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Millet P, Gauthier T, Vieillefosse S, Dewaele P, Rivain AL, Legendre G, Golfier F, Touboul C, Deffieux X. Should we perform cervix removal during hysterectomy for benign uterine disease? Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF). J Gynecol Obstet Hum Reprod 2021; 50:102134. [PMID: 33794370 DOI: 10.1016/j.jogoh.2021.102134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/25/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best evidence available, concerning subtotal or total hysterectomy, for benign disease. METHODS The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines). RESULTS Conservation of the uterine cervix is associated with an increased risk of cervical cancer (0.05 to 0.27%) and an increased risk of reoperation for cervical bleeding (QE: high). Uterine cervix removal is associated with a moderate (about 11 min) increase in operative time when hysterectomy is performed by the open abdominal route (laparotomy), but is not associated with longer operative time when the hysterectomy is performed by laparoscopy (QE: moderate). Removal of the uterine cervix is not associated with increased prevalence of short-term follow-up complications (blood transfusion, ureteral or bladder injury) (QE: low) or of long-term follow-up complications (pelvic organ prolapse, sexual disorders, urinary incontinence (QE: moderate). CONCLUSION Removal of the uterine cervix is recommended for hysterectomy in women presenting with benign uterine disease (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be sufficient and the risk-benefit balance was considered to be favorable).
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Affiliation(s)
- Pierre Millet
- APHP, GHU South, Antoione Béclere Hospital, Department of Obstetrics and Gynaecology, 157 rue de la porte de Trivaux, F-92140, Clamart, France
| | - Tristan Gauthier
- Département de Gynécologie et Obstétrique, CHU Limoges, 8 av Dominique Larrey, 87000 Limoges, France; INSERM, UMR-1248, CHU Limoges, 87000 Limoges, France
| | - Sarah Vieillefosse
- APHP, GHU South, Antoione Béclere Hospital, Department of Obstetrics and Gynaecology, 157 rue de la porte de Trivaux, F-92140, Clamart, France
| | - Pauline Dewaele
- APHP, GHU South, Antoione Béclere Hospital, Department of Obstetrics and Gynaecology, 157 rue de la porte de Trivaux, F-92140, Clamart, France
| | - Anne-Laure Rivain
- APHP, GHU South, Antoione Béclere Hospital, Department of Obstetrics and Gynaecology, 157 rue de la porte de Trivaux, F-92140, Clamart, France
| | - Guillaume Legendre
- CHU Angers, Department of Obstetrics and Gynaecology, F-49000, Angers, France
| | - François Golfier
- CHU Lyon, Department of Obstetrics and Gynaecology, F-69000, Lyon, France
| | - Cyril Touboul
- APHP, GHU East, Tenon Hospital, Department of Obstetrics and Gynaecology, 4 rue de la Chine, F-75020, Paris, France
| | - Xavier Deffieux
- APHP, GHU South, Antoione Béclere Hospital, Department of Obstetrics and Gynaecology, 157 rue de la porte de Trivaux, F-92140, Clamart, France; University Paris-Saclay, Faculté de Médecine, F94270, Le Kremlin-Bicêtre, France.
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Vink J, Yu V, Dahal S, Lohner J, Stern-Asher C, Mourad M, Davis G, Xue Z, Wang S, Myers K, Kitajewski J, Chen X, Wapner RJ, Ananth CV, Sheetz M, Gallos G. Extracellular Matrix Rigidity Modulates Human Cervical Smooth Muscle Contractility-New Insights into Premature Cervical Failure and Spontaneous Preterm Birth. Reprod Sci 2021; 28:237-251. [PMID: 32700284 PMCID: PMC9344974 DOI: 10.1007/s43032-020-00268-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022]
Abstract
Spontaneous preterm birth (sPTB), a major cause of infant morbidity and mortality, must involve premature cervical softening/dilation for a preterm vaginal delivery to occur. Yet, the mechanism behind premature cervical softening/dilation in humans remains unclear. We previously reported the non-pregnant human cervix contains considerably more cervical smooth muscle cells (CSMC) than historically appreciated and the CSMC organization resembles a sphincter. We hypothesize that premature cervical dilation leading to sPTB may be due to (1) an inherent CSMC contractility defect resulting in sphincter failure and/or (2) altered cervical extracellular matrix (ECM) rigidity which influences CSMC contractility. To test these hypotheses, we utilized immunohistochemistry to confirm this CSMC phenotype persists in the human pregnant cervix and then assessed in vitro arrays of contractility (F:G actin ratios, PDMS pillar arrays) using primary CSMC from pregnant women with and without premature cervical failure (PCF). We show that CSMC from pregnant women with PCF do not have an inherent CSMC contractility defect but that CSMC exhibit decreased contractility when exposed to soft ECM. Given this finding, we used UPLC-ESI-MS/MS to evaluate collagen cross-link profiles in the cervical tissue from non-pregnant women with and without PCF and found that women with PCF have decreased collagen cross-link maturity ratios, which correlates to softer cervical tissue. These findings suggest having soft cervical ECM may lead to decreased CSMC contractile tone and a predisposition to sphincter laxity that contributes to sPTB. Further studies are needed to explore the interaction between cervical ECM properties and CSMC cellular behavior when investigating the pathophysiology of sPTB.
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Affiliation(s)
- Joy Vink
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th St. PH16-66, New York, NY, 10032, USA.
- Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA.
| | - Victoria Yu
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th St. PH16-66, New York, NY, 10032, USA
| | - Sudip Dahal
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th St. PH16-66, New York, NY, 10032, USA
| | - James Lohner
- Department of Biological Sciences, Columbia University, New York, NY, USA
| | - Conrad Stern-Asher
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th St. PH16-66, New York, NY, 10032, USA
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th St. PH16-66, New York, NY, 10032, USA
- Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA
| | - George Davis
- Department of Obstetrics and Gynecology, Rowan University School of Osteopathic Medicine, Camden, NJ, USA
| | - Zenghui Xue
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Shuang Wang
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kristin Myers
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - Jan Kitajewski
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, USA
| | - Xiaowei Chen
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th St. PH16-66, New York, NY, 10032, USA
| | - Cande V Ananth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Epidemiology and Biostatistics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Michael Sheetz
- Department of Biological Sciences, Columbia University, New York, NY, USA
| | - George Gallos
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
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3
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Vavoulidis E, Margioula-Siarkou C, Petousis S, Dinas K. SARS-CoV-2 infection and impact on female genital tract: An untested hypothesis. Med Hypotheses 2020; 144:110162. [PMID: 32795833 PMCID: PMC7403865 DOI: 10.1016/j.mehy.2020.110162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022]
Abstract
COVID pandemic consists one of the most challenging medical realities. Apart from affecting respiratory system, current evidence has demonstrated multiorgan manifestations that SARS-Cov-2 infection may actually have. However, one of the medical hypotheses not yet thoroughly tested is the impact on female reproductive system and more specifically cervix. No large observational studies have been performed to test presence of SARS-Cov-2 in cervical samples, while potential correlation and impact on HPV infection has not yet been examined. In this context, our research team has already planned to begin a prospective observational study regarding detection rates of SARS-CoV-2 genetic material in cervical cytology. The collected specimen will be analyzed for the presence of COVID-19 genetic material and in case of positive results, HPV typing will be performed as well in order to detect potential correlations between SARS-CoV-2 infection and HPV-infection. We would therefore like to launch our idea to control for SARS-CoV-2 infection in cervical specimen as well as examine potential correlation with HPV infection. Potential scientific proof of such hypothesis would change much regarding follow-up of HPV-positive patients while also triggering further research regarding aitiopathogenetic pathways of COVID. Communication of such a medical hypothesis could potentially motivate colleagues worldwide to expand their interest also on the research of SARS-CoV-2 cervical infection, in an effort to optimize our level of knowledge towards this new threatening and unknown reality of SARS-CoV-2.
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Affiliation(s)
- Eleftherios Vavoulidis
- 2(nd) Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54624, Greece
| | - Chrysoula Margioula-Siarkou
- 2(nd) Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54624, Greece
| | - Stamatios Petousis
- 2(nd) Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54624, Greece.
| | - Konstantinos Dinas
- 2(nd) Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54624, Greece
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Castro L, García-Mejido JA, Arroyo E, Carrera J, Fernández-Palacín A, Sainz JA. Influence of epidemiological characteristics (age, parity and other factors) in the assessment of healthy uterine cervical stiffness evaluated through shear wave elastography as a prior step to its use in uterine cervical pathology. Arch Gynecol Obstet 2020; 302:753-762. [PMID: 32712928 DOI: 10.1007/s00404-020-05671-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to evaluate stiffness changes occurring in the healthy uterine cervix according to age, parity, phase of the menstrual cycle and other factors by shear wave elastography (SWE). METHODS Evaluations of cervical speed and stiffness measurements were performed in 50 non-pregnant patients without gynaecological pathology using SWE transvaginal ultrasound. We performed the evaluation in the midsagittal plane of the uterine cervix with measurements at 0.5, 1 and 1.5 cm from external cervical os, at both anterior and posterior cervical lips. RESULTS We evaluated 44 patients by SWE and obtained a total average velocity of 3.48 ± 1.08 m/s and stiffness of 42.39 ± 25.33 kPa. We found differences in speed and stiffness according to the cervical lip and depth evaluated; thus, we observed a velocity of 2.70 m/s at 0.5 cm of depth in the anterior lip and 3.53 m/s at 1.5 cm of depth in the posterior lip (p < 0.05). We observed differences according to parity, obtaining a wave transmission speed of 2.67 m/s and 4.41 m/s at the cervical canal of nulliparous and multiparous patients, respectively (p < 0 0.002). We observed differences according to patient age (from a speed of 2.75 m/s at the cervical canal in the age group of 20-35 years to 5.05 m/s in the age group > 50 years) (p < 0.008). We did not observe differences in speed or stiffness according to the phase of the menstrual cycle, BMI, smoking status or the presence or absence of non-HPV infections. CONCLUSIONS The wave transmission speed and stiffness of the uterine cervix evaluated by SWE varies according to the cervical lip and depth of the evaluation as well as according to the parity and age of the patient.
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Affiliation(s)
- Laura Castro
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain.
| | - Eva Arroyo
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Jara Carrera
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - José Antonio Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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5
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Lee JM, Mayall JR, Chevalier A, McCarthy H, Van Helden D, Hansbro PM, Horvat JC, Jobling P. Chlamydia muridarum infection differentially alters smooth muscle function in mouse uterine horn and cervix. Am J Physiol Endocrinol Metab 2020; 318:E981-E994. [PMID: 32315215 DOI: 10.1152/ajpendo.00513.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chlamydia trachomatis infection is a primary cause of reproductive tract diseases including infertility. Previous studies showed that this infection alters physiological activities in mouse oviducts. Whether this occurs in the uterus and cervix has never been investigated. This study characterized the physiological activities of the uterine horn and the cervix in a Chlamydia muridarum (Cmu)-infected mouse model at three infection time points of 7, 14, and 21 days postinfection (dpi). Cmu infection significantly decreased contractile force of spontaneous contraction in the cervix (7 and 14 dpi; P < 0.001 and P < 0.05, respectively), but this effect was not observed in the uterine horn. The responses of the uterine horn and cervix to oxytocin were significantly altered by Cmu infection at 7 dpi (P < 0.0001), but such responses were attenuated at 14 and 21 dpi. Cmu infection increased contractile force to prostaglandin (PGF2α) by 53-83% in the uterine horn. This corresponded with the increased messenger ribonucleic acid (mRNA) expression of Ptgfr that encodes for its receptor. However, Cmu infection did not affect contractions of the uterine horn and cervix to PGE2 and histamine. The mRNA expression of Otr and Ptger4 was inversely correlated with the mRNA expression of Il1b, Il6 in the uterine horn of Cmu-inoculated mice (P < 0.01 to P < 0.001), suggesting that the changes in the Otr and Ptger4 mRNA expression might be linked to the changes in inflammatory cytokines. Lastly, this study also showed a novel physiological finding of the differential response to PGE2 in mouse uterine horn and cervix.
