Previable Delivery Research Articles

Ectopic Pregnancy as Previable Delivery

Abstract Inside and outside of a Christian worldview, bioethicists have discussed ectopic pregnancy at some length as a maternal-fetal vital conflict. Most bioethicists agree that methotrexate and salpingostomy are low-risk, successful interventions for this life-threatening pathology, and are thus beneficent, just, and wholly acceptable. A small cohort of Christian, largely Catholic, bioethicists have reservations about methotrexate and salpingostomy, but cannot resolve their internal disputes about these because of flawed casuistry. This paper aims to settle the issue about whether methotrexate and salpingostomy are acceptable within a Catholic worldview: despite the best arguments in favor of methotrexate as a moral option, it is morally unacceptable, and despite hesitation about salpingostomy related to analogies with previable delivery, it is the optimal procedure for ectopic pregnancy.

Assessment of obstetric characteristics and outcomes associated with pregnancy with Turner syndrome

To assess national-level trends, characteristics, and outcomes of pregnancies with Turner syndrome in the United States. Cross-sectional study. The Healthcare Cost and Utilization Project's National Inpatient Sample. A total of 17,865,495 hospital deliveries from 2016-2020. A diagnosis of Turner syndrome, identified according to the World Health Organization's International Classification of Disease 10th revision code of Q96. Obstetrics outcomes related to Turner syndrome, assessed with inverse probability of treatment weighting cohort and multivariable binary logistic regression modeling. The prevalence of pregnant patients with Turner syndrome was 7.0 per 100,000 deliveries (one in 14,235). The number of hospital deliveries with patients who have a diagnosis of Turner syndrome increased from 5.0 to 11.7 per 100,000 deliveries during the study period (adjusted-odds ratio [aOR] for 2020 vs. 2016; 2.18, 95% confidence interval [CI] 1.83-2.60). Pregnant patients with Turner syndrome were more likely to have a diagnosis of pregestational hypertension (4.8% vs. 2.8%; aOR 1.65; 95% CI 1.26-2.15), uterine anomaly (1.6% vs. 0.4%; aOR, 3.01; 95% CI 1.93-4.69), and prior pregnancy losses (1.6% vs. 0.3%; aOR 4.70; 95% CI 3.01-7.32) compared with those without Turner syndrome. For the index obstetric characteristics, Turner syndrome was associated with an increased risk of intrauterine fetal demise (10.9% vs. 0.7%; aOR 8.40; 95% CI 5.30-13.30), intrauterine growth restriction (8.5% vs. 3.5%; aOR 2.11; 95% CI 1.48-2.99), and placenta accreta spectrum (aOR 3.63; 95% CI 1.20-10.97). For delivery outcome, pregnant patients with Turner syndrome were more likely to undergo cesarean delivery (41.6% vs. 32.3%; aOR 1.53; 95% CI 1.26-1.87). Moreover, the odds of periviable delivery (22-25 weeks: 6.1% vs. 0.4%; aOR 5.88; 95% CI 3.47-9.98) and previable delivery (<22 weeks: 3.3% vs. 0.3%; aOR 2.87; 95% CI 1.45-5.69) were increased compared with those without Turner syndrome. The results of contemporaneous, nationwide assessment in the United States suggest that although pregnancy with Turner syndrome is uncommon this may represent a high-risk group, particularly for intrauterine fetal demise and periviable delivery. Establishing a society-based approach for preconception counseling and antenatal follow-up would be clinically compelling.

