I. Cervical Cerclage
Petrikovsky, M.D., PhD*, M. Terrani, M.D.**, F. Gonzales, M.D.**, A. Dillon, RDMS** Fetal Research Fund*, Ocean Perinanology**, Wyckoff Heights Medical Center*
The efficacy of cerclage to treat cervical incompetence had been a subject of controversy. The majority of studies fail to address the importance of the location of cerclage placement for pregnancy outcomes. The goal of the study is to report clinical outcomes of cervical cerclages in patients with various locations of the stitch placement.
Materials and methods:
Sixty-seven consecutive images of the cervix performed within two weeks of cerclage placements were extracted from sonographic database collected between January 2012 and October 2015. McDonald technique of cervical cerclage was used in all cases. The location of cerclage was divided into three categories: within the vicinity of the internal os (group I), in the middle portion of the cervix (group II), and in the vicinity of the external os or lower third of the cervix (group III). Gestational age at delivery was analyzed in all three groups. The cerclage placement site was identified by echogenic appearances of the stitch on sagittal and transverse images of the cervix. Statistical evaluation was made using SPSS for Windows V 15.0 (SPSS Inc., USA). Data were shown as frequency (percentage) or mean ± standard deviation.
In 26 patients the cerclage stitch was identified in the close vicinity of the internal os in the upper third of the cervix. These cerclages were placed between 11 and 13 weeks in 21 patients, between 14 and 16 in the remaining five.
In 29 patients, cervical cerclage was detected in the middle portion of the cervix. In 23 of those cerclages were placed between 10 and 13 weeks, and between 14 and 17 in the remaining six. One patient had preterm premature rupture of membranes followed by cerclage removal and delivery at 27 weeks of pregnancy. The third group consisted of 12 patients in whom cervical cerclages were detected in the lower third of the cervix in the vicinity of external os. Date on the timing of delivery in all studied groups is reflected in table 1.
Timing of delivery *(mean ± SD) in patients with cerclage placed in different parts of the cervix.
|Group I||36 ± 4.2||NS|
|Group II||35 ± 3.8||NS|
|Group III||28 ± 4.8||P < 0.05|
*Patients who miscarried prior to 24 weeks of gestation were excluded.
It appears that location of the cerclage placement plays an important role in prolongation of pregnancies and should be taken into consideration in future studies.
II. Can Weekly Antepartum Testing Decrease Still-Birth Rate?
Terrani, MD*, F. Gonzales, MD*, A. Dillon, RNMS* B. Petrikovsky, MD, PhD**
Garden OB/GYN*, Fetal Research Fund**, New York, NY
Stillbirth rates in the USA plateaued between 2006 and 2012 at 6.05 per 1.000 deliveries, totaling 50.045 stillbirth and 8,268.41 live births. Although there are no clearly identifiable risk factors for stillbirth, advanced maternal age puts fetuses at risk. Frequent antepartum testing was shown to decrease stillbirth rate from 5.2/1000 to 3.9/1000 in the advanced maternal age group. The purpose of the study is to assess if weekly antepartum testing after 36 weeks of pregnancy can decrease stillbirth in all age groups.
Materials and methods:
Our antepartum testing model (full biophysical profile weekly at 36 weeks on) started with a cohort of 6600 women. Patients who experienced stillbirth prior to the onset of testing were excluded. Biweekly testing was used in high-risk patients using standard indications. A positive test served as an indication for delivery. Women with a negative test remained undelivered until the subsequent positive test or onset of labor. Control group consisted of 4420 patients in whom antepartum testing was performed using indications accepted by ACOG. All statistical computations were performed using DATA 4.0; Trec Age software, Williamstown, MA).
Without a strategy of weekly antepartum fetal surveillance between 36 and 41 weeks, women of all age groups experienced 3.04 stillbirths per 1000 pregnancies. For women undergoing weekly testing, the stillbirth rate was 1.24 per 1000. Thus, a strategy of weekly antepartum testing starting at 36 weeks of pregnancy in women of all age groups reduced the number of stillbirths by 58%.
Patients should be aware that in spite of the additional cost of testing and its effect on induction and operative delivery rates, weekly fetal assessment decreases stillbirth rate in all age groups by more than half.
III. Can Cervical Length Monitoring And Treatment Affect Prematurity Rate?
Authors: M Terrani, F Gonzales, B Petrikovsky, A Dillon
Institutions: Ocean Perinatology, Wyckoff Heights Medical Center
Prematurity remains a major contributor to perinatal morbidity and mortality. In 2007 the Institute of Medicine reported that the annual costs associated with preterm births exceed $26 billion. In spite of enhanced efforts, the rates of prematurity didn't change much. It appears, however, that in a subset of patients with progressively decreasing cervical length surgical or medical interventions may be beneficial.
