Short Cervical Length Research Articles

Prolonged progesterone administration is associated with less frequent cervicovaginal colonization by Ureaplasma urealyticum during pregnancy — Results of a pilot study

BackgroundPreterm birth is a leading cause of perinatal mortality and morbidity. Heavy cervicovaginal Ureaplasma colonization is thought to play a role in the pathogenesis of preterm birth. The administration of vaginal progesterone has been shown to reduce the incidence of preterm birth in women with short cervical length. Steroid hormones seem to modulate the presence of microorganisms in the vagina. The aim of this study was to assess whether the treatment with vaginal progesterone could reduce the incidence of preterm birth and cervicovaginal colonization by Ureaplasma urealyticum in a cohort of pregnant women with threatened preterm labor. MethodsA cohort of 63 females who presented with regular contractions and/or short cervical length between 24–32 weeks of gestation were recruited into a prospective study. 70% of patients had been treated with vaginal progesterone prior to recruitment and these patients continued with the treatment until birth. All patients were tested for the presence of cervicovaginal Ureaplasma urealyticum colonization at admission. The primary endpoint was preterm birth before 37 weeks. ResultsThe incidence of preterm delivery was significantly increased in patients who tested positive for Ureaplasma urealyticum. Prolonged vaginal progesterone administration was associated with less frequent cervicovaginal colonization by U. urealyticum. Cervicovaginal colonization by U. urealyticum and absence of progesterone treatment were identified as two independent risk factors for preterm delivery. ConclusionsOur results demonstrate the beneficial effects of progesterone administration in reducing the incidence of cervicovaginal colonization by Ureaplasma urealyticum.

Prior Uterine Evacuation and Risk of Short Cervix and Spontaneous Preterm Birth [24D

INTRODUCTION: Prior pregnancy termination has been associated with an increased risk of spontaneous preterm birth (sPTB). However there is little data on the association between prior uterine dilation and evacuation (D&E) and the risk of a short second trimester cervical length (CL) and subsequent sPTB in otherwise low risk women. METHODS: Retrospective cohort of singletons with no prior sPTB who underwent CL screening between 18 0/7–23 6/7 weeks from 1/2012–3/2014. Demographic, obstetric, and delivery outcome data were collected. Risk for short CL (≤20 mm) in women with and without a prior D&E were compared with odds ratio adjusted (aOR) for confounders. Among women with a short CL, the risk of sPTB for those with and without a prior D&E was also assessed. RESULTS: 2215 women were included, of those 26 (1.2%) women with a short CL and 596 (27%) had a prior D&E. Women with a short CL were more likely to be African American (69% vs 49%, P=.029). Women with a prior D&E were more likely to have a short CL (2.2% vs 0.7%, P<.01, aOR 2.8 [1.21–6.62]). Women with a short CL and prior D&E were more likely to have a sPTB (85% vs 40%, P=.039; aOR 23.9 [1.05–543.7]) than those with a short CL and no prior D&E. CONCLUSION: Women with prior D&E are at increased risk of a short CL. Furthermore, with a short CL they are at significantly higher risk of sPTB than those with a short CL without prior D&E.

High Maternal BMI Associated With Cervical Shortening in Women With Short Cervix on Second Trimester Anatomy Scan [27K

INTRODUCTION: Identify variables associated with cervical length (CL) changes in women with a short CL at time of second trimester anatomy scan. METHODS: Retrospective analysis of patients diagnosed with short CL at time of routine anatomy scan, between 16–26 weeks from October, 2012–June, 2015. Short CL was defined as <25 mm in high risk (HR) or <20 mm in low risk (LR) patients. Patients with history of spontaneous preterm delivery or 1+ 2nd trimester spontaneous abortions defined as HR. Change in CL calculated using difference between initial CL and subsequent measurement. Regression analysis performed with stepwise selection of variables, to assess for variables that are predictive of cervical change. RESULTS: 404 (4.6%)/8,732 scanned found to have short CL. Data incomplete for 208 were excluded from the analysis. Mean maternal age 28.7 and mean gestational age at diagnosis 21w1d. Mean Body Mass Index (BMI) 29.7 kg/m2 (14–57) and mean pregnancy weight gain 19.6 lbs (0–54). 25% were HR and 75% LR. The most common interventions were vaginal progesterone (38%) and cerclage (16%), with 40% expectant. Mean change in CL for this cohort between both scans was a decrease by 14 mm. Using regression analysis, BMI was predictive of CL shortening (P=.052). For every 10 BMI points, the cervix shortened by 1.8 mm. CONCLUSION: In this cohort of patients with short CL identified at time of routine anatomy scan, the BMI was predictive of further CL shortening. These results may imply a need for closer CL surveillance in patients with higher BMI who are found to have a short CL.