Analysis of Characteristics Associated With Pregnancy Duration After Cervical Cerclage Placement in Singleton Gestations [ID: 1378088

INTRODUCTION: Cervical cerclage technique and perioperative interventions vary widely among providers because of lack of evidence to inform management. Our aim was to identify factors independently associated with pregnancy duration in singleton gestations after cerclage placement. METHODS: This was a retrospective cohort analysis from 2008 to 2020 at an academic tertiary care center. Because of the inclusion of one or more pregnancies for ∼37% of the cohort, a linear mixed-effects model was utilized to evaluate the association between various factors and pregnancy duration. Variables with P&lt;.2 on unadjusted analysis were considered for incorporation into a multivariable model. Model fit was assessed using Akaike’s information criterion (AIC). RESULTS: Out of 762 pregnancies, 42% underwent history-indicated, 22% ultrasound-indicated, and 36% physical exam-indicated cerclage placement. Mean gestational age (GA) at delivery was 35.0±5.8 weeks. 22% occurred less than 32 weeks and 7% resulted in previable delivery. Mean duration of pregnancy after cerclage placement was 17.1±7.0 weeks. An 8-covariate multivariable analysis revealed adjusted differences (β) in weeks of GA at delivery (95% CI): nulliparity +1.61 (0.57, 2.64), multiparity with most recent delivery 34 weeks or greater +1.31 (0.53, 2.10), married +0.94 (0.18, 1.70), concomitant progesterone use +1.06 (0.35, 1.76), preoperative cervical dilation 0.5 cm or higher −1.26 (−2.10, −0.41), utilization of Foley balloon for membrane elevation −2.27 (−3.53, −1.01), postoperative cervical length less than 20 mm −6.34, (−7.37, −5.32), and requiring cerclage revision −3.79 (−5.40, −2.18). CONCLUSION: Apart from use of a Foley balloon for membrane elevation and concomitant progesterone, we did not find any modifiable factors associated with pregnancy duration after cervical cerclage placement. However, this information may inform counseling as well as management for those with a postoperative cervical length less than 20 mm.

The Effect of Antibiotics on Latency When Given at the Time of Membrane Rupture Prior to Viability [ID: 1357946

INTRODUCTION: Antibiotics administered when membranes rupture (ROM) after viability increase latency to delivery. This may also be true in previable prelabor preterm rupture of membranes (pPPROM). This study assesses the effect of prophylactic antibiotics on latency in individuals with pPPROM. METHODS: Retrospective cohort of pregnancies with pPPROM less than 23 weeks 0 days in a single health system (2013–2022). Patients opting for termination or with contraindication to expectant management were excluded. Prophylactic antibiotic administration (48 hours IV azithromycin/ampicillin followed by 5 days oral amoxicillin) was at clinician discretion. The primary outcome was latency (weeks) from diagnosed pPPROM to delivery. Secondary outcomes included maternal and neonatal morbidity and mortality. Bivariate statistics compared patients who did and did not receive antibiotics. Kaplan-Meier/Cox proportional hazards ratio using significant covariates (P&lt;.1) in bivariate analysis models antibiotic effect on latency. RESULTS: Ninety-three patients had pPPROM; 46 (49%) met inclusion criteria. Thirty-four (74%) received prophylactic antibiotics. Median gestational age (GA) at ROM trended later among those who received antibiotics (22.0 weeks [20.6, 22.4] versus 20.9 weeks [19.6, 21.7], P=.09). Median latency (interquartile range) did not differ with antibiotic receipt (1 week [0.4, 2.6] versus 0.6 weeks [0.3, 0.9], P=.27). When adjusted for GA at ROM, antibiotics were not associated with longer latency (hazard ratio 1.33 [0.91, 1.93]). Antibiotic receipt was associated with lower rates of previable delivery (23.0 weeks [22.7, 24.0] versus 21.3 weeks [20.5, 23.1], P=.006). After controlling for GA at ROM, adjusted odds of previable delivery remained lower with receipt of antibiotics (adjusted odds ratio 0.20 [0.04, 0.90]). CONCLUSION: Antibiotics at the time of pPPROM were not associated with longer latency but, after controlling for confounders, did increase the odds of delivering after viability. Further study should address optimal antibiotics strategies for this unique population.

Characteristics associated with previable delivery and/or delivery

To identify socio-demographic, clinical and sonographic predictors of cerclage failure, defined as previable delivery or delivery < 21 days after transvaginal cervical cerclage placement, among women with singleton gestations.

