Preterm Birth In Patients Research Articles

Nomogram-based risk assessment for emergency cervical cerclage failure in patients with cervical insufficiency

BackgroundCervical insufficiency can lead to preterm birth and neonatal mortality. Emergency cervical cerclage is a surgical intervention aimed at preventing preterm birth in patients with cervical insufficiency. However, some patients may experience cerclage failure. This study aimed to identify the risk factors associated with cerclage failure and develop a predictive nomogram model for patients with cervical insufficiency undergoing emergency cervical cerclage. MethodsData of 200 patients who underwent emergency cervical cerclage for cervical insufficiency were retrospectively analyzed. Patients were categorized into successful and failed groups based on their ability to take the infant home. Univariate and multivariate logistic regression analyses were performed to identify risk factors for cerclage failure. A nomogram model was developed based on multivariate logistic regression results, and its performance was assessed using receiver operating characteristic curves, calibration plots, and decision curve analysis (DCA). ResultsUnivariate logistic regression analysis identified 11 potential risk factors for cerclage failure, including the presence of polycystic ovary syndrome (PCOS), vaginitis, cervical dilation, preoperative C-reactive protein, routine vaginal lavage after cervical cerclage, delivery, gestational age, extended days, chorioamnionitis, intrauterine infection, cervical laceration, and premature rupture of membranes. Multivariate logistic regression analysis revealed that PCOS, cervical dilation after cervical cerclage were independent risk factors for cerclage failure while routine vaginal lavage was a protective factor against failure. The nomogram predictive model demonstrated an area under the curve value of 0.975, indicating excellent discriminatory ability. The calibration plot showed good consistency between the nomogram predictions and actual observations. DCA demonstrated the strong clinical applicability of the nomogram. ConclusionsThis study successfully identified risk factors associated with emergency cervical cerclage failure in patients with cervical insufficiency and developed a predictive nomogram model. This model can assist clinicians in making informed decisions and accurately predicting the risk of cerclage failure in these patients.

Reevaluating Associations between Prenatal Care Utilization and Current Trends in Preterm Birth.

Studies have suggested an association between prenatal care (PNC) and preterm birth (PTB). We evaluated trends in PTB and association of PNC and PTB. This was a retrospective cohort study of singleton, viable nonanomalous deliveries from 1991 to 2018. PNC utilization was defined by World Health Organization using number of visits: adequate (≥8), suboptimal (5-7), and inadequate (<5). Primary outcome was PTB. Tests of trend were used to assess changes in PTB over time. Baseline characteristics and outcomes were compared. Logistic regression estimated the association of PNC and PTB. We evaluated for effect modification by year of birth. Of 92,294 patients, 14,057 (15%) had PTB. Inadequate and suboptimal PNC were associated with higher odds of PTB compared to adequate PNC (adjusted odds ratios = [aOR 6.21], 95% confidence interval [CI]: 5.84-6.60; aOR = 3.57, 95% CI: 3.36-3.79). Inadequate PNC was associated with higher odds of PTB over time (effect modification p < 0.0001). Inadequate PNC was associated with 5.4 times higher odds of PTB in 1998, 7.0 times in 2008, and 9.1 times in 2018. Despite an increase in adequate PNC, there was a rise in PTB associated with inadequate and suboptimal PNC. PNC utilization was a stronger risk factor in recent years with higher PTB in patients who attended more than five PNC visits. · PNC utilization is associated with the risk of PTB.. · Despite an increase in PNC utilization, PTB rates have increased.. · There is an even stronger association between PNC utilization and PTB over time..

Factors contributing to preterm birth in patients presenting at tertiary care hospitals in Punjab.

To determine the various causes and factors leading to preterm birth in women presenting at tertiary care hospitals. The cross-sectional, prospective study was conducted from June 19, 2021, to January 19, 2022, at the Central Park Teaching Hospital, Lahore, Pakistan, in collaboration with other tertiary care teaching hospitals in Lahore, and comprised pregnant women aged 15-45 years with preterm birth. Demographic and obstetric data was collected. Depending on the factors contributing to preterm birth, the subjects were categorised as spontaneous labour group A, preterm prelabour rupture of membrane group B, and iatrogenic preterm birth group C. Data was analysed using SPSS 25. Of the 1,300 recorded births, 200(15.38%) were preterm. Group A had 86(43%) women with mean age 28.55±4.68 years, group B had 43(21,5%) women with mean age 27.14±3.25 years, and group C had 71(35.5%) women with mean age 28.28±3.74 years (p>0.05). There was significant difference among the groups with respect to body mass index (p=0.001) and parity (p=0.021). Vaginal and urinary tract infections were significantly higher in group A compared to the other groups (p<0.05). In group C, pre-eclampsia was the main reason for preterm birth 45(63.38%). Medically indicated preterm birth rate was found to be high, and pre-eclampsia was noted as the main cause in iatrogenic preterm birth.

Construction and validation of a novel nomogram for predicting spontaneous preterm birth in patients with gestational diabetes mellitus.

