Advanced Cervical Dilatation Research Articles

Antenatal corticosteroid timing: accuracy after the introduction of a rescue course protocol

Antenatal corticosteroid administration is a critical fetal intervention, and the use of a rescue protocol is now standard practice. Rescue antenatal corticosteroid may improve overall accuracy of antenatal corticosteroid administration timing, but this observation and its effect on the initial course is unknown. We sought to compare the accuracy of antenatal corticosteroid administration before and after the implementation of a rescue antenatal corticosteroid protocol. We performed a retrospective cohort study of patients who received a minimum of 1 dose of antenatal corticosteroid from 2006-2012 at the University of Washington Medical Center with the use of the University of Washington Medical Center Pharmacy Database. For inclusion, subjects were required to be admitted, receive the initial antenatal corticosteroid course at 24-34 weeks gestation, and deliver at University of Washington Medical Center. We designated 2 groups that were based on when rescue antenatal corticosteroid became standard practice at University of Washington Medical Center: before rescue antenatal corticosteroid (2006-2008) and after rescue antenatal corticosteroid (2009-2012). Primary outcome was delivery within any optimal antenatal corticosteroid window, which was defined as 48 hours to 7 days after the first dose or third dose. We also compared delivery within the optimal window of the initial and rescue antenatal corticosteroid courses independently and assessed antenatal corticosteroid timing by the indication for delivery. Chi squared and independent sample t-tests were used to compare results. From 2006-2012, 1356 women met inclusion criteria, 601 before and 755 after rescue antenatal corticosteroid. The study groups demonstrated similar demographics, with the exception of more white women in the group after rescue antenatal corticosteroid (47% vs 60%; P< .01) and delivered at comparable gestational ages (32.7 vs 32.6 weeks; P= .59). Availability of a second course did not increase total subjects who delivered within any optimal window (26.5% vs 28.5%; P=.41). Frequency of delivery within the initial course optimal window did not change after the introduction of the rescue course protocol (26.1% vs 26.4%; P= .92). Similarly, of the 73 subjects who received rescue antenatal corticosteroid, 24.7% delivered in the optimal window of the second course. Delivery within the optimal window varied by indication for antenatal corticosteroid, with highest accuracy among maternal indications (41.2% in any optimal window), followed by preterm premature rupture of membranes (32.1%). Lowest administration accuracy was among women with antenatal cervical shortening and advanced cervical dilation; only 2.8% and 6.3% delivered within the optimal window, respectively. Furthermore, for women with antenatal cervical shortening, the mean gestational age of delivery was 35.1 weeks, and the median interval from antenatal corticosteroid administration to delivery was 55 days (interquartile range, 34-72 days). The opportunity for a second course of antenatal corticosteroid did not improve the number of women who delivered within any optimal antenatal corticosteroid window. Administration timing was similar for the initial course and the rescue course, with approximately one-quarter of women delivering within the optimal antenatal corticosteroid window. These findings likely reflect the few circumstances in which rescue antenatal corticosteroid is useful and the poor predictability of preterm birth. Future focus should be aimed at tools to predict the timing of preterm birth to optimize antenatal corticosteroid administration.

Does the clinical presentation of a prior preterm birth predict risk in a subsequent pregnancy?

The objective of the study was to determine whether risk of recurrent preterm birth differs based on the clinical presentation of a prior spontaneous preterm birth (SPTB): advanced cervical dilatation (ACD), preterm premature rupture of membranes (PPROM), or preterm labor (PTL). This retrospective cohort study included singleton pregnancies from 2009 to 2014 complicated by a history of prior SPTB. Women were categorized based on the clinical presentation of their prior preterm delivery as having ACD, PPROM, or PTL. Risks for sonographic short cervical length and recurrent SPTB were compared between women based on the clinical presentation of their prior preterm birth. Log-linear regression was used to control for confounders. Of 522 patients included in this study, 96 (18.4%) had prior ACD, 246 (47.1%) had prior PPROM, and 180 (34.5%) had prior PTL. Recurrent PTB occurred in 55.2% of patients with a history of ACD compared with 27.2% of those with PPROM and 32.2% with PTL (P = .001). The mean gestational age at delivery was significantly lower for those with a history of ACD (34.0 weeks) compared with women with prior PPROM (37.2 weeks) or PTL (37.0 weeks) (P = .001). The lowest mean cervical length prior to 24 weeks was significantly shorter in patients with a history of advanced cervical dilation when compared with the other clinical presentations. Patients with a history of ACD are at an increased risk of having recurrent preterm birth and cervical shortening in a subsequent pregnancy compared with women with prior preterm birth associated PPROM or PTL.

