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1: Obstet Gynecol Surv. 2005 Jan;60(1):15-16.

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1: Ann Acad Med Singapore. 2004 Nov;33(6):780-3.

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Cervical Cerclage for Prevention of Preterm Delivery in Women With a Short Cervix: A Randomized, Controlled Trial. To MS, Alfirevic Z, Heath VC, Cicero S, Cacho AM, Williamson PR, Nicolaides KH. Harris Birthright Research Centre for Fetal Medicine, King's College Hospital Medical School, London, U.K.; University Department of Obstetrics and Gynaecology, Liverpool Women's Hospital, Liverpool, U.K.; and the Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, U.K. Although observational studies have often claimed high success rates in women undergoing cervical cerclage for an incompetent cervix, randomized trials have not consistently favored this procedure. This multicenter, randomized, controlled trial sought to determine whether patient selection for cerclage could be improved by transvaginal sonographic measurements of cervical length. More than 47,000 women were offered scanning at 11 to 14 and 22 to 24 weeks gestation. Of 470 women whose cervix measured 15 mm or less in length, 253 entered the trial and were randomly assigned to either cervical cerclage using a Shirodkar suture or expectant management. The major outcome was the frequency of delivery before 33 completed weeks gestation.Cervical cerclage did not significantly lower the rates of early preterm delivery, neonatal mortality, or neonatal morbidity compared with expectant management. The 2 groups had similar proportions of spontaneous delivery or delivery after preterm prelabor rupture of membranes. Mean birth weight was 204 g more in the cerclage group, but this arose from a 1-week difference in gestational age at delivery. More than twice as many women in the cerclage group received antibiotics, most often because of prolonged prophylaxis and symptomatic vaginal discharge. More women in the cerclage group received tocolytic agents immediately after the procedure or because of threatened preterm labor. Approximately one third of women required emergency removal of the suture, most often because of preterm labor or premature labor or rupture of membranes.In this trial, placing a cervical suture in women with a short cervix did not lower the risk of early preterm delivery in a substantial proportion of cases. Routinely measuring cervical length at 22 to 24 weeks gestation by transvaginal sonography does identify women who are at high risk of early preterm delivery. PMID: 15618903 [PubMed - as supplied by publisher]  Show:

Evaluation of a bedside test for phosphorylated insulin-like growth factor binding protein-1 in preterm labour. Kwek K, Khi C, Ting HS, Yeo GS. Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore. [e-mail] OBJECTIVE: The objective of this study was to assess the efficacy of a bedside test kit for phosphorylated insulin-like growth factor binding protein-1 (IGFBP-1) in the diagnosis of preterm labour and the prediction of subsequent preterm delivery. MATERIALS AND METHODS: We performed a bedside test for IGFBP-1 in 47 women who presented to the delivery suite in suspected preterm labour between 23 and 33 weeks. Tocolysis and steroid therapy were administered in all cases. RESULTS: Twenty-nine women (61.7%) tested negative and 18 women tested positive (38.3%). There was no statistical significance between the 2 groups except that the test-positive group had a greater median cervical dilatation (2.0 cm) compared to the testnegative group (1.0 cm) (P <0.05). The women who tested positive had a statistically significant longer median duration of hospitalisation, stay in delivery suite and tocolytic therapy (5.0 days, 56.0 hours and 34.5 hours respectively) compared to women who were test-negative (3.0 days, 19.0 hours and 10.0 hours respectively) (P <0.05). In addition, 91.7% of the patients in the IGFBP-1 negative group had a delay of more than 7 days between the onset of contractions and delivery, while only 44.4% of the women in the pIGFBP-1 positive group experienced such a delay. CONCLUSION: These results suggest that there may be a role for cervical IGFBP-1 test in the management of women presenting with suspected preterm labour. It may allow us to focus our efforts on women who are more likely to have a preterm delivery and perhaps allow us to avoid unnecessary treatment and to contain healthcare costs.

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[Caesarean section in preterm labour]

[Article in Polish]

Bilar M, Plonka T, Ronin-Walknowska E.