To explore the influencing factors of spontaneous preterm birth (sPTB) in patients with gestational diabetes mellitus (GDM) and construct a nomogram model. A retrospective analysis was conducted on the clinical data of 289 GDM patients who gave birth at Yangzhou University Affiliated Hospital from January 2021 to December 2022. The patients were divided into the sPTB (n = 52) and non-sPTB (n = 237) groups based on whether sPTB occurred. Logistic multivariate analysis was used to explore the influencing factors of sPTB in GDM patients and construct a nomogram model. The predictive performance of the nomogram model was evaluated using ROC curves and calibration curves in internal validation. Additionally, 62 GDM patients who visited Yangzhou University Affiliated Hospital from January 2023 to June 2023 were retrospectively selected for external validation of the prediction model. Logistic analysis showed that maternal age ≥30 years, pre-pregnancy BMI ≥26.3 kg/m2, history of spontaneous abortion, premature rupture of membranes, and oral glucose tolerance test (OGTT) fasting blood glucose ≥5.1 mmol/L were independent risk factors for sPTB in GDM patients (all P<0.05). In internal validation, the AUC value of the model's ROC curve was 0.901, and in external validation, the AUC value was 0.939. The calibration curve showed that the predicted probability was consistent with the actual probability. In addition, the sensitivity, specificity, and accuracy of the model in external validation were 84.21%, 81.40%, and 82.26%, respectively. Maternal age ≥30 years, pre-pregnancy BMI ≥26.3 kg/m2, history of spontaneous abortion, premature rupture of membranes, and OGTT fasting blood glucose ≥5.1 mmol/L are independent risk factors for sPTB in GDM patients. The nomogram model based on these risk factors has high discrimination and accuracy in predicting sPTB in GDM patients.

Clinical assessment of the placenta function in women at risk and threat of premature delivery

Premature birth, despite the significant achievements of perinatal medicine in recent decades, remains an urgent global and national medical and social problem, as it is the leading cause of perinatal morbidity and mortality. According to modern views, placental dysfunction can be one of the causes of premature birth, and its frequency, according to randomized studies, can be from 78 to 91%, depending on the gestational age. At the same time, the research conducted to date does not provide a clear understanding of the role of timely diagnosis and prevention of placental dysfunction in preventing premature birth.The objective: to perform clinical evaluation of the prevalence of placental dysfunction in women at risk of preterm birth and with threat of preterm birth.Materials and methods. 180 pregnant women were took part in the study. To achieve the research aim, three research groups were formed. I group – 73 pregnant women with threat of premature birth; II group – 77 pregnant women with risk factors for premature birth. Women with risk factors for premature birth were included in the study at the stage of pregnancy planning (IIA subgroup, 39 women) or from the moment of applying to a women’s outpatient clinic to monitor the course of pregnancy (IIB subgroup, 38 pregnant women). The control group included 30 pregnant women with an uncomplicated course of pregnancy.Transabdominal ultrasound examination with color Doppler mapping, determination of free estriol, progesterone and placental lactogen levels in blood serum were performed at 18–21+6 and 28–30 weeks of gestation.Results. Analysis of the prevalence of risk factors for placental dysfunction and preterm birth in patients of the studied cohort showed that in pregnant women with preterm birth (I group), the combination of risk factors was 5.2; in pregnant women who received pre-gravid training (IIA subgroup) – 3.2; in pregnant women who were included in the study in the I trimester of pregnancy (IIB subgroup) – 4.7, while in pregnant women of the control group – only 0.8 (p&lt;0.05).The threat of early spontaneous miscarriage with the formation of a retrochorial hematoma as a clinical manifestation of primary placental dysfunction was determined in 43.8% of pregnant women whose premature delivery was carried out for medical reasons. Placenta abruption in these patients can be considered as decompensation of the primary dysfunction of the placenta with the transition to acute placental insufficiency.The formation of chronic placental dysfunction, clinically manifested by the syndrome of fetal growth retardation, was most often observed in patients whose pregnancy ended in spontaneous premature birth at 34–36+6 weeks in the presence of an untouched amnion, – 68.6% compared to births at 28–33+6 weeks of gestation – 25.9% and with childbirth at 22–37+6 weeks – 13.3%.Conclusions. Clinical manifestations of placental dysfunction were detected in 30.6% of patients with premature birth, with morphological signs in 60.4% of cases, which indicates the hidden course of placental insufficiency before the development of premature birth.Morphological signs of placental dysfunction were determined in 87.5% of cases of premature births for medical reasons and in 100.0% of cases of spontaneous births at 22–27+6 weeks of gestation (with a combination of risk factors from 2.1 to 3.0), in 66.7% – with premature births at 28–33+6 weeks of pregnancy, in 40.0% – with premature births at 34–36+6 weeks of pregnancy and only in one (5.6%) case – with term births.The frequency of fixation of morphological characteristics of placental dysfunction correlates with the frequency of early pregnancy complications, primarily with the formation of retrochorial hematomas in the first half of pregnancy.

