History Of Second Trimester Miscarriage Research Articles

Uterocervical angle measurement for preterm birth prediction in singleton pregnant women with no history of preterm birth and normal cervical length: A prospective cohort study

ObjectiveTo evaluate the ability of second trimester uterocervical angle (UCA) to predict spontaneous preterm birth (sPTB) in low-risk singleton pregnant women. Study designTransvaginal sonographies were performed in the second trimester of 450 singleton pregnant women with no history of sPTB and no history of second trimester miscarriage with normal cervical length (CL) who attended antenatal care at Songklanagarind Hospital, a tertiary teaching hospital in southern Thailand. Gestational ages at delivery were recorded then the UCA values were evaluated according to sPTB occurrence. The differences in mean values of UCA between sPTB and full-term groups were evaluated using t-test. A receiver operating characteristics (ROC) curve was used to assess the ability of UCA to predict sPTB. ResultsAfter excluding women with unknown pregnancy outcomes or missing UCA images, the sPTB rate was 34/421 (8.1 %). In women with anteflexed uterus, the mean UCA value was wider in the sPTB group compared to those with term birth if the measurements were performed at GA 19.5–24 weeks (sPTB group, 123.4°vs controls, 104.3°; P = 0.017). The ROC curve showed an area under the curve (AUC) of 0.7045. The optimal UCA cut-off value was ≥110 degrees, which gave a sensitivity of 83.3 % and a specificity of 61.2 %. The positive predictive value (PPV) was 16.7 %, negative predictive value (NPV) 97.5 %, positive likelihood ratio (LR+) 2.2 and negative likelihood ratio (LR-) 0.3. ConclusionThe UCA in the second trimester is not a good predictor of sPTB in low risk pregnant women.

VAGINAL PROGESTERONE PESSARY FOR PRETERM LABOR PREVENTION IN WOMEN WITH A SHORT CERVIX EARLY IN THE SECOND TRIMESTER

Background: The prevention of preterm birth is a major health care priority. Objective: To evaluate the efficacy of vaginal progesterone pessary in reducing the rate of preterm delivery and subsequent neonatal morbidity and mortality events in pregnant women with a short cervical length early in the 2nd trimester. Methods: Women with a singleton pregnancy without a history of preterm labor nor a history of second trimester miscarriage, underwent cervical length measurement at 14+0 to 15+6 weeks of gestation. Women found to have a cervical length less than 30 mm received vaginal progesterone pessary (400 mg per pessary) on daily basis, or no treatment. Primary outcome was preterm delivery rate before 37 weeks gestation. Secondary outcome includes neonatal morbidity and mortality events. Results: From the 7725 pregnant women screened between the period from April 2015 to January 2017, 613 were found to have a cervical length less than 30 mm and only 518 pregnant women met the inclusion criteria and agreed to participate in this study. However, only 492 were followed up till the time of delivery. From those 252 women administered 400 mg vaginal progesterone pessary once daily at night and the remaining 240 women did not receive any form of progesterone and served as control. There was a significant reduction in preterm delivery rate less than 37 weeks gestation among women receiving progesterone vaginal pessary compared to the control group 11 (4.4%) vs 38 (15.8%), p value < 0.001. Regarding neonatal outcome, there were significant reduction in the frequency of respiratory distress syndrome, low birth weight neonates and admissions to neonatal intensive care unit in women taking vaginal progesterone pessary compared to the control. While other neonatal morbidity and mortality events, incidence of neonatal congenital anomalies were not significantly different between the two groups. Conclusion: Vaginal progesterone pessaries in women with a cervical length less than 30 mm early in the second trimester are found to be effective in reducing the rate of preterm birth and some of the prematurity related morbidity events. Keywords: preterm labor, vaginal progesterone pessaries, short cervix, premature delivery Citation: Khazaali EAA. Vaginal progesterone pessary for preterm labor prevention in women with a short cervix early in the second trimester. Iraqi JMS. 2018; 16(2): 133-143. doi: 10.22578/IJMS.16.2.4

Predictors of cerclage failure in patients with singleton pregnancy undergoing prophylactic cervical cerclage

