Likelihood Of Preterm Delivery Research Articles

831 Are we triaging effectively? likelihood of preterm delivery following triage discharge versus antepartum admission

Author(s): Waks, Ashten; Martinez-King, Carolina; Santiago, Gisselle; Mochizuki, Marina; Young, Brenda; Sanders, Brooke; Fratto, Victoria; Laurent, Louise C; Jacobs, Marni

Vaginal Candida infection in pregnancy and its implications for fetal well-being.

Vaginal Candida infection is one of the most common genital tract infections reported in pregnant women. This study was designed to determine the prevalence of vaginal Candida infection and pattern of Candida species isolates in the genital tract of pregnant women during antenatal period and in early labour; and the associated fetal outcome. The study was conducted at the antenatal clinic and labor ward of Olabisi Onabanjo University Teaching Hospital Sagamu, Ogun State, Nigeria. High vaginal swabs were collected from 408 pregnant women at the antenatal clinic and repeated in early labour. The samples were processed to isolate Candida species. Data were analysed using Statistical Package for Social Science (SPSS) windows version 21.0 (IBM Corp., Armonk, NY, USA). Prevalence of Candida infection was significantly higher in early labour (46%) than during antenatal period (38%) (P=0.02). Candida albicans was the predominant isolate, followed by Candida glabrata and Candida tropicalis. Candida infection was associated with increased likelihood of low birth weight babies (AOR 2.8, CI: 1.1-6.8; P= 0.03). However there was no statistically significant effect of Candida infection on the likelihood of preterm delivery (AOR 1.4, CI: 0.7-2.6; P= 0.35). Routine screening and prompt treatment of women at risk of delivering low birth weight babies is advocated.

Thyroid-stimulating hormone, anti–thyroid antibodies, and pregnancy outcomes

Overt thyroid dysfunction has been associated with adverse obstetric outcomes. However, less is known regarding subclinical hypothyroidism or thyroid autoimmunity and their relationship to pregnancy complications. The purpose of this study was to examine the association between prepregnancy anti-thyroid antibodies and subclinical hypothyroidism and preterm delivery, gestational diabetes mellitus, and preeclampsia. We conducted a secondary analysis of a prospective cohort of 18- to 40-year-old women with 1-2 previous pregnancy losses (n=1193) who participated in a multicenter randomized, placebo-controlled trial of low-dose aspirin. Prepregnancy levels of thyroid-stimulating hormone, free thyroxine, thyroglobulin antibody, and thyroid peroxidase antibody were measured. Relative risks and 95% confidence intervals were estimated with the use of generalized linear models with adjustment for age and body mass index. Among women with an ongoing pregnancy of >20 weeks estimated gestational age, there was no association between prepregnancy thyroid-stimulating hormone level (>2.5 vs ≤2.5 mIU/L) and preterm delivery (adjusted relative risk, 0.77; 95% confidence interval, 0.40-1.47), gestational diabetes mellitus (adjusted relative risk, 1.28; 95% confidence interval, 0.54-3.04), or preeclampsia (adjusted relative risk, 1.20; 95% confidence interval, 0.71-2.04). Similarly, among women with thyroid antibodies, there was no increase in the likelihood of preterm delivery (relative risk, 1.26; 95% confidence interval, 0.65-2.45), gestational diabetes mellitus (relative risk, 1.33; 95% confidence interval, 0.51-3.49), or preeclampsia (relative risk, 1.02; 95% confidence interval, 0.54-1.92), compared with women without these antibodies. Among women with 1-2 previous pregnancy losses, subclinical hypothyroidism and thyroid autoimmunity were not associated with an increased risk of preterm delivery, gestational diabetes mellitus, or preeclampsia. These data support current recommendations that low-risk asymptomatic women should not be screened routinely for thyroid dysfunction or autoimmunity.