Factors associated with successful vaginal birth after cesarean section and outcomes in rural area of Anatolia.

Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation. This study attempts to evaluate factors associated with success of vaginal birth after cesarean section and to compare the maternal and perinatal outcomes between vaginal birth after cesarean section and intrapartum cesarean section in patients who were admitted to hospital during the active or second stage of labor. A retrospective evaluation was made from the results of 127 patients. Cesarean section was performed in 57 patients; 70 attempted trial of labor. The factors associated with success of vaginal birth after cesarean section were investigated. Maternal and neonatal outcomes were compared between the groups. Vaginal birth after cesarean section was successful in 55% of cases. Advanced cervical opening, effacement, gravidity, parity, and prior vaginal delivery were factors associated with successful vaginal birth. The vaginal birth group had more complications (P<0.01), but these were minor. The rate of blood transfusion and prevalence of changes in hemoglobin level were similar in both groups (P>0.05). In this study, cervical opening, effacement, gravidity, parity, and prior vaginal delivery were important factors for successful vaginal birth after cesarean section. The patients’ requests influenced outcome. Trial of labor should take into consideration the patient’s preference, together with the proper setting.

Tocolysis in women with advanced preterm labor: a secondary analysis of a randomized clinical trial

Objective: To compare the efficacy of tocolytic treatment with indomethacin (I), magnesium sulfate (M) and nifedipine (N) for acute tocolysis in women with advanced cervical dilation (4–6 cm).Methods: A single center, randomized trial was carried out involving patients in preterm labor (cervix 1–6 cm). Secondary analysis of women with advanced cervical dilation (cervix 4–6 cm) at 24–32 weeks’ gestation who received intravenous M, oral N or I suppositories comprised this study population.Results: Over 38 months, 92 women with advanced cervical dilation were randomized to one tocoloytic type. Days gained in utero (11.7) and percent remaining undelivered at 48 h (60.8%), 72 h (53.1%) and >7 days (38.3%) were similar regardless of tocolytic employed (p = 0.923, 0.968, 0.791, 0.802, respectively). Likewise, gestational age at delivery (30.7 ± 3.2) was similar between groups (p = 0.771). Finally, neonatal statistics were not different when stratified by tocolytic treatment.Conclusion: There were no statistical differences between tocolytics in treating women with advanced cervical dilation. All offered significant days gained in utero after therapy, a high percentage remaining undelivered after 48 or 72 h and after 7 days. It would appear from data that there may be advantages to tocolytic treatment even in women with advanced cervical dilation.

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.

Effects of emergency cervical cerclage on pregnancy outcome: a retrospective study of 158 cases.

The aim of this study was to evaluate the effectiveness and safety of emergency cervical cerclage in women with advanced cervical dilatation and bulging of fetal membranes. The study included 158 women who underwent emergency cervical cerclage because of cervix dilatation and protruding membranes in mid-trimester at Sun Yat-sen Memorial Hospital of Sun Yat-sen University. Pregnancy outcomes and pregnancy outcome related to clinical features were analyzed retrospectively. Analysis revealed that the placement of emergency cerclage led to the delivery of live infants with a success rate of 82.28%. The mean interval between cerclage and delivery was 52.16.±26.62 days, with a mean gestation at delivery of 30.3±4.7 weeks and a mean birth weight of 1934.69±570.37 g. No severe maternal complications such as maternal death, hematosepsis, and hysterorrhexis occurred after the operation. Two women (1.25%) had laceration of the cervix, 1 woman (0.61%) suffered pulmonary edema, and 2 women (1.25%) developed deep vein thrombosis (DVT). There were significant correlations between the pregnancy outcome and risk factors, including any presenting symptoms, cervical dilatation, postoperative white blood cell count, and C-reactive protein (CRP) value. No significant difference was found in women with good vs. poor outcome in terms of maternal age and obstetric histories. Emergency cervical cerclage is effective in prolonging pregnancy and improving neonatal outcome in women with cervical incompetence. It should be considered a viable option for women with a dilated cervix in mid-trimester.

A Case of Delayed Interval Delivery with a Successful Hospital Move.