Klinika Medycyny Matczyno-Plodowej, Katedry Poloznictwa i Ginekologii PAM w Szczecinie. [e-mail]

The aim of this study was to estimate complications of pregnancy, indications to caesarean section, complications after caesarean operation and perinatal mortality of newborns who were delivered before the 37th week of gestation by caesarean section. The retrospective analysis of the total of 2693 deliveries (years 1991-2000) by caesarean section in the Department of Pregnancy and Labour Pathology in Pomeranian Academy of Medicine has been carried out. 590 women whose delivered before the 37th week of pregnancy have been chosen for subseguent examination. The patients have been divided into three groups: group I--patients with pregnancy completed before the 28th week, group II--patients with pregnancy completed between 29th and 32nd week, and group III--patients with pregnancy completed between the 33rd and 36th week. Obstetrical anamnesis, complications of pregnancy, indications to caesarean section and postoperative complications as well as newborns perinatal mortality have been analysed. Among women who experienced abortions, premature deliveries caesarean section a higher rate of caesarean section during subseguent premature delivery was stated. The increase of caesarean sections rate in premature deliveries after the 29th week of gestation is associated with a considerable decrease in newborns, mortality.

PMID: 15537274 [PubMed - in process]

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[Long-term tocolysis--sense and nonsense of modern practice]

[Article in Polish]

Semczuk M.

Katedra i Klinika Poloznictwa i Patologii City AM w Lublinie.

Preterm delivery is still a major medical and social problem in perinatology. Despite many efforts the appliance of efficient prevention methods is still not possible. The treatment and inhibition of uterine contractions is widely used in clinical practice. The use of tocolytic agents in arresting premature labor is justified by gaining time which is necessary for applying antibiotics and steroids. Short-term tocolysis, ordinarily used between 22 and 34 weeks gestation, prolongs pregnancy and usually delays the delivery by about 48 hours. There are two prevailing options to follow successful inhibition of preterm contractions. The first one recommends intravenous treatment in cases with recurrent premature contractions, the other recommends long-term tocolysis even in cases with no any threatening symptoms. In such cases many obstetricians apply oral beta-Adrenergic agonists, although most of literature data and clinical practice do not confirm good results in preventing premature labor long-term tocolytic therapy does not improve fetal condition and does not prolong the pregnancy. It is also not meaningless that during this therapy maternal adverse effects may occur. Taking the above into consideration long-term tocolysis cannot be recommended as the routine treating procedure.

PMID: 15537254 [PubMed
[Long-term tocolysis--sense and nonsense of modern practice]

[Article in Polish]

Semczuk M.

Katedra i Klinika Poloznictwa i Patologii City AM w Lublinie.

Preterm delivery is still a major medical and social problem in perinatology. Despite many efforts the appliance of efficient prevention methods is still not possible. The treatment and inhibition of uterine contractions is widely used in clinical practice. The use of tocolytic agents in arresting premature labor is justified by gaining time which is necessary for applying antibiotics and steroids. Short-term tocolysis, ordinarily used between 22 and 34 weeks gestation, prolongs pregnancy and usually delays the delivery by about 48 hours. There are two prevailing options to follow successful inhibition of preterm contractions. The first one recommends intravenous treatment in cases with recurrent premature contractions, the other recommends long-term tocolysis even in cases with no any threatening symptoms. In such cases many obstetricians apply oral beta-Adrenergic agonists, although most of literature data and clinical practice do not confirm good results in preventing premature labor long-term tocolytic therapy does not improve fetal condition and does not prolong the pregnancy. It is also not meaningless that during this therapy maternal adverse effects may occur. Taking the above into consideration long-term tocolysis cannot be recommended as the routine treating procedure.


PMID: 15537254 [PubMedv

Department of Perinatal Medicine, Royal Women's Hospital, Melbourne, Australia. [e-mail] PURPOSE OF REVIEW: There is persisting controversy about tocolytic treatment for preterm labour. This review addresses this controversy by appraising the recent clinical literature. RECENT FINDINGS: Surveys of obstetricians indicate a high usage of tocolysis for preterm labour, but evidence that this treatment confers overall benefit is still lacking. Betamimetics are now, correctly, being abandoned in favour of nifedipine, which has superior tocolytic properties and better neonatal outcomes. There is no evidence of effectiveness for magnesium sulphate as a tocolytic. Atosiban is a newer agent, which appears to be effective in delaying preterm birth with a favourable maternal safety profile, but there are persisting concerns about the lack of impact on perinatal mortality and morbidity. Current research is addressing the COX-2 inhibitor, rofecoxib, which has theoretical advantages with respect to fetal safety. SUMMARY: For the relatively small proportion of women in otherwise uncomplicated preterm labour prior to 34 weeks' gestation, there appears to be a place for short-term tocolysis to gain time so that corticosteroids can be administered to enhance fetal lung maturation and, if necessary, to transfer the woman to a facility with a neonatal intensive care unit. Nifedipine is an effective and cheap tocolytic agent. Atosiban appears to also be effective, but it is expensive and not universally available. Betamimetics and magnesium sulphate should be abandoned as tocolytic agents. There is a need for further clinical trials to establish an unequivocal evidence base for tocolysis, which requires placebo-controlled trials, and for comparative trials to identify the agent with superior characteristics. PMID: 15534440 [PubMed - in process]  Show:

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vpossible to improve diagnostic and prognostic criteria of preterm labour?

