Prior Uterine Evacuation and the Risk of Short Cervical Length: A Retrospective Cohort Study

Impact of first-trimester mechanical cervical dilatation during curettage on maternal and neonatal outcomes: A retrospective comparative study

OBJECTIVE

Earlier studies have indicated a potential link between dilatation and curettage (D&C) and subsequent preterm delivery, possibly attributed to cervical damage. This study examines outcomes in pregnancies subsequent to first-trimester curettage with and without cervical dilatation.

METHODS

A retrospective cohort study was conducted on women who conceived after undergoing curettage due to a first trimester pregnancy loss. Maternal and neonatal outcomes of the subsequent pregnancy were compared between two groups: women who underwent cervical dilatation before their curettage and those who had curettage without dilatation. The primary outcome assessed was the rate of preterm delivery at the subsequent pregnancy, and secondary outcomes included other adverse maternal and neonatal outcomes. Univariate analysis was performed, followed by multiple logistic regression models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Among the 1087 women meeting the inclusion criteria during the study period, 852 (78.4 %) underwent first-trimester curettage with cervical dilatation, while 235 (21.6 %) opted for curettage only. No significant maternal or neonatal different outcomes were noted between the study groups, including preterm delivery (5.5 % vs. 3.5 %, p = 0.16), fertility treatments, placental complications, and mode of delivery. However, deliveries following D&C were associated with higher rates of small for gestational age neonates (7.6 % vs. 3.8 %, p = 0.04). Multivariate analysis revealed that cervical dilation before curettage was not significantly linked to preterm delivery [adjusted odds ratio 0.64 (0.33-1.26), p = 0.20].

CONCLUSION

The use of cervical dilatation during a curettage procedure for first trimester pregnancy loss, does not confer additional risk of preterm delivery. Further studies are needed to reinforce and validate these results.

Double Balloon Combined with Oxytocin in Labor Induction: Analysis of Multivariate Factors Affecting the Efficacy of Cervical Ripening

Objective

Labor induction during the late trimester of pregnancy is a common option of terminating pregnancy by inducing uterine contractions through medication or cervical mechanical dilation. However, there are few researches on the factors influencing the effectiveness of cervical ripening balloon combined with oxytocin in inducing labor. To explore factors affecting the efficacy of cervical ripening double balloon combined with oxytocin in labor induction.

Methods

Using a convenient sampling method, this study retrospectively collected the clinical data of 230 pregnant women who underwent cervical ripening double balloon combined with oxytocin for labor induction in our hospital from September 2021 to August 2022. The included subjects were divided into a vaginal delivery group (n = 180) and a cesarean section group (n = 50) based on the delivery mode for comparing relevant indicators between the two groups.

Results

The presence of acute chorioamnionitis (OR = 1.456, 95% CI: 1.257-2.112), fetal distress (OR = 1.371, 95% CI: 1.331-2.633), and the placement of cervical ripening balloon catheter for >12h (OR = 1.563, 95% CI: 1.231-3.263) were risk factors for successful application of cervical ripening double balloon combined with oxytocin for labor induction in pregnant women; while multi-gravidity (OR = 0.736, 95% CI: 0.455-0.875) was a protective factor. In addition, evaluation of the predictive value revealed that acute chorioamnionitis, fetal distress, the placement of cervical ripening balloon catheter for >12h, and gravidity all had certain predictive value for the failure of cervical ripening double balloon combined with oxytocin for labor induction, with the highest predictive value found through joint predictive (AUC: 0.931, 95% CI: 0.714-0.811).

Conclusion

Cervical ripening double balloon combined with oxytocin for labor induction may have a high success rate in multigravida. Acute chorioamnionitis, fetal distress, and prolonged placement of the balloon may have a negative impact on the success rate of cervical ripening double balloon combined with oxytocin for labor induction.

Does repetitive dilatation and curettage or hysteroscopic biopsy in patients treated with progestins for endometrial hyperplasia or carcinoma affect subsequent fetomaternal outcomes? A population-based study using the National Health Insurance Research Database of Taiwan

OBJECTIVE

To investigate the impact of repeated dilatation and curettage or hysteroscopic biopsy on fetomaternal outcomes in patients receiving progestin treatment for endometrial hyperplasia or early-stage carcinoma.

