Gestational Latency Research Articles

Rescue Cerclage in Women With Acute Cervical Insufficiency and Intra-Amniotic Inflammation: A Retrospective Cohort Study.

To assess the effectiveness of rescue cerclage concerning pregnancy and neonatal outcomes in women with acute cervical insufficiency (CI) complicated with intra-amniotic inflammation (IAI) compared with those managed expectantly. This retrospective cohort study included 87 consecutive singleton pregnant women (17-25 weeks) with acute CI who underwent amniocentesis to assess IAI. Amniotic fluid (AF) samples were assayed for interleukin-6 to define IAI (≥ 2.6 ng/mL). Primary and secondary outcomes were assessed in a subset of CI patients with IAI. The primary outcome measures were spontaneous preterm birth (SPTB) at < 28 and < 34 weeks, and the secondary outcomes were interval from sampling to delivery, neonatal survival, neonatal birth weight, and histologic and clinical chorioamnionitis. Macrolide antibiotics were prescribed depending on the type of microorganism isolated from the AF, clinically suspected IAI, and the discretion of the attending clinician. IAI was identified in 65.5% (57/87) of patients with CI, of whom 73.6% (42/57) were treated with macrolide antibiotics. Among the CI patients with IAI (n = 57), 40 underwent rescue cerclage and 17 were expectantly managed. The rates of SPTBs at < 28 and < 34 weeks were significantly lower and the latency period was significantly longer in the cerclage group than in the group that was managed expectantly. The median birth weight and neonatal survival rate were significantly higher in the cerclage group than in the group that was managed expectantly. However, the rates of histologic and clinical chorioamnionitis did not differ between the groups. Multivariable analyses revealed that rescue cerclage placement and administration of macrolide antibiotics were significantly associated with a decrease in SPTBs at < 28 and < 34 weeks, prolonged gestational latency, and increased likelihood of neonatal survival, after adjusting for possible confounding parameters; however, macrolide antibiotic administration did not reach statistical significance with respect to SPTB at < 34 weeks and neonatal survival (P = 0.076 and 0.063, respectively). Rescue cerclage along with macrolide antibiotic treatment may positively impact pregnancy and neonatal outcomes in women with CI complicated by IAI, compared with expectant management. These findings suggest the benefit of cerclage placement even in patients with CI complicated by IAI.

Efficacy of emergency cervical cerclage in twin pregnancies and factors affecting the clinical effects of emergency cerclage

Objectives To estimate clinical effects of emergency cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation and to identify risk factors after cerclage. Methods This retrospective cohort study included 99 twin pregnancies with cervical dilation ≥1cm in the mid-trimester of gestation at three institutions, from December 2015 through December 2021. The cases were treated with emergency cervical cerclage (52 cases) or expectant management (47 cases). Compare the pregnancy and neonatal outcomes of the two groups. Multiple logistic regression analysis was used to determine the independent risk factors associated with cerclage. Results Cerclage placement was associated with significantly longer gestation age and prolongation of the gestational latency (p < .05). In the cases, compared to expectant treatments, spontaneous preterm birth (sPTB) at <26, <28, <30, <32 weeks was significantly less frequent (p < .05). Pre-operation WBC > 11.55 × 109/L, CRP > 10.1 and cervical dilation >3.5 cm were found to be independent risk factors for delivery 28 weeks after cerclage. Conclusions Cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation may prolong pregnancy and gestation age, and improve pregnancy and neonatal outcomes compared with expectant management. The strongest predictor of sPTB before 28 weeks after ECC were pre-operation WBC >11.55 × 109/L, CRP > 10.1 and cervical dilation >3.5 cm.