This report is the first case of delayed interval twin delivery in which the first infant and mother survived without major morbidity following transport to another facility. In addition, this case is only the second report of asynchronous delivery in which both twins survived and neither suffered any major morbidity. A 30-year-old G5P1031 African American female with a diamniotic/dichorionic twin pregnancy presented to U.S. Naval Hospital Okinawa, Japan, at 22 + 5 weeks due to vaginal bleeding. At 23 + 2 weeks, Twin A was born secondary to advanced cervical dilation. Twin A's birth weight was 650 g with APGAR scores of 6 (1 min) and 7 (5 min). Following delivery of Twin A, Placenta A was left in utero with high ligation of the umbilical cord. Due to a scheduled hospital move, the mother and Twin A were transported to the new facility at Camp Foster. Three weeks later, Twin B was delivered at 26 + 4 weeks. Twin B's birth weight was 930 g with APGAR scores of 3 (1 min) and 7 (5 min). Both twins were discharged without IVH, PVL, ROP, or CLD. This case demonstrates the possibility of transporting both the mother and surviving infant A to a higher level of care prior to delivery of subsequent fetuses.

Neonatal and infant outcomes in twin gestations with preterm premature rupture of membranes at 24-31 weeks of gestation.

To describe the perinatal and infant and early childhood morbidity associated with preterm premature rupture of membranes (PROM) in a cohort of twin pregnancies evaluated prospectively with neonatal follow-up to 2 years of age. This was a secondary analysis of a randomized controlled trial of magnesium sulfate for prevention of cerebral palsy. Inclusion criteria were twin gestation with preterm PROM diagnosed between 24 0/7 and 31 6/7 weeks of gestation and planned expectant management. Latency (time from membrane rupture to delivery) and perinatal outcomes were evaluated by gestational age at membrane rupture. Long-term neonatal outcomes were also analyzed. Among 151 women who met inclusion criteria, the median gestational age at preterm PROM was 28.1 weeks (range 24.1-31.6 weeks). Approximately one-third of women achieved a latency of at least 1 week. Gestational age at preterm PROM (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.63-0.90 for each week after 24 weeks of gestation) and cervical dilation at admission (OR 0.66, 95% CI 0.49-0.90 for each centimeter of dilation) were inversely associated with a latency period of at least 1 week. There were no stillbirths (95% CI 0-1%), but the rate of neonatal mortality was 90 per 1,000 newborns (95% CI 57-112) with a 7.3% cerebral palsy rate among survivors (95% CI 4.4-10.3%). In twin pregnancies, preterm PROM from 24 to 31 weeks of gestation is associated with a neonatal mortality rate of 9.0% and an overall cerebral palsy rate of 7.3%. A longer latency period is associated with less advanced cervical dilation and later gestational age at PROM. LEVEL OF EVIEDENCE: II.

Advanced cervical dilatation and spontaneous preterm labor: a comparison between twin and singleton gestations

To determine the admission to delivery interval and the rate of immediate delivery in twin versus singleton gestation complicated by spontaneous preterm labor (SPTL). A retrospective cohort study of pregnant women presenting with advanced cervical dilatation of 3-5 cm and frequent uterine contractions at 24-34 weeks of gestation was performed. The rate of progression to delivery within 12 h and 24 h, as well as rates of prolonged latency, were compared between twins and singletons gestations. Sixty-nine women were included, of which 25 carried twins and 44 singletons. The overall rate of spontaneous delivery within 12 h and 24 h was 47.8% and 59.4%, respectively, and similar between twins and singletons. Nevertheless, prolonged latency of 10 days or more after presentation was more frequent among twins compared with singletons [10/25 (40%) vs. 7/44 (15.9%), respectively; P=0.026]. Moreover, women carrying twins presenting with advanced cervical dilatation had a better chance of completing a full 2-dose antenatal betamethasone course compared with singletons [19/25 (76%) of twins compared with 21/44 (47.7%) of singletons, odds ratio 3.5, 95% confidence interval 1.16-10.34; P=0.022]. Up to 60% of women presenting with advanced cervical dilatation prior to 34 weeks' gestation give birth within 24 h. Nevertheless, women carrying twins have a better chance of completing a betamethasone course and having prolonged latency compared with singletons.