Role Of Low Dose Aspirin In Preventing Preterm Birth In Patients With Previous History Of Preterm Delivery

Objective: Preterm birth (PTB) occurs between 24-37 weeks of gestation. The important risk factor for PTB is a previous PTB and currently progesterone is used for the management of recurrent spontaneous PTB. Some studies have shown good outcomes but recent studies revealed that the use of vaginal progesterone was not related to a decreased likelihood of PTB or neonatal adverse effects. Thus, the controversy in the literature suggests multiple underlying pathological mechanisms involved in the progression of PTB. This study aims to determine the role of low-dose aspirin in the prevention of preterm birth in patients with a previous history of preterm delivery. Methodology: In this randomized controlled trial, a total of 172 patients fulfilling the inclusion criteria were selected from the inpatient and outpatient departments. Patients were divided randomly into two groups (group A and group B), using random number tables. In Group A, low-dose aspirin (75mg) was given while group B was taken as a control group. Patients were called every 8 weeks in the outpatient department for the assessment of compliance and side effects of the drug. The data were entered and analyzed by using SPSS v25.0. Chi-square was used to compare the two groups for incidence of preterm birth. Relative risk (along with a 95% confidence interval) for the decrease in the incidence of preterm birth with the use of aspirin was calculated. Results: The age of participants included in the study was 18 to 40 years. The mean age of patients in group A was 33.85±5.210 years and in group B was 32.86±4.139 years. The mean fetal birth weight in group A was 2281.1962±363.125 grams and in group B was 2271.4344±374.797 grams. In the low-dose aspirin group, 10(11.6%) had preterm birth and 31(36.0%) in the control group with a p-value of 0.001, which is statistically significant. The risk of having preterm birth with low-dose aspirin was 1.801 times less than controls. Conclusion: aspirin in low dose given before 14 weeks of gestation decrease spontaneous preterm birth as compared to the control group in a woman with a history of previous preterm birth which was spontaneous

Risk of Preterm Delivery in Very Advanced Maternal Age Parturients Utilizing In Vitro Fertilization.

Among patients ≥45 years, the birth rate in the United States continues to increase. As fertility declines with age, this cohort often utilizes assisted reproductive technology, specifically in vitro fertilization (IVF). While both advancing maternal age and IVF are independently associated with adverse maternal outcomes, data regarding their additive effect are scant. This article aims to determine if patients who conceive via IVF are at increased risk for preterm birth (PTB) compared to patients with non-IVF pregnancies in a very advanced maternal age (vAMA) cohort (≥45 years). Retrospective cohort study of all pregnant patients ≥45 years old who delivered at a single institution (2014-2021). Those with incomplete delivery/neonatal records or multiples beyond twins were excluded. We compared individuals who conceived via IVF to those who conceived without IVF. The primary outcome was preterm delivery <37 weeks gestation. Secondary outcomes included other adverse perinatal outcomes. Using multivariable logistic regression, we adjusted for multiple gestation as well as confounders found to be significantly different in the univariable analysis and other known risk factors for PTB. In our study cohort of 420 vAMA patients, individuals who underwent IVF were more likely to be older, privately insured, nulliparous, and with a twin gestation. The PTB rate in vAMA patients who underwent IVF was 24.4 compared to 8.4% in patients who did not use IVF (p < 0.001). After adjusting for confounders, IVF was an independent risk factor for PTB <37 weeks in vAMA patients (adjusted odds ratio {aOR] = 4.3, 95% confidence interval [CI]: 1.7-10.4, p = 0.001). In vitro fertilization was also associated with a composite of adverse maternal outcomes (hypertensive disorder of pregnancy, postpartum hemorrhage, blood transfusion, and unplanned hysterectomy) (aOR = 1.7, 95% CI: [1.1-2.9], p = 0.03). In the vAMA population, conception via IVF is associated with an increased risk of PTB <37 weeks. · This study examines IVF as an independent risk factor for PTB in patients ≥45 years at delivery, which has not been specifically addressed in prior studies.. · In vAMA patients, use of IVF is associated with an increased risk of PTB <37 weeks. These patients also have higher rates of cesarean delivery. Neonates from IVF pregnancies are more likely to be very low birth weight or low birth weight.. · Bodies of research exist for both advanced maternal age and assisted reproductive technology, there is a paucity of data specifically in parturients of vAMA who conceive via IVF..