Outcomes after extended azithromycin administration in preterm premature rupture of membranes

Preterm premature rupture of membranes accounts for approximately one-quarter of all preterm deliveries and occurs in 2% to 3% of all pregnancies. With subclinical infection being a suspected cause of preterm premature rupture of membranes, the administration of prophylactic antibiotics is an accepted standard of care to extend the latency period. Historically, erythromycin was used in the antibiotic regimen recommended for women with preterm premature rupture of membranes during expectant management; however, azithromycin has recently been shown to be a suitable alternative. This study aimed to evaluate whether extended azithromycin administration affects the latency time in preterm premature rupture of membranes. This was a retrospective multi-institutional cohort study in Washington, District of Columbia, of patients admitted from January 2012 to December 2019 with preterm premature rupture of membranes of singleton pregnancies between 23 0/7 and 33 6/7 weeks of gestation. Patients were excluded if they had multiple pregnancies, had an allergy to penicillin or macrolides, were in labor, had suspected placental abruptions, had overt chorioamnionitis, or had nonreassuring fetal status on presentation indicating the need for prompt delivery. Patients that received limited azithromycin administration (<2 days) and patients that received extended azithromycin administration (7 days) were compared. All patients otherwise received the institutional standard of 2 days of intravenous ampicillin followed by 5 days of oral amoxicillin. The primary outcome was length of gestational latency, defined as the time from membrane rupture to delivery. The selective secondary outcomes that were evaluated were rates of chorioamnionitis and adverse neonatal outcomes, including sepsis, respiratory distress, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. During the study period, 416 cases of preterm premature rupture of membranes were identified. Of the 287 patients who met the inclusion criteria, 165 (57.5%) received limited azithromycin administration, and 122 (42.5%) received extended azithromycin administration. Adjusted median gestational latency was significantly longer for patients who received extended azithromycin administration, extended by >3 days (2.6 days [interquartile range, 2.2-3.1] for limited azithromycin administration vs 5.8 days [interquartile range, 4.8-6.9] for extended azithromycin administration; P<.001). Neonatal secondary outcome evaluation was performed on 216 cases (76%). There was no difference in chorioamnionitis or adverse neonatal outcomes between the 2 groups. Among patients with preterm premature rupture of membranes, extended azithromycin administration was associated with increased latency, without any effect on other maternal or neonatal outcomes.

Inpatient versus outpatient management of gestational hypertension or preeclampsia without severe features

To compare maternal and neonatal outcomes along with gestational latency, in patients diagnosed with a hypertensive disorder of pregnancy (HDP) (gestational hypertension or preeclampsia), without severe features managed inpatient versus outpatient setting. A retrospective, cohort study of patients with HDP without severe features before 37 weeks from 2014-2021. Patients were managed inpatient or outpatient at discretion of obstetric provider. Patients with initial presentation with severe features were excluded. The primary outcome was severe maternal morbidity (SMM) as defined by the 21 CDC maternal morbidity identifiers. Secondary outcomes included maternal ICU admission, development of severe features, placental abruption, time from diagnosis to delivery, preterm birth< 37 weeks, low birthweight (< 2500g), 5-minute Apgar score < 7, and stillbirth. A total of 279 patients met the inclusion criteria with 236 (84.6%) being managed outpatient and 43 (15.4%) being managed inpatient. In univariate analysis, SMM rates were higher in inpatient compared to outpatient group (14.0% vs. 2.3%, p=0.001). Maternal ICU admission was higher in the inpatient management group (7.0% vs. 0.4%, p< 0.001). Frequencies of placental abruption and development of severe features did not differ between the groups. Time from diagnosis to delivery was longer in the outpatient compared to inpatient group (13d vs. 3d, p< 0.001). Low birth weight and preterm birth were more frequent in the inpatient group (Table 1). In multivariate analyses, controlling for gestational age at HDP diagnosis, HDP type, twin gestation, maternal diabetes, BMI, and residential distance from the hospital, SMM did not differ between the groups (aOR 0.17, 95% CI 0.02-1.78) Secondary outcomes did not differ between outpatient and inpatient management groups (Table 2). Outpatient management of gestational hypertension or preeclampsia without severe features was not associated with adverse maternal or neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Factors associated with latency duration in growth-restricted fetuses with absent end diastolic flow

Gestational latency after findings of abnormal umbilical artery doppler indices, such as absent end diastolic flow (AEDF), in the setting of fetal growth restriction (FGR), is important yet difficult to predict. Our objective was to describe latency and factors associated with prolonged latency in growth-restricted fetuses with AEDF.