METHOD

This was a population-based study using the Taiwan National Health Insurance Research Database between 2009 and 2017 of women who gave birth and had a history of endometrial hyperplasia and early-stage carcinoma treated with progestins. Logistic regression analysis was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) reflecting the association between repeated procedures and fetomaternal outcomes.

RESULTS

A total of 6956 women with 8690 deliveries were identified. Compared with those who had two or fewer procedures, women who received more than two procedures had a significantly higher risk for cervical insufficiency (aOR, 5.09 [95 CI, 2.31-11.24]). Furthermore, women who had more than two procedures were prone to have adverse neonatal outcomes, including Apgar score < 7 at 1 min (aOR, 1.97 [95% CI, 1.13-3.43]) and 5 min (aOR, 3.11 [95% CI, 1.33-7.23]) and preterm delivery <32 weeks (aOR, 2.86 [95% CI, 1.50-5.45]).

CONCLUSION

Undergoing more than two procedures was associated with subsequent maternal cervical insufficiency, preterm delivery <32 weeks, and low neonatal Apgar score. Health care providers should be aware of the potential risks and balance the benefits and harms of repeated procedures.

Maternal and obstetrical factors associated with short cervical length at midtrimester in women with no history of preterm delivery

AIM

To evaluate associations between maternal characteristics and a short cervix in patients without history of preterm delivery, and to determine if these characteristics can predict the presence of a short cervix.

MATERIALS AND METHODS

This is a retrospective cohort study that included 18,592 women with singleton pregnancies without history of previous preterm deliveries who underwent universal transvaginal cervical length (TVCL) screening between 18 + 0 and 23 + 6 weeks/days of gestation. A short cervix was defined as a cervical length (CL) ≤25 mm, ≤20 mm, and ≤15 mm. Associations between maternal age, weight, height, body mass index (BMI), previous term deliveries, and history of previous miscarriages, with a short cervix were evaluated using logistic regression models.

RESULTS

The prevalence of a short cervix in our population was: CL ≤25 mm, 2.2% (n = 403); CL ≤20 mm, 1.2% (n = 224); and CL ≤15 mm, 0.9% (n = 161). Women with BMI >30 and/or previous abortions constituted 45.5% of the total population (8463/18,582). Significant associations with short cervix were observed for women with BMI ≥30, and for women with at least one previous abortion (p < .001). Parous women had a significantly lower association with a short cervix than nulliparous women (p < .001). Maternal age or height were not associated with a short cervix. Prediction of short cervix based on presence of any of the following: BMI ≥ 30 or previous abortions showed sensitivities of 55.8% (≤25 mm), 61.6% (≤20 mm), and 63.4% (≤15 mm) with similar specificity (50.1-54.6%) and likelihood ratio positive (1.2-1.5); and prediction based on BMI ≥ 30 and previous abortions showed sensitivities of 11.1% (≤25 mm), 14.7% (≤20 mm), and 16.7% (≤15 mm) with specificity 93%.

CONCLUSIONS

Among low risk women for spontaneous preterm delivery, those with a BMI ≥30 and/or previous miscarriages had a significantly increased risk for a short cervix at 18 + 0 and 23 + 6 weeks/days of gestation. Despite these significant associations, screening by maternal risk factors in a low risk population of pregnant women should not be an alternative to mid-trimester universal CL measurement.