The safety of progestogen in the prevention of preterm birth: meta-analysis of neonatal mortality.

The safety of preventive progestogen therapy for preterm birth remains to be established. This meta-analysis aimed to evaluate the effects of preventive progestogen therapy on neonatal mortality. Randomized controlled trials (RCTs) on the preventive use of progestogen therapy, published between October 1971 and November 2015, were identified by searching MEDLINE/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Library databases, CINAHL, POPLINE, and LILACS using "progesterone" and "preterm birth" as key terms. We conducted separate analyses according to the type of progestogen administered and plurality of the pregnancy. Twenty-two RCTs provided data on 11,188 neonates. Preventive progestogen treatment in women with a history of preterm birth or short cervical length was not associated with increased risk of neonatal death compared to placebo in all analyzed progestogen types and pregnancy conditions. The pooled relative risks (95% confidence interval) of neonatal mortality were 0.69 (0.31-1.54) for vaginal progestogen in singleton pregnancies, 0.6 (0.33-1.09) for intramuscular progestogen in singleton pregnancies, 0.96 (0.51-1.8) for vaginal progestogen in multiple pregnancies, and 0.96 (0.49-1.9) for intramuscular progestogen in multiple pregnancies. The results of this meta-analysis suggest that administration of preventive progestogen treatment to women at risk for preterm birth does not appear to negatively affect neonatal mortality in single or multiple pregnancies regardless of the route of administration.

Progesterone Therapy for the Prevention of Preterm Labor in Women with Single Risk-factor: A Systematic Review and Meta-analysis

Background: Preterm labor is a common complication of pregnancy which has become a main health concern around the world due to its negative consequences. Objective: To investigate the efficacy of progesterone therapy in the prevention of preterm labor in women with single risk factor. Search strategy: A PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Science Direct, Scopus, OVID, EMBASE, SID, Magiran and Google Scholar search (date last searched April 2016) without any time, language and location restriction was done. Inclusion criteria: All randomized clinical trials of singleton pregnancies with single risk factor (prior preterm labor without short cervical length or short cervical length without prior preterm labor) which were randomized to progesterone and control groups were included in our meta-analysis. Primary outcome: Our primary outcome was gestational age at delivery. Results: 13 studies (1259 subjects and 2653 control women) were included in the meta-analysis. Using random effect model showed that mean gestational age at delivery of progesterone group is 0.74 (0.41-1.06) month longer than that of control group with CI=95% which is significant statically. Conclusions: Progesterone therapy is an effective intervention for the prevention of preterm labor in women with single risk factor.

A comparison of cervical length measurement techniques for the prediction of spontaneous preterm birth

Objective: To evaluate the clinical utility of a novel means of assessing the cervix by measuring the angle of the curvature and to evaluate the performance of this technique as well as two other commonly used techniques of cervical length assessment in predicting spontaneous preterm birth (SPTB).Methods: This was a retrospective cohort analysis of singleton gestations with a history of SPTB. Transvaginal ultrasound images of cervical length obtained between 20 and 23 6/7 weeks were re-measured using three techniques: (1) straight linear distance between the internal and external os, (2) sum of two contiguous linear segments tracing the internal to the external os, and (3) measurement of the angle of the curve within the cervix using an electronic protractor. A short cervical length was defined as ≤25 mm.Results: A total of 181 women were included. The relative risk (RR) for SPTB by cervical angle ≤160° was 1.2 (95% CI 0.7–2.0) and the ROC curve revealed an area under the curve of 0.54 (95% CI 0.44–0.63). The RR for SPTB by short cervical length measured by the straight technique was 2.3 (95% CI 1.3–4.0) and by the segmental technique 2.1 (95% CI 1.2–3.8). There was a 99.4% agreement between the two techniques with an intraclass Kappa coefficient of 0.96.Conclusions: In women with a history of SPTB, cervical angle measurement does not correlate with the risk of SPTB. Cervical length measured via straight and segmental techniques had excellent agreement in identifying short cervix, and both identified a short cervix predictive of SPTB.