Simulation-based mastery learning improves physical exam-indicated cerclage skills among OB/GYN residents

The use of physical exam-indicated cerclage (PEIC) has been associated with a reduction in perinatal morbidity and prolonged gestational latency. However, it is a technically challenging, infrequent procedure with associated risks. Simulation-based mastery learning (SBML) is an evidence-based teaching modality that has been shown to improve competency among medical trainees, especially for low frequency, high acuity procedures. We aimed to develop a SBML curriculum to teach PEIC placement to first and second-year OB/GYN residents.

Adjunct Therapy at Time of Examination-Indicated Cervical Cerclage in Singleton Pregnancies: A Systematic Review and Meta-analysis.

Physical examination-indicated cerclage for cervical insufficiency prolongs gestation, but evidence on the addition of adjuncts to further prolong latency is limited. The aim of this systematic review and meta-analysis was to compare gestational latency between those who did and did not receive adjunct antibiotic or tocolytic therapy at the time of examination-indicated cerclage. Electronic databases (1966-2020) were searched for randomized controlled trials (RCTs) and cohort studies comparing adjunct antibiotic or tocolytic use versus nonuse at time of examination-indicated cerclage, defined as placement for cervical dilation ≥1 cm, in a current singleton pregnancy. Studies including individuals with intra-amniotic infection, cerclage in place, nonviable gestation, or ruptured membranes were excluded. The primary outcome was latency from cerclage placement to delivery. Secondary outcomes included preterm birth, preterm premature rupture of membranes, birth weight, and neonatal survival. Risk of bias was assessed using standardized tools. Heterogeneity was assessed using χ 2 and I 2 tests. Results were pooled and analyzed using a random-effects model. This study is registered with The International Prospective Register of Systematic Reviews (PROSPERO) with registration no.: CRD42021216370. Of 923 unique records, 163 were reviewed in full. Three met inclusion criteria: one RCT and two retrospective cohorts. The included RCT (n = 50) and one cohort (n = 142) compared outcomes with and without adjunct use of antibiotic and tocolytic, while the second cohort (n = 150) compared outcomes with and without adjunct tocolytic, with a subpopulation also receiving antibiotics. The RCT was nested within one of the cohorts, and therefore only one of these two studies was utilized for any given outcome to eliminate counting individuals twice. Risk of bias was "critical" for one cohort study, "moderate" for the other cohort study, and "some concerns" for the RCT. Gestational latency could not be pooled and meta-analyzed. Adjunct tocolytic-antibiotic therapy was not associated with a decrease in risk of preterm delivery <28 weeks (relative risk [RR] = 0.90, 95% confidence interval [CI]: 0.65-1.26; χ 2 = 0.0, I 2 = 0.0%) or neonatal survival to discharge (RR = 1.11, 95% CI: 0.91-1.35; χ 2 = 0.05, I 2 = 0.0%). There is not enough evidence to robustly evaluate the use of adjunct tocolytics or antibiotics at time of examination-indicated cerclage to prolong latency. · Limited data on adjunct antibiotic tocolytics at cerclage.. · Widely variable practices at time of cerclage identified.. · Role of adjunct therapies at time of examination-indicated cerclage remains unclear..

Management of an incompetent mid-second (mid-2nd) trimester absent ecto-cervix: a case series. Cervical amplification pre-cerclage insertion.