847 Risk Factors Related to Preterm Birth Among Mothers Who Gave Birth in Gynecology and Obstetrics Department of Services Hospital, Lahore, Punjab: A Case-Control Study

Abstract Introduction Preterm labor remains one of the most important problems faced by obstetricians globally, because of the high rates morbidity and mortality in preterm infants. It is said to be caused by interplay of multiple factors that include inadequate nutrition, antenatal care, low income, lack of education, multiple gestations, chronic illnesses, hypertension, anemia, infections, and substance abuse. Thus, understanding of these factors is crucial for reducing morbidity and mortality due to complications of preterm birth. Aim To determine maternal, fetal, and socioeconomic factors leading to preterm birth in patients delivering in the Gynecology and Obstetrics Department of Services Hospital, Lahore. Method A case-control study was conducted on 226 mothers delivering in Gynecology and Obstetrics Department of Services Hospital, Lahore in November 2020. A well-designed structured questionnaire was used to collect data about the sociodemographic profile, past gynecological and obstetric history, history of current pregnancy, past medical history, and the newborn. SPSS version 25 statistical tool was used to enter and analyze data. Results Height of respondent ≤155cm, parity &amp;gt;3, previous preterm birth, twin pregnancy, hypertensive disorder in pregnancy, hospitalization during pregnancy, hemoglobin level &amp;lt;11g/dl during pregnancy, history of UTI during pregnancy, fetal distress, cephalopelvic disproportion, oligohydramnios, polyhydramnios, PROM, no use of iron and multivitamins during pregnancy use of alcohol or other drugs during pregnancy, psychological stress during pregnancy and history of dental problems were found to be statistically significant. Conclusions In our study it was found that characteristics of current obstetrical history were the most important factors contributing to preterm birth.

Elevated antimüllerian hormone levels are not associated with preterm delivery after in vitro fertilization or ovulation induction

To investigate the association between anti-Müllerian hormone and preterm birth risk in a larger cohort of patients who underwent either in vitro fertilization or ovulation induction with intrauterine insemination at a US academic fertility center. Retrospective cohort study SUBJECTS: Live singleton births from patients who underwent in vitro fertilization or ovulation induction between 2016 and 2020 at a single academic fertility center were included in this study. Patients were excluded if they had a missing pre-pregnancy AMH level, a pregnancy using donor oocytes or a gestational carrier, multiple gestations, a delivery prior to 20 weeks gestation, or a cerclage in place. AMH level MAIN OUTCOME MEASURES: The primary outcome was proportion of preterm delivery. Secondary outcomes included rate of pregnancy-induced hypertension, gestational diabetes, and small for gestational age. In the entire cohort (n=875), 8.4% of deliveries were preterm. Mean AMH values were similar between those with term and preterm births (3.9 vs 4.2 ng/mL, p=0.29). Similar proportions of patients with term and preterm deliveries had AMH levels greater than the 75th percentile (25% vs 21%, p=0.4). The odds of preterm birth were similar by AMH quartile after adjusting for history of preterm birth. Similarly, in the PCOS cohort, there was no difference between mean AMH values of term and preterm births (n=139, 9.6 vs 10.0 ng/mL, p=0.9). The proportions of PCOS patients with AMH levels greater than the 75th percentile were similar between those with term and preterm deliveries (25% vs 22%, p=0.9). The odds of preterm birth were similar by AMH quartile after adjusting for history of preterm birth. Elevated AMH levels were not associated with an increased risk of preterm birth in patients who conceived after in vitro fertilization and ovulation induction, including PCOS patients. Although studies suggest that AMH level may help stratify risk of preterm birth in this population, our findings indicate that further studies are needed prior to clinical application.

СРАВНИТЕЛЬНАЯ ОЦЕНКА ТЕЧЕНИЯ И ИСХОДОВ БЕРЕМЕННОСТИ У ПАЦИЕНТОК С НЕДИФФЕРЕНЦИРОВАННОЙ ДИCПЛАЗИЕЙ СОЕДИНИТЕЛЬНОЙ ТКАНИ ПРИ ИСПОЛЬЗОВАНИИ ОБЩЕПРИНЯТОЙ И ПЕРСОНАЛИЗИРОВАННОЙ ПРЕГРАВИДАРНОЙ ПОДГОТОВКИ

Background. Preparation for pregnancy in patients with extragenital pathology is an important problem of current obstetrics. Purpose. To perform comparative assessment of the course and outcomes of pregnancy in patients with undifferentiated connective tissue dysplasia (UCTD) after using conventional and personalized preconception preparation. Material and methods. A total of 262 patients were examined, including 159 with UCTD. Group I (the main group) included 125 patients with minor heart abnormalities and at least 4 signs of undifferentiated connective tissue dysplasia, who underwent the generally accepted preconception preparation: folic acid – 400 μg/day, potassium iodide – 200 μg/day orally for 3 months. Group II (the intervention group) consisted of 34 patients who received personalized preconception preparation: folic acid – 400 μg/day orally, potassium iodide – 200 μg/day orally for 3 months, Mg2+ preparations at a dose of 300 mg/day, glycine –400 mg/day, multivitamin complex containing vitamin B1 (10 mg/day), vitamin B2 (10 mg/day), vitamin B6 (10 mg/day), vitamin E (400 mg/day) for 3 months. Group III (the control group) included 103 patients without signs of UCTD who received a standard amount of preconception preparation. The evaluation of the effectiveness of personalized preconception preparation was carried out according to the criteria of evidence-based medicine. Relative risk (RR), relative risk reduction (RRR), absolute risk reduction (ARR), the number of patients who needed treatment to prevent 1 adverse outcome (NNT), the odds ratio (OR) for a particular outcome were calculated. Results of the study. In the intervention group, statistically significant results were obtained in terms of reducing the risk of developing a threatened miscarriage and preterm birth in patients with undifferentiated connective tissue dysplasia, as well as reducing the absolute risk of developing isthmic-cervical isufficiency. Conclusions. Identification of signs of UCTD at the preconception stage and the use of personalized preconception preparation in this group of patients contributes to the improvement of perinatal outcomes.