758: Predictors of preterm birth after emergent cerclage in a twin gestation

To identify patient characteristics associated with preterm birth (PTB) prior to 28 weeks after emergent cerclage and to identify any differences specific to twin gestations. This is a retrospective cohort of women who underwent an exam-indicated cerclage at a single university hospital between January 1, 1980 and December 31, 2013. Patient characteristics associated with PTB < 28 weeks were identified in bivariable analysis. A multivariable logistic regression was then performed to identify if any of these clinical associations were modified in a twin gestation. During the study period, 442 women underwent an exam-indicated cerclage: 104 twins and 338 singletons. Of these, 121 (35.8%) of the singletons and 35 (33.7%) of the twins delivered prior to 28 weeks. In bivariable analysis, neither maternal age nor race were associated with PTB < 28 weeks. Earlier gestational age at cerclage placement was associated with a decreased odds of PTB < 28 weeks, whereas more advanced cervical dilation, a shorter cervical length, and the presence of membrane prolapse were associated with an increased odds of PTB < 28 weeks. Interaction terms were created between twin gestation and each of the patient characteristics associated with PTB < 28 weeks. A logistic regression was performed including all patient factors significantly associated with PTB < 28 weeks, gestational pleurality, and any significant interaction terms. Results are shown in Table 1. Early gestational age at cerclage placement, cervical dilation, and prolapsing membranes are all significantly associated with PTB <28 weeks in women undergoing emergent cerclage placement independent of gestational pleurality. A short cervical length (< 2cm) at the time of cerclage placement is a risk factor for PTB < 28 weeks in twin but not singleton gestations.Tabled 1 Open table in a new tab

Outcome of Late Second Trimester Emergency Cerclage in Patients with Advanced Cervical Dilatation with Bulging Amniotic Membranes: A Report of Six Cases Managed at the Douala General Hospital, Cameroon

Purpose. To show the feasibility of emergency late second trimester cerclage with advanced cervical dilatation and bulging of amniotic membranes. Setting. Department of Obstetrics and Gynecology of the Douala General Hospital. Method. This is a retrospective study of case files of patients who underwent emergency late second trimester cerclage with advanced cervical dilatation, some with bulging of fetal membranes between June 2003 and June 2010. The modified Shirodkar technique was employed in all the cases. Results. Altogether, six patients (100%) underwent late second trimester cervical cerclage between 24 and 26 weeks of gestational age. Four cases (66.7%) carried on their pregnancies to term that resulted in healthy live-born babies all delivered vaginally. The other two cases (33.3%) presented with preterm premature rupture of fetal membranes (PPROM) which led us to undo the stitch with eventual delivery of live-born premature fetuses which died in the neonatal intensive care unit because of complications of prematurity and neonatal infection. Conclusion. In experienced hands and in the absence of other risk factors like infection, the success rates of this procedure are encouraging with improved prognosis. Finally, the modified Shirodkar technique yielded excellent results in our series.

Relationship of the Length of the First Stage of Labor to the Length of the Second Stage

To evaluate the relationship between the lengths of the first and second stages of labor. In this observational study of women delivering at our hospital, the onset of the first stage of labor was defined as admission at 3-cm to 4-cm dilatation in the presence of uterine contractions with or without rupture of membranes. This study was limited to nulliparous women with a singleton, cephalic live birth at 37 0/7 weeks of gestation or more. Women presenting with more advanced cervical dilatation (greater than 4 cm), prior cesarean delivery, diabetes, hypertension, and placental accidents were excluded. Each woman was analyzed based on her specific lengths of first and second stages of labor, that is, paired observations for each woman. Between January 1, 2001, and June 30, 2012, a total of 172,522 women were delivered and 12,523 (7.3%) met the inclusion criteria. The 95 percentile was 15.6 and 2.9 hours for the first and second stages, respectively. Women with first stages greater than the 95 percentile had a 16.3% rate of a second-stage length greater than the 95 percentile compared with 4.5% (P<.001) in women with first stages less than the 95 percentile. This relationship persisted when analyzed for variables influencing labor to include neonate birth weight, epidural analgesia, or maternal size. Overall, the length of the second stage significantly increased concomitantly with increasing length of the first stage (P<.001). II.

Successful Cerclage at Advanced Cervical Dilatation in the Second Trimester

ABSTRACTThe aim of our study is to verify whether some maternal features are related to pregnancy outcome of emergency cerclage when membranes are protruding through the dilated cervix. We present a retrospective review of 20 cases of emergency cervical cerclage performed over a 3 years period at Al Wasl hospital, a tertiary level centers in Dubai. Analysis shows presence of membrane prolapse with infection causing rupture of membranes, to be the strongest predictor of poor outcome. Analysis also reveals a significant association between initial white blood cell count and perinatal outcome. This information is helpful in decision making and counseling patients regarding the likely outcome.How to cite this articleDeb P, Aftab N, Rangwala T. Successful Cerclage at Advanced Cervical Dilatation in the Second Trimester. Int J Infertility Fetal Med 2013;4(2):56-58.