Cervical cerclage is a treatment for an incompetent cervix, the latter being a contributor to spontaneous preterm birth. There is significant difficulty with a transvaginal cerclage insertion for the absent vaginal or ecto-cervix in the mid-2nd trimester period resulting in a higher risk of late miscarriages, extremely preterm labour with increased neonatal morbidity and mortality. A retrospective review of 5 consecutive cases managed by a surgical technique-modified high vaginal cerclage insertion at 18-20 weeks-and adjunct protocols which included vaginal progesterone use, serial infection screening and lifestyle advice, over a 12-month period ending in August 2021, is presented. Inclusion criteria included minimal or absent ecto-cervix, singleton pregnancies with an incompetent cervix attending for a vaginal cerclage whilst exclusion criteria were the usual contraindications to a cerclage insertion. Primary outcome was delivery after 34 weeks whilst seconday outcomes included maternal hemorrhage, bowel/bladder injury, chorioamnionitis and neonatal admission. A increased gestational latency of 13 gestational weeks (range 12-18). Mean gestational age at delivery was 36 weeks +1 (253 days) with a range of 241-264 days. Delivery after 34 weeks gestational age was 100% with no maternal surgical complications and corresponding neonatal outcomes. There is a potential therapeutic benefit of this technique and adjunct management, in managing an incompetent mid-2nd trimester absent ecto-cervix.

Estimating gestational latency among individuals with a twin gestation undergoing physical exam-indicated cerclage

A recent randomized trial supports the efficacy of physical exam-indicated cerclage (PEIC) in twin gestations. Quantifying gestational latency PEIC is an important part of shared decision making and informed consent. Thus, our objective was to create a model for estimating gestational latency in the setting of PEIC in twin gestations.

Is azithromycin associated with a reduction in acute placental inflammation in the setting of PPROM?

Following a national antibiotic shortage, azithromycin has been substituted for erythromycin in the setting of preterm premature rupture of membranes (PPROM) as adjuvant treatment to enhance gestational latency. While clinical outcomes are not inferior, azithromycin’s longer half-life and better tissue penetration has biological plausibility to be a superior antibiotic choice. Acute placental inflammation in the form of maternal (MIR) or fetal inflammatory response (FIR) has been described as a histological correlate and possible early signal for clinical chorioamnionitis.

Pregnancy outcomes and factors affecting the clinical effects of emergency cerclage in twin pregnancies with cervical dilation and prolapsed membranes.

To determine the effect of mid-trimester emergency cerclage in women with twin pregnancies with cervical dilation and prolapsed membranes, and to identify risk factors predicting spontaneous preterm birth (sPTB) before 28weeks, after cerclage. Retrospective analysis of twin gestations with cervical dilation and prolapsed membranes treated with emergency cerclage or expectant management (2015-2020). The primary outcomes were the rate of sPTB before 28weeks and the gestational latency. Multiple logistic regression analysis was used to determine the factors associated with sPTB before 28weeks, after cerclage. Ninety-seven women were included, cerclage (n=58) or no cerclage (n=39). Cerclage placement was associated with significantly lower incidence of sPTB before 28weeks of pregnancy (34.5% vs 82.1%) and prolongation of the gestational latency (46.71±27.52 vs 10.95±11.71days). Positive cervical culture (odds ratio [OR] 10.69, 95% confidence interval [CI] 1.82-62.95), pregnancy duration at diagnosis less than 22weeks (OR 9.42; 95% CI 1.69-52.69) and cervical dilation at least 4cm (OR 7.92; 95% CI 1.40-44.71) were found to be independent risk factors for sPTB before 28weeks, after cerclage. Emergency cerclage in women with twin pregnancies with cervical dilation and prolapsed membranes was associated with an overall 40% decrease in sPTB before 28weeks and a prolongation of latency by 5weeks. The strongest predictor of sPTB before 28weeks after cerclage was a positive cervical culture.