The use of cervical sonography to differentiate true from false labor in term patients presenting for labor check

Cervical length by transvaginal ultrasound to predict preterm labor is widely used in clinical practice. Virtually no data exist on cervical length measurement to differentiate true from false labor in term patients who present for labor check. False-positive diagnosis of true labor at term may lead to unnecessary hospital admissions, obstetrical interventions, resource utilization, and cost. We sought to determine if cervical length by transvaginal ultrasound can differentiate true from false labor in term patients presenting for labor check. This is a prospective observational study of women presenting to labor and delivery with labor symptoms at 37-42 weeks, singleton cephalic gestation, regular uterine contractions (≥4/20 min), intact membranes, and cervix ≤4 cm dilated and ≤80% effaced. Those patients with placenta previa and indications for immediate delivery were excluded. The shortest best cervical length of 3 collected images was used for analysis. Providers managing labor were blinded to the cervical length. True labor was defined as spontaneous rupture of membranes or spontaneous cervical dilation ≥4 cm and ≥80% effaced within 24 hours of cervical length measurement. In the absence of these outcomes, labor status was determined as false labor. Receiver operating characteristic curves were generated to assess the predictive ability of cervical length to differentiate true from false labor and were analyzed separately for primiparous and multiparous patients. The diagnostic accuracies of various cervical length cutoffs were determined. The relationship of cervical length and time to delivery was also analyzed including both use and nonuse of oxytocin. In all, 77 patients were included in the study; the prevalence of true labor was 58.4% (45/77). Patients who were in true labor had shorter cervical length as compared to those in false labor: median 1.3 cm (range 0.5-4.1) vs 2.4 cm (range 1.0-5.0), respectively (P < .001). The area under the receiver operating characteristic curve for primiparous patients was 0.88 (P < .001) and for multiparous patients was 0.76 (P < .01), both demonstrating good correlation. The area under the receiver operating characteristic curves were not significantly different between primiparous and multiparous (P= .23). The area under the receiver operating characteristic curve for primiparous and multiparous patients combined was 0.8 (P < .0001), indicating a good overall correlation between cervical length and its ability to differentiate true from false labor. Overall, a cervical length cutoff of ≤1.5 cm to predict true labor had the highest specificity (81%), positive predictive value (83%), and positive likelihood ratio (4.2). There were no differences in cervical length prediction between primiparous and multiparous patients. Cervical length was positively correlated with time to delivery, regardless of the use of oxytocin. In differentiating true from false labor in term patients who present for labor check, a cervical length of ≤1.5 cm was the most clinically optimal cutoff with the lowest false positive rate-due to its highest specificity-and highest positive predictive value and positive likelihood ratios. Its use to decide admission in patients at term with labor symptoms may prevent unnecessary admissions, obstetrical interventions, resource utilization, and cost.

The greater risk of preterm birth in triplets is mirrored by a more rapid cervical shortening along gestation

The risk of preterm birth increases with plurality. However, data are limited about the role of cervical length in triplet pregnancies and how the greater predisposition for preterm birth in triplet pregnancies, compared with twin pregnancies, is reflected by cervical length. Specifically, it is unclear whether the greater predisposition of triplet pregnancies for preterm birth is reflected by a more rapid cervical shortening during gestation compared with twin pregnancies (and therefore a shorter cervical length at any given gestational age), by a greater risk for preterm birth per given cervical length at any given gestational age, or both. The purpose of the study was to compare the rate of cervical shortening during gestation and the correlation between cervical length and gestational age at birth in asymptomatic women with triplet vs twin pregnancies. This was a retrospective study of women with triplet or twin pregnancies who were who were observed in a tertiary center who underwent serial sonographic measurement of cervical length from 16-32 weeks gestation. Change in cervical length during gestation and relationship of cervical length with gestational age at birth were compared between the triplets and twins groups. A total of 431 measurements of cervical length from 86women with triplets was analyzed and compared with 2826 measurements of cervical length from 441 women with twins. The rate of cervical shortening among triplet pregnancies was higher than among twin pregnancies starting from 18 weeks of gestation (slope of regression line, -1.297 vs -0.907; P < .001). Similarly, the proportion of women with cervical length of <25 mm or 15 mm was higher among triplet pregnancies than among twin pregnancies (34.0% vs 21.0% [P < .001] and 16.7% vs 8.4% [P = .001]), respectively. For any given cervical length measured after 22 weeks of gestation, the associated gestational length at birth in triplet pregnancies was lower by 2.7 weeks on average compared with twin pregnancies (P < .001). The higher rate of preterm birth in triplet pregnancies, compared with twin pregnancies, is reflected by both a more rapid cervical shortening during gestation and a lower gestational age at birth per any given cervical length.