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Affiliation(s)
- Jia Ming Lee
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Jemma R Mayall
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Anne Chevalier
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Huw McCarthy
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Dirk Van Helden
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Philip M Hansbro
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
- Centenary Institute and the University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jay C Horvat
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Phillip Jobling
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Du L, Zhang LH, Zheng Q, Xie HN, Gu YJ, Lin MF, Wu LH. Evaluation of Cervical Elastography for Prediction of Spontaneous Preterm Birth in Low-Risk Women: A Prospective Study. J Ultrasound Med 2020; 39:705-713. [PMID: 31626344 DOI: 10.1002/jum.15149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/13/2019] [Accepted: 09/21/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether cervical elastographic parameters in addition to cervical length (CL) during the 3 trimesters of pregnancy would be predictive of spontaneous preterm birth (sPTB) among low-risk women. METHODS This work was a prospective nested case-control study evaluating cervical elastographic parameters and CL in low-risk women during the 3 trimesters of pregnancy. A binary logistic regression analysis was used to calculate significant covariates for prediction of sPTB. The area under the curve of the prediction model was calculated by using a receiver operating characteristic curve. RESULTS There were 286 women (26 cases and 260 controls) included in the analysis. The parameters of cervical elasticity became softened and heterogeneous during the 3 trimesters of pregnancy in both women with and without sPTB. The differences in the mean strain value at the internal os of the cervix (IOS), ratio (strain ratio of the internal os to the external os) during the second trimester and the IOS during the third trimester between the groups had statistical significance (P < .01; P = .01; P < .01, respectively). The CL had no association with sPTB during the 3 trimesters. The IOS during the second trimester was a better predictor of sPTB, with an area under the curve of 0.730, and sensitivity was 72.73%. CONCLUSIONS We observed multiple elastographic parameters and demonstrated the physiologic changes in the cervix during the 3 trimesters of pregnancy. Furthermore, we found that the IOS during the second trimester can be helpful in predicting sPTB. However, the CL had no association with sPTB during the 3 trimesters of pregnancy.
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Affiliation(s)
- Liu Du
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-He Zhang
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiao Zheng
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hong-Ning Xie
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu-Jun Gu
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mei-Fang Lin
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-Hong Wu
- Department of Ultrasonic Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Price JT, Phiri WM, Freeman BL, Vwalika B, Winston J, Mabula-Bwalya CM, Mulenga HB, Stringer JSA. Vaginal progesterone to prevent preterm delivery among HIV-infected pregnant women in Zambia: A feasibility study. PLoS One 2020; 15:e0224874. [PMID: 31995557 PMCID: PMC6988922 DOI: 10.1371/journal.pone.0224874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/22/2019] [Indexed: 01/08/2023] Open
Abstract
Antenatal vaginal progesterone (VP) reduces the risk of preterm birth (PTB) in women with shortened cervical length, and we hypothesize that it may also prevent PTB in women with HIV as their primary risk factor. We conducted a pilot feasibility study in Lusaka, Zambia to investigate uptake, adherence, and retention in preparation for a future efficacy trial. This was a double-masked, placebo-controlled, randomized trial of 200mg daily self-administered VP suppository or placebo. Pregnant women with HIV who were initiating or continuing antiretroviral therapy were eligible for participation. Potential participants underwent ultrasound to assess eligibility; we excluded those ≥24 gestational weeks, with non-viable, multiple gestation, or extrauterine pregnancies, with short cervix (<2.0cm), or with prior spontaneous PTB. Participants initiated study product between 20–24 weeks of gestation and continued to 37 weeks (or delivery, if sooner). The primary outcome was adherence (proportion achieving ≥80% study product use), assessed by dye stain assay of returned single-use vaginal applicators. Secondary outcomes with pre-defined feasibility targets were: uptake (≥50% eligible participants enrolled) and retention (≥90% ascertainment of delivery outcomes). We also evaluated preliminary efficacy by comparing the risk of spontaneous PTB <37 weeks between groups. From July 2017 to June 2018, 208 HIV-infected pregnant women were eligible for screening and 140 (uptake = 67%) were randomly allocated to VP (n = 70) or placebo (n = 70). Mean adherence was 94% (SD±9.4); 91% (n = 125/137) achieved overall adherence ≥80%. Delivery outcomes were ascertained from 134 (96%) participants. Spontaneous PTB occurred in 10 participants (15%) receiving placebo and 8 (12%) receiving progesterone (RR 0.82; 95%CI:0.34–1.97). Spontaneous PTB < 34 weeks occurred in 6 (9%) receiving placebo and 4 (6%) receiving progesterone (RR 0.67; 95%CI:0.20–2.67). In contrast to findings from vaginal microbicide studies in HIV-uninfected, non-pregnant women, our trial participants were highly adherent to daily self-administered vaginal progesterone. The study’s a priori criteria for uptake, adherence, and retention were met, indicating that a phase III efficacy trial would be feasible.
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Affiliation(s)
- Joan T. Price
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
- * E-mail:
| | | | - Bethany L. Freeman
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jennifer Winston
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Jeffrey S. A. Stringer
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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8
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Rottenstreich A, Levin G, Kleinstern G, Zigron R, Rottenstreich M, Elchalal U, Yagel S. History-indicated cervical cerclage in management of twin pregnancy. Ultrasound Obstet Gynecol 2019; 54:517-523. [PMID: 30549119 DOI: 10.1002/uog.20192] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/20/2018] [Accepted: 12/06/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Cervical cerclage, when performed in twin gestation, has been reported to be associated with poor outcome. However, the role of first-trimester history-indicated cerclage among women with a twin pregnancy and a history of preterm birth has not been evaluated. The aim of this study was to assess pregnancy outcomes among women with a twin pregnancy who underwent first-trimester history-indicated cervical cerclage compared with outcomes in those managed expectantly. METHODS This was a retrospective matched case-control study. The study group comprised all women with a twin pregnancy who had undergone first-trimester history-indicated cerclage during the period 2006 to 2017 at Hadassah-Hebrew University Medical Center. A control group of women with a twin pregnancy who were managed expectantly was established by matching age, history of spontaneous preterm birth (20-36 weeks' gestation) and year of delivery. Pregnancy and delivery characteristics and neonatal outcomes were compared between the two groups. RESULTS Data from 82 women with a twin gestation were analyzed, of whom 41 underwent first-trimester history-indicated cerclage and 41 were matched controls who were managed expectantly. Gestational age at delivery was higher in the cerclage group than in those managed expectantly (median 35 vs 30 weeks; P < 0.0001). Rates of spontaneous preterm birth before 24 weeks (2.4% vs 19.5%; odds ratio (OR), 0.10 (95% CI, 0.01-0.87); P = 0.03), before 28 weeks (12.2% vs 34.1%; OR, 0.27 (95% CI, 0.09-0.84); P = 0.03), before 32 weeks (22.0% vs 56.1%; OR, 0.22 (95% CI, 0.08-0.58); P = 0.003) and before 34 weeks (34.1% vs 82.9%; OR, 0.11 (95% CI, 0.04-0.30); P < 0.0001) were significantly lower in the cerclage group than in the control group. Median birth weight was higher in the cerclage group (2072 g vs 1750 g; P = 0.003), with lower rates of low birth weight (< 2500 g) (65.0% vs 89.4%; P = 0.001) and very low birth weight (< 1500 g) (21.3% vs 37.9%; P = 0.03) than in the group managed expectantly. Rates were also lower in the cerclage group for stillbirth, admission to the neonatal intensive care unit, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal mortality and composite adverse neonatal outcome. CONCLUSIONS History-indicated cerclage performed in the first trimester, as compared with expectant management, in women with a twin pregnancy had an overall positive effect on pregnancy and neonatal outcomes. These findings suggest the need for adequate randomized trials on cerclage placement in this subset of women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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MESH Headings
- Adult
- Case-Control Studies
- Cerclage, Cervical/adverse effects
- Cerclage, Cervical/methods
- Cervix Uteri/physiopathology
- Cervix Uteri/surgery
- Female
- Gestational Age
- Humans
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/mortality
- Intensive Care Units, Neonatal/statistics & numerical data
- Pregnancy
- Pregnancy Outcome
- Pregnancy Trimester, First/physiology
- Pregnancy, Twin/statistics & numerical data
- Premature Birth/surgery
- Retrospective Studies
- Stillbirth/epidemiology
- Uterine Cervical Incompetence/epidemiology
- Uterine Cervical Incompetence/surgery
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Affiliation(s)
- A Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Kleinstern
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - R Zigron
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - M Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - U Elchalal
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Yagel
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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9
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Massó P, Callejas A, Melchor J, Molina FS, Rus G. In Vivo Measurement of Cervical Elasticity on Pregnant Women by Torsional Wave Technique: A Preliminary Study. Sensors (Basel) 2019; 19:s19153249. [PMID: 31344796 PMCID: PMC6696138 DOI: 10.3390/s19153249] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/18/2019] [Accepted: 07/22/2019] [Indexed: 12/12/2022]
Abstract
A torsional wave (TW) sensor prototype was employed to quantify stiffness of the cervix in pregnant women. A cross-sectional study in a total of 18 women between 16 weeks and 35 weeks + 5 days of gestation was performed. The potential of TW technique to assess cervical ripening was evaluated by the measurement of stiffness related to gestational age and cervical length. Statistically significant correlations were found between cervical stiffness and gestational age (R2=0.370, p=0.0074, using 1 kHz waves and R2=0.445, p=0.0250, using 1.5 kHz waves). A uniform decrease in stiffness of the cervical tissue was confirmed to happen during the complete gestation. There was no significant correlation between stiffness and cervical length. A stronger association between gestational age and cervical stiffness was found compared to gestational age and cervical length correlation. As a conclusion, TW technique is a feasible approach to objectively quantify the decrease of cervical stiffness related to gestational age. Further research is required to evaluate the application of TW technique in obstetric evaluations, such as prediction of preterm delivery and labor induction failure.
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Affiliation(s)
- Paloma Massó
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- San Cecilio University Hospital, 18016 Granada, Spain
| | - Antonio Callejas
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- Department of Structural Mechanics, University of Granada, 18071 Granada, Spain
| | - Juan Melchor
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain.
- Department of Structural Mechanics, University of Granada, 18071 Granada, Spain.
- Excellence Research Unit, "Modelling Nature" (MNat), University of Granada, 18071 Granada, Spain.
| | - Francisca S Molina
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- San Cecilio University Hospital, 18016 Granada, Spain
| | - Guillermo Rus
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- Department of Structural Mechanics, University of Granada, 18071 Granada, Spain
- Excellence Research Unit, "Modelling Nature" (MNat), University of Granada, 18071 Granada, Spain
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10
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Abstract
BACKGROUND The aim of the study was to evaluate the diagnostic accuracy of cervical elastography in predicting preterm delivery (PTD). METHODS We searched the PubMed, EMBASE, and Cochrane databases to identify relevant studies that applied ultrasound (US) elastography to assess cervical stiffness and predict PTD. All the studies were published before December 11, 2018, and only studies published in English were collected. The cervical length (CL) was considered a comparator, and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was applied to assess the quality of the included studies. Summary receiver operating characteristic (SROC) modeling was performed to evaluate the diagnostic performance of cervical elastography in predicting PTD. Subgroup analyses were also performed. RESULTS Seven studies, including 1488 pregnant women, were included in this meta-analysis. Cervical elastography showed a summary sensitivity of 0.84 [95% confidence interval (CI): 0.68, 0.93], a specificity of 0.82 (95% CI: 0.63, 0.93), a diagnostic odds ratio of 25 (95% CI: 7, 93), and an area under the curve (AUC) of SROC of 0.90 (95% CI: 0.87-0.93). CL measurement showed that the AUC of SROC was 0.60 (95% CI: 0.56-0.64). The results of subgroup analysis showed that the summary sensitivity and specificity were different in the QUADAS-2 score subgroups. CONCLUSION Cervical elastography is a promising and reliable method to predict PTD. Cervical elastography showed better diagnostic performance to predict PTD than CL measurement.