The role of cervical cerclage to prevent preterm birth (PTB) remains controversial. The aim of this study was to identify prognostic factors for cerclage failure among singleton pregnant women following prophylactic cerclage (PC). A retrospective analysis of PC was performed in a single center. The main outcome measure was cerclage failure, defined by spontaneous early PTB prior to 32weeks' gestation. Age, BMI, history of instrumentation of the uterus, history of second trimester miscarriage, previous conization, positive vaginal swab prior cerclage, gestational age at time of cerclage, CRP 1week after cerclage and post-cerclage US changes of cervical length were tested as predictive factors. Descriptive statistical and binary logistic regression analyses were performed. 141 women underwent cerclage procedures between 2007 and 2016. 39 patients had PC with McDonald suture, singleton pregnancy and complete clinical follow-up information, thus fulfilling the inclusion criteria. Multivariate analysis showed that history of instrumentation of the uterus was the only independent prognostic factor [OR=0.14 (0.03, 0.72) p=0.019] for cerclage failure. This is the first study showing that a history of previous uterine instrumentation is an independent predictor of cerclage failure. This finding has significant clinical implications for women of childbearing age, particularly when management of miscarriage/abortion is being considered. Women should be informed about the potential risks when counseled prior to surgical evacuation and medical management or cervical ripening should be considered. These results are also helpful in counseling patients undergoing cerclage, when a prior uterine instrumentation has been performed.

Polymorphisms in Genes Coding for Cytokines, Mannose-Binding Lectin, Collagen Metabolism and Thrombophilia in Women with Cervical Insufficiency

Objective: To study the association between cervical insufficiency and single nucleotide polymorphisms in seven genes coding for pro- and anti-inflammatory cytokine-related factors, mannose-binding lectin 2 (MBL2), collagen1α1 (COL1A1), factor II and factor V Leiden genes. Methods: In a case-control study, potential maternal biomarkers for cervical insufficiency were investigated in 30 women with a history of second-trimester miscarriage or preterm birth due to cervical insufficiency and in 70 control women. Results: Homozygous carriers of the interleukin 6 (IL6) -174 genotype GG had an odds ratio (OR) of 3.1 [95% confidence interval (95% CI) 1.3-7.4, p = 0.01] and MBL2 genotypes coding for low or intermediate levels of plasma MBL had an OR of 3.3 (95% CI 1.2-9.0, p = 0.01) for cervical insufficiency compared with controls. Serum MBL levels were lower in women with cervical insufficiency than in controls (median 408 and 1,985 ng/ml, respectively, p < 0.01). Conclusions: Single nucleotide polymorphisms in the IL6 gene and the MBL2 gene and low MBL levels related to the latter polymorphism may increase the risk of preterm birth due to cervical insufficiency.

Laparoscopic Cervical Cerclage Using 5-mm Mer-Silene Tape

Study Objective: One patient with a history of second trimester miscarriage after failed vaginal cerclage. A laparoscopic cervical cerclage was placed before pregnancy under general anesthesia. The bladder flap of peritoneum was been dissected horizontally. Both side uterine artery was revealed and isolated from the parametrium with monopolar diathermy. Curved laparoscopic forceps were used to create a tunnel in the avascular space close to uterus at the level of the cervicourerine junction. A 5-mm Mersilene tape was placed into the right side tunnel from anterior to posterior broad ligament and then placed into the left side tunnel from posterior to anterior broad ligament round the posterior cervicourerine junction.

Laparoscopic Cervical Cerclage: A Series in Women with a History of Second Trimester Miscarriage

We sought to develop a laparoscopic technique for placement of a cervical cerclage in women with a history of failed vaginal cerclage and recurrent miscarriage. This was a case series, design classification III. The study took place at The Recurrent Miscarriage Clinic at National Women's Hospital, Auckland, New Zealand. Ten women with a history of second trimester miscarriage after failed vaginal cerclage, and 1 woman with a history of second trimester miscarriage and findings of a clinically deficient cervix were studied. A laparoscopic cervical cerclage was placed before pregnancy. No intraoperative or postoperative complications were experienced. Ten of 11 women subsequently became pregnant and all delivered live babies by cesarean section in the third trimester. Laparoscopic cervical cerclage is feasible and effective. Outcomes are good in a particularly high-risk group of women with cervical incompetence, who have had failed vaginal cerclage and have a history of recurrent pregnancy loss.

