 47,000 women were offered scanning at 11 to 14 and 22 to 24 weeks gestation. Of 470 women whose cervix measured 15 mm or less in length, 253 entered the trial and were randomly assigned to either cervical cerclage using a Shirodkar suture or expectant management. The major outcome was the frequency of delivery before 33 completed weeks gestation. Cervical cerclage did not significantly lower the rates of early preterm delivery, neonatal mortality, or neonatal morbidity compared with expectant management. The 2 groups had similar proportions of spontaneous delivery or delivery after preterm prelabor rupture of membranes. Mean birth weight was 204 g more in the cerclage group, but this arose from a 1-week difference in gestational age at delivery. More than twice as many women in the cerclage group received antibiotics, most often because of prolonged prophylaxis and symptomatic vaginal discharge. More women in the cerclage group received tocolytic agents immediately after the procedure or because of threatened preterm labor. Approximately one third of women required emergency removal of the suture, most often because of preterm labor or premature labor or rupture of membranes. In this trial, placing a cervical suture in women with a short cervix did not lower the risk of early preterm delivery in a substantial proportion of cases. Routinely measuring cervical length at 22 to 24 weeks gestation by transvaginal sonography does identify women who are at high risk of early preterm delivery.

Cervical cerclage for prevention of preterm delivery in women with a short cervix: A randomized, controlled trial

Objective The primary aim of the "Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be" is to determine maternal characteristics, which include genetic, physiologic response to pregnancy, and environmental factors that predict adverse pregnancy outcomes. Study Design Nulliparous women in the first trimester of pregnancy were recruited into an observational cohort study. Participants were seen at 3 study visits during pregnancy and again at delivery. We collected data from in-clinic interviews, take-home surveys, clinical measurements, ultrasound studies, and chart abstractions. Maternal biospecimens (serum, plasma, urine, cervicovaginal fluid) at antepartum study visits and delivery specimens (placenta, umbilical cord, cord blood) were collected, processed, and stored. The primary outcome of the study was defined as pregnancy ending at Results We recruited 10,037 women to the study. Basic characteristics of the cohort at screening are reported. Conclusion The "Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be" cohort study methods and procedures can help investigators when they plan future projects.

A description of the methods of the Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be (nuMoM2b)

Red Blood Cell Alloimmunization in the Pregnant Patient.

INTRODUCTION Bishop score, the traditional method to assess cervical condition, is not a promising predictive tool of the outcome of labor induction. As an objective assessment tool, many cervical ultrasound measurements have been proposed to represent the individual components of the Bishop score, but none of them can measure the cervical stiffness. Cervical shear wave elastography is a novel tool to assess the cervical stiffness quantitatively. MATERIAL AND METHODS A total of 475 women who required labor induction were studied prospectively. Prior to routine digital assessment of the Bishop score, transvaginal sonographic measurement of cervical length, posterior cervical angle, angle of progression and shear wave elastography was performed. Shear wave elastography measurement was made at the inner, middle and outer regions of the cervix to assess homogeneity. Association of labor induction outcomes including the overall cesarean section and subgroups of cesarean section for failure to enter active phase, with cervical sonographic parameters and the Bishop score, were assessed using multivariate regression analyses. The predictive accuracy of the outcomes using models based on ultrasound measurement and the Bishop score was compared using the area under the receiver-operating characteristics curves. RESULTS Among 475 women, 82 (17.3%) required cesarean section. Shear wave elasticity was significantly higher in the inner cervical region than in other regions, indicating a greater stiffness (P < 0.001). Both inner cervical shear wave elasticity and cervical length were independent predictors of overall cesarean section (respective adjusted odds ratio [95% CI] 1.338 [1.001-1.598] and 1.717 [1.077-1.663]) and cesarean section for failure to enter active phase (respective adjusted odds ratio [95% CI] 1.689 [1.234-2.311] and 2.556 [1.462-4.467]), after adjusting for other covariates. Outcome prediction models using inner cervical shear wave elasticity and cervical length, had increased area under curve compared with models using the Bishop score (0.888 vs 0.819, P = 0.009). CONCLUSIONS The cervix is not a homogenous structure, with the inner cervix having the highest stiffness, which is an independent predictor of overall cesarean section, and specifically for those indicated because of failure to enter active phase. Models based on shear wave elastography and cervical length had higher predictive accuracy than models based on the Bishop score.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/aogs.13706

The predictive value of cervical shear wave elastography in the outcome of labor induction.