127 Gestational latency associated with erythromycin vs azithromycin in patients admitted with PPROM

Administration of antibiotics after preterm premature rupture of membranes (PPROM) has been shown to increase gestational latency. While the original studies included ampicillin and erythromycin, shortages of erythromycin have led to use of azithromycin in its stead. We sought to evaluate whether the use of azithromycin compared to erythromycin, is associated with changes in perinatal outcomes including gestational latency. This retrospective cohort study included women with singleton gestations admitted to a quaternary center from 9/2014 to 3/2020 with a diagnosis of PPROM between 23w0d and 33w5d. In 2017, the hospital’s policy universally changed from a 7-day course of erythromycin to one dose of oral azithromycin 1000mg. The primary outcome was gestational latency. Secondary outcomes included gestational age (GA) at delivery; chorioamnionitis; birthweight; 5-minute Apgar <7; respiratory distress syndrome; necrotizing enterocolitis; intraventricular hemorrhage; neonatal length of stay; and neonatal death. An a priori power analysis determined that a sample of 120 patients per group would identify a 2-day difference in gestational latency (with a power of 80% and an alpha of 0.05). Bivariable and multivariable analyses were performed. 280 patients met inclusion criteria. Patients receiving erythromycin had a higher frequency of prior spontaneous preterm birth (PTB) and presented at a later GA with PPROM (Table 1). No other differences were observed in patient characteristics. There were no differences in gestational latency between patients who received azithromycin compared to erythromycin in bivariable [10 (4-15) vs 8.5 (3-14) days, p=0.16) or multivariable analyses [adjusted β = 0.13 days (95% CI: -0.08-0.34 days) (Table 2). There were no statistically significant differences in secondary outcomes. There was no difference in gestational latency or incidence of adverse perinatal outcomes when comparing azithromycin to erythromycin. A single dose of azithromycin appears to be a reasonable substitute to erythromycin for gestational latency in the setting of PPROM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

744 Clinical factors associated with gestational latency in women with twins undergoing physical exam-indicated cerclage

A randomized trial demonstrated that, compared to expectant management, physical exam-indicated cerclage (PEIC) reduced preterm birth in twins with advanced cervical dilation < 24 weeks gestational age (GA). However, data are limited to personalize the expected gestational latency after PEIC placement. Thus, we assessed clinical factors associated with gestational latency among pregnant women with twin gestations undergoing PEIC. This single-site retrospective cohort study included all women with a twin gestation who underwent a PEIC and delivered between 2009 and 2018. PEIC was performed in the setting of painless cervical dilation ≥ 1 cm between 16 0/7 and 23 6/7 weeks GA. The primary outcome was gestational latency ≥ 28 days. Generalized linear models using a Poisson error distribution with robust error variances were created. A priori covariates included a history of preterm birth and use of perioperative antibiotics and indomethacin. Other clinical covariates were included based on statistical significance of p < 0.10 on bivariable analyses. Effect modification between clinical variables associated with gestational latency was evaluated using interaction variables. Subgroup analyses were performed for interaction variables significant on multivariable analysis at p < 0.05. 130 women were included. Women who achieved a gestational latency ≥ 28 days had a lower frequency of prolapsing membranes (36.6% v 64.9%, p = 0.003) and cervical dilation ≥ 2 cm (32.3% v. 62.2%, p = 0.002) when compared to those who did not (Table 1). On multivariable analysis, the interaction between prolapsing membranes and cervical dilation was significant (p=0.004). Women with cervical dilation ≥ 2 cm and prolapsing membranes had a lower risk of achieving a gestational latency ≥ 28 days than women with cervical dilation < 2 cm and no prolapsing membranes (aRR 0.51, 95% CI 0.32-0.80, Table 2). Both cervical dilation and prolapsing membranes are associated with gestational latency after PEIC in twin gestations and can be used to counsel women on anticipated clinical outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Importance of Clinical Presentation in Risk and Management of Recurrent Preterm Birth.

