Funisitis as a Risk Factor for Adverse Neonatal Outcomes in Twin Neonates with Spontaneous Preterm Birth: A Retrospective Cohort Study

Cervical elastography: finding a novel predictor for improving the prediction of preterm birth in uncomplicated twin pregnancies

OBJECTIVE

This study set out to investigate a novel ultrasound parameter using cervical elastosonography for improving the prediction of spontaneous preterm birth (sPTB) in twin pregnancies.

STUDY DESIGN

The study was comprised of 106 twin pregnancies from October 2020 to January 2022 in Beijing Obstetrics and Gynecology Hospital. They were divided into two groups according to gestational age (GA) at delivery (delivery < 35 weeks and delivery ≥ 35 weeks). There were five elastographic parameters: Elasticity Contrast Index (ECI), Cervical Hardness Ratio (CHR), Closed Internal cervical ostium Strain rate (CIS); External cervical ostium strain rate (ES), CIS/ES ratio and Cervical Length (CL). All of the clinical and ultrasonic indicators with P < 0.1 were considered candidate indicators via univariate logistic regression. Based on the extracted unified combination of clinical indicators, the combinations of permutation with the candidate ultrasound indicators were performed step by step in multivariable logistic regression. The best ultrasound indicator with the lowest Akaike Information Criterion (AIC) and the highest Areas Under the receiver operating characteristic Curve (AUC) was chosen for establishing the prediction score.

RESULTS

Over 30% (36/106) of those who delivered before 35 weeks gestation. There were distinct differences in the clinical characteristics and cervical elastography parameters between the two groups. Seven major clinical variables were identified as a unified clinical indicator. CISmin as the best ultrasound elastography predictor indicated the lowest AIC and the highest AUC and outperformed alternative indicators significantly in the prediction of delivery before 35 weeks of gestation. Unfortunately, CLmin which was commonly used in clinical practice ranked far from all of the cervical elastography parameters and presented the highest AIC and the lowest AUC. A preliminary scoring rule was established and the ability to predict the risk of sPTB in twin pregnancies was improved (Accuracy: 0.896 vs 0.877; AIC: 81.494 vs 91.698; AUC: 0.923 vs 0.906).

CONCLUSIONS

The cervical elastosonography predictor such as CISmin might be a more useful indicator applied for enhancing the ability in predicting twin pregnancies preterm birth than CL. Furthermore, there would be more benefits for advancing clinical decision-making in actual clinical practice by using cervical elastosonography in the near future.

Association of Funisitis with Short-Term Outcomes of Prematurity: A Frequentist and Bayesian Meta-Analysis

The fetal systemic inflammatory response associated with intra-amniotic inflammation may play a key role in the pathogenesis of complications of preterm birth. Funisitis is the histologic equivalent of the fetal inflammatory response, whereas chorioamnionitis represents a maternal inflammatory response. We conducted a frequentist and Bayesian model average (BMA) meta-analysis of studies investigating the effects of funisitis on short-term outcomes of prematurity. Thirty-three studies (12,237 infants with gestational age ≤ 34 weeks) were included. Frequentist meta-analysis showed that funisitis was associated with an increased risk of any bronchopulmonary dysplasia (BPD), moderate/severe BPD, retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), any sepsis, early-onset sepsis (EOS), and mortality. However, Bayesian meta-analysis showed that the evidence in favor of the alternative hypothesis (i.e., funisitis is associated with an increased risk of developing the outcome) was strong for any IVH, moderate for severe IVH and EOS, and weak for the other outcomes. When the control group was restricted to infants having chorioamnionitis without funisitis, the only outcome associated with funisitis was any IVH. In conclusion, our data suggest that the presence of funisitis does not add an additional risk to preterm birth when compared to chorioamnionitis in the absence of fetal inflammatory response.