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Affiliation(s)
- Bo Wang
- Department of Ultrasonic Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang
| | - Yong Zhang
- Department of Nephrology, The First Affiliated Hospital of Yangtze University, Jingzhou
| | - Shuangshuang Chen
- Department of Ultrasonic Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang
| | - Xiaowei Xiang
- Department of Ultrasonic Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang
| | - Juan Wen
- Department of Ultrasonic Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang
| | - Mei Yi
- Department of Ultrasonic Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang
| | - Baiyun He
- Department of Gynecology and Obstetrics, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, PR China
| | - Bing Hu
- Department of Ultrasonic Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang
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11
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Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is most commonly associated with small cell lung carcinoma, while it is rarely associated with gynecological and breast carcinoma. We herein report a case of LEMS associated with synchronous double cancer, which was a combination of small cell carcinoma of the cervix and breast carcinoma. The early diagnosis and treatment of LEMS are important for achieving a good outcome. The possibility of accompanying paraneoplastic neurological syndrome must be sufficiently considered in gynecology and breast cancer patients. To our knowledge, this is the first report of LEMS associated with synchronous double cancer.
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Affiliation(s)
- Hiroyuki Fukuda
- Division of Neurology, Shizuoka Cancer Center Hospital, Japan
| | - Akira Tanaka
- Division of Gynecology, Shizuoka Cancer Center Hospital, Japan
- Department of Obstetrics and Gynecology, Chutoen General Medical Center, Japan
| | | | - Ichiro Ito
- Division of Pathology, Shizuoka Cancer Center Hospital, Japan
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12
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Abstract
Cervical length (CL) measured by transvaginal ultrasound examination (TVUE) best identifies the risk for preterm birth (PTB). It identifies women at risk who can benefit from corticosteroids or in utero transfer. Early screening improves effectiveness of tocolysis. It reduces iatrogenicity and cost. In preterm premature rupture of membranes (PPROM), CL is devoid of infectious risk and predicts duration of the latency phase but not the risk of perinatal sepsis. Asymptomatic women at risk should be screened at a 2-week interval starting from 16 to 18 weeks, up to 24 weeks. CLs <10th centile are at risk of PTB, especially with decrease in CL after 16 weeks. Repeat ultrasound improves predictive values. Stable CL calls for term delivery. Funneling does not improve predictivity of CL. In twin pregnancies, CL reduces unnecessary interventions. In symptomatic women, fetal fibronectin performs less than CL. Its combination with inconclusive CL has not emerged productive through randomized controlled trials (RCTs), and studies with homogeneous management for preterm labor (PTL) suggest that up to 15% of unjustified hospitalizations and treatment could be avoided.
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Affiliation(s)
- Yves Ville
- Université Paris Descartes, EHU-PACT, Department of Obstetrics and Fetal Medicine, Hôpital Necker Enfants-Malades, 149 rue de Sèvres, 75015, Paris, France.
| | - Patrick Rozenberg
- Université Versailles Saint-Quentin, Department of Obstetrics and Gynecology, Hôpital Intercommunal de Poissy, France
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13
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Abstract
Approximately one in ten (approximately 500,000) pregnancies results in preterm birth (PTB) annually in the United States. Although we have seen a slight decrease in the U.S. PTB rate between 2007 and 2014, data from 2014 to 2015 shows the preterm birth rate has slightly increased. It is even more intriguing to note that the rate of PTB has not significantly decreased since the 1980s. In order to decrease the rate of spontaneous preterm birth (sPTB), it is imperative that we improve our understanding of normal and abnormal reproductive tissue structure and function and how these tissues interact with each other at a cellular and biochemical level. Since other chapters in this issue will be focusing on the myometrium and fetal membranes, the goal of this chapter is to focus on the compartment of the cervix. We will review the current literature on normal and abnormal human cervical tissue remodeling and identify gaps in knowledge. Our goal is also to introduce a revised paradigm of normal cervical tissue structure and function which will provide novel research opportunities that may ultimately lead to developing safe and effective interventions to significantly decrease the rate and complications of prematurity.
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Affiliation(s)
- Joy Vink
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 West 168th St, PH16-66, New York, NY 10025.
| | - Mirella Mourad
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 West 168th St, PH16-66, New York, NY 10025
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14
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Saccone G, Ciardulli A, Xodo S, Dugoff L, Ludmir J, Pagani G, Visentin S, Gizzo S, Volpe N, Maruotti GM, Rizzo G, Martinelli P, Berghella V. Cervical Pessary for Preventing Preterm Birth in Singleton Pregnancies With Short Cervical Length: A Systematic Review and Meta-analysis. J Ultrasound Med 2017; 36:1535-1543. [PMID: 28398701 DOI: 10.7863/ultra.16.08054] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/12/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with a second trimester short cervix. METHODS Electronic databases were searched from their inception until February 2016. We included randomized clinical trials (RCTs) comparing the use of the cervical pessary with expectant management in singletons pregnancies with transvaginal ultrasound cervical length (TVU CL) ≤25 mm. The primary outcome was incidence of SPTB <34 weeks. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI). RESULTS Three RCTs (n = 1,420) were included. The mean gestational age (GA) at randomization was approximately 22 weeks. The Arabin pessary was used as intervention in all three trials, and was removed by vaginal examination at approximately 37 weeks. Cervical pessary was not associated with prevention of SPTB <37 (20.2% vs 50.2%; RR 0.50, 95% CI 0.23 to 1.09), <34, <32, and <28 weeks, compared to no pessary. No differences were found in the mean of GA at, interval from randomization to delivery, incidence of preterm premature rupture of membranes and of cesarean delivery, and in neonatal outcomes. The Arabin pessary was associated with a significantly higher risk of vaginal discharge. CONCLUSIONS In singleton pregnancies with a TVU CL ≤25mm at 200 -246 weeks, the Arabin pessary does not reduce the rate of spontaneous preterm delivery or improve perinatal outcome. Individual patient data meta-analysis may clarify whether cervical pessary may be beneficial in subgroups, such as only singleton gestations without prior SPTB or by different CL cutoffs.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
| | - Andrea Ciardulli
- Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, Italy
| | - Serena Xodo
- Department of Gynaecology and Obstetrics, School of Medicine, University of Udine, Udine, Italy
| | - Lorraine Dugoff
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Reproductive Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jack Ludmir
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giorgio Pagani
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Maternal and Fetal Health, Fondazione Poliambulanza, Brescia, Italy
| | - Silvia Visentin
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Woman's and Child's Health, University of Padua, Padua, Italy
| | - Salvatore Gizzo
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Woman's and Child's Health, University of Padua, Padua, Italy
| | - Nicola Volpe
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Feto-Maternal Medicine Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
| | - Giuseppe Rizzo
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Rome, Italy
| | - Pasquale Martinelli
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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15
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Lee SM, Park KH, Jung EY, Jang JA, Yoo HN. Frequency and clinical significance of short cervix in patients with preterm premature rupture of membranes. PLoS One 2017; 12:e0174657. [PMID: 28358839 PMCID: PMC5373606 DOI: 10.1371/journal.pone.0174657] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/13/2017] [Indexed: 12/31/2022] Open
Abstract
Objective Cervical length measurement has been uggested as a useful tool for predicting intra-amniotic infection/inflammation in preterm labor, but little information is available in the setting of preterm premature rupture of membranes (pPROM). We aimed to determine whether a short cervical length is independently associated with an increased risk of intra-amniotic infection or inflammation and impending preterm delivery in women with pPROM. Methods This was a retrospective cohort study involving 171 consecutive singleton pregnant women with pPROM (21+0–33+6 weeks’ gestation), who underwent amniocentesis. Amniotic fluid (AF) was cultured, and assayed for interleukin (IL)-6 and IL-8. Cervical length was measured at the time of amniocentesis by transvaginal ultrasonography with an aseptic technique. Short cervical length was defined as a cervical length of ≤15 mm. Intra-amniotic infection was defined as a positive AF culture for microorganisms and intra-amniotic inflammation was defined as elevated AF concentrations of IL-6 or IL-8 (IL-6 ≥1.5 ng/mL and/or IL-8 ≥1.3 ng/mL). Results Fifty (29.2%) women had a sonographic cervical length of ≤15mm. On univariate analysis, short cervical length was associated with an increased risk for intra-amniotic infection and/or inflammation; no other parameters studied showed a significant association. Multivariable analyses indicated that short cervical length was significantly associated with a higher risk of impending preterm delivery (within 2 days of measurement, within 7 days of measurement, and before 34 weeks), and remained significant after adjustment for potential confounders. Conclusion In women with pPROM, short cervical length is associated with an increased risk for intra-amniotic infection/inflammation and associated with impending preterm delivery, independent of the presence of intra-amniotic infection/inflammation.
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Affiliation(s)
- Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Kyo Hoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- * E-mail:
| | - Eun Young Jung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Ae Jang
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ha-Na Yoo
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
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16
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Verbruggen SW, Oyen ML, Phillips ATM, Nowlan NC. Function and failure of the fetal membrane: Modelling the mechanics of the chorion and amnion. PLoS One 2017; 12:e0171588. [PMID: 28350838 PMCID: PMC5370055 DOI: 10.1371/journal.pone.0171588] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/22/2017] [Indexed: 12/31/2022] Open
Abstract
The fetal membrane surrounds the fetus during pregnancy and is a thin tissue composed of two layers, the chorion and the amnion. While rupture of this membrane normally occurs at term, preterm rupture can result in increased risk of fetal mortality and morbidity, as well as danger of infection in the mother. Although structural changes have been observed in the membrane in such cases, the mechanical behaviour of the human fetal membrane in vivo remains poorly understood and is challenging to investigate experimentally. Therefore, the objective of this study was to develop simplified finite element models to investigate the mechanical behaviour and rupture of the fetal membrane, particularly its constituent layers, under various physiological conditions. It was found that modelling the chorion and amnion as a single layer predicts remarkably different behaviour compared with a more anatomically-accurate bilayer, significantly underestimating stress in the amnion and under-predicting the risk of membrane rupture. Additionally, reductions in chorion-amnion interface lubrication and chorion thickness (reported in cases of preterm rupture) both resulted in increased membrane stress. Interestingly, the inclusion of a weak zone in the fetal membrane that has been observed to develop overlying the cervix would likely cause it to fail at term, during labour. Finally, these findings support the theory that the amnion is the dominant structural component of the fetal membrane and is required to maintain its integrity. The results provide a novel insight into the mechanical effect of structural changes in the chorion and amnion, in cases of both normal and preterm rupture.
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Affiliation(s)
- Stefaan W. Verbruggen
- Department of Bioengineering, Imperial College London, London, United Kingdom
- * E-mail:
| | - Michelle L. Oyen
- Engineering Department, University of Cambridge, Trumpington Street, Cambridge, United Kingdom
| | - Andrew T. M. Phillips
- Structural Biomechanics, Department of Civil and Environmental Engineering, Imperial College London, London, United Kingdom
| | - Niamh C. Nowlan
- Department of Bioengineering, Imperial College London, London, United Kingdom
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17
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Polanco Rodríguez ÁG, Riba López MI, DelValls Casillas TÁ, Araujo León JA, Mahjoub O, Prusty AK. Monitoring of organochlorine pesticides in blood of women with uterine cervix cancer. Environ Pollut 2017; 220:853-862. [PMID: 27876223 DOI: 10.1016/j.envpol.2016.10.068] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 10/23/2016] [Accepted: 10/23/2016] [Indexed: 06/06/2023]
Abstract
In Yucatan, Mexico, chronic exposure of Mayan population to pesticides is expected as about 30 per cent are drinking polluted water. Residues of organochlorine pesticides (OCP) were monitored in 18 municipalities of Yucatan with high mortality rates due to uterine cervix cancer. 70 blood samples collected from Mayan women living in livestock, agricultural and metropolitan area were analyzed for OCP. Solid Phase Extraction was performed on C18 cartridges and analyzed by Gas Chromatography with Electron Capture Detector. The results showed that the highest OCP levels were detected in blood of women living in the livestock area. OCP detected were endosulfan I (7.35 μg/mL), aldrin (3.69 μg/mL), 4,4' DDD (2.33 μg/mL), 1.39 and 1.46 μg/mL of δ-HCH. Women from the agricultural area had high concentrations of OCP in their blood, particularly dieldrin (1.19 μg/mL), and 1.26 μg/mL of 4,4' DDE. In the metropolitan area, 0.080 μg/mL of γ-HCH and 0.064 μg/mL of heptachlore were detected. This monitoring study was also based on epidemiological data of uterine cervical cancer. It was found that environmental factors may have facilitated the infiltration of OCP to the aquifer used for potable water supply. These factors in addition to poverty can have impacts on public health. This first exploratory study suggests that monitoring of OCP in human is important for the establishment of health promotion programs. The integrative analysis of both, environmental and social factors would be helpful to characterize the bioaccumulation of pesticides in humans.