This study aimed to compare the risk of recurrent spontaneous preterm birth (sPTB), as well as cerclage efficacy, between groups stratified by phenotype of the index sPTB. This is a retrospective cohort study of women with a history of sPTB. Included were women with a history of singleton sPTB who received progesterone in a subsequent pregnancy. Multifetal gestations and abdominal cerclage were excluded. Exposure groups were based upon the presenting symptom that preceded their first sPTB and included painless cervical dilation (PCD), preterm premature rupture of membranes (PPROM), and painful dilation (preterm labor [PTL]). Primary outcome was delivery <34 weeks in a subsequent pregnancy. Secondary outcomes included delivery <28 and <37 weeks. Rates were compared using the Chi-square test. Multivariable Poisson regression was used to adjust for confounders. A total of 723 women were included. A total of 114 (16%) presented with PCD, 305 (42%) with PPROM, and 304 (42%) with PTL in their first sPTB. Cerclage in subsequent pregnancy was highest in the PCD group (42%) when compared with the PPROM (16%) and PTL (12%) groups. Rates of sPTB <34 and 37 weeks were similar among the groups. After adjusting for confounders, PCD was found to significantly increase the risk of recurrent sPTB <28 weeks (incidence rate ratio: 3.46 [1.09-11.0]; p = 0.04). Of the 121 women who underwent cerclage, there were no significant differences in rates of sPTB between the clinical presentation groups. PCD as a specific phenotype of sPTB impacts recurrence of delivery before 28 weeks, but not at later gestational ages. In contrast, there was no significant association between clinical presentation of index sPTB and gestational latency in women who also underwent cerclage placement in a subsequent pregnancy. Our data suggest that clinical presentation is important with regards to recurrence of early sPTB, but not sPTB at later gestational ages. · Phenotype is critical to understanding PTB.. · Phenotype is associated with recurrent PTB.. · Painless dilation is associated with recurrent PTB..

Perioperative Use of Cefazolin and Indomethacin for Physical Examination-Indicated Cerclages to Improve Gestational Latency.

To evaluate gestational latency in individuals who did and did not receive perioperative cefazolin and indomethacin after physical examination-indicated cerclage. This is a retrospective cohort study of all pregnant women with a singleton gestation who underwent physical examination-indicated cerclage placement and delivered at Northwestern Memorial Hospital from 2009 to 2018. Physical examination-indicated cerclage was performed in the setting of painless cervical dilation of at least 1 cm between 16 0/7 and 23 6/7 weeks of gestation. After 2014, our practice universally implemented perioperative prophylaxis of cefazolin and indomethacin. Individuals were categorized based on exposure to perioperative prophylaxis. The primary outcome was pregnancy latency at least 28 days after cerclage placement. Secondary outcomes included median latency; median gestational age at delivery; preterm birth before 28 weeks of gestation; preterm prelabor rupture of membranes; chorioamnionitis; and median birth weight. Multivariable analyses were performed, as well as a sensitivity analysis using propensity score matching. Cerclages were placed in 142 people: 72 (50.7%) received perioperative prophylaxis. Baseline demographics were not significantly different between groups. On multivariable analyses, individuals who received perioperative prophylaxis had a higher incidence of achieving a pregnancy latency at 28 days or more (adjusted relative risk [aRR] 1.21, 95% CI 1.05-1.40). Individuals who received perioperative prophylaxis had a significant improvement in gestational latency (+17.8 days, 95% CI 1.4-34.2 days) and birth weight (+489.8 g, 95% CI 64.6-915.0 g), with no differences in other outcomes. On sensitivity analysis, individuals receiving perioperative prophylaxis had a higher incidence of achieving a pregnancy latency at 28 days or more, (aRR 1.17, 95% CI 1.01-1.36) with no differences in other outcomes. Perioperative use of cefazolin and indomethacin prophylaxis during physical examination-indicated cerclage placement is associated with a significant prolongation in gestational latency without an increase in incidence of chorioamnionitis.