Women's perception of the onset of labour and epidural analgesia: A prospective study

Objectivechildbearing women and their midwives differ in their diagnoses of the onset of labour. The symptoms women use to describe the onset of labour are associated with the process of labour. Perinatal factors and women's attitudes may be associated with the administration of epidural analgesia. Our study aimed to assess the correlation between women's perception of the onset of labour and the frequency and timing of epidural analgesia during labour. Designprospective cohort study. Setting41 maternity units in Lower Saxony, Germany. Participants549 nulliparae (as defined in the “Methods” section) and 490 multiparae giving birth between April and October 2005. Women were included after 34 completed weeks of gestation with a singleton in vertex presentation and planned vaginal birth. Measurementsthe association between women's symptoms at the onset of labour and the administration of epidural analgesia – frequency, timing in relation to onset of labour and cervical dilatation – was assessed. The analysis was performed by Kaplan–Meiers estimation, logistic regression and Cox regression. Findingsa total of 174 nulliparae and 49 multiparae received epidural analgesia during labour. Nulliparae received it at a median time of 5.47hrs (range: 0.25–51.17hrs) after onset of labour, at a median cervical dilatation of 3.3cm (range: 1.0–10.0cm). In multiparae, epidural analgesia was applied at a median time of 3.79hrs (range: 0.42–28.55hrs) after onset of labour; the median cervical dilatation was 3.0cm (range: 1.0–8.0cm). Women who were admitted with advanced cervical dilatation received epidural analgesia less often. Women who defined their onset of labour earlier than it was diagnosed by their midwives received epidural analgesia earlier. Gastrointestinal symptoms and irregular pain at the onset of labour were associated with later administration of epidural analgesia. Induction of labour was associated with a reduced interval from the onset of labour to epidural analgesia. Key conclusionswomen's self-diagnosis of the onset of labour and their perception of their labour duration when meeting their midwives has some impact on their admission to the labour ward and the timing of epidural analgesia. Implications for practiceconsideration of women's own perceptions and expectations regarding the onset and process of labour is necessary for individual care during labour.

470: Betamethasone for threatened preterm labor: a clinical review at a single academic medical center

To review timing of administration of betamethasone for pregnancies with threatened preterm labor or advanced cervical dilation A retrospective cohort study of patients who received betamethasone (BMZ) for the reduction of preterm morbidity was performed between July 1, 2004 and June 30, 2009. Rescue or repeat courses of BMZ were not administered. The Northwestern University Electronic Database Warehouse was used to identify all patients who received BMZ. Each identified patient was assigned a diagnosis of preterm labor (PL) if they received tocolysis or delivered imminently. Advanced cervical dilation (ACD) was defined as those patients who did not require tocolysis or deliver imminently. PL and ACD groups were stratified by the cervical dilation and cervical effacement at the time BMZ was administered. The primary outcome was the interval between the gestational age (GA) at BMZ administration and the GA at delivery. NICU length of stay and the percentage of patients who delivered within 7 days of BMZ administration were secondary outcomes. All data was analyzed with the Kruskal-Wallis test. Three hundred and fifty six patients received BMZ for PL and 247 patients for ACD. The median interval between administration of BMZ and delivery was 35 days for preterm labor and 47 days for advanced 28 days (p<0.0001). Compared to ACD patients, PL patients were more dilated (2 vs. 1 cm, p<0.0001) and more effaced (1.5 vs. 2 cm, p<0.0001) at the time of BMZ administration. There was no significant difference in the median NICU length of stay between PL and ACD patients. Only patients who presented with PL and were 3.5+ cm dilated or completely effaced delivered within 7 days of BMZ administration (p<0.005). For ACD patients, only those who were 0.5 cm effaced or less delivered within 7 days of BMZ administration (p<0.005). The interval between BMZ administration and delivery at our institution is greater than 7 days for patients who present with PL or ACD. Improvements need to be made in order to better triage patients who present with threatened PL or ACD. Tabled 1