Is interpreter use an independent risk factor for small for gestational age infants?

Limited English proficiency (LEP) is associated with worse health outcomes regardless of health literacy. Prior research suggests that using interpreter services for LEP helps to mitigate the language barrier, and is associated with improved health outcomes and patient satisfaction; however, this is not well studied in obstetric and neonatal outcomes. We performed a retrospective cohort study at a single center between 1/1/2016 and 12/31/2021; we included singleton, live births ≥21 weeks gestation. We excluded multiple gestations, intrauterine fetal demise, and previable delivery. The primary outcome was rate of small for gestational age (SGA). SGA was defined as birthweight < 10th percentile for gestational age using the 2018 Fenton newborn growth curve. Multivariate logistic regression was performed to control for confounding variables. Of the 26,260 patients included in the study, 71.3% were White, 9.5% were Hispanic/Latino, and 7.9% were Black. Overall, 1,662 (6.3%) patients required or preferred an interpreter. Over half (58.0%) of patients requesting interpreter services were Hispanic. In unadjusted analysis, the rate of SGA was not different between patients who used interpreter services (n = 106, 6.4%) and those who did not (n = 1612, 6.6 %), p = 0.779. After adjusting for race, age, gravidity, gestational age, private insurance, diabetes, hypertension, and pre-pregnancy BMI, the use of interpreter services was associated with decreased odds of SGA (aOR 0.67, 95% CI 0.53 – 0.84). Our findings suggest that use of an interpreter is protective for SGA when controlling for other socioeconomic factors. Additional research is required to explore this association, but our results indicate that recognizing demographic risk factors and providing patients with social resources such as access to interpreter services positively impacts obstetric and neonatal outcomes.

693 Transabdominal cerclage vs. vaginal cerclage: a cost-effectiveness analysis

Patients with recurrent pregnancy loss due to cervical insufficiency often receive a vaginal cerclage (VC). The MAVRIC trial demonstrated the superior efficacy of transabdominal cerclage (TAC) compared with VC for those with a history of a prior failed VC. However, the TAC is costly and may have other complications. In this study, we evaluated the cost-effectiveness of performing TAC versus VC for patients with a history of VC failure. We used TreeAge to construct a decision-analytic model to compare patient outcomes between those who received a TAC to those who received VC. Our theoretical cohort contained 20,000 patients, the approximate number of pregnancies with prior VC failure per year in the US. We assumed that all patients with TAC undergo cesarean delivery. Outcomes were wound infection in TAC, cesarean delivery, previable delivery, stillbirth, neonatal death, maternal mortality, and cerebral palsy. We derived all values from literature including MAVRIC for cerclage outcomes and discounted QALYs at a rate of 3%. To further assess our model, we performed univariate sensitivity analyses. In our theoretical cohort, TAC was associated with a decrease in 3,363 previable deliveries, 261 neonatal deaths, and 236 cases of cerebral palsy. However, TAC was associated with an additional 11,656 cesarean deliveries, 1 maternal mortality, and 870 wound infections (Table 1). TAC was a cost-effective strategy as it resulted in increased QALYs (despite increased costs) and an incremental cost-effectiveness ratio (ICER) of $3,007/QALY. Sensitivity analyses demonstrated that TAC was cost-effective over a wide range of the probabilities for cesarean delivery, neonatal death, and previable delivery. In this study, TAC was a cost-effective strategy to prevent previable deliveries and improve neonatal outcomes, but required additional cesarean deliveries and increased costs. We found that TAC is a cost-effective strategy and may be considered for patients with a history of VC failure.