Prior Spontaneous or Induced Abortion Is a Risk Factor for Cervical Dysfunction in Pregnant Women: a Systematic Review and Meta-analysis

A history of abortion is associated with cervical dysfunction during pregnancy, but there remains uncertainty about whether risk can be stratified by the abortion type, the abortion procedure, or number of previous abortions. The objective of this study was to verify the relationship between cervical dysfunction measures in pregnancies with and without a history of termination. Embase and Medline databases were searched from 01 January 1960 to 01 March 2022 resulting in a full-text review of 28 studies. The Newcastle-Ottawa Scale (NOS) was used to assess the quality and risk of bias for non-randomized studies. The meta-analysis consisted of 6 studies that met all inclusion and exclusion criteria and included a combined total of 2,513,044 pregnancies. Cervical dysfunction was defined as either cervical insufficiency/incompetence in 4 of the studies and as short cervix in the others. Results from a random-effects model using reported adjusted odds ratios (aOR) estimated an increase in the odds of 2.71 (95% CI 1.76, 4.16) for cervical dysfunction in the current pregnancy related to a history of induced or spontaneous abortion. Subgroup analyses with only induced abortions (surgical/medical) estimated an aOR of 2.54 (95% CI 1.41, 4.57), while studies limited to surgical abortions had an aOR of 4.08 (95% CI 2.84, 5.86). The risk of cervical dysfunction in the current pregnancy was also found to be dependent on the number of previous abortions. In this meta-analysis, a prior history of abortion, and specifically induced abortions, was associated with cervical dysfunction. The protocol was registered in PROSPERO (CRD42020209723).

Perinatal outcome and risk factors of precipitate labor in term primipara: an analysis of 381 cases

OBJECTIVE

To investigate the perinatal outcome and risk factors of precipitate labor in term primipara.

METHODS

A total of 6951 full-term singleton primiparas with cephalic vaginal delivery in Women's Hospital, Zhejiang University School of Medicine from January 2020 to December 2020 were enrolled, among whom 381 cases of precipitate labor were classified as the precipitate labor group and 762 cases of normal labor were randomly selected as the control group. The perinatal outcomes of the two groups were compared, and the risk factors of precipitate labor were analyzed by multivariate logistic regression.

RESULTS

The incidence of precipitate labor in full-term, singleton pregnancy and cephalic primiparas was 5.48% (381/6951). The durations of the first and second stages of labor in the precipitate labor group were significantly shorter than that in the control group ( P<0.01); while there was no significant difference in the duration of the third stage of labor between the two groups ( P>0.05). Compared with the control group, the incidence of soft birth canal laceration in the precipitate labor group was increased ( P<0.01). However, there was no significant difference in postpartum hemorrhage and neonatal related perinatal outcomes between the two groups (all P>0.05). Multivariate logistic regression analysis showed that maternal height ( OR=1.038, 95% CI: 1.010-1.067, P<0.01), gestational age at delivery ( OR=0.716, 95% CI: 0.618-0.829, P<0.01), late miscarriage ( OR=1.986, 95% CI: 1.065-3.702, P<0.05), membrane rupture before labor ( OR=1.802, 95% CI: 1.350-2.406, P<0.01), labor induction by transcervical balloon ( OR=3.230, 95% CI: 2.027-5.147, P<0.01), labor induction by propess ( OR=2.332, 95% CI: 1.632-3.334, P<0.01) and labor induction by oxytocin ( OR=0.291, 95% CI: 0.219-0.386, P<0.01) were independently associated with precipitate labor.

CONCLUSIONS

The incidence of precipitate labor in full-term, singleton pregnancy was not low. Precipitate labor could lead to a significant increase in perineal laceration. Maternal height, history of late miscarriage, membrane rupture before labor and labor induction by transcervical balloon, labor induction by propess are risk factors, while labor induction by oxytocin and late gestational time of delivery are protective factors for precipitate labor in term primipara.

Maternal and Neonatal Outcomes of Women Conceived Less Than 6 Months after First Trimester Dilation and Curettage

Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single tertiary medical center between 2016 and 2021. The maternal and neonatal outcomes of women who had D&C were compared to those of women who had non-medical or spontaneous miscarriages. The primary outcome of this study was the rate of preterm birth (<37 weeks). Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: During the study period, 1773 women met the inclusion criteria; of those, 1087 (61.3%) women gave birth following D&C. We found no differences between the study groups in any maternal or neonatal parameter examined including preterm birth (PTB), miscarriage to pregnancy interval, fertility treatments, hypertension disorders of pregnancy, placental complications, mode of delivery and neonatal birth weights. This was confirmed on a multivariate analysis as well [aOR 1.74 (0.89−3.40), p = 0.11] for preterm birth. Conclusion: Watchful waiting or the medical treatment of a first trimester missed abortion present no more risks than D&C to pregnancies conceived within six months of the index miscarriage. Further studies in other settings to strengthen these findings are needed.