Fetal fibronectin, cervical length, and the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage

Objective: The objective of this study is to estimate the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage based on the results of fetal fibronectin (fFN) and cervical length (CL) screening.Methods: Retrospective cohort of patients with a singleton pregnancy and an ultrasound or physical exam indicated Shirodkar cerclage placed by one maternal–fetal medicine practice from November 2005 to January 2015. Patients routinely underwent serial CL and fFN testing from 22 to 32 weeks. Based on ROC curve analysis, a short CL was defined as ≤15 mm. All fFN and CL results included are from after the cerclage placement.Results: One hundred and four patients were included. Seventy eight (75%) patients had an ultrasound-indicated cerclage and 26 (25%) patients had a physical exam-indicated cerclage. A positive fFN was associate with preterm birth <32 weeks (15.6% versus 4.2%, p = 0.043), <35 weeks (37.5% versus 11.1%, p = 0.002), <37 weeks (65.6% versus 20.8%, p < 0.001), and earlier gestational ages at delivery (35.2 ± 3.9 versus 37.4 ± 2.9, p = 0.001). A short CL was also associated with preterm birth <35 weeks (50.0% versus 11.9%, p < 0.01), preterm birth <37 weeks (55.0% versus 29.8%, p = 0.033), and earlier gestational ages at delivery (34.8 ± 4.1 versus 37.2 ± 3.0, p = 0.004). The risk of preterm birth <32, <35, and <37 weeks increased significantly with the number of abnormal markers.Conclusion: In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short CL are both associated with preterm birth. The risk of preterm birth increases with the number of abnormal biomarkers.

Assessment of a cervicometer compared to transvaginal ultrasound in identifying women with a short cervical length: a multicenter study

Preterm birth remains a major cause of neonatal morbidity and mortality worldwide. Short cervical length (CL) as measured by transvaginal ultrasound (TVU) in the second trimester represents the single most predictive risk factor for spontaneous preterm birth. Previous studies have addressed, in part, the limitations of TVU availability by utilizing a cervicometer to screen patients for short cervix, identifying those patients who may not benefit from TVU CL screening. In view of the prior studies indicating that a cervicometer measurement may have a high negative predictive value (NPV) for a sonographically short cervix, we sought to identify the ideal cervicometer threshold value in a prospective, multicenter study. The primary objective was to determine the cervicometer CL measurement threshold that provides a high NPV for the identification of patients who are highly unlikely to have a TVU CL measurement ≤20 and ≤25 mm and, therefore, may forego TVU. This prospective study, executed in 5 US centers, included 401 women ≥18 years of age who provided written informed consent to undergo CL measurement in the mid trimester. All women underwent both cervicometer- and TVU-measured CLs by individuals blinded to results of the other measurement. Both measurements were performed at 17-23 weeks' gestation (visit 1) and repeated at 24-29 weeks' gestation (visit 2). All TVU measurement images were reviewed by a central reader. Test characteristics and receiver operating characteristic curves were created to determine and confirm the optimal cervicometer CL threshold, maximizing the NPV. In all, 358 subjects were evaluable at visit 1 and 267 at visit 2. At visit 1, the average TVU CL was 38.7 ± 7.6 mm and the average cervicometer CL was 30.3 ± 8.8 mm. Similar measurements were seen at visit 2. Receiver operating characteristic curves were utilized to graphically identify a cervicometer CL threshold of 30 mm that maximized sensitivity while minimizing the false-positive rate. The 30-mm cervicometer CL threshold provided a 98-100% NPV and 0.0 negative likelihood ratio for identification of women who have a low likelihood to have a sonographic short cervix (ie, transvaginal CL ≤20 mm or ≤25 mm). The 17-23 weeks' gestation 30-mm cervicometer CL threshold has 100% sensitivity, 45-46% specificity, and 1.8 and 0.0 positive and negative likelihood ratios to predict sonographic CL ≤20 and ≤25 mm. Cervicometer CL screening successfully identifies women at low risk for short transvaginal CL. Use of a 30-mm threshold by cervicometer CL measurement confers a 98-100% NPV, with high sensitivity and moderate specificity to predict a TVU short CL. Cervicometer measurement of CL may permit almost 50% of women to avoid TVU.