Noninvasive Cerclage for the Management of Cervical Incompetence: A Prospective Study

Surgical cerclage is a traditional treatment for cervical incompetence, but randomized, controlled trials of its effectiveness have yielded conflicting results. This method does not convincingly lower the rate of spontaneous preterm birth. The investigators evaluated a noninvasive cerclage pessary in a prospective cohort study of 32 pregnant women treated for cervical incompetence during the years 2001-2004. All of them had a history of second-trimester miscarriage, delivery before 34 weeks gestation, cervical conization, or multiple pregnancy. Starting at 17-19 weeks gestation, cervical ultrasound studies were done at 2- to 3-week intervals. A cerclage pessary was offered to women with progressive cervical shortening before 30 weeks gestation when cervical length was 25 mm or less. After a sterile vaginal speculum examination and taking cervical swabs, the pessary was inserted into the vagina and fitted around the cervix as high as possible. Women received two 12-mg doses of betamethasone intramuscularly 24 hours apart at the time the pessary was placed or at 23-24 weeks gestation. The pessary was removed at 34-36 weeks gestation or earlier in the event of membrane rupture, uterine contractions, vaginal bleeding, or significant discomfort. Nearly half of the 32 women in the study had two or more risk factors for preterm delivery, and eight had positive vaginal swab cultures. The mean gestational age when placing cerclage was 23 weeks, and cervical length averaged 17 mm. Excluding three indicated preterm births, the mean interval between cerclage placement and delivery was 10.4 weeks. The mean gestational age at delivery was 34 weeks. Nearly half the women (45%) delivered before 34 weeks gestation. Birth weight averaged 2255 g. The cerclage-to-delivery interval was only 7.4 weeks in women having multiple gestations, and they delivered 5 weeks earlier on average than those with singleton pregnancies. Nearly one fourth of women had cesarean section. There were four intrapartum fetal deaths. Two women had the pessary removed prematurely because of constipation and discomfort. The only other significant complication was increased vaginal discharge. It proved easy to insert and remove the pessary. Placement of a cerclage pessary may prove helpful in women with cervical incompetence, but further studies are needed to be sure that this is a viable noninvasive alternative to surgical cerclage.

Mid-trimester loss--appraisal of a screening protocol.

The main causes for mid-trimester loss are known. There is likely to be overlap with those of first trimester loss, but the proportions may be different. We wished to perform an aetiological survey in a large population of patients with a history of recurrent miscarriage, for possible explanations for their second trimester miscarriages. Database analysis of 636 patients attending a UK University Teaching Hospital dedicated miscarriage clinic between 1991 and 1996 revealed a 25% prevalence (n = 158) for second trimester miscarriage. Results from an investigative screening protocol were positive in 50% of cases: 33% (n = 52) tested positive for antiphospholipid syndrome (APS); 8% (n = 13) fulfilled strict criteria for cervical incompetence; there was a 4% prevalence of uterine anomaly; 3% for infection (n = 5) and 2% of patients (n = 3) proved to be hypothyroid. Importantly, dual pathology was found in 5% of patients with a history of second trimester miscarriage. As idiopathic mid-trimester loss is a diagnosis by exclusion, a high index of suspicion is required, as are modern diagnostic techniques.

The association of bacterial vaginosis with a history of second-trimester miscarriage

The association of bacterial vaginosis with a history of second-trimester miscarriage

Association of bacterial vaginosis with a history of second trimester miscarriage.

The aim of this study was to determine whether bacterial vaginosis (BV) is associated with a history of recurrent pregnancy loss. A total of 500 consecutive patients attending the Recurrent Miscarriage Clinic were screened for the presence of BV. In women who had had at least one late miscarriage BV was found twice as commonly (27/130; 21%) as in women who had had only early losses (31/370; 8%) (P < 0.001). The difference was even larger (26 versus 8%) if women who had had term pregnancies were excluded. Moreover, BV was found three times more commonly in Afro-Caribbean women [17 (29%) of 58] than in Caucasian women [36 (9%) of 379] and, in both groups of women, BV was diagnosed at least twice as frequently in those with a history of at least one late miscarriage than in those who had experienced first trimester pregnancy losses only (P < 0. 001). The condition occurred twice as often among smokers than non-smokers and, in both groups, it was at least twice as common in women with a history of at least one late miscarriage as in those who had had early pregnancy losses only (P < 0.001). However, the relationship between BV and smoking was independent of ethnic origin. Women who douched with chloroxylenol were mostly Afro-Caribbean and had BV more than twice as often as women who did not douche.

Second-trimester pregnancy loss is associated with activated C resistance.

We have investigated whether activated protein C resistance (APCR) is associated with second-trimester miscarriage. The prevalence of APCR was significantly higher amongst women with a history of second-trimester miscarriage (10/50; 20%) compared with either women with a history of first-trimester miscarriages only (4/70; 5.7%) or a control group of parous women with no previous history of pregnancy losses (3/70; 4.3%) (P < 0.02). These results suggest that APCR may be an important mechanism of second-trimester pregnancy loss, possibly related to the increase in intravascular coagulation that occurs during pregnancy.