1203: The relationship between perioperative use of cefazolin and indomethacin for exam-indicated cerclages and gestational latency

1203: The relationship between perioperative use of cefazolin and indomethacin for exam-indicated cerclages and gestational latency

Phenotypic overlap in neonatal respiratory morbidity following preterm premature rupture of membranes versus spontaneous preterm labor

Background Bronchopulmonary dysplasia (BPD), a major source of morbidity in premature neonates, has been associated with intrauterine infection and preterm birth. Both preterm premature rupture of membranes (PPROM) and spontaneous preterm labor (sPTL) are linked with intrauterine inflammation. Whether PPROM and sPTL, as two phenotypic categories of preterm birth, are associated with exposure to different degrees and durations of inflammation that might impact fetal lung development is unknown. PPROM may be associated with longer latency until delivery, which is beneficial for neonatal mortality, but may impart greater injury risk to the developing fetal lungs. It is unknown if PPROM is associated with a greater risk of adverse neonatal respiratory outcomes than sPTL. Objective The objective of this study was to determine if PPROM imparts a differentially greater risk for neonatal BPD than sPTL. A secondary objective was to determine if PPROM was associated with a greater risk of adverse neonatal respiratory outcomes other than BPD and whether gestational latency following PPROM or sPTL diagnosis constitutes a risk factor for fetal lung injury. Study design We conducted a retrospective secondary analysis of a large cohort of women at risk for spontaneous preterm birth, who were originally enrolled in a randomized controlled trial of magnesium sulfate versus placebo examining neuroprotection. For our study, we included women with a singleton pregnancy complicated by PPROM or sPTL and delivery between 24 and 34 weeks gestational age. Cases with multiple gestation, congenital anomalies, maternal seropositivity for human immunodeficiency virus, or hypertensive diseases of pregnancy (including preeclampsia) were excluded. The primary outcome was BPD. Secondary outcomes were respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), requirement for mechanical ventilation, pneumonia, neonatal sepsis, fetal or neonatal death, and a composite of adverse neonatal respiratory outcomes including (BPD, pneumonia, RDS, and TTN). Statistical analyses included chi-square, Student’s t-test and logistic and multiple regression. Results A total of 1729 women were included in this analysis including 1554 with PPROM and 175 with sPTL. Women in the PPROM group were more likely to be older, not of Hispanic race, married, more educated, have smoked during pregnancy and have a greater body mass index. The BPD rate was not significantly different following PPROM versus sPTL. Neonates in the PPROM group experienced a lower rate of pneumonia (p = .001), neonatal sepsis (p = .009) and patent ductus arterious (PDA) requiring either medical or surgical therapy (p < .001) than neonates in the sPTL group. Chorioamnionitis was more common in the PPROM group (p = .008) than the sPTL group. After multivariable logistic regression with BPD or composite of adverse neonatal respiratory outcomes as the dependent outcomes, and controlling for gestational age at delivery, maternal smoking history, duration of mechanical ventilation and RDS, there was no significant difference between PPROM and sPTL. Conclusions BPD rates were not significantly different in neonates born to women following PPROM versus sPTL. However, PPROM was associated with lower rates of pneumonia, neonatal sepsis, and PDA requiring therapy in the univariate analysis, but not the multivariate analysis. Neonatal respiratory outcomes may have a similar phenotypic overlap regardless of whether preterm birth follows PPROM or sPTL.

Utility of cervical length and quantitative fetal fibronectin for predicting spontaneous preterm delivery among symptomatic nulliparous women.

To validate the utility of fetal fibronectin (fFN) and cervical length (CL) in predicting preterm delivery among symptomatic nulliparous women. A retrospective cohort study of nulliparous women who presented with uterine contractions, abdominal pain, or cervical change at 21-34 gestational weeks at Fukushima Medical University Hospital, Japan, between 2008 and 2017. fFN (categorized as <50ng/dL, 50-199ng/dL, >200ng/dL) and CL (≥15mm or <15mm) were evaluated simultaneously. Adjusted odds ratios (aORs) and confidence intervals (CIs) for preterm delivery before 37 or 34weeks, and delivery within 28 or 14days were calculated (references: fFN, <50ng/dL; CL, ≥15mm). Among 285 women who met the study criteria, CL less than 15mm was a risk factor for preterm delivery before 37 (aOR, 4.1; 95% CI, 1.1-6.7) and 34 (aOR, 6.8; 95% CI, 2.3-20.2) weeks. fFN of 200ng/dL or higher was a risk factor for delivery within 28 (aOR, 19.8; 95% CI, 4.3-90.2) and 14 (aOR, 10.8; 95% CI, 1.7-67.6) days. Among symptomatic nulliparous women, short CL was found to be a risk factor for preterm delivery and higher fFN levels were related to short gestational latency.