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Affiliation(s)
- Ángel G Polanco Rodríguez
- Laboratorio de Medicina Social y Salud Pública, Centro de Investigaciones Regionales, Universidad Autónoma de Yucatán, Av. Itzáez x 59 #490, Centro, C.P. 97000, Mérida, Yucatán, Mexico.
| | - M Inmaculada Riba López
- UNESCO/UNITWIN Wicop, Departamento de Química Física, Facultad de Ciencias del Mar y Ambientales, Universidad de Cádiz, Puerto Real, Cádiz, Spain
| | - T Ángel DelValls Casillas
- UNESCO/UNITWIN Wicop, Departamento de Química Física, Facultad de Ciencias del Mar y Ambientales, Universidad de Cádiz, Puerto Real, Cádiz, Spain
| | - J Alfredo Araujo León
- Laboratorio de Cromatografía, Facultad de Química, Universidad Autónoma de Yucatán, C. 43 No. 613 x C. 90 Col. Inalámbrica, C.P. 97069, Mérida, Yucatán, Mexico
| | - Olfa Mahjoub
- National Research Institute for Rural Engineering, Water, and Forestry, Hédi Karrai Street, P.O. Box 10, 2080, Ariana, Tunisia
| | - Anjan Kumar Prusty
- Environmental Impact Assessment Division, Gujarat Institute of Desert Ecology, Post Box - 83, Mundra Road, Opp. Changleshwar Temple, Bhuj 370001, Gujarat, India
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18
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Meyberg-Solomayer G, Gerlinger C, Hamza A, Schlaegel F, Takacs Z, Solomayer EF. Cervical Strain Elastography in Pregnancy and Association with Maternal Factors. Ultraschall Med 2017; 38:71-77. [PMID: 25734411 DOI: 10.1055/s-0034-1398991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Purpose To assess cervical elasticity in different regions by sonoelastography, to compare the results to the Bishop score, cervical length, week of pregnancy and other maternal factors (age, weight, parity) and to evaluate the reproducibility of the method. Materials and Methods 131 patients between 17 - 41 gestational weeks were examined by transvaginal cervical strain elastography. In the sagittal view strain values were calculated in 7 regions of interest (ROI; external and internal os anterior/posterior, middle part anterior/posterior, cervical canal). In the cross sectional views strain values in 3 ROIs were evaluated at the level of the internal and external cervical os (anterior/posterior, cervical canal). The intra- and interobserver variance was tested. Results Strain values differed highly significantly in different parts of the cervix (p < 0.001). The anterior parts and the cervical canal were significantly softer with increasing gestational age and Bishop score, and the posterior parts were significantly harder with increasing maternal age, weight, parity. Cervical length showed an inverse relationship to cervical softness. The intra- and interobserver variance was low. Conclusion Elastography is a reproducible method for the evaluation of cervical elasticity in pregnancy. It showed a significant association with the Bishop score and other maternal factors and could provide additional information about changes in cervical stiffness in pregnancy.
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Affiliation(s)
| | | | - Amr Hamza
- OB/Gyn, University of Saarland, Homburg, Germany
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19
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Rodpenpear N. Tuberculosis of Cervix Resembling Cervical Cancer. J Med Assoc Thai 2016; 99 Suppl 8:S249-S252. [PMID: 29906057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A rare case of 40-years-old women presented with yellow-white and clear yellow mucous vaginal discharge, foul smell and itching per vagina 7 months ago. She had pleuritic chest pain and amenorrhea for 2 years. The cervix revealed a hyperemic, irregular in outline, ulcerated, and contact bleeding that similar to cervical cancer. The colposcopic examination showed acetowhite epithelium. Cervical biopsy revealed granulomatous inflammation. Cervical tissue culture was Mycobacterial tuberculosis. Standard anti-tuberculotic drugs treated patient’s disease for 6 months. The abnormal vaginal discharge, cervical lesion and chest pain were resolved. Tuberculosis should be an important differential diagnosis of the malignantappearing cervical lesion in the area that high prevalence of disease, especially Thailand.
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20
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Vink JY, Qin S, Brock CO, Zork NM, Feltovich HM, Chen X, Urie P, Myers KM, Hall TJ, Wapner R, Kitajewski JK, Shawber CJ, Gallos G. A new paradigm for the role of smooth muscle cells in the human cervix. Am J Obstet Gynecol 2016; 215:478.e1-478.e11. [PMID: 27166013 DOI: 10.1016/j.ajog.2016.04.053] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/14/2016] [Accepted: 04/29/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Premature cervical remodeling resulting in spontaneous preterm birth may begin with premature failure or relaxation at the internal os (termed "funneling"). To date, we do not understand why the internal os fails or why funneling occurs in some cases of premature cervical remodeling. Although the human cervix is thought to be mostly collagen with minimal cellular content, cervical smooth muscle cells are present in the cervix and can cause cervical tissue contractility. OBJECTIVE To understand why the internal os relaxes or why funneling occurs in some cases of premature cervical remodeling, we sought to evaluate cervical smooth muscle cell content and distribution throughout human cervix and correlate if cervical smooth muscle organization influences regional cervical tissue contractility. STUDY DESIGN Using institutional review board-approved protocols, nonpregnant women <50 years old undergoing hysterectomy for benign indications were consented. Cervical tissue from the internal and external os were immunostained for smooth muscle cell markers (α-smooth muscle actin, smooth muscle protein 22 calponin) and contraction-associated proteins (connexin 43, cyclooxygenase-2, oxytocin receptor). To evaluate cervical smooth muscle cell morphology throughout the entire cervix, whole cervical slices were obtained from the internal os, midcervix, and external os and immunostained with smooth muscle actin. To correlate tissue structure with function, whole slices from the internal and external os were stimulated to contract with 1 μmol/L of oxytocin in organ baths. In separate samples, we tested if the cervix responds to a common tocolytic, nifedipine. Cervical slices from the internal os were treated with oxytocin alone or oxytocin + increasing doses of nifedipine to generate a dose response and half maximal inhibitory concentration. Student t test was used where appropriate. RESULTS Cervical tissue was collected from 41 women. Immunohistochemistry showed cervical smooth muscle cells at the internal and external os expressed mature smooth muscle cell markers and contraction-associated proteins. The cervix exhibited a gradient of cervical smooth muscle cells. The area of the internal os contained 50-60% cervical smooth muscle cells that were circumferentially organized in the periphery of the stroma, which may resemble a sphincter-like pattern. The external os contained approximately 10% cervical smooth muscle cells that were randomly scattered in the tissue. In organ bath studies, oxytocin stimulated the internal os to contract with more than double the force of the external os (1341 ± 693 vs 523 ± 536 integrated grams × seconds, respectively, P = .009). Nifedipine significantly decreased cervical tissue muscle force compared to timed vehicle control (oxytocin alone) at doses of 10(-5) mol/L (vehicle 47% ± 15% vs oxytocin + nifedipine 24% ± 16%, P = .007), 10(-4) mol/L (vehicle 46% ± 16% vs oxytocin + nifedipine -4% ± 20%, P = .003), and 10(-3) mol/L (vehicle 42% ± 14% vs oxytocin + nifedipine -15% ± 18%, P = .0006). The half maximal inhibitory concentration for nifedipine was 1.35 × 10(-5) mol/L. CONCLUSION Our findings suggest a new paradigm for cervical tissue morphology-one that includes the possibility of a specialized sphincter at the internal os. This new paradigm introduces novel avenues to further investigate potential mechanisms of normal and premature cervical remodeling.
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Affiliation(s)
- Joy Y Vink
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY.
| | - Sisi Qin
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Clifton O Brock
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Noelia M Zork
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Helen M Feltovich
- Department of Maternal-Fetal Medicine, Intermountain Healthcare, Provo, UT; Medical Physics Department, University of Wisconsin, Madison, WI
| | - Xiaowei Chen
- Department of Pathology, Columbia University Medical Center, New York, NY
| | - Paul Urie
- Department of Pathology, Intermountain Healthcare, Provo, UT
| | - Kristin M Myers
- Department of Mechanical Engineering, Columbia University, New York, NY
| | - Timothy J Hall
- Medical Physics Department, University of Wisconsin, Madison, WI
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Jan K Kitajewski
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Carrie J Shawber
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - George Gallos
- Department of Anesthesia, Columbia University Medical Center, New York, NY
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Lamblin G, Mayeur O, Giraudet G, Jean Dit Gautier E, Chene G, Brieu M, Rubod C, Cosson M. Pathophysiological aspects of cystocele with a 3D finite elements model. Arch Gynecol Obstet 2016; 294:983-989. [PMID: 27402504 DOI: 10.1007/s00404-016-4150-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/06/2016] [Indexed: 01/01/2023]
Abstract
PURPOSES The objective of this study is to design a 3D biomechanical model of the female pelvic system to assess pelvic organ suspension theories and understand cystocele mechanisms. METHODS A finite elements (FE) model was constructed to calculate the impact of suspension structure geometry on cystocele. The sample was a geometric model of a control patient's pelvic organs. The method used geometric reconstruction, implemented by the biomechanical properties of each anatomic structure. Various geometric configurations were simulated on the FE method to analyse the role of each structure and compare the two main anatomic theories. RESULTS The main outcome measure was a 3D biomechanical model of the female pelvic system. The various configurations of bladder displacement simulated mechanisms underlying medial, lateral and apical cystocele. FE simulation revealed that pubocervical fascia is the most influential structure in the onset of median cystocele (essentially after 40 % impairment). Lateral cystocele showed a stronger influence of arcus tendineus fasciae pelvis (ATFP) on vaginal wall displacement under short ATFP lengthening. In apical cystocele, the uterosacral ligament showed greater influence than the cardinal ligament. Suspension system elongation increased displacement by 25 % in each type of cystocele. CONCLUSIONS A 3D digital model enabled simulations of anatomic structures underlying cystocele to better understand cystocele pathophysiology. The model could be used to predict cystocele surgery results and personalising technique by preoperative simulation.
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Affiliation(s)
- Géry Lamblin
- Department of Urogynecology, HFME, HCL, Femme Mère Enfant University Hospital, 59 Boulevard Pinel, Lyon-Bron, 69677, Bron, France.
- University of Claude Bernard Lyon 1, Villeurbanne, France.