RELATIONSHIP BETWEEN HEMOGLOBIN A1C LEVELS IN EARLY PREGNANCY AND ADVERSE OUTCOMES AMONG NON-DIABETIC PATIENTS

This study was designed to assess the effects of increased hemoglobin A1c in the first trimester on adverse perinatal outcomes in patients without gestational diabetes mellitus. A prospective study was conducted in the Obstetrics and Gynecology Department of Buch International Hospital Multan from January 2022- January 2023. A total of 160 women with singleton pregnancies in their first trimester and elevated hemoglobin A1c were included in the study. The following outcomes were evaluated in patients: miscarriage, shoulder dystocia, preterm delivery &lt;37 weeks, macrosomia, small or large for gestational age, hypertensive disorders of pregnancy, third- or fourth-degree lacerations, operative vaginal delivery, cesarean delivery, neonatal hypoglycemia, neonatal jaundice, NICU admission, and intrauterine fetal demise. The multivariate analysis evaluated the relationship between hemoglobin A1c and adverse outcomes. The Hb1Ac level in patients ranged from 5.7-6.4%. Elevated levels were noted in elderly patients who were multiparous, obese, and diagnosed with chronic hypertension. 5.6% of patients had a preterm delivery, and 31.2% had a c-section delivery. 7.5% had a likelihood of hypertensive pregnancy disorder, and 10.6% were likely to deliver a macrosomic infant. Based on the results, it can be concluded that elevated hemoglobin A1c levels are significantly associated with preterm birth in patients without gestational diabetes.&#x0D;

Association of Vaginal Progesterone Treatment With Prevention of Recurrent Preterm Birth

Association of Vaginal Progesterone Treatment With Prevention of Recurrent Preterm Birth

Analysis of pregnancy outcomes in patients undergoing ultrasound-indicated cerclage and identification the influence factors for predicting preterm birth: A retrospective study of 87 cases.

To investigate the factors influencing preterm birth in patients after ultrasound-indicated cerclage with different cervical lengths (CL), and explore the optimal cut-off value of CL. The retrospective study included 87 pregnant women with a history of preterm birth and second-trimester loss that received ultrasound-indicated cerclage in our hospital between January 2004 and April 2021. Groups were divided by CL at the demarcation point of 1.0, 1.5 and 2.0cm respectively. The pregnancy outcomes were compared. Logistic regression analysis was performed to assess the independent influence factors. Receiver-operating characteristic (ROC) curves were constructed and the area under the curve (AUC) was used to compare the prediction capability of the associated factors. Significant difference was found in terms of patients delivered at ≥32 weeks of gestation (19 [55.9%]vs. 41 [77.4%], p<0.05) and neonatal birth weight (2495 [1138,3185]vs. 2995 [2155,3235] g, p<0.05), when the CL was categorized at the demarcation point of 1.5cm. Body mass index (BMI) (odds ratio [OR]=1.224, p<0.05), a history of preterm birth and second-trimester loss (OR=3.153, p<0.05), and C-reactive protein (CRP)>5mg/L (OR=8.097, p<0.05) were independent risk factors for gestational age more than 28 weeks. The AUC of joint predictor A included those factors was 0.849 (95% CI: 0.701-0.998, p<0.05). CRP>5mg/L was found to be a significant independent risk factor for different gestational age at delivery. A CL of 1.5cm was the optimal cut-off value that could help women who underwent serial CL surveillance choose ultrasound-indicated cerclage at an appropriate time. High BMI, more history of preterm birth and second-trimester loss and abnormal CRP could be used as combined predictors to recognize the risk of preterm birth (<28 weeks) post-surgery.

Pregnancy Outcomes in Females with Eosinophilic Esophagitis: A Nationwide Population-Based Study

Introduction: Eosinophilic esophagitis (EoE) is a chronic, allergic inflammatory disease of the esophagus. It has a peak incidence in the 2nd and 3rd decades of life. Despite this, little is known about pregnancy outcomes in patients with EoE. Methods: Using a validated histopathologic and nationwide population-based cohort for the diagnosis of EoE, we examined maternal and fetal outcomes, with preterm birth as the primary outcome, in females with EoE compared to matched controls. Odds ratios (ORs) were calculated using logistic regression. Results: Between 1992 and 2016, we identified 19 females with EoE who gave birth to 23 children (reference births: n = 115). There was 1 (4.3%) preterm birth in the EoE cohort versus 8 (7.0%) in the reference cohort (OR = 0.60; 95% CI = 0.07–5.14). Secondary fetal outcomes included stillbirth, neonatal death, small for gestational age, low birth weight (LBW), and low Apgar score. Of these, LBW (<2,500 g) in patients with EoE compared to controls correlated to an OR of 12.42 (95% CI = 1.26–122.42); however, this finding was based on very low numbers. The remaining fetal outcomes were not significantly different between females with EoE and controls. Secondary pregnancy and maternal outcomes including induction of labor, instrumental delivery, gestational diabetes, or pre-eclampsia were not significantly different between patients with EoE and controls. Discussion/Conclusion: Overall in this nationwide cohort study, we did not find increased association of preterm birth in patients with EoE.