Materials and methods:
Our protocol includes cervical length measurements at 12, 16, and 20 weeks of pregnancy using transvaginal approach in all pregnant patients. A cervical length of less than 25 mm served as an indication for interventions, e.g., cerclage, progesterone therapy, or both depending on the gestational age and preference of patient and doctor. Patients of different group practice using standard management protocol served as a control group. Preterm birth was defined as a delivery between more than 24 and less than 37 weeks of pregnancy, and further subdivided into the ones delivered at less than 32 weeks of pregnancy and those delivered between 32 and 37 weeks.
A total of 1,319 patients comprised the study group and 2,518 – control group. Patients who delivered at less than 32 weeks were considered extreme prematurity, less than 37 weeks – moderate prematurity (Table 1).
|Gestational age at birth||Study group (N=1319)||Control group (N=2518)|
|Under 32 weeks||30 2.3%||78 3.1% *|
|More than 32 weeks, less than 37 weeks||55 4.17%||152 6.03% **|
|Total preterm: 85 6.47% 230 9.13% *|
Our policy of universal cervical length screening at 12, 16, and 20 weeks of pregnancy and indicated interventions confirms its effectiveness in reducing preterm births. It led to decreased incidence of preterm birth at less than 32 weeks and total prematurity rate.
IV. Pre-Term Birth Rates: Our Efforts to Keep Preterm Birth Rates Low:
Premature labor can impact the baby's health, including increasing the risk of brain and other neurological complications, breathing problems, and digestive problems. Some babies born prematurely may also have developmental delays or learning disabilities. The risk and severity of health problems is directly related to how early a baby is born. While many babies do well after receiving care from a neonatal intensive care unit, their prematurity does increase health and developmental risks. At Garden OB/GYN, we, therefore, work diligently to incorporate consistent monitoring efforts into each of our patients’ pregnancy appointments so to help reduce the chances of premature births.
We believe that the key to a favorable pregnancy outcome is routine monitoring for fetal and maternal well being. We have therefore created guidelines which create favorable patient and child outcomes. Thanks to these routine monitoring efforts, our premature birth rate is lower than the national average.
Through such routine monitoring, using frequent sonograms, routine Doppler studies, and other techniques, we can detect changes in pregnancy and potential problems early on in the pregnancy, allowing the issue to be easier to treat and manage. For example, the use of Doppler sonograms, which detects movement in blood vessels using sound waves, reassure us and the mother that the baby is well. In instances where the Dopplers are abnormal, we opt to further investigate and likely deliver the baby as soon as possible so that it does not result in a stillborn.
Our compassion and consistent monitoring of each patient’s pregnancy helps promote the well-being of both the patient and their developing baby. Our research-based expertise, utilization of top pregnancy monitoring techniques and dedicated, caring obstetrical team provide the medical and emotional support needed during your pregnancy. To schedule an obstetric appointment, call one of the nine offices located throughout the greater New York City area or use the online booking feature.
V. Importance of sonographic endometrial appearance in detecting hyperplasia and carcinoma
In 2008, the American College of Obstetricians and Gynecologists (ACOG) put together a special committee to produce recommendations on the role of transvaginal sonography to evaluate endometrium in postmenopausal women.1 Transvaginal ultrasonography usually is sufficient for an initial evaluation of postmenopausal bleeding if the ultrasound images reveal a thin endometrial echo (less than or equal to 4 mm), given that an endometrial thickness of 4 mm or less has a greater than 99% negative predictive value for endometrial value for endometrial cancer.1
However, certain types of endometrial carcinoma e.g., type II can present with endometrial thickness of less than 4 mm.1 The International Endometrial Tumor Analysis (IETA) group was formed in Chicago at the World Congress of Ultrasound in Obstetrics and Gynecology in 2008 with the aim of agreeing on terms and definitions to describe ultrasound findings in the uterine cavity.
We present retrospective analysis of 1,842 patients in whom we compare endometrial thickness and appearance (morphology) with the results of clinically indicated endometrial biopsy results.