309: Uterine rupture in women with previous cesarean for dystocia in second stage of labor

for dystocia in second stage of labor Nicole Jastrow, Suzanne Demers, Robert J. Gauthier, Nils Chaillet, Normand Brassard, Emmanuel Bujold University Hospital of Geneva, Obstetrics and Gynecology, Geneva, Switzerland, University Laval, Obstetrics and Gynecology, Quebec, QC, Canada, University of Montreal, Obstetrics and Gynecology, Montreal, QC, Canada OBJECTIVE: To evaluate the risk of uterine rupture in women undergoing a trial of labor (TOL) after a previous cesarean for dystocia in second stage of labor. STUDY DESIGN: A retrospective cohort study of women with a single previous low-transverse cesarean undergoing a first TOL was performed. Women with a previous cesarean for dystocia in second stage were compared to those with previous dystocia in first stage and those with previous cesarean for non-recurrent reasons. Chi-square and Fishers exact were used when appropriate. RESULTS: Out of 1950 women, those with previous dystocia in second stage of labor (n 220) had a similar risk of uterine rupture than women with previous dystocia in the first stage (n 639) and women with previous cesarean for non-recurrent indication (1.8%, 1.7%, and 1.5%, respectively, p 0.88). However, we found that all (100%) uterine ruptures in the former group occurred in the second stage of labor (p 0.05) compared to 18% and 25% in the two other groups (p 0.05). The median length of the second stage of labor before uterine rupture was 2.5 hours (interquartile: 1.5 3.2 hours) for those cases. CONCLUSION: Previous cesarean for dystocia in the second stage of labor is associated with uterine rupture in the second stage of the subsequent delivery. This may be related to a lower location of the uterine scar, which may be more prone to rupture at an advanced cervical dilatation during the next delivery. Prolonged second stage should be avoided in these women.

Septic shock following cervical cerclage for advanced cervical dilatation

had wide local excision and one vulvectomy. Four recurrences occurred. The vulvectomy and two of the three local excisions (one unstated) did not recur. Recurrence can occur as late as 11 years after initial excision. Vulvar leiomyomas are rare and may be misdiagnosed if the clinician is not aware. Even rarer still is combined vulvar and oesophageal leiomyomas, which may represent a specific syndrome. Treatments for isolated or syndromal vulvar leiomyoma are the same and should generally involve a marginal excision. Regular follow-up is warranted as late recurrence may occur.

Association between women's self-diagnosis of labor and labor duration after admission

To examine the association between women's perception of onset and the duration of labor after hospital admission. Women whose labor started spontaneously at term, delivering at the Hannover Medical School Hospital, Germany, between 2001 and 2004 were asked when and how labor had started. Answers were analyzed using structured content analysis. Women's symptoms were grouped in eight predefined categories; inter-rater agreement was assessed (kappa=0.93). Associations between women's symptoms and labor duration after admission were also analyzed. Duration of labor after admission was longer in nulliparas (n=347) than in multiparas (n=304, P<0.001). Nulliparas experienced shorter labor in association with recurrent pain, advanced cervical dilatation at admission and spontaneous rupture of membranes. Oxytocin augmentation and epidural analgesia were associated with a longer duration. In multiparas, advanced cervical dilatation at admission, spontaneously ruptured membranes, blood-tinged mucus or emotional upheaval perceived by women were associated with a shorter interval from admission until birth. How women diagnose their onset of labor relates to some extent with labor duration after admission. Recognized symptoms and their association with labor duration differed between nulliparas and multiparas.

298: Transabdominal uterine electromyography- a better predictor of preterm birth compared to advanced cervical dilation

298: Transabdominal uterine electromyography- a better predictor of preterm birth compared to advanced cervical dilation

Emergency cervical cerclage: Predictors of success

Objective. To document predictors of success of emergency cervical cerclage.Methods. This is a retrospective cohort study of 8 years at a university hospital. Emergency cerclage was defined as when the membranes were at or beyond the external os and was only performed where evidence of infection or labour were absent. Outcomes used were interval between cerclage and delivery, gestation at delivery; a ‘good outcome’ was defined as delivery after 32 weeks and healthy at discharge. Predictive factors for a successful pregnancy outcome were analysed using odds ratios (OR) with 95% confidence intervals.Results. Forty-five emergency cerclages were performed, including 11 twin pregnancies. Twenty-one (47%) had a ‘good outcome’, including two twin pregnancies; 20 (44%) pregnancies reached 36 weeks. In 79.2% of ‘poor outcomes’ chorioamnionitis was found. Prolapsed membranes, advanced cervical dilatation, maternal symptoms and equivocal markers of infection were associated with a poor outcome, but not consistently enough to dictate management.Conclusions. Given the poor natural history of an open external os, emergency cerclage appears beneficial. That this might apply to twin pregnancies has implications for their management. Although success is indeed partly predictable, it can still be achieved even when there is advanced dilatation, prolapse, bleeding or discomfort.