Interventions to Prevent Spontaneous Preterm Birth in Women With Singleton Pregnancy Who Are at High Risk: Systematic Review and Network Meta-Analysis

(BMJ. 2022;376:e064547. doi: https://doi.org/10.1136/bmj-2021-064547) Two-thirds of preterm births (&lt;37 wk gestation) occur spontaneously, while one-third are intentionally induced. Patients at risk of spontaneous preterm birth may or may not exhibit symptoms. Among high-risk patients without symptoms, cervical length &lt;25 mm and history of spontaneous preterm birth are the 2 strongest predictors of a subsequent spontaneous preterm birth. In the United Kingdom, vaginal progesterone or cervical cerclage are the recommended interventions for preventing spontaneous preterm birth in patients with those 2 predictors, though only 16% of preterm birth clinics in the UK routinely administer vaginal progesterone in this setting. This study used network meta-analysis estimates and compares the effectiveness of vaginal progesterone and cervical cerclage in preventing spontaneous preterm birth in at-risk patients.

Risk Factors of Preterm Birth in Women After Local Treatment of Cervical Intraepithelial Neoplasia - a Retrospective Cohort Study.

Purpose A previous cervical intraepithelial neoplasia is associated with an increased obstetrical risk. It was the aim of the study to identify risk factors of preterm birth in patients with cervical intraepithelial neoplasia in dependence of the treatment modality (excisional vs. ablative). Methods Women with treated cervical intraepithelial neoplasia and subsequent pregnancy (n=155) were included in this retrospective study. Methods of treatment were either conization by large loop excision of the transformation zone (LLETZ) or ablative laser vaporization. Results Of the total population 60.6% (n=94) had a conization and 39.4% (n=61) a laser vaporization alone. The frequency of preterm birth <37 weeks was 9.7% (n=15) without differences between conization and laser (11.7 vs. 6.7%, p=0.407) with an odds ratio (OR) of 1.9 (95% confidence interval [CI] 0.6-6.2). Preterm birth <34 weeks was found in 2.6% (n=4), of which all had a conization (4.3 vs. 0%, p=0.157). Risk factors for preterm birth were repeated cervical intervention (OR 4.7 [95%CI 1.5-14.3]), especially a combination of conization and laser ablation (OR 14.9 [95%CI 4.0-55.6]), age at intervention <30 years (OR 6.0 [95%CI 1.3-27.4]), a history of preterm birth (OR 4.7 [95%CI 1.3-17.6]) and age at delivery <28 years (OR 4.7 [95%CI 1.5-14.3]). Conclusion The large loop excision of the transformation zone as a modern, less invasive ablative treatment did not obviously increase the risk of preterm birth compared to laser vaporization. The most important risk factor for preterm delivery was the need of a repeated intervention, especially at younger age. We assume that the persistence or recurrence of the cervical intraepithelial neoplasia following a high-risk human papillomavirus infection is mainly responsible for the observed effect.

O-058 Obstetric outcomes of twin gestation after In-Vitro Fertilization and Embryo Transfer (IVT-ET) treatment in patients who underwent hysteroscopic septoplasty for subseptate uterus