Previable Induction of Labor for Life-Threatening Maternal Disease without Placental Pathology

Pregnancy causes maternal pathology by combining maternal predispositions with healthy physiology. In maternal cardiovascular collapse, previable induction of labor is justifiable despite the definition of abortion in directive 45 of the Ethical and Religious Directives for Catholic Health Care Services. Central to this conclusion, the placenta is a fetal organ, and pregnancy is a cardiovascular condition placing new demands on the maternal cardiovascular system. Previable delivery, a morally neutral separation, addresses the cause of pathology even if fetal death is anticipated. This is acceptable under double-effect reasoning. Directive 45 defines all previable deliveries as abortions, so this analysis proposes an alternative definition established by obstetrician/gynecologists.

CERVICAL CERCLAGE FOR PREVENTION OF PRETERM DELIVERY IN WOMEN WITH CONGENITAL UTERINE ANOMALIES: A CASE SERIES

To characterize a population of women with congenital uterine anomalies (CUA) and cervical cerclage placement, and to evaluate the subsequent incidence of preterm delivery (PTD). Case Series Subjects were identified from an existing database including women with CUAs and a singleton, non-anomalous gestation with delivery from 2013-2018 at a single tertiary care center. Inclusion criteria included women with a CUA (arcuate, septate, unicornuate, bicornuate, or uterine didelphys) and placement of cervical cerclage for any indication. Women with multiple gestations and fetal anomalies were excluded. Out of 100 women in the database, seven met inclusion criteria; four bicornuate, one unicornuate, one septate, and one didelphys. Five underwent history indicated cerclage placement, one ultrasound indicated, and one exam indicated (Table). Cerclage was placed at a median gestational age of 14w0d (range: 12w0d to 19w2d). Three women experienced a previable delivery with stillbirth or neonatal demise at a median gestational age of 21w1d. Among those delivering beyond viability, the median gestational age at delivery was 32w4d. Of women with history indicated cerclage, 3 of 5 delivered viable infants, as did the patient with the ultrasound indicated cerclage. Delivery complications included chorioamnionitis (n=1) and placental abruption (n=1). No cases of postpartum hemorrhage, endometritis, or need for maternal admission to the intensive care unit were noted. The median birth weight of the four living infants was 1888g (range: 1320 to 2385g) with a median hospital length of stay of 26 days (range: 2-56). One infant suffered from retinopathy of prematurity, while no neonates had intraventricular hemorrhage, neonatal sepsis, or necrotizing enterocolitis. There is limited data available regarding the utility of cerclage placement in women with CUAs to prevent PTD. However, in this small case series, more than half of women experienced birth of a viable neonate who survived to hospital discharge following cerclage placement. Further research is needed to support the benefit of cerclage in women with CUAs.Tabled 1CUA TypeCerclage IndicationGA at Prior PTDGA at CerclageShort CervixGA at DeliveryBirth Weight (g)Neonatal Outcome#1BicornuateHistory24w0d18w0dNo22w5d400Neonatal Demise#2BicornuateHistory18w3d14w0dNo29w3d1320Living#3BicornuateHistory24w0d12w0dNo37w1d2385Living#4BicornuateExam-indicatedN/A18w0dYes19w4d260Stillbirth#5UnicornuateHistory22w5d12w2dNo34w3d2375Living#6SeptateHistory16w1d13w2dYes20w0dUnknownStillbirth#7DidelphysUltrasound25w0d19w2dYes30w5d1400Living Open table in a new tab