Material and Methods. This is a retrospective cohort study of 1,842 patients aged 45 – 76 years old who underwent transvaginal sonography between June 2008 and August 2018. Seven hundred and twelve patients were premenopausal, 1,130 patients – postmenopausal. Endometrial sampling was performed in 612 cases based on suspicious sonographic or clinical symptoms. Sonographic features of the endometrium and intrauterine lesions were described using IETA criteria.2
In premenopausal patients, a sonographic examination was performed in the early proliferative phase and in postmenopausal women on cyclic hormonal replacement therapy 5 – 10 days after the last progestin tablet. The uterus was scanned in the sagittal plane from cornu to cornu and in the (oblique) transverse plane from the cervix to the fundus.
For endometrial thickness assessment the calipers were placed at the level of the two opposite endometrial-myometrial interfaces and the endometrium was measured where it appears to be at its thickest perpendicular to the midline. The measurement of the total double-layer thickness was reported in millimeters, rounded up to one decimal point. When intracavitary fluid is present, the thickness of both single layers were measured and the sum is recorded. If the endometrium is thickened asymmetrically the largest anterior and posterior endometrial thickness was reported separately.
An evaluation of endometrial morphology included an assessment of endometrial echogenicity, the endometrial midline and the endometrial-myometrial junction. A ‘uniform’ endometrium included the three-layer pattern, as well as a homogenous hyperechogenic, hypoechogenic and isoechogenic endometrium. The echogenicity is defined as ‘non-unifrom’ if the endometrium appears heterogenous, asymmetrical or cystic. The endometrial midline was defined as ‘linear’, if a straight hyperechogenic interface within the endometrium is visualized, as ‘non-linear’ if a waved hyperechogenic interface is seen, and as ‘irregular’ or as ‘not defined’ in the absence of a distinct interface. All studies were performed at the AIUM certified sonographic unit.
Statistical Analysis. Data analysis was performed with SPSS 21.0. Normality was evaluated using Shapiro-Wilk test. Standard X 2 test and analysis of variance test were used to compare categorical and continuous variables. Variables that were found to be different between groups (P<.05) in the bivariate analysis were entered to the multivariable logistic regression model. The model was tested for goodness of fit. Differences were considered significant when the Pvalue was <.05.
Results. Endometrial pathology was detected in 69 out of 612 patients who underwent biopsy for accepted clinical indications, polyps in 36, simple hyperplasia in 25, complex hyperplasia in 13, and endometrial cancer in 5.
Comparison of endometrial thickness and morphology with biopsy results revealed the following: Simple hyperplasia has increased thickness in 9 out of 15 cases and abnormal appearance in 6 (non-uniform echogenicity, lack of 3-layer pattern); in cases of complex hyperplasia and cancer, endometrial thickness was abnormal in 15 out of 18 cases (83%) and morphology in all cases (heterogeneous, asymmetrical or cystic).
Discussion. Cancer of the endometrium is the most common type of gynecologic cancer in the United States. In 2007, an estimated 61,380 new cases of uterine cancer were diagnosed and an estimated 10,920 deaths occurred.3 The earliest reports comparing transvaginal ultrasonography with endometrial sampling consistently found that an endometrial thickness of 4-5 mm or less reliably excluded endometrial cancer.4,5However, type II endometrial carcinomas and endometrial cancer precursors had been detected in women with endometrial thickness of less than 3 mm.1
Using a 4 mm endometrial echo as a cut-off value, transvaginal ultrasonography has high negative predictive value. However, a thickened endometrial echo is not diagnostic of any particular pathology.1 Furthermore, a thin endometrial echo does not reliably exclude type II endometrial cancer (uterine papillary serous, mucinous, or clear cell carcinomas).6
The presence of endometrial cancer in polyps, although rare, have been reported as well.7 In view of the above, we conducted a retrospective study comparing the value of endometrial thickness versus morphology in recognizing endometrial pathology.
We conclude that abnormal morphology matters more than abnormal thickness in detection of precancerous and cancerous lesions of the endometrium. The loss of trilinear appearance in premenopausal women and monolayer in postmenopausal is most indicative of endometrial pathology. This conclusion doesn't neglect the significance of endometrial thickness in screening for endometrial pathology but rather add another important parameter – endometrial morphology.
The weaknesses of the study are its retrospective nature and the fact that endometrial biopsy had been performed in a selected number of indicated cases. This allows the possibility of some cases of endometrial pathology to remain undetected. The strength of the study is a large number of participants and the fact that all sonographic examinations were performed by AIUM certified technicians using uniform IETA protocol.