Serial Change in Cervical Length for the Prediction of Emergency Cesarean Section in Placenta Previa.

PurposeTo evaluate whether serial change in cervical length (CL) over time can be a predictor for emergency cesarean section (CS) in patients with placenta previa.MethodsThis was a retrospective cohort study of patients with placenta previa between January 2010 and November 2014. All women were offered serial measurement of CL by transvaginal ultrasound at 19 to 23 weeks (CL1), 24 to 28 weeks (CL2), 29 to 31 weeks (CL3), and 32 to 34 weeks (CL4). We compared clinical characteristics, serial change in CL, and outcomes between the emergency CS group (case group) and elective CS group (control group). The predictive value of change in CL for emergency CS was evaluated.ResultsA total of 93 women were evaluated; 31 had emergency CS due to massive vaginal bleeding. CL tended to decrease with advancing gestational age in each group. Until 29–31 weeks, CL showed no significant differences between the two groups, but after that, CL in the emergency CS group decreased abruptly, even though CL in the elective CS group continued to gradually decrease. On multivariate analysis to determine risk factors, only admissions for bleeding (odds ratio, 34.710; 95% CI, 5.239–229.973) and change in CL (odds ratio, 3.522; 95% CI, 1.210–10.253) were significantly associated with emergency CS. Analysis of the receiver operating characteristic curve showed that change in CL could be the predictor of emergency CS (area under the curve 0.734, p < 0.001), with optimal cutoff for predicting emergency cesarean delivery of 6.0 mm.ConclusionsPrevious admission for vaginal bleeding and change in CL are independent predictors of emergency CS in placenta previa. Women with change in CL more than 6 mm between the second and third trimester are at high risk of emergency CS in placenta previa. Single measurements of short CL at the second or third trimester do not seem to predict emergency CS.

Cervical Length and Androgens in Pregnant Women With Polycystic Ovary Syndrome: Has Metformin Any Effect?

Women with polycystic ovary syndrome (PCOS) have increased risk of preterm delivery. Shortening of the cervix is a sign of preterm delivery. This study aimed to investigate potential effect of metformin on cervical length and whether androgen levels correlate with cervical length in PCOS pregnancies. This was a sub-study of a randomized, placebo-controlled, multicenter study (The PregMet study) performed at 11 secondary or tertiary centers from 2005 to 2009. Two-hundred sixty-one pregnancies of 245 women with PCOS, age 18-42 years participated. Participants were randomly assigned to metformin or placebo from first trimester to delivery. We compared cervical length and androgen levels in metformin and placebo groups at gestational weeks 19 and 32. We also explored whether cervical length correlated with androgen levels. We found no difference in cervical length between the metformin and the placebo groups at gestational week 19 and 32. Dehydroepiandrosterone (DHEAS) tended to be higher in the metformin group. There were no correlations between androgens and cervical length at week 19. At gestational week 32, androstenedione (P = .02) and DHEAS (P = .03) showed a trend toward negative correlation to cervical length. High androstenedione level correlated with shortening of cervical length from week 19 to 32 when adjusted for confounders (P = .003). T (P = .03), DHEAS (P = .02), and free testosterone index (P = .03) showed a similar trend. Metformin in pregnancy did not affect cervical length in women with PCOS. High maternal androgen levels correlated with cervical shortening from the second to the third trimester of pregnancy, as a sign of cervical ripening.