146: Clinical presentation of preterm birth and gestational latency after cerclage

Spontaneous preterm birth (sPTB) remains a leading cause of perinatal morbidity. Recent data have demonstrated that the risk of recurrent sPTB differs significantly between patients based upon symptoms at the time of presentation. Our primary objective was to evaluate cervical cerclage efficacy based upon clinical presentation of prior sPTB. This is a retrospective cohort study of women with a history of preterm birth and cervical cerclage placement at a large academic center from 2011-2016. Included were women with a history of singleton sPTB who received progesterone and underwent ultrasound or history-indicated cerclage placement in the current pregnancy. Women with a multifetal gestation and those with a previously placed abdominal cerclage were excluded. Women were divided into groups based upon the presenting symptom that preceded their first sPTB. Those groups included painless dilation, preterm premature rupture of membranes (PPROM), and painful dilation (preterm labor or PTL). The primary outcome was delivery after 34 weeks. Secondary outcomes included delivery after 28 and 37 weeks. Rates of sPTB in the 3 groups were compared using the Chi-square test. Multivariable logistic regression was used to adjust for race and cerclage indication. A total of 121 women were included. Of those, 34 presented with painless dilation, 51 with PPROM, and 36 with PTL in their first preterm delivery. The painless dilation group had the highest proportion of history-indicated cerclages (53%) placed in the index pregnancy whereas the preterm labor group had the highest proportion of ultrasound-indicated cerclages (89%). PTL was significantly associated with earliest sPTB after 32 weeks, as was painless dilation with earliest sPTB before 24 weeks [Table 1]. After adjusting for race and cerclage indication, and using the PTL group as referent, rates of delivery after 28, 34, and 37 weeks were similar among the 3 groups [Table 2]. Though limited by sample size, our study found no significant association between clinical presentation of prior sPTB and gestational latency after cerclage placement. With this data we cannot conclude that the clinical presentation of preterm birth predicts the outcome of subsequent cerclage. Our findings support current recommendations surrounding cerclage candidacy and may aid in the counseling and management of these high -risk patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Is Uterocervical Angle Associated with Gestational Latency after Physical Exam Indicated Cerclage?

Prediction of gestational latency after placement of physical exam indicated cerclage (PEIC) is limited. Uterocervical angle (UCA) has been associated with spontaneous preterm delivery in the general population. Our objective was to examine whether UCA is associated with gestational latency in women with PEIC. This retrospective cohort included women with a singleton gestation who had PEIC placed at a single tertiary care center between January 2010 and September 2015. Ultrasound images of the cervix obtained prior to placement of PEIC were reviewed. Spearman's correlation coefficient for the relationship between UCA and gestational latency was estimated. UCA was dichotomized at 95° and 105°. Survival analyses were performed and Cox proportional hazard ratios were calculated. Sixty women met the inclusion criteria. Median gestational latency was 93 days (IQR 39-121 d). There was no significant correlation between UCA and gestational latency (Spearman's rho 0.08, p = 0.54). Survival analyses demonstrated no significant difference in gestational latency stratified by UCA ≥ 95° (HR 1.19, 95% CI 0.70-2.04) or UCA ≥ 105° (HR 0.95, 95% CI 0.56-1.63). Findings persisted after adjusting for potential confounders (aHR 1.29, 95% CI 0.74-2.23 for UCA ≥ 95° and aHR 1.04, 95% CI 0.60-1.82). UCA is not associated with gestational latency in women with PEIC.