- University of Medicine Henri Warembourg, Lille University, Villeneuve-d'Ascq, France.
| | - Olivier Mayeur
- FRE 3723-LML-Laboratoire de Mécanique de Lille, Univ. Lille, 59000, Lille, France
- Centrale Lille, Cité Scientifique CS 20048, 59000, Lille, France
| | - Géraldine Giraudet
- University of Medicine Henri Warembourg, Lille University, Villeneuve-d'Ascq, France
- Department of Urogynecology, Jeanne de Flandre Hospital, Lille, France
- Lille 2 University, Lille, France
| | - Estelle Jean Dit Gautier
- University of Medicine Henri Warembourg, Lille University, Villeneuve-d'Ascq, France
- Department of Urogynecology, Jeanne de Flandre Hospital, Lille, France
- Lille 2 University, Lille, France
| | - Gautier Chene
- Department of Urogynecology, HFME, HCL, Femme Mère Enfant University Hospital, 59 Boulevard Pinel, Lyon-Bron, 69677, Bron, France
- University of Claude Bernard Lyon 1, Villeurbanne, France
| | - Mathias Brieu
- FRE 3723-LML-Laboratoire de Mécanique de Lille, Univ. Lille, 59000, Lille, France
- Centrale Lille, Cité Scientifique CS 20048, 59000, Lille, France
| | - Chrystèle Rubod
- University of Medicine Henri Warembourg, Lille University, Villeneuve-d'Ascq, France
- FRE 3723-LML-Laboratoire de Mécanique de Lille, Univ. Lille, 59000, Lille, France
- Department of Urogynecology, Jeanne de Flandre Hospital, Lille, France
- Lille 2 University, Lille, France
| | - Michel Cosson
- University of Medicine Henri Warembourg, Lille University, Villeneuve-d'Ascq, France
- FRE 3723-LML-Laboratoire de Mécanique de Lille, Univ. Lille, 59000, Lille, France
- Department of Urogynecology, Jeanne de Flandre Hospital, Lille, France
- Lille 2 University, Lille, France
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Grobman WA, Lai Y, Iams JD, Reddy UM, Mercer BM, Saade G, Tita AT, Rouse DJ, Sorokin Y, Wapner RJ, Leveno KJ, Blackwell SC, Esplin MS, Tolosa JE, Thorp JM, Caritis SN. Prediction of Spontaneous Preterm Birth Among Nulliparous Women With a Short Cervix. J Ultrasound Med 2016; 35:1293-1297. [PMID: 27151903 PMCID: PMC5086428 DOI: 10.7863/ultra.15.08035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/30/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate whether demographic and sonographic factors associated with spontaneous preterm birth among nulliparous women with a cervical length of less than 30 mm could be combined into an accurate prediction model for spontaneous preterm birth. METHODS We conducted a secondary analysis of a trial of nulliparous women with a singleton gestation and a cervical length of less than 30 mm on transvaginal sonography between 16 and 22 weeks who lacked other risk factors for spontaneous (eg, prior cervical excisional procedure) or medically indicated (eg, chronic hypertension) preterm birth, who were randomized to either 17α-hydroxyprogesterone caproate treatment or a placebo. Risk factors associated with spontaneous preterm birth within the entire cohort were identified by univariable analysis. Factors significantly associated (P < .05) with spontaneous preterm birth were included in a multivariable logistic regression analysis to determine whether an accurate prediction model could be developed. RESULTS Of the 657 randomized patients, 109 (16.6%) had spontaneous preterm birth before 37 weeks' gestation. Logistic regression analysis revealed only cervical length (odds ratio, 1.06 per 1-mm decrease; 95% confidence interval, 1.02-1.10) to be associated with spontaneous preterm birth. The area under the receiver operating characteristic curve based on this regression was low (0.63; 95% confidence interval, 0.58-0.69). Results were similar for the outcome of spontaneous preterm birth before 34 weeks. CONCLUSIONS An accurate prediction model for spontaneous preterm birth among nulliparous women with a short cervix could not be developed.
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Affiliation(s)
- William A Grobman
- Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois USA
| | - Yinglei Lai
- George Washington University Biostatistics Center, Washington, DC USA
| | - Jay D Iams
- Ohio State University, Columbus, Ohio USA
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland USA
| | - Brian M Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio USA
| | - George Saade
- University of Texas Medical Branch, Galveston, Texas USA
| | - Alan T Tita
- University of Alabama at Birmingham, Birmingham, Alabama USA
| | | | | | | | - Kenneth J Leveno
- University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - Sean C Blackwell
- University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas USA
| | - M Sean Esplin
- University of Utah Health Sciences Center, Salt Lake City, Utah USA
| | - Jorge E Tolosa
- Oregon Health and Science University, Portland, Oregon USA
| | - John M Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
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Shin JE, Shin JC, Lee Y, Kim SJ. Serial Change in Cervical Length for the Prediction of Emergency Cesarean Section in Placenta Previa. PLoS One 2016; 11:e0149036. [PMID: 26863133 PMCID: PMC4749281 DOI: 10.1371/journal.pone.0149036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 01/26/2016] [Indexed: 11/19/2022] Open
Abstract
Purpose To evaluate whether serial change in cervical length (CL) over time can be a predictor for emergency cesarean section (CS) in patients with placenta previa. Methods This 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. Results A 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. Conclusions Previous 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.
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Affiliation(s)
- Jae Eun Shin
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Chul Shin
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Lee
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sa Jin Kim
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Sochacki-Wójcicka N, Wojcicki J, Bomba-Opon D, Wielgos M. Anterior cervical angle as a new biophysical ultrasound marker for prediction of spontaneous preterm birth. Ultrasound Obstet Gynecol 2015; 46:377-8. [PMID: 25627241 DOI: 10.1002/uog.14801] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/18/2015] [Accepted: 01/22/2015] [Indexed: 05/15/2023]
Affiliation(s)
- N Sochacki-Wójcicka
- Department of Obstetrics and Gynaecology, Medical University Warsaw, Warsaw, Poland
| | - J Wojcicki
- Department of Obstetrics and Gynaecology, Medical University Warsaw, Warsaw, Poland
| | - D Bomba-Opon
- Department of Obstetrics and Gynaecology, Medical University Warsaw, Warsaw, Poland
| | - M Wielgos
- Department of Obstetrics and Gynaecology, Medical University Warsaw, Warsaw, Poland
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25
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Myers KM, Feltovich H, Mazza E, Vink J, Bajka M, Wapner RJ, Hall TJ, House M. The mechanical role of the cervix in pregnancy. J Biomech 2015; 48:1511-23. [PMID: 25841293 PMCID: PMC4459908 DOI: 10.1016/j.jbiomech.2015.02.065] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 02/28/2015] [Indexed: 01/10/2023]
Abstract
Appropriate mechanical function of the uterine cervix is critical for maintaining a pregnancy to term so that the fetus can develop fully. At the end of pregnancy, however, the cervix must allow delivery, which requires it to markedly soften, shorten and dilate. There are multiple pathways to spontaneous preterm birth, the leading global cause of death in children less than 5 years old, but all culminate in premature cervical change, because that is the last step in the final common pathway to delivery. The mechanisms underlying premature cervical change in pregnancy are poorly understood, and therefore current clinical protocols to assess preterm birth risk are limited to surrogate markers of mechanical function, such as sonographically measured cervical length. This is what motivates us to study the cervix, for which we propose investigating clinical cervical function in parallel with a quantitative engineering evaluation of its structural function. We aspire to develop a common translational language, as well as generate a rigorous integrated clinical-engineering framework for assessing cervical mechanical function at the cellular to organ level. In this review, we embark on that challenge by describing the current landscape of clinical, biochemical, and engineering concepts associated with the mechanical function of the cervix during pregnancy. Our goal is to use this common platform to inspire novel approaches to delineate normal and abnormal cervical function in pregnancy.
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Affiliation(s)
- Kristin M Myers
- Department of Mechanical Engineering, Columbia University, New York, NY, USA.
| | - Helen Feltovich
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Provo, UT, USA; Department of Medical Physics, University of Wisconsin, Madison, WI, USA
| | - Edoardo Mazza
- Department of Mechanical and Process Engineering, ETH Zurich, & EMPA Dübendorf, Switzerland
| | - Joy Vink
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY USA
| | - Michael Bajka
- Department of Obstetrics and Gynecology, University Hospital of Zurich, Switzerland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY USA
| | - Timothy J Hall
- Department of Medical Physics, University of Wisconsin, Madison, WI, USA
| | - Michael House
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA, USA
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Abstract
Nitric oxide molecules serve as neurotransmitters to relax smooth muscle tension in many parts of the body. In humans and other mammals they play an important role for correct smooth muscle function in unusual locations. We previously described this mechanism (Stelzner, Chirurg. doi:10.1007/s00104-014-2777-z, 2014) using the occlusive mechanism of the upper and lower esophageal sphincters as an example. Cells producing nitric oxide can be found in the gastric fundus, the anorectal continence organ, vesicourethraltract and also in the uterine cervix in the final trimester of pregnancy. In all these locations they serve as elements of anatomical sphincter structures that have a paradoxical function. These observations confirm the points made in the introduction of this article on the stretch sphincter mechanism of the lower esophageal sphincter and the treatment of gastroesophageal reflux disease by retensioning of the esophagus in the diaphragmatic hiatus. In particular, high-resolution esophageal manometry of the lower esophageal sphincter can easily detect every functional disturbance caused by gastric plication and such changes were to be expected based on what we described in articles I and II.
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Affiliation(s)
- F Stelzner
- Chirurg. Univ.-Klinik Bonn, Zentrum für Chirurgie, Sigmund-Freud-Str. 25, 53127, Bonn-Venusberg, Deutschland,
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27
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Mazza E, Parra-Saavedra M, Bajka M, Gratacos E, Nicolaides K, Deprest J. In vivo assessment of the biomechanical properties of the uterine cervix in pregnancy. Prenat Diagn 2014; 34:33-41. [PMID: 24155152 DOI: 10.1002/pd.4260] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 10/14/2013] [Accepted: 10/17/2013] [Indexed: 02/02/2023]
Abstract
Measuring the stiffness of the cervix might be useful in the prediction of preterm delivery or successful induction of labor. For that purpose, a variety of methods for quantitative determination of physical properties of the pregnant cervix have been developed. Herein, we review studies on the clinical application of these new techniques. They are based on the quantification of mechanical, optical, or electrical properties associated with increased hydration and loss of organization in collagen structure. Quasi-static elastography determines relative values of stiffness; hence, it can identify differences in deformability. Quasi-static elastography unfortunately cannot quantify in absolute terms the stiffness of the cervix. Also, the current clinical studies did not demonstrate the ability to predict the time point of delivery. In contrast, measurement of maximum deformability of the cervix (e.g. quantified with the cervical consistency index) provided meaningful results, showing an increase in compliance with gestational age. These findings are consistent with aspiration measurements on the pregnant ectocervix, indicating a progressive decrease of stiffness along gestation. Cervical consistency index and aspiration measurements therefore represent promising techniques for quantitative assessment of the biomechanical properties of the cervix.
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28
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Gonzalez JM, Pedroni SMA, Girardi G. Statins prevent cervical remodeling, myometrial contractions and preterm labor through a mechanism that involves hemoxygenase-1 and complement inhibition. Mol Hum Reprod 2014; 20:579-89. [PMID: 24623738 DOI: 10.1093/molehr/gau019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Preterm birth (PTB) is a major public health problem, with a global prevalence of 9.6% and over a million annual neonatal deaths. In a mouse model of preterm labor (PTL) induced by intravaginal administration of a subclinical dose of lipopolysaccharide (LPS), we previously demonstrated that LPS ascends to the cervix, inducing complement activation, cervical remodeling and PTL. Here we show that complement activation also plays a role in myometrial contractions during PTL in this model. Increased levels of C5a were detected in the myometrium of LPS-treated mice but not in age-matched control or term myometrium. Human and mouse myometrium incubated with C5a showed increased frequency of contractions and expression of connexin 43, suggesting that C5a is an uterotonic molecule. Statins, which showed beneficial effects in preventing complement-mediated pregnancy complications, prevented cervical remodeling, myometrial contractions and PTL in the LPS model. The protective effects of statins in PTL were associated with increased synthesis, expression and activity of heme oxygenase (HO-1) in myometrium and cervix. Coadministration of HO-1 inhibitor tin-protoporphyrin-IX with pravastatin abrogated the protective effects of pravastatin on cervical remodeling and myometrial contractions leading to PTB. In addition, pravastatin inhibited complement activation in the cervix by increasing the synthesis and expression of complement inhibitor decay-accelerating factor. This study in mice suggests that statins might be useful to prevent PTL in humans. Clinical trials in humans are needed and if these results are confirmed, they may form the basis for a new clinical approach to prevent PTB.