Progesterone treatment for the prevention of preterm birth

Preterm birth (PTB) is defined as birth before 37 completed weeks of gestation, which occurs in approximately 10% of all pregnancies. Prior PTB history and short cervical length (CL) are the most significant predictors of PTB. Prior PTB history can increase the risk of recurrence of PTB more than two-fold in the next pregnancy. A short CL of less than 25 mm as measured by ultrasound between 16 and 24 weeks of gestation has been shown to be the most reliable predictor of an increased risk of PTB. Progesterone is one of the few proven effective methods of preventing PTB in women with a previous history of spontaneous PTB and women with a short CL. Progestins are available in natural micronized or synthetic formulations for intramuscular or vaginal (tablet or gel) administration. Several studies have reported that 17 hydroxyprogesterone caproate injection can prevent recurrent PTB in women with a previous history of PTB. Vaginal micronized natural progesterone has also been shown to be effective in preventing PTB in women with previous PTB history or with a short CL. At present, we are performing a multi-center, randomized trial in Korea (a multicenter, randomized, open-label, investigator-initiated trial of vaginal compared with intramuscular progesterone for the prevention of PTB in high-risk pregnant women: VICTORIA protocol) to compare the efficacy between vaginal progesterone and intramuscular injection of progesterone in women with a previous preterm history or short CL. This study will provide important information to both obstetricians and patients on whether a vaginal or intramuscular regimen is better for prevention of a recurrent PTB.

Value of transvaginal cervical ultrasonographic assessment and bacterial vaginosis in prediction of preterm birth

Objective The objective of this study was to determine the diagnostic value of cervical length (CL) measurement, in the second trimester of pregnancy, and the impact of bacterial vaginosis (BV) as a preterm labor (PTL) predictor. Background Preterm birth is the leading direct cause of neonatal death and morbidity, and it imposes large costs to the healthcare system. Early detection of pregnant women at risk of PTL will help reduce the occurrence of prematurity-related mortality and morbidity. Cervical insufficiency and BV are two items that have been recently known to have an essential role in preterm delivery. They can be diagnosed using safe, simple, and reliable methods. Patients and methods This is a prospective cohort study that included 580 pregnant women with uncomplicated singleton pregnancy between 20 and 22 weeks of gestation to assess CL, which was measured by a transvaginal probe immediately after collecting a vaginal swab for the diagnosis of BV by Amsel's criteria. CL) less than 30 mm was considered a short cervix and suggested cervical insufficiency. The vaginal swab fulfilled three out of four Amsel's criteria and was considered positive for BV. Patients were followed up until delivery. Results Our final analysis was based on the results of 500 participants. The incidence of PTL was 100 out of 500 (20%). The incidence of PTL in women who had BV was 52 out of 100 (52%), which is statistically significant. The incidence of PTL in cases with short CL less than and equal to 30 mm was 39 out of 100 (39%), whereas the incidence of short cervix cases in full term was three out of 400 (0.8%), which was statistically significant. The incidence of PTL was 16% for cases with BV and short CL, whereas there were no cases for full-term labor, which is statistically significant ( P Conclusion The assessment of CL by transvaginal ultrasound and detection of BV during pregnancy have significant value in prediction of PTL.

A comparison of the predictive value of transvaginal cervical length at 11–14 weeks and at 18–22 weeks of gestation in preterm labour

Preterm labor is the major cause of preterm birth that affects 12–18% of all births in India. Cervical shortening or effacement is one of the first steps in the parturition process. In the present study the mean cervical length at 11-14weeks for the term delivered group is 4.04+-0.35cms and the mean cervical length for the preterm delivered group 3.85±0.33 cms. The cervical length at 18-22 weeks was significantly shorter in the group that had preterm deliveries (2.77 cms) than in those who had term deliveries (3.74 cms) (P < 0.001). The cervical length at 18-22 weeks in the group that delivered preterm was significantly shorter than in those who had delivered at term. The mean cervical length showed a gradual decrease from the first to the second scan and an increased risk for preterm delivery was seen in those cases which demonstrated a rapid shortening in cervical length. Keywords: Cervical length, Preterm labor, Predictive value, Transvaginal ultrasound

MANAGEMENT OF PATIENTS WITH CERVICAL INSUFFICIENCY

The article presents a literature review on methods of diagnosis, therapy and management of patients with isthmic-cervical insufficiency. Risk factors for the development of isthmic-cervical insufficiency are the acquired and congenital anomalies of the cervix. The diagnosis can be made only during pregnancy. Shortening of cervical length <25 mm before 24 weeks indicates the presence of ICN and the significant risk of miscarriage. Initial evaluation of the cervical length is from 14 weeks. When finding a shortening of the length of the closed part of the cervical canal is less than 25 mm the treatment of choice is surgical correction. When the cervical length more than 25 mm prophylactically from 19 to 32 weeks assigned to micronized progesterone 200 mg vagina. In identifying ICN after 24 weeks, the method of choice is the appointment of micronized progesterone and the installation of an unloading obstetric pessary. The use of a differentiated algorithm of management of patients with ICN reduces the chance of unexpected premature birth and neonatal morbidity and mortality.