Angiogenic factors and prediction of adverse pregnancy outcomes in suspected preeclampsia: the PROGNOSIS study

Dysregulated angiogenic factors in the maternal circulation, including high soluble fms-like tyrosine kinase-1 (sFlt-1) and low placental growth factor (PlGF), as well as their ratio (sFlt1/PlGF), have been investigated as a diagnostic and prediction marker of preeclampsia. These circulating markers may represent markers for syncytiotrohoblast stress and placentally associated pregnancy complications, which represent major threats to maternal and offspring health globally. The talk will present recently published results from the PROGNOSIS [1] , [2] study as well as discuss future potential clinical and research implications of the study findings. PROGNOSIS was a prospective, multicenter, observational study in pregnancy where preeclampsia was suspected (gestational weeks 24 to 36 + 6 days). Maternal serum sFlt-1 and PlGF were measured after delivery (the results were unknown for clinicians) using Elecsys® sFlt-1 and PlGF assays (cobas e electrochemiluminescence immunoassay platform). The results from the development and validation cohorts (n = 500 and 550 pregnancies) identified an sFlt-1/PlGF ratio cut-off of 38 to optimally predict preeclampsia and that a ratio of ⩽38 is useful for predicting short-term absence of preeclampsia in women in whom the syndrome is suspected clinically [1] . In our second PROGNOSIS published paper [2] , we found that pregnancies with an sFlt-1/PlGF ratio >38 had three-times greater likelihood of preterm delivery and a substantially shorter remaining time to delivery than women with an sFlt-1/PlGF ratio of 38 or lower, whether or not they developed preeclampsia. Women who had iatrogenic preterm delivery (without preeclampsia) had higher median sFlt-1/PlGF ratios at the first study visit versus women with spontaneous preterm or at-term delivery. Clinical implications include the need for testing whether the use of the sFlt1/PlGF ratio to guide clinical decisions, as compared with usual care, will improve clinical outcome for mother and offspring. If cost-efficient, the use of circulating biomarkers can revolutionize the obstetric surveillance in countries that can offer such follow-up.

Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes

To examine the relationship of anxiety and depression symptoms with treatment outcomes (treatment discontinuation, rates of ongoing use of illicit drugs and likelihood of preterm delivery) in opioid-dependent pregnant women and describe their use of psychotropic medications. Secondary data analysis from a randomized clinical trial of treatment for opioid dependence during pregnancy. A total of 175 opioid-dependent pregnant women, of whom 131 completed treatment. Symptoms of anxiety and depression were captured with the 15-item Mini International Neuropsychiatric Interview (MINI) screen. Use of illicit drugs was measured by urine drug screening. Preterm delivery was defined as delivery prior to 37 weeks' gestation. Self-reported use of concomitant psychotropic medication at any point during the study was recorded. Women reporting only anxiety symptoms at study entry were more likely to discontinue treatment [adjusted odds ratio (OR) = 4.56, 95% confidence interval (CI) : 1.91-13.26, P = 0.012], while those reporting only depression symptoms were less likely to discontinue treatment (adjusted OR = 0.14, 95% CI : 0.20-0.88, P = 0.036) compared to women who reported neither depression nor anxiety symptoms. No statistically significant between-group differences were observed for ongoing illicit drug use or preterm delivery. A majority (61.4%) of women reported use of concomitant psychotropic medication at some point during study participation. Opioid agonist-treated pregnant patients with co-occurring symptoms of anxiety require additional clinical resources to prevent premature discontinuation.

OC22.06: Discordant anomalies in monochorionic twins

Methods: Retrospective cohort of 453 twin pregnancies in two tertiary centers over an 11-year period. All women had serial ultrasound assessment of CL from 11–13+6 weeks through to 14–15+6, 16–17+6, 18–19+6 and 20–21+6 weeks as part of routine antenatal care. A total of 720 serial CL measurements were recorded. Monochorionic twin pregnancies complicated with twin to twin transfusion syndrome and monoamniotic pregnancies were excluded. We estimated the association between cervical length at each of the five study periods and preterm delivery before 28, 32 and 34 weeks’ respectively. Results: The cumulative incidence of preterm delivery was 6.8%, 13.2% and 26.1% before 28, 32 and 34 weeks’ respectively. A CL below 50 mm at 11–13+6 weeks was associated with preterm delivery before 28 weeks (RR = 1.63, 95% CI = 1.21–2.18, P 45 mm for delivery before 28 (LR− 0.33) and 34 weeks (LR− 0.29) respectively. CL 50 mm at this gestation reflects a low likelihood of preterm delivery.