Personalized assessment of cervical length improves prediction of spontaneous preterm birth: a standard and a percentile calculator

BACKGROUND

A sonographic short cervix (length <25 mm during midgestation) is the most powerful predictor of preterm birth. Current clinical practice assumes that the same cervical length cutoff value should apply to all women when screening for spontaneous preterm birth, yet this approach may be suboptimal.

OBJECTIVE

This study aimed to (1) create a customized cervical length standard that considers relevant maternal characteristics and gestational age at sonographic examination and (2) assess whether the customization of cervical length evaluation improves the prediction of spontaneous preterm birth.

STUDY DESIGN

This retrospective analysis comprises a cohort of 7826 pregnant women enrolled in a longitudinal protocol between January 2006 and April 2017 at the Detroit Medical Center. Study participants met the following inclusion criteria: singleton pregnancy, ≥1 transvaginal sonographic measurements of the cervix, delivery after 20 weeks of gestation, and available relevant demographics and obstetrical history information. Data from women without a history of preterm birth or cervical surgery who delivered at term without progesterone treatment (N=5188) were used to create a customized standard of cervical length. The prediction of the primary outcome, spontaneous preterm birth at <37 weeks of gestation, was assessed in a subset of pregnancies (N=7336) that excluded cases with induced labor before 37 weeks of gestation. Area under the receiver operating characteristic curve and sensitivity at a fixed false-positive rate were calculated for screening at 20 to 23 6/7, 24 to 27 6/7, 28 to 31 6/7, and 32 to 35 6/7 weeks of gestation in asymptomatic patients. Survival analysis was used to determine which method is better at predicting imminent delivery among symptomatic women.

RESULTS

The median cervical length remained fundamentally unchanged until 20 weeks of gestation and subsequently decreased nonlinearly with advancing gestational age among women who delivered at term. The effects of parity and maternal weight and height on the cervical length were dependent on the gestational age at ultrasound examination (interaction, P<.05 for all). Parous women had a longer cervix than nulliparous women, and the difference increased with advancing gestation after adjusting for maternal weight and height. Similarly, maternal weight was nonlinearly associated with a longer cervix, and the effect was greater later in gestation. The sensitivity at a 10% false-positive rate for prediction of spontaneous preterm birth at <37 weeks of gestation by a short cervix ranged from 29% to 40% throughout pregnancy, yet it increased to 50%, 50%, 53%, and 54% at 20 to 23 6/7, 24 to 27 6/7, 28 to 31 6/7, and 32 to 35 6/7 weeks of gestation, respectively, for a low, customized percentile (McNemar test, P<.001 for all). When a cervical length <25 mm was compared to the customized screening at 20 to 23 6/7 weeks of gestation by using a customized percentile cutoff value that ensured the same negative likelihood ratio for both screening methods, the customized approach had a significantly higher (about double) positive likelihood ratio in predicting spontaneous preterm birth at <33, <34, <35, <36, and <37 weeks of gestation. Among symptomatic women, the difference in survival between women with a customized cervical length percentile of ≥10th and those with a customized cervical length percentile of <10th was greater than the difference in survival between women with a cervical length ≥25 mm and those with a cervical length <25 mm.

CONCLUSION

Compared to the use of a cervical length <25 mm, a customized cervical length assessment (1) identifies more women at risk of spontaneous preterm birth and (2) improves the distinction between patients at risk for impending preterm birth in those who have an episode of preterm labor.

Reproductive outcome after early pregnancy loss treated with misoprostol versus surgical aspiration

RESEARCH QUESTION

Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration.

DESIGN

A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention.