Opioid Maintenance Therapy (OMT) Outcomes on Maternal Weight Gain [24E

INTRODUCTION: The Institute of Medicine's (IOM) guidelines provide recommendations for appropriate gestational weight gain based solely on pre-pregnancy body mass index (BMI). Opioid use disorders (OUD) are known risk factors for poor nutrition and inadequate weight gain. We sought to compare methadone vs buprenorphine OMT effects on obtaining appropriate maternal weight gain. METHODS: We conducted an IRB approved retrospective cohort study using electronic medical records from an academic center between 2007 and 2017. Inclusion criteria: women with a singleton pregnancy receiving OMT with either methadone or buprenorphine. Exclusion criteria: women with a pre-viable delivery, multiple gestation pregnancy, or anomalous fetus incompatible with life. We compared both OMT groups for differences in insufficient, appropriate, or excessive weight gain based upon IOM's guidelines. P-value &lt;.05 was considered significant. RESULTS: 181 pregnancies were analyzed. 51% (n=93) received buprenorphine and 49% (n=88) received methadone. Patients in the methadone arm were more likely to be prescribed medications at a methadone/pain clinic vs OB provider (P&lt;.05). Baseline demographics for both groups were similar in age, parity, race and BMI. There were no statistically significant differences in inadequate, appropriate, or excessive weight gain between the 2 groups (P=.47). Additionally, there were no statistical differences between the groups regarding recommended weight gain, regardless of BMI (P=.53). CONCLUSION: The findings amongst our cohorts revealed there is no superiority of either OMT selection to achieve the recommended weight gain in pregnancy. This data illustrates that the decision to select the optimal OMT should be guided by other factors than achieving the ideal weight gain.

Factors Associated with Previable Delivery following Second Trimester Rupture of Membranes

Factors Associated with Previable Delivery following Second Trimester Rupture of Membranes

Factors Associated with Previable Delivery following Second Trimester Rupture of Membranes

To identify factors associated with previable delivery in second trimester preterm rupture of membranes (PROM). We conducted a single-center retrospective cohort study of women with pregnancies complicated by second trimester PROM (14.0-21.9 weeks' gestation) from 2000 to 2015 who elected expectant pregnancy management and achieved at least 24 hours latency. Maternal characteristics and clinical factors were compared among pregnancies that reached viability (≥ 23.0 weeks) and pregnancies delivered before viability (< 23.0 weeks) using appropriate statistical methods. Of 73 pregnancies complicated by second trimester PROM, 49 (67%) delivered before viability. Maternal race, history of preterm birth, and tobacco use were similar between women who delivered < 23 weeks versus ≥ 23 weeks. Gestational age at PROM, cervical dilation > 1cm, Group B streptococcus carrier status, bacterial vaginosis, and chlamydial infection during pregnancy were similar between groups. Median time to delivery was significantly shorter in women who delivered < 23 weeks compared with those who reached ≥ 23 weeks (6 vs. 46 days, p < 0.01). Previable delivery occurred in the majority of women with second trimester PROM. No maternal or clinical factors were associated with delivery prior to viability. Counseling women with second trimester PROM should include the inability to determine which pregnancies will reach viability.

P17.04: Factors for prevention of previable delivery following rescue cerclage

To evaluate factors associated with previable delivery after cerclage in women protruding amniotic membrane. The retrospective cohort study was conducted in 55 women with protruding amniotic membrane whom underwent McDonald cerclage and were delivered by a single surgeon between January 2006 and June 2017. They were grouped based on 24+0 weeks gestation at delivery. We compared clinical characteristics and association factors affected previable delivery after recue cerclage. Twenty women delivered before 24+0 weeks gestation and 35 women delivered at or after 24weeks gestation. Gestational age at cerclage was earlier (20.4 versus 22.7 weeks, p=0.003) and latency period after cerclage (0.9 versus 10.2 weeks, p<0.001) was shorter in delivered before 24 weeks. Postoperative white blood cell (12755 versus 10230, p=0.006) and C-reactive protein (1.8 vs. 1.4, p=0.049) were elevated and cerclage height, length from cerclage stitch to internal os, was shorter (0.7 versus 1.3cm, p=0.005) while cervical length after cerclage was not differ significantly in delivered before 24 weeks. (1.4 versus 2.2cm, p=0.058). After adjusting for confounding factors, cerclage height (OR 4.116; 95% CI: 1.078-15.711) and gestational age at cerclage (OR 1.545; 95% CI: 1.120-2.131) were associated with a higher likelihood whereas postoperative C-reactive protein level was reduced likelihood (OR 0.620; 95% CI: 0.391-0.982) of reaching at least 24 weeks gestation. Longer cervical height increases prolongation of pregnancy at least until 24 weeks significantly. Elevated postoperative C-reactive protein and earlier diagnosed bulging amniotic membrane are associated with previable birth. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Outcomes in Oligohydramnios: The Role of Etiology in Predicting Pulmonary Morbidity/Mortality [28R