Serum macrophage migration inhibitory factor in the prediction of preterm delivery

Macrophage migration inhibitory factor is a soluble mediator that helps govern the interaction between cytokines and stress hormones (eg, cortisol). We determined whether maternal macrophage migration inhibitory factor levels predicted subsequent preterm delivery. A nested case-control study measuring serum macrophage migration inhibitory factor concentration at 9-23 weeks' gestation in women who ultimately delivered preterm (n = 60) compared with control women who delivered at term (n = 122). We also examined the connection of macrophage migration inhibitory factor with self-reported psychosocial variables. Macrophage migration inhibitory factor was elevated in the preterm delivery cases (P = .0004), and log macrophage migration inhibitory factor concentration showed a graded response relationship with likelihood of preterm delivery. High-macrophage migration inhibitory factor was also associated with maternal risk-taking behavior, which itself was a risk factor for preterm delivery. Macrophage migration inhibitory factor remained associated independently with preterm delivery after adjusting regression models for several other preterm delivery risk factors (odds ratio, 3.11, 95% confidence interval, 1.54-6.30). High-serum macrophage migration inhibitory concentration in early to midpregnancy is linked with subsequent preterm delivery.

Assessing the relationship between preterm delivery and various microorganisms recovered from the lower genital tract

Objective. To determine if the likelihood of preterm delivery is more dependent on the specific organisms present in the vagina than on the presence of bacterial vaginosis.Methods. We evaluated the vaginal fluid of a prospective cohort of women at 23–32 weeks of gestation with signs and symptoms of preterm labor and intact membranes. Forward stepwise logistic regression models were used to evaluate the relationship between preterm delivery and the presence of anaerobic bacteria, Gardnerella, ureaplasmas and mycoplasmas, and sialidase.Results. The cohort included 137 women, and complete delivery information was available for 134 of them. The rate of preterm delivery was 28% (37 of 134). Mycoplasma genitalium independently was associated with spontaneous preterm delivery (OR 3.48; 95% CI 1.41, 8.57). After controlling for this factor, none of the other variables were significantly prognostic for spontaneous preterm delivery (residual overall p = 0.19).Conclusion. The presence of Mycoplasma genitalium in the vagina of pregnant women is an independent risk factor for spontaneous preterm delivery.

P11.10: Ultrasonographic cervical length measurement in the assessment of preterm delivery risk

To determine if cervical shortening between 12 and 28 weeks' gestation predicts risk of spontaneous preterm birth or cervical funneling requiring cerclage. We reviewed retrospectively all the patients who had transvaginal cervical ultrasound assessment during one year. 49 patients who had a second and early third trimester delivery or cerclage placement were chosen for the study. The control group consisted of 78 patients without signs of preterm labor and cervical shortening as assessed by transvaginal ultrasound. The results of the last ultrasound cervical length measurement were correlated with the likelihood of preterm delivery or cervical funneling requiring cerclage. 34 of 127 patients studied delivered preterm and 15 required cervical cerclage because of cervical shortening and funneling. The mean cervical length assessed by ultrasound was 20.22 ± 3.07 mm in the group with preterm contractions and delivery and 15.99 ± 7.05 mm in the group with cervical incompetence. In the normal pregnancy group mean cervical length was 35.59 ± 3.07 mm. Cervical length of < 2.5 cm and further shortening of the cervix is predictive of preterm delivery or cervical incompetence requiring cerclage.

An additional approach of repeat digital examination for preterm labor. Comment on Volumenie et al. [Eur J Obstet Gynecol RB 117 (2004) 33–7

