RESUMEN
OBJECTIVE: Preterm birth, defined as delivery before 37 weeks' gestation, is a major obstetric challenge and is associated with serious long-term complications in those infants that survive. Preventative management includes cervical cerclage, either as an elective procedure or performed following transvaginal ultrasound surveillance and shortening of the cervix (≤25 mm). Significant questions remain regarding the optimal management, target population and technique. Therefore, this study aimed to assess differences in risk factors and pregnancy outcomes for women who received an elective cerclage versus ultrasound surveillance, following one prior premature event (spontaneous preterm birth/second trimester loss). STUDY DESIGN: Women were retrospectively identified from St Thomas's Hospital Preterm Birth Clinical Network Database. Women who had one prior premature event (between 14+0 and 36+6 weeks' gestation) were included and they were separated into those that an elective cerclage and those who underwent ultrasound surveillance to assess differences in demographics, pregnancy risk factors and preterm birth outcomes. We excluded women who received other preventative therapies. We also separately analysed those women who required an ultrasound-indicated cerclage, comparing the differences between women that delivered preterm and term. RESULTS: We collected data from 1077 women who had a prior preterm event. 66 women received an elective cerclage. 11.4% of women who had ultrasound surveillance received an ultrasound indicated cerclage. Women with a prior history of mid-trimester loss, instead of preterm birth, were more likely to receive an elective cerclage. The mean gestational age of delivery was similar between those women who received an elective cerclage and those who had ultrasound surveillance with and without an ultrasound-indicated cerclage (38+1 vs 37+1), however, preterm birth rates <37 weeks' were twice as high in this ultrasound group (OR 2.3 [1.1-4.5], p = 0.02). In those women that do require an ultrasound-indicated cerclage, 50.4% deliver preterm. CONCLUSIONS: In conclusion, this study shows that in women with one prior preterm event, both history-indicated cerclage and ultrasound surveillance are appropriate management options. The majority of women undergoing ultrasound surveillance did not require a cerclage and so avoided the potential perioperative complications of cerclage insertion. However, those that did require an ultrasound-indicated cerclage were at high risk of preterm birth so should be followed up closely to enable adequate preterm birth preparation. Further prospective studies comparing history indicated cerclage and US surveillance in women with one prior preterm event are necessary.
Asunto(s)
Cerclaje Cervical , Nacimiento Prematuro , Recién Nacido , Embarazo , Femenino , Humanos , Nacimiento Prematuro/prevención & control , Nacimiento Prematuro/epidemiología , Estudios Retrospectivos , Estudios Prospectivos , Resultado del Embarazo , Cerclaje Cervical/métodos , Cuello del Útero/cirugía , Medición de Longitud CervicalRESUMEN
OBJECTIVE: To evaluate clinical differences in the safety of dilation and evacuation (D&E) and induction of labor (IOL) for the treatment of intrauterine fetal demise (IUFD) between 14 and 24 weeks gestation. STUDY DESIGNS: A retrospective chart review was conducted at a single institution comparing rates of major and minor complications between patients who undergo D&E and those that undergo IOL in the treatment of IUFD between 14 and 24 weeks gestation. Demographic and medical variables were stratified by management method and analyzed using chi-squared and t-tests where appropriate. RESULTS: Patients who underwent IOL were of a more advanced gestational age and more likely to be uninsured. Patients who underwent D&E were more likely to be privately insured. Hospital time for an IOL was significantly longer than for D&E. Composite rates of complication did not differ significantly between management groups. Patients treated with D&E were more likely to require uterine aspiration. CONCLUSIONS: D&E and IOL are equally safe methods for the management of IUFD between 14 and 24 weeks gestation. Both options should be made available to patients who experience this rare pregnancy outcome.
Asunto(s)
Aborto Inducido , Muerte Fetal , Aborto Inducido/efectos adversos , Aborto Inducido/métodos , Dilatación , Femenino , Muerte Fetal/etiología , Humanos , Trabajo de Parto Inducido/efectos adversos , Trabajo de Parto Inducido/métodos , Embarazo , Segundo Trimestre del Embarazo , Estudios Retrospectivos , MortinatoRESUMEN
PURPOSE: To examine the association of chronic endometritis (CE) with cervical incompetence (CI) in Chinese women with mid-trimester loss, and the impact of the presence of CE on the outcome of laparoscopic cervical cerclage (LCC). METHODS: This retrospective cohort study included a study group of 293 women with mid-trimester loss due to CI (group I) and a comparison group of 332 women with recurrent first-trimester miscarriage (group II). Immunohistochemical study using CD138 epitope for the diagnosis of CE was completed in all subjects. Pre-conception LCC was undertaken in 247 women in the study group (group I). The study was approved by Institutional Review Board (IRB) (number 2015FXHEC-KY005). RESULTS: The prevalence of CE in group I was 42%, significantly (P < 0.001) higher than that of 23.5% in group II. Among 247 women in group I, there were no significant difference in mid-trimester loss rate, preterm delivery rate and term delivery rate in women with and without CE (2.2, 12.0, 85.8% vs. 1.8, 10.1, 88.1% respectively) and between women with CE treated and not treated with antibiotics prior to conception (2.3, 9.3, 88.4% vs. 2.0, 14.3, 83.7% respectively). CONCLUSIONS: Mid-trimester loss due to cervical incompetence is associated with chronic endometritis; However, the presence or not of CE and whether it was treated with antibiotics prior to conception did not appear to significantly influence the obstetric outcomes of women with CI after LCC.