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Affiliation(s)
- Juan M Gonzalez
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94117, USA
| | - Silvia M A Pedroni
- MRC Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK Clinical Sciences, Imperial College London, London W12 0NN, UK
| | - Guillermina Girardi
- MRC Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK MRC Centre for Inflammation Research, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK King's College London, St Thomas' Hospital, London SE1 7EH, UK
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Mourant JR, Marina OC, Hebert TM, Kaur G, Smith HO. Hemoglobin parameters from diffuse reflectance data. J Biomed Opt 2014; 19:37004. [PMID: 24671524 PMCID: PMC3966635 DOI: 10.1117/1.jbo.19.3.037004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/11/2014] [Accepted: 02/18/2014] [Indexed: 05/20/2023]
Abstract
Tissue vasculature is altered when cancer develops. Consequently, noninvasive methods of monitoring blood vessel size, density, and oxygenation would be valuable. Simple spectroscopy employing fiber optic probes to measure backscattering can potentially determine hemoglobin parameters. However, heterogeneity of blood distribution, the dependence of the tissue-volume-sampled on scattering and absorption, and the potential compression of tissue all hinder the accurate determination of hemoglobin parameters. We address each of these issues. A simple derivation of a correction factor for the absorption coefficient, μa, is presented. This correction factor depends not only on the vessel size, as others have shown, but also on the density of blood vessels. Monte Carlo simulations were used to determine the dependence of an effective pathlength of light through tissue which is parameterized as a ninth-order polynomial function of μa. The hemoglobin bands of backscattering spectra of cervical tissue are fit using these expressions to obtain effective blood vessel size and density, tissue hemoglobin concentration, and oxygenation. Hemoglobin concentration and vessel density were found to depend on the pressure applied during in vivo acquisition of the spectra. It is also shown that determined vessel size depends on the blood hemoglobin concentration used.
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Affiliation(s)
- Judith R. Mourant
- Bioscience Division, Los Alamos National Laboratory, Los Alamos, P.O. Box 1663, MS M888, New Mexico 87544
- Address all correspondence to: Judith R. Mourant, E-mail:
| | - Oana C. Marina
- Bioscience Division, Los Alamos National Laboratory, Los Alamos, P.O. Box 1663, MS M888, New Mexico 87544
| | - Tiffany M. Hebert
- Jack D. Weiler Hospital, 1825 Eastchester Road, Room 3-37, Bronx, New York 10461
| | - Gurpreet Kaur
- Einstein Cancer Center, Department of Obstetrics and Gynecology and Women’s Health, 1695 Eastchester Road, Bronx, New York 10461
| | - Harriet O. Smith
- Einstein Cancer Center, Department of Obstetrics and Gynecology and Women’s Health, 1695 Eastchester Road, Bronx, New York 10461
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Oláh KS. Stimulated by the cervix. BJOG 2014; 121:446. [PMID: 24533476 DOI: 10.1111/1471-0528.12581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 11/29/2022]
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Mahmoud H, Wagoner Johnson A, Chien EK, Poellmann MJ, McFarlin B. System-level biomechanical approach for the evaluation of term and preterm pregnancy maintenance. J Biomech Eng 2013; 135:021009. [PMID: 23445054 PMCID: PMC3705860 DOI: 10.1115/1.4023486] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/20/2013] [Accepted: 11/28/2013] [Indexed: 01/08/2023]
Abstract
Preterm birth is the primary contributor to perinatal morbidity and mortality, with those born prior to 32 weeks disproportionately contributing compared to those born at 32-37 weeks. Outcomes for babies born prematurely can be devastating. Parturition is recognized as a mechanical process that involves the two processes that are required to initiate labor: rhythmic myometrial contractions and cervical remodeling with subsequent dilation. Studies of parturition tend to separate these two processes rather than evaluate them as a unified system. The mechanical property characterization of the cervix has been primarily performed on isolated cervical tissue, with an implied understanding of the contribution from the uterine corpus. Few studies have evaluated the function of the uterine corpus in the absence of myometrial contractions or in relationship to retaining the fetus. Therefore, the cervical-uterine interaction has largely been neglected in the literature. We suggest that a system-level biomechanical approach is needed to understand pregnancy maintenance. To that end, this paper has two main goals. One goal is to highlight the gaps in current knowledge that need to be addressed in order to develop any comprehensive and clinically relevant models of the system. The second goal is to illustrate the utility of finite element models in understanding pregnancy maintenance of the cervical-uterine system. The paper targets an audience that includes the reproductive biologist/clinician and the engineer/physical scientist interested in biomechanics and the system level behavior of tissues.
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Affiliation(s)
- Hussam Mahmoud
- Department of Civil and Environmental Engineering, College of Engineering, Colorado State University, Fort Collins, CO 80523, USA
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House M, Feltovich H, Hall TJ, Stack T, Patel A, Socrate S. Three-dimensional, extended field-of-view ultrasound method for estimating large strain mechanical properties of the cervix during pregnancy. Ultrason Imaging 2012; 34:1-14. [PMID: 22655487 PMCID: PMC4467314 DOI: 10.1177/016173461203400101] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Cervical shortening and cervical insufficiency contribute to a significant number of preterm births. However, the deformation mechanisms that control how the cervix changes its shape from long and closed to short and dilated are not clear. Investigation of the biomechanical problem is limited by (1) lack of thorough characterization of the three-dimensional anatomical changes associated with cervical deformation and (2) difficulty measuring cervical tissue properties in vivo. The objective of the present study was to explore the feasibility of using three-dimensional ultrasound and fundal pressure to obtain anatomically-accurate numerical models of large-strain cervical deformation during pregnancy and enable noninvasive assessment of cervical-tissue compliance. Healthy subjects (n = 6) and one subject with acute cervical insufficiency in the midtrimester were studied. Extended field-of-view ultrasound images were obtained of the entire uterus and cervix. These images aided construction of anatomically accurate numerical models. Cervical loading was achieved with fundal pressure, which was quantified with a vaginal pressure catheter. In one subject, the anatomical response to fundal pressure was matched by a model-based simulation of the deformation response, thereby deriving the corresponding cervical mechanical properties and showing the feasibility of noninvasive assessment of compliance. The results of this pilot study demonstrate the feasibility of a biomechanical modeling framework for estimating cervical mechanical properties in vivo. An improved understanding of cervical biomechanical function will clarify the pathophysiology of cervical shortening.
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Affiliation(s)
- Michael House
- Department of Obstetrics and Gynecology, Tufts Medical Center, 800 Washington St., Boston MA 02111, USA.
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Kiefer DG, Keeler SM, Rust O, Chow SSW, Craig ME, Peltier MR, Vintzileos AM, Rawlinson WD, Hanna N. Amniotic fluid inflammatory score is associated with pregnancy outcome in patients with mid trimester short cervix. Am J Obstet Gynecol 2012; 206:68.e1-6. [PMID: 21974988 DOI: 10.1016/j.ajog.2011.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 07/07/2011] [Accepted: 08/04/2011] [Indexed: 01/16/2023]
Abstract
OBJECTIVE We propose a novel amniotic fluid inflammatory score from a comprehensive cytokine analysis of patients with mid-trimester short cervix. STUDY DESIGN Amniotic fluid from singleton gestations (n = 44) with a cervical length of ≤25 mm between 16-24 weeks was assayed for 25 inflammatory mediators. Patient data were stratified according to gestational age at delivery (<34 vs ≥34 weeks). Mediators that reached statistical significance were included in the amniotic fluid inflammatory score. Patients were assigned 1 point for each significant mediator if their level was in the upper quartile. The amniotic fluid inflammatory score was determined, and its relationship to other clinical characteristics was examined. RESULTS Fourteen mediators met the criteria. A score of ≥8 was predictive of delivery at <34 weeks' gestation (sensitivity, 87.0%; specificity, 100%; positive predictive value, 100%; negative predictive value, 87.5%). Twenty patients had a high inflammatory score (≥8); 24 patients had a low score. All patients with a high inflammatory score delivered at <30 weeks' gestation. CONCLUSION The amniotic fluid inflammatory score is related to delivery outcome and clinical characteristics.
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Affiliation(s)
- Daniel G Kiefer
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA, USA
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Abstract
PURPOSE The association between tenaculum application to the cervix just before embryo transfer and lower pregnancy rate has been reported. However, studies on the use of tenaculum in intrauterine insemination (IUI) cycles are not available. This study attempted to investigate whether the use of tenaculum affects the clinical outcomes of IUI. MATERIALS AND METHODS Two hundred and thirty three CC/hMG/ IUI cycles of one hundred and forty three couples were recruited at Seoul National University Hospital from October 2006 to December 2008. Mock insemination and IUI with or without tenaculum application to the cervix were also performed, and clinical pregnancy rate was compared. RESULTS The incidence of difficult mock insemination at the beginning of cycle was higher in the tenaculum use group (p < 0.001). No significant statistical difference in the clinical pregnancy rate was observed between the groups with or without tenaculum application (12.1% vs. 18.5%; p = 0.175), which was not influenced by the difficulty of mock insemination. CONCLUSION The use of tenaculum during IUI may not affect the pregnancy outcome. Our results need to be confirmed by a prospective study in a larger population.
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Affiliation(s)
- Kyung Eui Park
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
| | - Seung-Yup Ku
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
- Institute of Reproductive Medicine and Population, Seoul National University, Seoul, Korea
| | - Hoon Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
| | - Byung Chul Jee
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
| | - Chang Suk Suh
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
- Institute of Reproductive Medicine and Population, Seoul National University, Seoul, Korea
| | - Seok Hyun Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
- Institute of Reproductive Medicine and Population, Seoul National University, Seoul, Korea
| | - Young Min Choi
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
- Institute of Reproductive Medicine and Population, Seoul National University, Seoul, Korea
| | - Jung Gu Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
| | - Shin Yong Moon
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Korea
- Institute of Reproductive Medicine and Population, Seoul National University, Seoul, Korea
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Vaisbuch E, Romero R, Erez O, Kusanovic JP, Mazaki-Tovi S, Gotsch F, Romero V, Ward C, Chaiworapongsa T, Mittal P, Sorokin Y, Hassan SS. Clinical significance of early (< 20 weeks) vs. late (20-24 weeks) detection of sonographic short cervix in asymptomatic women in the mid-trimester. Ultrasound Obstet Gynecol 2010; 36:471-81. [PMID: 20503224 PMCID: PMC2937193 DOI: 10.1002/uog.7673] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether the risk of early spontaneous preterm delivery (PTD) in asymptomatic women with a sonographic cervical length of ≤ 15 mm in the mid-trimester changes as a function of gestational age at diagnosis. METHODS This cohort study included 109 asymptomatic patients with a sonographic cervical length of ≤ 15 mm diagnosed at 14-24 weeks of gestation. Women with a multifetal gestation, cerclage and a cervical dilatation of > 2 cm were excluded. The study population was stratified by gestational age at diagnosis (< 20 weeks vs. 20-24 weeks) and by cervical length (≤ 10 mm vs. 11-15 mm). The primary outcome variables were PTD at < 28 and < 32 weeks of gestation and the diagnosis-to-delivery interval. RESULTS The median gestational age at diagnosis of a short cervix before 20 weeks and at 20-24 weeks was 18.9 and 22.7 weeks, respectively. Women diagnosed before 20 weeks had a higher rate of PTD at < 28 weeks (76.9% vs. 30.9%; P < 0.001) and at < 32 weeks (80.8% vs. 48.1%; P = 0.004), and a shorter median diagnosis-to-delivery interval (21 vs. 61.5 days, P = 0.003) than those diagnosed at 20-24 weeks. The rate of amniotic fluid sludge was higher among patients diagnosed with a short cervix at < 20 weeks of gestation than in those in whom it was diagnosed between 20 and 24 weeks (92.3% vs. 48.2%; P < 0.001). CONCLUSIONS Asymptomatic women with a sonographic cervical length of ≤ 15 mm diagnosed before 20 weeks of gestation have a dramatic and significantly higher risk of early preterm delivery than women diagnosed at 20-24 weeks. These findings can be helpful to physicians in counseling these patients, and may suggest different mechanisms of disease leading to a sonographic short cervix before or after 20 weeks of gestation.