We read with great interest the article by Volumenie et al. [ [1] Volumenie J.L. Luton D. Spirlet M.D. Sibony O. Blot P. Oury J.F. Ultrasonographic cervical length measurement is not a better predictor of preterm delivery than digital examination in a population of patients with idiopathic preterm labor. Eur J Obstet Gynecol RB. 2004; 117: 33-37 Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar ]. Most studies that have compared digital and ultrasonographic examination of the cervix for the prediction of preterm delivery without distinguishing the population based on the likelihood of preterm delivery, supported the dominance of the latter examination. However, Volumenie's study related that ultrasonographic cervical length measurement is not a better predictor of preterm delivery than digital examination especially in the high-risk population. Recently, Rozenberg suggested that repeating ultrasonographic cervical length measurement after successful tocolysis for preterm labor is useless [ [2] Rozenberg P. Rudant J. Chevret S. Boulogne A.I. Femme S. Ville Y. Repeat measurement of cervical length after successful tocolysis. Obstet Gynecol. 2004; 104: 995-999 Crossref PubMed Scopus (18) Google Scholar ]. In Rozenberg's study, subjects were also inferred to be of the high-risk population as in Volumenie's study because of the gestation with a cervical length on admission and the agreement of preterm delivery rates. Accordingly, Volumenie's study would have become better research if an investigation of repeat digital examination of cervical length for preterm labor had been added to their study. Reply to Dr. Shukunami concerning “Ultrasonographic cervical length measurement is not a better predictor of preterm delivery than digital examination in a population of patients with idiopathic preterm labor” [Eur J Obstet Gynecol Reprod Biol 2004;117:33–7]European Journal of Obstetrics and Gynecology and Reproductive BiologyVol. 120Issue 1PreviewWe thank Dr. Shukunami for his interest in our study and greatly appreciate the relevant remarks made. We did not use the results of repeat digital examination, although such an examination was generally performed on discharge. Theoretically, it could have been of interest, in order to analyse the clinical utility of this attitude, as Rozenberg et al. did for ultrasonography [1]. Full-Text PDF

A randomized comparison of home uterine activity monitoring in the outpatient management of women treated for preterm labor

Objective: The aim of the study was to evaluate home uterine activity monitoring as an intervention in reducing the rate of preterm birth among women treated for preterm labor. Study Design: A total of 186 women were treated in the hospital with magnesium sulfate for preterm labor and were prospectively randomly assigned to study groups; among these, 162 were ultimately eligible for comparison. Eighty-two of these women were assigned to the monitored group and 80 were assigned to an unmonitored control group. Other than monitoring, all women received identical prenatal follow-up, including daily perinatal telephone contact and oral terbutaline therapy. Outcome comparisons were primarily directed toward evaluation of preterm birth at <35 weeks’ gestation. Readmissions for recurrent preterm labor and observations lasting <24 hours were evaluated in monitored and unmonitored groups. Compliance with monitoring was also evaluated in the monitored group. Results: The monitored and control groups were demographically similar. According to a multivariate logistic regression model, women with cervical dilatation of ≥2 cm were 4 times more likely to be delivered at <35 weeks’ gestation ( P < .05). Gestational ages at delivery were similar in the monitored and control groups. There was no significant difference in the overall rate of preterm delivery at <35 weeks’ gestation between the monitored group (10.9%) and the control group (15.0%). The overall rates of delivery at <37 weeks’ gestation were high (48.8% and 60.0% for monitored and control groups, respectively), and the difference was not significant. The numbers of women with ≥1 instance of readmission and treatment for recurrent preterm labor were equal in the monitored and control groups. The numbers of women with ≥1 hospital observation lasting <24 hours were not different between the groups. Compliance with monitoring did not significantly differ for women who were delivered at <35 weeks’ gestation, women with ≥2 cm cervical dilatation at enrollment, or for African American women. Conclusion: A reduction in the likelihood of preterm delivery at <35 weeks’ gestation was not further enhanced by the addition of home uterine monitoring to the outpatient management regimens of women treated for preterm labor. (Am J Obstet Gynecol 1999;180:798-805.)

The incidence of positive amniotic fluid cultures in patients in preterm labor with intact membranes

The possible relationship between intrauterine infection and preterm labor has received considerable attention in recent years. The purpose of this study was twofold: first, to determine the frequency of asymptomatic infection in patients who came to the hospital in preterm labor, and second, to determine the significance of a positive amniotic fluid culture in relation to latency period and likelihood of preterm delivery. Patients who came to the hospital in preterm labor with intact membranes between 20 and 35 weeks' gestation underwent transabdominal amniocentesis. Amniotic fluid was sent for Gram stain and culture. Patients received tocolytic therapy as clinically indicated. Of 127 patients cultured, seven (5.5%) had positive amniotic fluid cultures. These patients had a significantly decreased latency period from amniocentesis to delivery (4.4 days versus 28.6 days), and a significantly increased chance of being delivered of preterm infants (100% versus 52.5%), as compared with patients with negative cultures. The rate of positive Gram stain was 7 of 125 positive. However, there was no correlation between positive Gram stain and positive culture results. Similarly, positive Gram stain results were not associated with any difference in the latency period or rate of preterm delivery. (Ann J OBSTET GYNECOL 1989;161:813-6.)