Asunto(s)
Cerclaje Cervical , Endometritis , Laparoscopía , Incompetencia del Cuello del Útero , Endometritis/epidemiología , Femenino , Humanos , Recién Nacido , Embarazo , Estudios Retrospectivos , Incompetencia del Cuello del Útero/epidemiología , Incompetencia del Cuello del Útero/cirugíaRESUMEN
BACKGROUND: Minimising the risks of mortality, morbidities, and the costs associated with preterm birth is reliant on accurate prediction, appropriate decision-making and timely intervention. This study aimed to determine for the first time the decisional and informational requirements of women and clinicians during preterm labour diagnosis and intervention. A secondary objective was to explore their experiences. STUDY DESIGN: A qualitative, interpretive approach was used in three tertiary referral units in England and Scotland. Women with experience of or risk factors for preterm birth and clinicians with experience of caring for women in preterm labour took part in semi-structured interviews individually face-face or via telephone, or in a small focus-group. Data was analysed using a framework approach. RESULTS: Women and clinicians welcomed a more accurate tool for predicting preterm birth. Women wanted to be actively involved in their care, but desired different levels of control over decisions. Communication between women and clinicians influenced women's overall experiences and shaped clinicians' practice. Women found accessing care difficult, due to uncertainty about symptoms and gatekeepers to face-face care. The emotional impact of their experiences influenced family plans and subsequent pregnancies. Women's overall perception of their experience was influenced by their judgement of the care they received. CONCLUSIONS: Decision-making is complex and a tool to more accurately predict preterm birth than is currently available was valued. Further research is warranted to evaluate a tool in clinical practice and to improve services for women with symptoms of preterm labour attempting to gain access to face-face care. Trial Registration ISRCTN: 41598423 and CPMS:31277.
Asunto(s)
Toma de Decisiones Clínicas , Toma de Decisiones Conjunta , Trabajo de Parto Prematuro/diagnóstico , Trabajo de Parto Prematuro/terapia , Comunicación , Emociones , Femenino , Grupos Focales , Ginecología , Accesibilidad a los Servicios de Salud , Humanos , Entrevistas como Asunto , Partería , Trabajo de Parto Prematuro/psicología , Obstetricia , Embarazo , Embarazo de Alto Riesgo/psicología , Investigación Cualitativa , Medición de RiesgoRESUMEN
BACKGROUND: Mid-trimester loss (MTL) is an area that is poorly defined in the literature and often under reported in clinical practice. The prevalence of MTL in Ireland is uncertain and has a huge impact on the woman, her family and maternity care services. AIMS: To explore the prevalence and patterns of care for women with MTL in a large Maternity hospital in Ireland. METHODS: A descriptive, exploratory study was used involving a retrospective chart audit. RESULTS: 220 women presented with MTL over the 3 year data collection period (January 2011-December 2013), giving a rate of 0.8 % of all deliveries. The majority of women had no previous pregnancy losses and were multiparous (i.e., had a previous pregnancy >500 g). The mean gestational age was 17.69 weeks (SD = 2.73). The mean length of hospital stay was 1.89 days. Intra muscular (IM) analgesia was the most commonly (58.5 %) used medication. Follow up hospital care was received in over 78 % of cases. The majority of women were referred the CMS Bereavement and Chaplain services, with a small number (approx. 5 %) referred to the social worker. Over 46.4 % of families availed of the hospital burial service. CONCLUSIONS: Results suggest the incidence of mid-trimester loss may be slightly lower than the 1 or 2 % of pregnancies reported in the literature. The incidence of mid-trimester loss in multiparous women is approximately twice that of nulliparous women. The referral services offered in the study were utilised by most of the women, as were follow-up clinic appointments.
Asunto(s)
Aborto Espontáneo/epidemiología , Edad Gestacional , Adulto , Femenino , Humanos , Irlanda , Embarazo , Prevalencia , Estudios RetrospectivosRESUMEN
OBJECTIVE: To study the value of the cervical length (CL) measurement at 11-14 weeks in predicting second trimester miscarriage occurring at 16-24 weeks. METHODS: Prospective study in routine obstetric population using transvaginal ultrasound examination to measure the length of the endocervical canal at 11-14 weeks. RESULTS: The study group consisted of 2836 singleton pregnancies. Eleven (0.0038%) women miscarried between 16 and 24 weeks whereas 2825 delivered after 34 weeks. CL was significantly shorter (Mann-Whitney U test, p = 0.001), in women that had a second trimester miscarriage in comparison to those who delivered after 34 weeks (median CL 28 mm versus 32 mm, respectively). First trimester CL was predictive of a late miscarriage (OR = 0.7093304, R(2 )= 0.1211, AUC = 0.7838, p < 0.001). The detection rate was 63.64% for 20% screen positive rate. CONCLUSIONS: First trimester endocervix is significantly shorter in women destined to miscarry between 16 and 24 weeks. In low risk singleton pregnancies, first trimester CL can be useful in predicting second trimester miscarriage.
Asunto(s)
Aborto Espontáneo/diagnóstico por imagen , Medición de Longitud Cervical/estadística & datos numéricos , Aborto Espontáneo/epidemiología , Femenino , Grecia/epidemiología , Humanos , Embarazo , Primer Trimestre del Embarazo , Segundo Trimestre del Embarazo , Estudios ProspectivosRESUMEN
Mid-trimester pregnancy loss (MTL) occurs between 12 and 24 weeks' gestation. The true incidence of this pregnancy complication is unknown, because research into MTL in isolation is scarce, although the estimated incidence has been noted to be 2% to 3% of pregnancies. A comprehensive preconceptual screening protocol is recommended, because the cause for an MTL may be present in isolation or combined (dual pathology), and is often heterogeneous. Patients with a history of MTL are at an increased risk of future miscarriage and preterm delivery. This risk is increased further depending on the number of associative factors diagnosed.