Carbonne B.

Department of Obstetrics and Gynaecology, Service de Gynecologie Obstetrique, Hopital Saint Antoine, 184, rue du faubourg Saint Antoine, 75012 Paris, France. [e-mail]

Preterm labour is a frequent cause of admission to hospital during pregnancy. However, in most cases, preterm labour is diagnosed with reference to clinical criteria only. Since the clinical assessment of uterine contractions and of cervical changes is highly subjective, few of the patients admitted to the hospital with suspected preterm labour will ultimately deliver preterm. There is a need for sensitive methods of detecting patients who are genuinely at high risk of preterm birth, but on the other hand, specific methods of reducing unnecessary treatments or hospital admissions are also required. Recently, a few techniques such as ultrasonographic measurement of cervical length and fetal fibronectin have been introduced into clinical practice with the aim of improving prediction of the risk of actual preterm delivery. In the future, the assessment of cervical status may be based not only on anatomical changes, but also on functional criteria. New techniques are being developed for evaluation of the mechanical properties of the cervix (cervical distensibility), noninvasive measurement of its collagen content (light-induced fluorescence of cervical collagen), or even direct assessment of the changes in cervical water content (magnetic resonance imaging). Correlations have been found between these measurements and the risk of preterm birth, but clinical studies are still needed to allow better assessment of the predictive value of these new methods in clinical practice.

PMID: 1553071Perspectives in the prevention of premature birth.

Ancel PY.

Epidemiological Research Unit on Perinatal and Women's Health, INSERM U149-IFR69, 16 Avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France. [e-mail]

Obstetric and neonatal interventions have improved the survival of preterm infants, but there has not been an equivalent reduction in long-term neurological disability. Thus, some effort must be invested in finding ways of preventing preterm birth. Numerous programmes have been promoted to address the matter of how the frequency of preterm birth could be prevented. Most interventions intended to prevent preterm labour do not have the desired effect, except for antibiotic treatment in cases of asymptomatic bacteriuria or bacterial vaginosis and progesterone administered prophylactically in high-risk women. Tocolytic drugs appear to delay delivery long enough for successful administration of corticosteroids in women in preterm labour, but without decreasing the risk of preterm birth. Some authors promote public health approaches that address all risk factors and affect the entire population of pregnant women, given that prevention programmes directed only at high-risk women have had little effect in preventing preterm births. However, the lack of progress in reducing the frequency of preterm births is also due to our limited understanding of the aetiology of preterm delivery. Although there is growing evidence that infection and neuroendocrine processes are involved, progress has remained slow. Recently, the hypothesis of a genetic predisposition to preterm delivery has been set up. Additional research exploring the pathophysiology of preterm labour is obviously needed, which will hopefully lead to the development of new therapeutic approaches.

PMID: 15530What is the future of tocolysis?

Terrien J, Marque C, Germain G.

Genie Biologique--UMR CNRS 6600, U.T.C.--BP 20529, F-60205 Compiegne Cedex, France.

Use of the currently available tocolytics is controversial because it has not been associated with improved perinatal outcomes. New markers of preterm labour may come from gene-profiling studies, in as much as they may help in identifying novel genes regulating myometrial quiescence and in expanding our understanding of the pathologic process of uterine dysfunction. Study of certain transcripts in circulating white blood cells by RT-PCR could assist the obstetrician in evaluation of the risks. Uterine electromyography (EMG) also has the potential benefit of monitoring tocolytic treatment, although no standard method of clinical interpretation has yet been devised for the results yielded by this instrumentation. Recent functional genomic studies found that in the uterus at term there is a massive down-regulation of a large panel of developmental cell adhesion molecules and proliferation-related genes. Conversely, maintaining the developmental processes in an active state in patients at risk would help to prevent preterm delivery. It is too early to suggest any therapies with anticytokines in pregnant women. However, exploration of genetic polymorphisms, which may influence the balance of pro- and anti-inflammatory cytokines that are relevant to the course of preterm labour, seems to be a novel avenue that should be explored.710 [PubMed - in process] [PubMed - in process]

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