Abstract Study question Is there an associated increased risk of preterm birth (PTB) in patients who underwent hysteroscopic septoplasty for subseptate uterus (SSU) with twin gestation through IVF-ET? Summary answer This study suggests an increased risk of PTB in patients, who underwent hysteroscopic septoplasty for SSU, and subsequently conceived twins after IVF-ET treatment. What is known already In general, the incidence of PTB is higher after IVF-ET treatment. In addition, Müllerian uterine anomalies, such as unicornuate uterus, are considered risk factors for PTB, even with singleton pregnancy. Furthermore, historical data suggest that some patients with uterine anomaly may have cervical incompetence. Twin gestation is associated with PTB in approximately 50% of cases. It is assumed that the obstetric outcome of twin gestation after successful septoplasty should be no different from those with normal uterine cavity. The impact of previous septoplasty for SSU on the obstetric outcomes of twin gestation after IVF-ET treatment has not been adequately studied. Study design, size, duration This retrospective cohort study included 377 fertility patients who received treatment between 2006-2019. The study group included 162 patients who underwent hysteroscopic septoplasty for SSU and subsequently conceived dichorionic-diamniotic (DI-DI) twins after IVF-ET treatment (Group 1). The control group included 215 patients who had normal endometrial cavity on hysteroscopy (#109) or Transvaginal 3D ultrasound scan with saline sonohysterogram (#106) and subsequently conceived DI-DI twins after IVF-ET treatment (Group 2). Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with an academic hospital. Demographic, clinical, and obstetric outcome data were collected for both groups and compared using appropriate statistical methods. PTB, severe PTB, extreme PTB, and peri-viable birth were defined as &amp;lt; 37 weeks, &amp;lt;32 weeks, &amp;lt;28 weeks and between 20 weeks-25 weeks 6 days gestation respectively. Main results and the role of chance There was no significant difference in mean age, BMI and infertility duration or in the incidence of smoking, primary infertility, tubal factors and unexplained infertility between the two groups. There was significantly lower mean baseline FSH levels (p &amp;lt; 0.01), lower incidence of male infertility (p &amp;lt; 0.001) and higher incidence of ovulatory disorders (p &amp;lt; 0.001) and endometriosis (p &amp;lt; 0.05) in Group 1 compared to Group 2. As expected, there was past history of lower parity rate (p &amp;lt; 0.01) and higher miscarriage rate (p &amp;lt; 0.001) in Group 1 compared to Group 2 prior to septum division. There was significantly higher incidence of PTB (72.8% vs 56.3%, p &amp;lt; 0.01), severe PTB (20.3% vs 8.2%, p &amp;lt; 0.01), extreme PTB (8.3% vs 3.9%, p &amp;lt; 0.05), and peri-viable birth (6.3% vs 1.9%, p &amp;lt; 0.05) in Group 1 compared to Group 2. There was no significant difference in cesarean section rate (82.8% vs 87.5%, p = 0.349) between Group1 and Group 2 respectively. There was significantly lower gestational age at birth in weeks (34.0 + 4.0 vs 35.6 + 3.0, p &amp;lt; 0.001), birth weight of the first newborn (2180.5 + 717.9 vs 2436.4 + 606.6, p &amp;lt; 0.001), and the second newborn (2235.2 + 674.2 vs 2398.0 + 537.9, p &amp;lt; 0.05) in grams in Group 1 compared to Group 2. Limitations, reasons for caution Our study has limitations being retrospective in nature. Data on cervical length measurements via ultrasound, if performed, was not available. However, recall bias was prevented by retrieving data from that submitted to the Society of Assisted Reproductive Technology. Additionally, procedural variation was reduced as this was a single-center study. Wider implications of the findings Our study suggests that twin gestation after IVF-ET in patients who underwent successful hysteroscopic septoplasty for SSU may increase the likelihood of PTB. Such patients may require increased surveillance with ultrasound cervical length and signs for preterm labor. Future research should focus on measures to reduce PTB in such patients. Trial registration number Not Applicable

ОСОБЕННОСТИ ЦИТОКИНОВОГО СТАТУСА ПРИ АКУШЕРСКИХ И ПЕРИНАТАЛЬНЫХ ОСЛОЖНЕНИЯХ У ЖЕНЩИН С ВНУТРИПЕЧЁНОЧНЫМ ХОЛЕСТАЗОМ БЕРЕМЕННЫХ

Background. Intrahepatic cholestasis of pregnancy (COP) is the most common complication of pregnancy that occurs during the 2nd-3rd trimester and is accompanied by liver damage manifested as cholestasis and cytolysis. Objective. To establish the role of cytokine response in the pathogenesis of COP as well as its obstetric and perinatal complications. Material and methods. 87 pregnant women were examined: 57 with intrahepatic cholestasis of pregnancy and 30 patients of the comparison group. The levels of pro-inflammatory (interleukin 6) and anti-inflammatory (interleukin 4) cytokines were determined by enzyme-linked immunosorbent assay, and their prognostic significance as predictors of obstetric and perinatal complications in women with COP was estimated. Results. The course of COP is accompanied by a decrease in the concentrations of IL-6 and IL-4 cytokines and a lower ratio of IL-4/IL-6 (P(U)IL-6=0.041; P(U)IL-4=0.0007 and P(U)IL4/IL-6=0.008). The concentration of IL-6 in blood serum that is &gt; 2.53 pg/ml (Se=83.3 %, Sp=73.9 %; AUC=0.822; 95 % CI 0.636–0.938; p=0.004) and IL-4 concentration that is &gt; 41.99 pg/ml in symptomatic COP (Se=100.0 %, Sp=78.6 %; AUC=0.839; 95 % CI 0.593–0.965; p=0.011) are regarded as a risk factor for preterm labor (PL) in women with COP. The concentration of IL-6 &gt; 3.07 pg/ml in women with COP and negative vaginal discharge culture can be considered as a predictor of meconium staining of amniotic fluid (MSAF) (Se=100.0 %, Sp=62.9 %; AUC=0.770; 95 % CI 0.597–0.895; p=0.024). Conclusions. COP is accompanied by a lower level of IL-6; an atypical immune deviation with no shift towards the Th2 immune response that is characteristic of a normal pregnancy; as well as an imbalance in the cytokine response with a decrease in the anti-inflammatory link. Preterm birth in patients with COP is associated with higher levels of IL-6 during pregnancy. The release of meconium into amniotic fluid in women with COP (in the absence of significant pathogenic and opportunistic microflora according to the results of vaginal discharge culture) correlates with higher concentrations of IL-6 in the blood.