OBJECTIVES: There is no consensus about the optimal surveillance strategy in women with a diagnosis of vasa previa. The aim of this study was to evaluate the role of the rate of change in cervical length measurements in the management of singleton pregnancies with a diagnosis of vasa previa.

METHODS: We performed a retrospective case‐control study of our databases for pregnancies with a prenatal diagnosis of vasa previa that were followed with transvaginal sonography for cervical length and evaluated the impact of the changes in cervical length on the need for emergency cesarean delivery.

RESULTS: The cohort included 29 singleton pregnancies with a prenatal diagnosis of vasa previa in the second trimester. There were 14 and 15 pregnancies that underwent elective and emergency cesarean delivery, respectively. The rate of cervical length shortening was significantly slower for women with elective compared to emergency cesarean delivery (median [range], 0.7 [0.1–2.0] versus 1.5 [0.25–3.0] mm/wk; P = .011). For each additional millimeter‐per‐week decrease in cervical length, the odds of emergency cesarean delivery increased by 6.50 (95% confidence interval, 1.02–41.20). The receiver operating characteristic curve for the rate of cervical length shortening in the prediction of emergency cesarean delivery yielded an area under the curve of 0.85 (95% confidence interval, 0.69–0.99).

CONCLUSIONS: Our findings indicate an association between the rate of cervical length shortening and the risk of emergency cesarean delivery in pregnancies with a diagnosis of vasa previa in the second trimester. Further multicentric studies are required to validate our data prospectively and, in particular, the role of serial cervical length measurements in determining the optimal delivery time for individual cases.

/pdf/the-rate-of-cervical-length-shortening-in-the-management-of-45mup9mwyx.pdf

The Rate of Cervical Length Shortening in the Management of Vasa Previa.

Objective The objective of this study was to review the management strategies and outcomes in gravidas with anti-M alloimmunization over 15 years. Study Design Data collected from 195 pregnant patients with anti-M antibodies from July 2000 through June 2016 were reviewed retrospectively. We analyzed indirect antiglobulin test titer results, paternal or fetal/neonatal M antigen status, antepartum course, and perinatal outcomes. Results Anti-M antibodies were found in 146 women and 195pregnancies. Among those with positive indirect antiglobulin tests, 193 pregnancies had titers at or below 1:4. Only one patient with an initial low titer experienced a more than twofold increase to a titer 1:64. Two women underwent an amniocentesis and cordocentesis. Ninety-five (73.6%) of the 129 infants tested were positive for the M antigen. Nine infants required phototherapy. There were no cases of hemolytic disease of the fetus or newborn, mild or severe. Conclusion The incidence of severe hemolytic disease of the newborn due to anti-M is extremely low. We found no cases in our review of 195 pregnancies, despite several cases of severe hemolytic disease of the newborn reported in the literature. We have created an algorithm for the management of anti-M antibodies in pregnancy based on our data and extensive literature review.

/pdf/anti-m-alloimmunization-management-and-outcome-at-a-single-1260xehk26.pdf

Anti-M Alloimmunization: Management and Outcome at a Single Institution.

An important step toward the goal of eradicating spontaneous preterm birth was achieved with the advent of cervical sonography, a tool that advanced our knowledge of the entity of preterm parturition, improved our ability to detect women at risk for early delivery, and allowed us to prevent some of these premature births. We will describe here the correct technique for obtaining such measurements and will review the literature regarding the use of this tool in specific pregnant populations.

Measuring the Cervical Length.

Objectives  The objective is to present a pregnancy complication associated with intravenous drug use, namely, that of red blood cell alloimmunization and hemolytic disease of the fetus and newborn. Methods  An observational case series is presented including women with red blood cell alloimmunization most likely secondary to intravenous drug abuse Results  Five pregnancies were identified that were complicated by red blood cell alloimmunization and significant hemolytic disease of the fetus and newborn, necessitating intrauterine transfusion, an indicated preterm birth, or neonatal therapy. Conclusions  As opioid abuse continues to increase in the United States, clinicians should be aware of the potential for alloimmunization to red blood cell antibodies as yet another negative outcome from intravenous drug abuse.

/pdf/hemolytic-disease-of-the-fetus-and-newborn-due-to-3m63ureyb0.pdf

Hemolytic Disease of the Fetus and Newborn due to Intravenous Drug Use

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Anti-M Alloimmunization: Management and Outcome at a Single Institution.

Measuring the Cervical Length.

Hemolytic Disease of the Fetus and Newborn due to Intravenous Drug Use