A Comparative Study of Modified Shirodkar's Cerclage and Mcdonald's Cerclage in Cervical incompetence

Background and Objectives: The term ‘cervical incompetence’ is used to describe a disorder in which painless cervical dilatation led to recurrent second trimester pregnancy losses .Structural weakness of cervical tissue was thought to cause or contribute to these adverse outcomes. The diagnosis has also been applied to women with one or two such losses/deliveries or at risk for such a loss/delivery. The aims and objectives of this study were to study the maximum gestational age upto which pregnancy can reach after cerclage, the morbidity of the procedure in terms of complications of the surgery, days of hospital stay, cost effectiveness, etc. and to estimate if cerclage prevents preterm birth and perinatal mortality and morbidity in women with previous preterm birth and short cervical length. Methods: A hospital based prospective study including 50 cases of Modified Shirodkar’s Cerclage and 50 cases of McDonald’s Cerclage, from July 2012 to September 2014 at Dr. D.Y. Patil Medical College and Hospital, Pimpri. Results: The average gestational age up to which pregnancy continued in patients with Modified Shirodkar’s Cerclage was 36 weeks compared to patients with McDonald’s Cerclage which was 33 weeks. Conclusion: Modified Shirodkar’s Cerclage was found to be a comparatively better method of cerclage than McDonald’s Cerclage in terms of preventing preterm birth. Women undergoing Modified Shirodkar’s Cerclage carried their pregnancy significantly longer, had lower neonatal admission rates and suffered a lower cost for maternal and neonatal care. They also showed higher birth weights and lower neonatal death rates. Key Words: Cervical Incompetence, Modified Shirodkar’s Cerclage, McDonald’s Cerclage

254: Cervical pessary in twin pregnancies with a short cervix

In 2014, we introduced cervical pessary as an optional treatment for patients with twin pregnancies and a short cervical length. The objective of this study was to evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix. Retrospective cohort study of twin pregnancies with a short cervical length (<20mm) at 22-29 weeks. We compared outcomes between patients who received a pessary and controls matched 3:1 according to cervical length (within 5mm) and gestational age (within 1 week). The primary outcome was preterm birth <32 weeks. We also examined gestational age at delivery and days from pessary placement to delivery. Patients with cerclage were excluded. All patients received vaginal progesterone. Sample size was calculated to have 80% power to detect a difference in preterm birth <32 weeks from 33% to 16.5%. 19 patients received a cervical pessary and they were compared to 57 matched controls. As expected (due to matching), baseline gestational age (25.5 +/- 2.2 vs. 25.8 +/- 2.2 weeks, p=0.626) and cervical length (10.6 +/- 3.6 vs. 11.8 +/- 4.6 mm, p=0.240) were similar between the groups. Outcome data from 2 ongoing pregnancies with pessaries and their 6 controls were limited to information available at time of submission (preterm birth <32 weeks). The incidence of spontaneous preterm birth <32 weeks was significantly lower in the pessary group (1/19, 5.3% vs. 17/57, 31.5%, p=0.032), and the time from pessary placement to delivery was significantly longer by 12.5 days (66.2 +/- 18.4 vs. 53.7 +/- 26.2 days, p=0.036). Gestational age at delivery was 1.6 weeks later in the pessary group, but this did not reach statistical significance (34.7 +/- 2.8 vs. 33.1 +/- 4.2 weeks, p=0.095). For twin pregnancies with a short cervix, cervical pessary appears to prolong pregnancy and reduce the risk of preterm birth <32 weeks. A large randomized trial should be performed to verify these exciting retrospective findings.

667: Do clinical characteristics differ amongst women, with different subsets of preterm premature rupture of membranes?