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Affiliation(s)
- Edi Vaisbuch
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Shali Mazaki-Tovi
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Francesca Gotsch
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
| | - Vivian Romero
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Clara Ward
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Pooja Mittal
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
| | - Sonia S. Hassan
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI
- Department of Obstetrics and Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI
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Kim SN, Park KH, Jung HJ, Hong JS, Shin DM, Kang WS. Clinical and sonographic parameters at 37 weeks' gestation for predicting the risk of primary Cesarean delivery in nulliparous women. Ultrasound Obstet Gynecol 2010; 36:486-492. [PMID: 20586108 DOI: 10.1002/uog.7734] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To identify the clinical and sonographic parameters at 37 weeks' gestation that predict the risk of Cesarean delivery in labor for nulliparas. METHODS This prospective observational study recruited nulliparas with singleton pregnancies at 37 weeks' gestation. Determination of the Bishop score, ultrasound measurement of the cervical length, and fetal biometry were performed. The clinical parameters studied were maternal age, height and weight and Bishop score. The sonographic parameters included fetal biparietal diameter, femur length, abdominal circumference (AC), estimated fetal weight (EFW), amniotic fluid index and cervical length. RESULTS Four hundred and fifty-three women were examined; 57 women (12.6%) underwent an emergency Cesarean delivery in labor. Logistic regression analysis identified maternal age and height and fetal AC and EFW, but not cervical length or Bishop score, as the best predictors of Cesarean delivery. Of these predictors, maternal age and height and fetal AC at 37 weeks were included in a final model for risk scoring. The model was shown to have an adequate goodness of fit (P = 0.473), and the area under the receiver-operating characteristics curve was 0.758, indicating reasonably good discrimination. CONCLUSIONS Maternal age and height and fetal AC and EFW at 37 weeks' gestation are the most important parameters in predicting the risk of Cesarean delivery in nulliparas; sonographic measurement of the cervical length and the Bishop score were not predictive of Cesarean delivery. A predictive model using these parameters at 37 weeks provides useful information in the decision-making process regarding the mode of delivery.
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Affiliation(s)
- S N Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnamsi, Korea
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Clock CA, Ghamsary M, Das A, Kurtzman JT. Is dynamic cervical shortening during symptomatic contractions predictive of preterm delivery in patients with a normal baseline cervical length? J Ultrasound Med 2010; 29:1187-1192. [PMID: 20660452 DOI: 10.7863/jum.2010.29.8.1187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether dynamic cervical change in symptomatic patients with a normal baseline cervical length (CL; >or=30 mm) is predictive of preterm delivery (PTD). METHODS A prospective observational study was performed in 120 symptomatic patients between 23 and 34 weeks' gestation. Patients underwent standardized CL sonography with contraction monitoring, and CL measurements were recorded each minute for approximately 10 minutes. Initial and minimum CLs as well as the presence of dynamic change were assessed for prediction of PTD. RESULTS Forty-seven patients (39.2%) had dynamic cervical change and delivered at a mean gestational age +/- SD of 37.1 +/- 2.7 weeks compared to 38.7 +/- 1.5 weeks for those without dynamic change (P < .01). A larger proportion of those with dynamic change delivered before 37 weeks (43% versus 15%; P < .01) and before 35 weeks (19% versus 0%; P < .01). Multivariable logistic regression analysis showed that dynamic cervical change was predictive of PTD, but not independently of the minimum CL. Statistical analyses were completed using the Student t test, chi(2) test, Fisher exact test, Wilcoxon rank sum test. and logistic regression as appropriate. CONCLUSIONS Although symptomatic patients with a normal baseline CL who have dynamic shortening generally deliver at term, they appear to be at increased risk of PTD.
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Affiliation(s)
- Charlotte A Clock
- Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, California, USA.
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Campaner AB, Eras AE, Paganini CBL, Galvão MAL. The effect of cigarette smoking on cell proliferation in normal uterine cervix epithelium. Arch Gynecol Obstet 2010; 284:119-23. [PMID: 20677025 DOI: 10.1007/s00404-010-1586-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 07/04/2010] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the effect of smoking on cell proliferation in normal cervical epithelium. METHODS A total of 45 women undergoing hysterectomies due to uterine leiomyomata were investigated. Thirty were nonsmokers and 15 were current smokers. A segment of tissue was taken from cervix after removal of the uterus, and the identification of cell proliferation was performed by immunohistochemical analysis employing Ki-67 staining. The number of positive cells colored by Ki-67 staining was finally expressed as number of cells per square millimeter (mm²) of epithelium. RESULTS The comparison of the number of proliferating cells measured by ki-67 staining among smoking and nonsmoking women did not show significant difference. Among smoking women, there was no significant difference related to the number of cigarettes smoked per day or time of consumption and epithelial cell proliferation. However, the total amount of cigarettes smoked throughout presented significant association with Ki-67 staining (p < 0.001); the number of proliferating cells per mm² increased proportionally to the increase in consumption of cigarettes. CONCLUSIONS The results indicated that there was no significant difference between cell proliferation in smokers and nonsmokers; however, it was shown that in the smokers' group, amount of cigarettes smoked during throughout lifetime can increase cell proliferation in normal cervical epithelium.
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Affiliation(s)
- Adriana Bittencourt Campaner
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, América, São Paulo, SP, 05401-200, Brazil.
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Oxlund BS, Ørtoft G, Brüel A, Danielsen CC, Oxlund H, Uldbjerg N. Cervical collagen and biomechanical strength in non-pregnant women with a history of cervical insufficiency. Reprod Biol Endocrinol 2010; 8:92. [PMID: 20673361 PMCID: PMC2927597 DOI: 10.1186/1477-7827-8-92] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 07/30/2010] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It has been suggested that cervical insufficiency (CI) is characterized by a "muscular cervix" with low collagen and high smooth muscle concentrations also in the non-pregnant state. Therefore, the aim of this study was to investigate the biomechanical properties, collagen concentration, smooth muscle cell density, and collagen fiber orientation in cervical biopsies from non-pregnant women with a history of CI. METHODS Cervical punch biopsies (2 x 15 mm) were obtained from 57 normal non-pregnant women and 22 women with a history of CI. Biomechanical tensile testing was performed, and collagen content was determined by hydroxyproline quantification. Histomorphometry was used to determine the volume densities of extracellular matrix and smooth muscle cells from the distal to the proximal part of each sample. Smooth muscle cells were identified using immunohistochemistry. Finally, collagen fiber orientation was investigated. Data are given as mean +/- SD. RESULTS Collagen concentration was lower in the CI group (58.6 +/- 8.8%) compared with the control group (62.2 +/- 6.6%) (p = 0.033). However, when data were adjusted for age and parity, no difference in collagen concentration was found between the two groups. Maximum load of the specimens did not differ between the groups (p = 0.78). The tensile strength of cervical collagen, i.e. maximum load normalized per unit collagen (mg of collagen per mm of specimen length), was increased in the CI group compared with controls (p = 0.033). No differences in the volume density of extracellular matrix or smooth muscle cells were found between the two groups. Fibers not oriented in the plane of sectioning were increased in CI patients compared with controls. CONCLUSIONS Cervical insufficiency does not appear to be associated with a constitutionally low collagen concentration or collagen of inferior mechanical quality. Furthermore, the hypothesis that a "muscular cervix" with an abundance of smooth muscle cells contributes to the development of cervical insufficiency is not supported by the present study.
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Affiliation(s)
- Birgitte S Oxlund
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, DK-8200 Aarhus N, Denmark
| | - Gitte Ørtoft
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, DK-8200 Aarhus N, Denmark
| | - Annemarie Brüel
- Institute of Anatomy, Aarhus University, DK-8000 Aarhus C, Denmark
| | | | - Hans Oxlund
- Institute of Anatomy, Aarhus University, DK-8000 Aarhus C, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, DK-8200 Aarhus N, Denmark
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Parikh R, Horne H, Feinstein SJ, Anasti JN. Cervical length screening in patients who have undergone loop electrosurgical excision procedure. J Reprod Med 2008; 53:909-913. [PMID: 19160648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine whether cervical length measurements in patients who have undergone a loop electrosurgical excision procedure (LEEP) is a predictor of spontaneous preterm delivery (PTD) at < 35 weeks. STUDY DESIGN A retrospective chart review of 97 pregnant patients with a history of prior LEEP undergoing cervical length screening by transvaginal ultrasound (TVUS) was done. Of these, 87 were included in the study. All patients delivered at the St. Luke's Hospital and Health Network over a 5-year study period. Cervical length measurements in the LEEP group were included. Incidence of PTD in patients who have undergone prior LEEP was compared to patients delivered during the same period who had not undergone LEEP. RESULTS Of 87 patients who had undergone LEEP, 3 (3.4%, 95% CI 1.1-9.6%) delivered at < 35 weeks. None of the 3 patients had cervical shortening on TVUS. The PTD rate was not statistically different in the LEEP and non-LEEP groups. A shortened cervix was noted in 4 of the 87 patients in the LEEP group (4.5%, 95% CI 1.8-11%) but none had a PTD. CONCLUSION Cervical length screening in LEEP patients may not be a predictor of PTD.
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Affiliation(s)
- Reshma Parikh
- Department of Obstetrics and Gynecology, St. Luke's Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA
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Affiliation(s)
- P Rozenberg
- Department of Obstetrics & Gynaecology, Centre Hospitalier Poissy Saint Germain, Versailles-St Quentin University, 10, rue du Champ Gaillard, 78300 Poissy, France
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Eggebø TM, Heien C, Økland I, Gjessing LK, Romundstad P, Salvesen KA. Ultrasound assessment of fetal head-perineum distance before induction of labor. Ultrasound Obstet Gynecol 2008; 32:199-204. [PMID: 18528923 DOI: 10.1002/uog.5360] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To evaluate fetal head-perineum distance measured by ultrasound imaging as a predictive factor for induction of labor, and to compare this distance with maternal factors, the Bishop score and ultrasound measurements of cervical length, cervical angle and occiput position. METHODS The study included 275 women admitted for induction of labor. The fetal head-perineum distance was measured by transperineal ultrasound imaging as the shortest distance from the outer bony limit of the fetal skull to the skin surface of the perineum. Cervical length and angle was measured by transvaginal ultrasound examination, and fetal head position was assessed by transabdominal ultrasound imaging. The Bishop score was assessed without knowledge of ultrasound measurements. Receiver-operating characteristics (ROC) curves were used for evaluation of the probability of a successful vaginal delivery. The time from induction to delivery was tested using Cox regression analysis with ultrasound measurements, parity and body mass index (BMI) as possible predictive factors. RESULTS Areas under the ROC curve for prediction of vaginal delivery were 62% (95% CI, 52-71%) for fetal head-perineum distance (P = 0.03), 61% (95% CI, 51-71%) for cervical length (P = 0.03), 63% (95% CI, 52-74%) for cervical angle (P = 0.02), 61% (95% CI, 52-70%) for Bishop score (P = 0.03) and 60% (95% CI, 51-69%) for BMI (P = 0.05). The Cesarean delivery rate was 22% among nulliparous and 5% among parous women (P < 0.01). Parity, fetal head-perineum distance, cervical length and cervical angle were contributing factors predicting vaginal delivery within 24 h in a Cox regression model. Occiput posterior position had no significant predictive value. CONCLUSIONS Fetal head-perineum distance measured by transperineal ultrasound examination can predict vaginal delivery after induction of labor, with a predictive value similar to that of ultrasonographically measured cervical length and the Bishop score. However, we judge none of these methods used alone to be good enough in a clinical setting.
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Affiliation(s)
- T M Eggebø
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway.