RESULTS

Baseline characteristics were comparable between women who received misoprostol (n = 163) and women who underwent surgical aspiration (n = 122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; P = 0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; P = 0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; P = 0.16), 12 months (78.5% versus 78.7%, respectively; P = 0.97) and 24 months (92.0% versus 91.8%, respectively; P = 0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; P = 0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; P = 0.81) and birthweight (3295 versus 3161 g, respectively; P = 0.07).

CONCLUSIONS

Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction.

Predicting asymptomatic cervical dilation in pregnant patients with short mid-trimester cervical length: A secondary analysis of a randomized controlled trial

INTRODUCTION

Second trimester asymptomatic cervical dilation is a significant risk factor for early preterm birth. The objective of this study is to evaluate whether transvaginal ultrasound cervical length (CL) predicts asymptomatic cervical dilation on physical exam in women with short cervix (CL ≤25 mm) and no prior preterm birth.

MATERIAL AND METHODS

Secondary analysis of a randomized trial on pessary in asymptomatic singletons without prior preterm birth diagnosed with CL ≤25 mm between 18+0/7 and 23+6/7  weeks. Participants had transvaginal ultrasound and physical cervical exam and were randomized to pessary or no pessary with all patients with cervical length ≤20 mm offered vaginal progesterone. The primary outcome was to determine whether CL was predictive of asymptomatic physical cervical dilation ≥1 cm using receiver operating characteristic curve.

RESULTS

In all, 119 women were included. Based on receiver operating characteristic curve, CL ≤11 mm was best predictive of cervical dilation ≥1 cm, with 75% sensitivity, 80% specificity, and area under the curve 0.73 (0.55-0.91), P = 0.009. Cervical length ≤11 mm had increased incidence of cervical dilation ≥1 cm on physical exam (30% vs 3%, odds ratio 12.29 (3.05-49.37) P < 0.001) with a negative predictive value of 97%. Patients with ≥1 cm dilation had increased preterm birth <37 weeks (75% vs 39%, P = 0.03) compared to those not dilated. Women with a CL ≤11 mm had increased preterm birth <37 weeks (77% vs 31%, P < 0.001), preterm birth <34 weeks (63% vs 22%, P < 0.001), and lower birthweight (1552 ± 1047 vs 2560 ± 1072 g, P < 0.001) compared to women with CL >11 mm.

CONCLUSIONS

Among singletons without prior preterm birth diagnosed with short cervix (≤25 mm), CL ≤11 mm may identify a subgroup of patients at high risk for asymptomatic cervical dilation and poor perinatal outcome. Physical exam should be considered and adjunctive preterm birth prevention measures should be studied in singletons with CL ≤11 mm.

Maternal body mass index and cervical length among women with a history of spontaneous preterm birth†

Objectives: To evaluate whether women with a prior spontaneous preterm birth (SPTB) with a higher body mass index (BMI) have a lower risk of a shortened cervix in a subsequent pregnancy.Study Design: A secondary analysis of the Maternal-Fetal Medicine Units Network RCT of omega-3 fatty acid supplementation for recurrent SPTB prevention. All women had ≥1 prior SPTB <37 weeks, a singleton pregnancy, and initiated 17-alpha hydroxyprogesterone caproate(17-OHPC). The primary exposure was pre-pregnancy BMI. The primary outcome was the shortest transvaginal cervical length <30 mm.Results: Of the 356 women with a prior SPTB receiving 17-OHPC and a cervical length available, 108 (30%) were overweight and 103 (29%) obese; 12% had a cervical length <30 mm. Fewer overweight/obese women had a shortened cervix compared to normal-weight women (43 versus 57%; odds ratio: 0.47 [95%CI: 0.25-0.89]). After adjusting for maternal age, number of prior SPTBs, and tobacco use, overweight/obese women were less than half as likely to have a shortened cervix compared to normal-weight women (adjusted odds ratio: 0.46, 95%CI: 0.24-0.89).Conclusions: Overweight and obese women with a prior SPTB receiving 17-OHPC have longer cervical lengths compared to normal weight women, and this finding could explain a possible mechanism between the decreased rate of SPTB and larger BMI.