Our results confirm IETA statement that, “Endometrial thickness is certainly important as a predictor of pathology, but endometrial morphology may prove just as useful. In particular, it might be useful in premenopausal patients, in whom endometrial thickness has been shown to be of limited value as a predictor of abnormal findings.2,8
Attention to sonographic endometrial morphology may be especially important to premenopausal patients with risk factors for developing malignancy, unopposed estrogen, diabetes, nulliparity, and obesity, characterized by a BMI > 25 kg/m2, among others. Transvaginal assessment of endometrial thickness can be used with the same cutoff in postmenopausal women estrogen replacement, but assessment of endometrial thickness is less useful in the premenopausal population.9
- The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. ACOG Committee Opinion. Number 734, May 2018.
- Leone FPG, Timmerman D, Bourne T, et al, for IETA group. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol 2010; 35: 103-112.
- American Cancer Society. Cancer facts and figures 2017. Atlanta (GA): ACS; 2017.
- Varner RE, Sparks JM, Cameron CD, et al. Transvaginal sonography of the endometrium in postmenopausal women. Obstet Gynecol 1991; 78: 195-9.
- Granberg S, Wikland M, Karlsson B, et al. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality. Am J Obstet Gynecol 1991; 164: 47-52.
- Wang J, Wieslander C, Hansen G. Thin endometrial echo complex on ultrasound does not reliably exclude type 2 endometrial cancers. Gynecol Oncol 2006; 101: 120-5.
- Ferrazzi E, Zupi E, Leone FP, et al. How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study. Am J Obstet Gynecol 2009; 200: 235. e1-6.
- Dijkhuizen FP, Brölman HA, Potters AF, et al. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol 1996; 87: 345-349.
- Trimble CL, Method M, Leitao M, et al, for the Society of Gynecologic Oncology Clinical Practice Committee. Management of endometrial precancers. Obstet Gynecol 2012(Nov); 120(5): 1160-75.
VI. Transatlantic Air Travel in the Third Trimester of Pregnancy: Does It Affect the Fetus?
B. Petrikovsky, MD, PhD** M. Terrani, MD*, L. Sichinava, MD, PhD*
Garden OB/GYN*, Fetal Research Fund**, New York, NY
Most commercial airlines allow pregnant women to fly up to 36 weeks of gestation.1 Some restrict pregnant women from international flights earlier in gestation and some require documentation of gestational age. For specific air- line requirements, women should check with the individual carrier.1 Recent cohort studies suggest no increase in adverse pregnancy outcomes for occasional air travelers for low-risk patients.2,3 Available information suggest that noise, vibration, and cosmic radiation present a small risk for the pregnant air traveler.4 Both the National Council on Radiation Protection and Measurements and the Interna- tional Commission on Radiological Protection recommend a maximum annual radiation exposure limit of 1 millisievert (mSv) (100 rem) for members of the general public and 1 mSv over the course of a 40-week pregnancy.5 Even the longest available intercontinental flights will expose pas- sengers to no more than 15% of this limit5; therefore, it is unlikely that the occasional traveler will exceed current exposure limits during pregnancy. However, aircrew or frequent flyers may exceed these limits. There is a paucity of information regarding risks of air travel in pregnancy, most of it stemming from fairly old series.3 While one study deduced that “such low level of hypoxia as that which in an aircraft has little effect on the fetus,” another author argued that the “changing mechanics of pregnancy lend credence to the argument that pregnant stewardesses should not fly.”6,7
The goal of the study was to assess the possible effect of transatlantic flights on the condition of the third-trimester fetus.
Materials and Methods
One hundred and twelve patients were recruited into the study between January 2005 and June 2016. All underwent a transatlantic flight in the third trimester of pregnancy. All patients were between 34 and 37 weeks of gestation. All underwent nonstress test (NST) before and within 12 hours after the transatlantic flight, and 24 hours later. Patients were asked to report changes in fetal movements (FMs), if any, during takeoff, flight itself, and landing.
Statistical evaluation was made using SPSS for Windows V 15.0 (SPSS Inc.). Data were shown as frequency (percentage) or mean standard deviation.
The time of flight varied from 8 to 15 hours; average flight time was 9 3.8 hours. Ninety-eight patients were the passengers of first or business class, and the rest were of economy class. Patients’ ages varied from 22 to 39 years, average being 26 5.2 years. NST parameters are reflected in ►Table 1. Increased FM during takeoff was reported by 17 patients (15%), no change in FM by 62 (35%), decreased FM by 4 (3.6%). During flight itself, increased FM was reported by 6 pregnant passengers (5.4%), no change in FM by 70 (63%), decreased FM by 8 (7%).