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Fedele L, Bianchi S, Frontino G, Berlanda N, Montefusco S, Borruto F. Laparoscopically assisted uterovestibular anastomosis in patients with uterine cervix atresia and vaginal aplasia. Fertil Steril 2008; 89:212-6. [PMID: 17482183 DOI: 10.1016/j.fertnstert.2007.01.168] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 01/31/2007] [Accepted: 01/31/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the surgical technique and the long-term anatomic and functional results of laparoscopically assisted uterovestibular anastomosis. DESIGN Descriptive study. SETTING Tertiary referral center. PATIENT(S) Twelve consecutive patients with uterine cervix atresia and vaginal aplasia. INTERVENTION(S) Laparoscopically assisted uterovestibular anastomosis was performed in all patients. Follow-up assessments at 1, 6, and 12 months included pelvic examination, transvaginal ultrasonography, and, in selected cases, vaginoscopy and hysteroscopy. Subsequent follow up was done by referring physicians or by means of telephone interview. Mean follow-up was 6 years. MAIN OUTCOME MEASURE(S) Intra- and postoperative characteristics and anatomic and functional outcome. RESULT(S) The surgical procedure was successful in all cases and all of the women have experienced regular menstruation. At 6-month follow-up, mean vaginal length was 6 cm and at least 80% of neovaginal epithelium was iodine-positive in all patients. Six women were sexually active during follow-up without difficulty. None have yet attempted to seek a pregnancy. CONCLUSION(S) The study shows the safety and effectiveness of a laparoscopic approach to uterovestibular anastomosis in women with cervical atresia and vaginal aplasia. In these patients, we believe that conservative surgery should represent the first therapeutic option. A longer follow-up is needed to assess pregnancy rates and outcome.
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Affiliation(s)
- Luigi Fedele
- Department of Obstetrics, Gynecology and Neonatology, Fondazione Policlinico-Mangiagalli-Regina Elena, University of Milan, Milan, Italy.
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Anthony GS, Walker RG, Robins JB, Cameron AD, Calder AA. Management of cervical weakness based on the measurement of cervical resistance index. Eur J Obstet Gynecol Reprod Biol 2007; 134:174-8. [PMID: 17123693 DOI: 10.1016/j.ejogrb.2006.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2005] [Revised: 10/13/2006] [Accepted: 10/14/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the value of measuring cervical resistance index (CRI) as an aid to selecting patients with a history of spontaneous mid-trimester miscarriage for cervical cerclage in subsequent pregnancies. STUDY DESIGN An observational study of 175 patients with a history of one or more spontaneous mid-trimester losses and 123 non-pregnant women who had CRI measurements performed while undergoing routine gynaecological surgery. Those women whose CRI indicated an incompetent cervix were recommended for cervical cerclage in future pregnancies while women with a normal CRI were recommended for conservative management without cerclage. RESULTS The median CRI in the 123 control women was 38.26 N while the median CRI in the study group was 17.00 N. In 62 of the 175 study women (35%) the CRI findings were at variance with the history of previous mid-trimester loss; 30 (16.6%) were deemed competent on CRI whereas the history suggested incompetence and 32 (18.4%) were incompetent on CRI while the history suggested that the cervix should be competent. The 175 study women had had 486 previous pregnancies with a successful outcome in 27.4% of the pregnancies. Ninety-four patients have now had 148 pregnancies with a successful outcome in 75.8% of the pregnancies. CONCLUSIONS Non-pregnant women with a history of spontaneous mid-trimester miscarriage have a significantly lower cervical resistance index than parous women who have not suffered mid-trimester loss. In 35% of patients the CRI was at variance with the history of the previous loss. CRI may be a useful technique to aid the diagnosis of cervical weakness allowing a rational selection for treatment with prophylactic cervical cerclage.
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Affiliation(s)
- George S Anthony
- Inverclyde Royal Hospital, Larkfield Road, Greenock PA16 0XN, United Kingdom.
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Fatehi D, van der Zee J, Notenboom A, van Rhoon GC. Comparison of Intratumor and Intraluminal Temperatures During Locoregional Deep Hyperthermia of Pelvic Tumors. Strahlenther Onkol 2007; 183:479-86. [PMID: 17762921 DOI: 10.1007/s00066-007-1768-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Accepted: 05/18/2007] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate whether intraluminal thermometry provides sufficient information to apply high quality deep hyperthermia in pelvic tumors. PATIENTS AND METHODS The intratumor and intraluminal temperatures of 48 patients were analyzed per cancer type: rectum (21 male, 14 female), cervix (n=8), and bladder (n=5). Temperature-dose parameters were calculated, temperature curves within each treatment session were compared, and correlation between intratumor and intraluminal temperatures was analyzed. RESULTS Intratumor and intraluminal temperatures at the same time points during individual treatments were highly correlated (mean correlation coefficient: 0.93). However, the quantitative level differed from 0.1 to 1.1 degrees C and the differences of the time-temperature graphs varied per tumor group. Average intratumor and intraluminal temperatures were not different in the four groups. Intratumor thermometry was found not superior over intraluminal thermometry to improve tumor temperature level and homogeneity by SAR steering. CONCLUSION Intraluminal thermometry provides sufficient information to apply deep hyperthermia to individual patients with centrally located rectum, cervix or bladder cancer.
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Affiliation(s)
- Daryoush Fatehi
- Unit Hyperthermia, Department of Radiation Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Fadare O, Yi X, Liang SX, Ma Y, Zheng W. Variations of mitotic index in normal and dysplastic squamous epithelium of the uterine cervix as a function of endometrial maturation. Mod Pathol 2007; 20:1000-8. [PMID: 17643095 DOI: 10.1038/modpathol.3800935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cervical intraepithelial neoplasia is a premalignant (dysplastic) lesion that is characterized by abnormal cellular proliferation, maturation and nuclear atypia. The intraepithelial distribution, density, and nature (typical or atypical) of mitotic figures are routinely utilized diagnostic criteria to grade dysplasia and to distinguish high-grade dysplasia from potential histologic mimics such as transitional metaplasia, atrophy or immature squamous metaplasia. In this study, we evaluated the total mitotic indices of the cervical epithelia in hysterectomy specimens from patients with and without dysplastic lesions and investigated a possible relationship between mitotic index and hormonal status, using the endometrial maturation phase as a surrogate indicator of the latter. Two hundred seventy-four cervices from hysterectomy specimens (135 cases without dysplasia, 33, 35 and 71 cases with grades 1, 2 and 3 cervical intraepithelial neoplasia, respectively) were analyzed. A cervical mitotic index (total mitotic figures/10 high-power fields in the most proliferative area) was determined for each case. The endometrium in each case was classified into atrophic, early proliferative, late proliferative and secretory. For all three dysplasia grades, cases in the proliferative endometrium group always had a higher average mitotic index than those in the secretory and atrophic endometrium groups; this observation also held true for the benign cases. Furthermore, in all three dysplasia grades, the average mitotic index was always lowest in the atrophic endometrium group. Although the mitotic index showed expected patterns of increases with increasing dysplasia grades for most of the endometrial phases, this was not a universal finding. Notably, the average mitotic index for our cervical intraepithelial neoplasia 1 cases with late proliferative endometrium was higher than our cervical intraepithelial neoplasia 2 cases with secretory and atrophic endometrium. It is concluded that hormonal status, as reflected in endometrial maturation, can significantly affect the mitotic index of dysplastic squamous epithelium of the uterine cervix. Our findings confirm that the pathologic grading of dysplasia, especially in equivocal cases such as in metaplastic squamous epithelium, should not be solely dependent on the finding mitoses in the cervical squamous epithelium. The full composite of histopathologic features should form the basis for this determination.
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Affiliation(s)
- Oluwole Fadare
- Department of Pathology, Wilford Hall Medical Center, Lackland AFB, TX, USA
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Mahajan NN. Re: Fetal adrenal gland volume: a novel method to identify women at risk for impending preterm birth. Obstet Gynecol 2007; 110:187; author reply 187-8. [PMID: 17601919 DOI: 10.1097/01.aog.0000269872.72622.c6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Engelen E, Taverne MAM, Everts ME, van der Weijden GC, Doornenbal A, Breeveld Dwarkasing VNA. Cervical diameter in relation to uterine and cervical EMG activity in early postpartum dairy cows with retained placentas after PGF2alpha induced calving. Theriogenology 2007; 68:213-22. [PMID: 17555807 DOI: 10.1016/j.theriogenology.2007.04.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 04/25/2007] [Accepted: 04/25/2007] [Indexed: 11/23/2022]
Abstract
The cervix must regain its normal diameter after parturition. Until now, little has been known about the pattern of cervical closure and the possible influences of myometrial and cervical contractions in this process. We continuously measured the cervical diameter with ultrasound cervimetry during the first 48h after calving in six cows with retained fetal membranes, while uterine (n=6) and cervical outer muscular layer (n=4) electromyographic (EMG) activity was measured with bipolar EMG electrodes. We found that the cervical diameter which was 6.2cm (+/-0.7) at 1.4h after calving, initially increased to 9.0cm (+/-1.0) during the first 14.8h (+/-2.8) postpartum. After this time, the diameter decreased gradually to 5.3cm (+/-1.0) at 48h after calving. The overall EMG activity after parturition decreased by 59% (+/-6) and 35% (+/-17) for the uterus and cervix, respectively. The decrease in EMG activity was due to a 50% (+/-7) decrease in EMG amplitudes of the myometrium; the EMG amplitudes of the cervix decreased by only 8% (+/-21) (P>0.05). At the same time in the cervix, burst frequency decreased by 69% (+/-17), while the decrease in burst frequency of the myometrium was only 11% (+/-5) (P>0.05). Uterine myometrial and cervical EMG activity after parturition showed burst patterns. These contractions of the uterus and cervix were accompanied by and correlated with transient dilatations of the caudal cervix. This could have functional relevance in the evacuation of the uterus.
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Affiliation(s)
- E van Engelen
- Department of Pathobiology, Faculty of Veterinary Medicine, Utrecht University, P.O. Box 80.158, 3508 TD Utrecht, The Netherlands.
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Abstract
Fetal loss is a painful experience. A history of second or early third trimester fetal loss, after painless dilatation of the cervix, prolapse or rupture of the membranes, and expulsion of a live fetus despite minimal uterine activity, is characteristic for cervical insufficiency. In such cases the risk of recurrence is high, and a policy of prophylactic cerclage may be safer than one of serial cervical length measurements followed by cerclage, tocolysis and bed rest in case of cervical shortening or dilatation. In low risk cases, however, prophylactic cerclage is not useful. There is a need for more basic knowledge of cervical ripening, objective assessment of cervical visco-elastic properties, and randomized controlled trials of technical aspects of cervical cerclage (e.g. suturing technique).
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Affiliation(s)
- Frederik K Lotgering
- Department of Obstetrics and Gynecology, 791 Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Mateus J, Pereira L, Baxter J, Berghella V, Tolosa J. Effectiveness of fetal fibronectin testing compared with digital cervical assessment of women with preterm contractions. Am J Perinatol 2007; 24:381-5. [PMID: 17566945 DOI: 10.1055/s-2007-981849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The purpose of this study is to determine the effectiveness of fetal fibronectin (FFN) compared to assessment of cervical dilation (CD) in clinical management of women with symptomatic preterm labor (PTL). Pregnant women presenting to Thomas Jefferson University Hospital between May 1, 2001 and November 30, 2002 with symptomatic PTL underwent FFN sampling and had a complete clinical evaluation including a pelvic bimanual examination. Inclusion criteria were singleton pregnancy, gestational age (GA) between 24 (0) and 33 (6) weeks, CD < 3 cm, and intact amniotic membranes. FFN samples were sent out and results were available within 4-12 hours. Clinical management including tocolysis, antenatal steroids, and hospitalization was determined based on digital CD assessment and FFN status. A dilated cervix was defined as CD > 1 cm. Ninety-three patients were included. Spontaneous preterm delivery (SPTD) at < 37 weeks occurred in 20 of 93 (21.5%) patients. Medical therapy use was significantly higher in patients with dilated cervix than in those with a closed cervix (all P values < 0.05). Tocolysis and steroid use in FFN-negative patients and FFN-positive patients were not significantly different. Furthermore, tocolytic use was higher in FFN-negative patients than in women with positive FFN (50% versus 42.1%; P = 0.53). Use of antenatal steroids was similar in patients with CD >/= 1 cm and a positive FFN (54.5% versus 47.4%; P = 0.92). Compared with FFN-negative patients, women with closed cervix were less likely to undergo interventions. In symptomatic PTL patients, CD determined clinical management more than FFN status. Overall, the use of FFN was not effective in decreasing "unnecessary" clinical interventions.
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Affiliation(s)
- Julio Mateus
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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