To study clinical characteristic and the time course to delivery in women presenting with premature rupture of membranes (PPROM). This was a prospective observational study in 106 singletons presenting with PPROM between 23- 33 weeks gestation from July 2011 to March 2014. All women had a TV cervical length on admission. We classified our cohort into three retrospectively assigned groups: 1) spontaneous delivery 2) delivered for maternal or fetal indications and 3) induced for GA beyond 34 weeks. The cumulative times to delivery were examined by life table analysis. Demographic and clinical characteristics were compared using chi-square, Fisher’s-Exact and Kolmogorov-Smirnov tests Eighty one delivered spontaneously. Fifteen women were delivered in group 2 with indications including non-reassuring fetal status (n=5), placental abruption (n=3), cord prolapse (n=3), clinical chorioamnionitis (n=3) and preeclampsia (n=1). Ten women delivered in group 3. No significant differences were seen in days from PROM to delivery among three groups (Figure). Demographics were similar between spontaneous labor group vs. combined non-spontaneous groups, except for higher illicit drug use (16.3% vs. 0.0%, p<0.05) and more maternal asthma (18.8% vs. 0.0%, p<0.05) among the spontaneous labor group. In women with spontaneous labor, the median GA at delivery was lower than the median GA of combined groups 2&3 (31.6 weeks and IQR [29.3-33.1] vs. 32.7 weeks [30.6- 34.0]; (p<0.05). The median initial cervical length after admission and [IQR] was shorter in the group 1 compared to combined groups 2&3; (2.14 cm [1.2-3.4] vs. 3.2 cm [2.2-3.6]; p<0.05). In a prospective study of women with PPROM, the group that eventually delivered spontaneously had a higher incidence of illicit drug use and asthma. Also, they were more likely to have a shorter cervical length on initial transvaginal ultrasound.

Vaginal progesterone combined with cervical pessary: A chance for pregnancies at risk for preterm birth?

Precocious cervical ripening, as defined by cervical shortening on transvaginal sonography, has prompted a broad evaluation of secondary strategies (such as cerclage, vaginal progesterone, or a cervical pessary) to prevent preterm delivery. However, there is still a lackof direct comparisons between individual treatments or their combinations. We sought to compare at-risk patients and screening patients who had been treated with cervical pessary alone with patients who had been treated with pessary plus vaginal progesterone. This is a pre- and postintervention cohort study from a preterm labor clinic where placement of a cervical pessary has been the standard treatment since 2008 for at-risk women defined by (1) a history of spontaneous preterm birth at <37 weeks of gestation, (2) conization, or (3) a cerclage because of a previous short cervical length of <3rd percentile and, additionally, with a cervical length of <10th percentile in the ongoing pregnancy. Patients who did not meet the criteria for the "at risk" group, but who had a cervical length of <3rd percentile comprised the screening group. From July 2011 onward, vaginal progesterone (200 mg, suppositories) was prescribed in addition to the pessary. Both at-risk patients (n= 55) and screening patients (n= 51) were treated at the time of diagnosis. The primary outcome was the rate of preterm deliveries at <34 weeks of gestation. Secondary outcomes included deliveries at <28, <32, and <37 weeks of gestation, the days from start of therapy until delivery, a composite index of neonatal outcome, and the number of days in the neonatal intensive care unit. Primary and secondary outcomes were compared between groups with the use of multivariable models to adjust for possible confounders. Delivery at <34 weeks of gestation occurred in 17 of 53 patients (32.1%) who were treated with pessary plus progesterone, compared with 13 of 53 patients (24.5%) who were treated with pessary alone (P= .57). Similarly, there was no difference in the rate of preterm delivery at <28, <32, or <37 weeks of gestation. The composite poor neonatal outcome was 15.1% in the pessary group vs 18.9% in the combined group (P= .96). The mean duration of stay in the neonatal intensive care unit was 46.5 days (range, 9-130 days) in the combined vs52.0 days (range, 3-151 days) in the pessary group (P < .001). In this cohort study, treatment of precocious cervical ripening with cervical pessary plus vaginal progesterone did not reduce the rates of preterm delivery at <28, <32, <34, or <37 weeks of gestation compared with pessary alone. The neonatal intensive care use was shorter in patients who received additional vaginal progesterone, although there was no difference in composite poor neonatal outcome. These preliminary results may serve as a pilot for future trials and provide a basis for treatment until larger trials are completed.