The association between induction of labour in nulliparous women at term and subsequent spontaneous preterm birth: a retrospective cohort study.

To evaluate the rate of subsequent spontaneous preterm birth in patients with previous induction of labour at term compared to women with previous spontaneous labour at term. This was a retrospective cohort study of all women with consecutive births at the Royal Brisbane and Women's Hospital between 2014 and 2018. All nulliparous women with a singleton pregnancy and induction of labour at term or in spontaneous labour at term in the index pregnancy were included. Data was extracted from electronic medical records. The outcome of spontaneous preterm birth in the subsequent pregnancy was compared between patients with previous term induction of labour and in previous term spontaneous labour. A total of 907 patients with consecutive births met the inclusion criteria; of which 269 (29.7%) had a term induction of labour and 638 (70.3%) had a term spontaneous labour in the index pregnancy. The overall subsequent spontaneous preterm birth rate was 2.3%. Nulliparous women who underwent term induction of labour were less likely to have a subsequent preterm birth compared to nulliparous women in term spontaneous labour (0.74 vs. 2.98%; odds ratio [OR], 0.25; 95% confidence interval, 0.06-1.07; p=0.0496) in the index pregnancy. This however was not significant once adjusted for confounders (adjusted OR, 0.29; p=0.10). Spontaneous preterm birth was associated with a previous spontaneous labour compared to induction of labour between 37 to 37+6 and 38 to 38+6 weeks (adjusted OR 0.18 and 0.21; p=0.02 and 0.004 respectively). Term induction of labour does not increase the risk of subsequent spontaneous preterm birth compared to spontaneous labour at term in nulliparous women. Further research is needed to validate these findings in a larger cohort of women and to evaluate the effect of elective IOL among low-risk nulliparous women.

Elevated midtrimester maternal plasma cytokines and preterm birth in patients with cerclage

Cerclage is used for the prevention of spontaneous preterm birth; however, many patients at high risk of spontaneous preterm birth who have a cerclage in place eventually deliver before term. Although inflammation, measured by biomarkers (eg, cytokines), is a known risk factor for preterm delivery, evaluation of inflammation to determine pregnancy outcomes among patients with cerclage is poorly understood. We sought to examine levels of maternal plasma inflammatory cytokines in the midtrimester among asymptomatic patients with a cervical cerclage (placed for any indication, including history, ultrasound, and examination indications) to evaluate the association between cytokine levels and preterm birth. This was a prospective cohort study of singleton, nonanomalous pregnancies who had a cerclage placed at <24 weeks of gestation from 2015 to 2018 at a single tertiary institution. Maternal plasma was collected perioperatively whenever possible. A custom magnetic bead Luminex cytokine assay was used to measure plasma inflammatory cytokine levels from these stored samples. The primary outcome was preterm birth at <37 weeks of gestation. A statistical cut point was calculated for each cytokine level to assess its optimal sensitivity and specificity for spontaneous preterm birth prediction. Patients were classified as having a "high" or "low" result for each cytokine based on this cut point. Receiver operating characteristic curve analysis was performed to estimate sensitivity, specificity, and positive and negative predictive values for spontaneous preterm birth prediction. Cox proportional-hazards regression modeled the association between the number of "high" inflammatory cytokines and gestational age at delivery, adjusting for confounders. Additional analyses were performed on the subgroup of patients with history-indicated cerclage and those with an ultrasound- or examination-indicated cerclage. A total of 43 patients participated in this study: 20 (46.5%) had spontaneous preterm birth (median, 30.9 weeks of gestation; interquartile range, 28.4-35.0). Plasma samples were collected at a median of 0 (interquartile range, -2 to 17) days concerning cerclage placement and a median of 18 (interquartile range, 13-21) weeks of gestation. Based on the statistical cut point for each cytokine level, 7% of patients had zero, 20.9% had 1, 18.6% had 2, 20.9% had 3, and 32.6% had ≥4 "high" cytokine results. Each additional "high" cytokine level was associated with earlier delivery (hazard ratio, 1.51; 95% confidence interval, 1.25-1.81) even after controlling for ultrasound- or examination-indication for cerclage (hazard ratio, 1.73; 95% confidence interval, 0.95-3.15). The presence of ≥4 "high" cytokine levels was 70% sensitive and 74% specific for predicting spontaneous preterm birth (area under the curve, 0.846; 95% confidence interval, 0.728-0.964; positive predictive value, 70%; negative predictive value, 73.9%). Among patients with a cervical cerclage, elevated midtrimester maternal plasma cytokine profiles were associated with subsequent preterm birth and can estimate the probability of preterm birth. Confirmation and refinement of this noninvasive panel may provide insight into improved selection of individuals who may benefit from cerclage placement and investigation of therapeutic strategies to mitigate midpregnancy inflammation.