INTRODUCTION: Early-onset oligohydramnios is most commonly secondary to renal-urinary anomalies (RUA) or preterm premature rupture of membranes (PPROM). We compared pulmonary outcomes between these etiologies. METHODS: A single tertiary care center's ultrasound database was searched for women with decreased amniotic fluid before 24 weeks gestation due to either PPROM or suspected RUA. Patients were excluded if they delivered elsewhere or if there were other major congenital anomalies or aneuploidy. Obstetrical/neonatal outcomes were recorded. Respiratory morbidity was assessed by need for oxygen at 36 corrected weeks or at hospital discharge if this occurred prior to 36 corrected weeks, or respiratory cause of neonatal death. RESULTS: 118 identified patients included 56 with oligohydramnios secondary to PPROM and 62 with RUA. 54 women elected to terminate their pregnancies. 36.4% of PPROM and 35.0% of RUA pregnancies that remained experienced an IUFD or pre-viable delivery (n=16/44 vs.7/20; χ2=6.23e-32, p=1.00). 18.2% of the PPROM pregnancies (n=8/44) resulted in neonatal respiratory mortality, as opposed to 40.0% (n=8/20) of the RA pregnancies (χ2=2.42, p=0.12). 25.0% of prior PPROM infants required oxygen at 36 weeks/discharge (n=11/44), while 10.0% of the RUA infants did (n=2/20; χ2=2.00, p=0.25). The collective incidence of respiratory morbidity/mortality was not different between etiologies (χ2=0.06, p=0.81). CONCLUSION: This analysis suggests that the prognoses for oligohydramnios due to pre-viable PPROM vs. ultrasound-identified renal anomalies are similarly grave. The trend towards increased respiratory mortality in neonates with RUA warrants further investigation.

40: Antibiotic use in previable delivery

40: Antibiotic use in previable delivery

Short cervical length after history-indicated cerclage: Is a reinforcing cerclage beneficial?

The purpose of this study was to determine if a reinforcing cerclage improves outcome in women with a history-indicated cerclage who develop a short cervix on ultrasound. The management of women with a history-indicated transvaginal cerclage who subsequently developed a short cervix (< or = 25 mm) on transvaginal ultrasound before 24 weeks was retrospectively reviewed. Exposed subjects that received a reinforcing cerclage were compared with similar unexposed subjects that were followed with expectant management. The primary outcome was preterm delivery <35 weeks. Twenty-four eligible women were identified, of which 5 received a reinforcing cerclage and 19 were managed expectantly. There was no difference in patient demographics and risk factors between the exposed and unexposed groups. Reinforcing cerclage was associated with a significantly earlier gestational age at delivery (20.8 vs 32.9 weeks, P = .002) as well as higher rates of both preterm delivery <35 weeks (100% vs 32%, P = .01) and previable delivery <24 weeks (80% vs 16%, P = .01). In pregnancies with a history-indicated cerclage and subsequently diagnosed ultrasound cervical shortening before 24 weeks, placement of a reinforcing cerclage is associated with earlier delivery than expectant management.

Natural History of Twin Gestation Complicated by in utero Fetal Demise: Associations of Chorionicity, Prematurity, and Maternal Morbidity

Objectives: To evaluate the pathophysiology by which the in utero death of 1 twin might increase morbidity to its co-twin survivor and its mother. To assess previously reported risks for maternal disseminated intravascular coagulopathy, peripartal hemorrhage, retained placenta and infection, as well as the fetal risk of prematurity. Material and Methods: A retrospective analysis of the natural history of twin pregnancies from three institutions was performed. A total of 1,989 cases of twin pregnancy were identified, Wayne State University included 1,266 cases from 1984 to 1993; Madigan Army Medical Center 136 cases, 1995–2000, and Rockford Regional Perinatal Center, 587 cases, 1990–2000. The findings were classified by the presence or absence of fetal death in utero (IUFD) as follows: both IUFD (0/0); 1 IUFD (0/+), and both live born (+/+). A case-control study was performed on the subgroup of patients for whom complete records as to chorionicity, etc., were available. Results: Of the 1,989 cases reviewed there were 49 both IUFD (0/0), 61 complicated by 1 IUFD (0/+), and 1,879 with both live born (+/+). The overall fetal death rate for this twin cohort was 55/1,000. IUFD of 1 or both twins was related to an increased risk of previable delivery 55% in 0/0, and 28% in 0/+ versus 4% for +/+ with p < 0.001. IUFD also was associated with early preterm delivery (mean gestational age at delivery of 23 (0/0) and 30 (0/+) versus 35 (+/+) weeks). Chorionicity as well as maternal risks were examined in the case-control study (24 (0/0), 43 (0/+), 134 (+/+)) with the following results: monochorionic placentation was more likely in pregnancies complicated by IUFD (54% (0/0), 51% (0/+) versus 14% (+/+); p < 0.001). Retained placenta, requiring dilation and curettage, occurred more frequently when both twins died in utero, but may be related to the earlier gestational age at delivery. Discussion: Independent of retained placenta, there is no difference in the maternal risks for hemorrhage, abruption, coagulopathy or infection between groups. Immaturity at delivery and monochorionicity are more common in pregnancies complicated by fetal demise. Neonatal morbidity and developmental outcome will be the focus of a longitudinal study comparing cotwin survivors to twins matched for chorionicity and gestational age at delivery.

Non-viable delivery at 20–23 weeks gestation: observations and signs of life after birth

Objective: To describe the outcome of labour, signs of life at birth, and duration of survival after delivery at 20–23 weeks gestation. Design: An observational study using data from the...

Current controversies in cervical cerclage

Cervical incompetence is defined as the inability to support a full-term pregnancy because of a functional or structural defect of the cervix. It is characterized clinically by acute, painless dilatation of the cervix usually in the mid-trimester culminating in prolapse and/or premature rupture of the membranes with resultant preterm and often previable delivery. Cervical cerclage has become the mainstay for the management of cervical incompetence, but remains one the more controversial surgical interventions in obstetrics. This article reviews the current state of the literature as regards the indications, contraindications, and techniques of cervical cerclage. This article also focuses in detail on 4 areas of controversy, namely transabdominal cerclage, cervical cerclage for a short cervix, the management of cerclage after preterm premature rupture of the membranes, and the utility of a second (salvage) cerclage.

Evaluation of 239 cases of perinatal death using a fundamental classification system

Objective: To classify 239 cases of perinatal death in a newly introduced classification system for underlying causes of perinatal death. Design: Prospective, descriptive. Setting: Dutch healthcare region Delft–Westland–Oostland (DWO). Materials and methods: In 10 years (1983–1992), all cases of perinatal death with a birthweight above 500 g ( n=239) were included into the study. We used a classification model based upon the underlying cause of death using simple principles of obstetrical and neonatal pathology. A team consisting of a gynaecologist, neonatologist and pathologist classified all cases of perinatal death into seven groups to determine the “most-probable” cause of death. Results: Birth trauma was seen in two cases (0.8%). Infections were seen in 16 cases (6.8%). Acute/subacute placental pathology in 77 cases (32.2%) and chronic placental pathology in 50 cases (21%). Bloodtype antagonism was seen in two cases (0.8%). Lethal congenital malformations in 55 cases (23%). Complications of pre-viable delivery in 20 cases (8.4%). Unclassifiable were 17 cases (7%): two cases could not be classified despite thorough investigation (1%) and 15 cases were lost for follow-up (6%). Conclusions: Classification of perinatal death causes by using our fundamental classification system gives insight in the possible underlying causes of death. The results of such a classification can be used as guidelines for preventive measures in the future.