Magann et al8 conducted a literature review on air travel and pregnancy outcome among other issues (e.g., cosmic radia- tion, risk of acquiring respiratory disease, possibility of obstetrical emergencies) and addressed one of the possible risks to the fetus, aircraft noise. A review of perinatal effects of noise emphasizes the lack of properly controlled studies to draw meaningful conclu- sions about the effects or lack of effects of noise on birth defects and perinatal outcomes.9 The World Health Orga- nization has labeled noise of greater than 85 dB as poten- tially hazardous.10 In both military and civilian aircraft, the greatest noise exposure is during takeoff and landing. Indeed, Freeman et al3 observed increased fetal heart rate during takeoff and landing. The majority of our patients reported increased FMs at these times. It remains unclear whether these changes are caused by aircraft noise, mater- nal anxiety, or a combination of both. These fetal responses are very similar to the ones experienced by fetuses exposed to cell phone noise. Frequent acoustic stimulation by cell phones and beepers was accompanied by a startle response manifested by head turning toward the source of the sound, increased swallowing, and frequent eye blinking. Startle responses were observed in all fetuses of the study group and only in 12% of the fetuses in the control group. Besides causing startle response, acoustic stimulations were asso- ciated with changes in behavioral states, most notable, from quiet and active sleep into an awakened state.11,12 The partial pressure of oxygen in inspired air in airplane cabin environments maintained by cabin pressure is usually lower than that at sea level. Physiological adaptations to this relative reduction in inspired oxygen include an increase in heart rate, increase in blood pressure, and decrease in transcutaneously measured arterial oxygen saturation. Fetal hemoglobin has a greater affinity for oxygen than adult hemoglobin, and the fetus is able to maintain a higher oxygen saturation in this environment, which protects it during routine flight conditions. Most healthy pregnant women will have no adverse effects, but those with preexisting cardiovascular problems, sickle cell disease, or anemia13 may experience complications. Our study demonstrated significant changes in FHR para- meters immediately after the transatlantic flight. It mani- fested in the increased rate of nonreactive NSTs and more frequent appearances of variable decelerations. The strength of the paper is its prospective nature and the fact that all patients were flying the same or similar distances. In most previous studies, data from intercontinental and domestic flights were analyzed together, thus causing confusion. In spite of the fact that on long commercial flights, traveling at 39,000 to 41,000 ft., cabin pressure is maintained at the equivalent of an altitude pressure of 8,000 ft., whereas at 32,000 ft. (for shorter flights), cabin pressure is set at an equivalent of 6,000 ft.14 The conditions at a cabin pressure of 8,000 ft. will create a more hypoxic environment than those at 6,000 ft. At 6,000 ft., oxygen consumption in pregnant women is 13% (L/minute) lower than that at sea level in comparison with nonpregnant women for whom the decrease is only 3% lower.2 The limitations of the study are relatively small sample size and the subjective nature of FM assessment based on patients’ diaries. Our study demon- strated that although transatlantic flights may cause only temporary changes in fetal behavior and appears safe for the fetus, these conclusions are limited to third-trimester fetuses
Conflict of Interest: None.
- ACOG Committee on Obstetric Practice. ACOG Committee Opi- nion Number 443: Air travel during pregnancy. Obstet Gynecol 2009;114(04):954–955
- Chibber R, Al-Sibai MH, Qahtani N. Adverse outcome of pregnancy following air travel: a myth or a concern? Aust N Z J Obstet Gynaecol 2006;46(01):24–28
- Freeman M, Ghidini A, Spong CY, Tchabo N, Bannon PZ, Pezzullo JC. Does air travel affect pregnancy outcome? Arch Gynecol Obstet 2004;269(04):274–277
- Barish RJ. In-flight radiation exposure during pregnancy. Obstet Gynecol 2004;103(06):1326–1330
- Federal Aviation Administration. In-flight radiation exposure. Advisory Circular No. 120–61A. Washington, DC: FAA; 2006
- Scholten P. Pregnant stewardess–should she fly? Aviat Space Environ Med 1976;47(01):77–81
- Cameron RG. Should air hostesses continue flight duty during the first trimester of pregnancy? Aerosp Med 1973;44(05): 552–556
- Magann EF, Chauhan SP, Dahlke JD, McKelvey SS, Watson EM, Morrison JC. Air travel and pregnancy outcomes: a review of pregnancy regulations and outcomes for passengers, flight atten- dants, and aviators. Obstet Gynecol Surv 2010;65(06):396–402
- Morrell S, Taylor R, Lyle D. A review of health effects of aircraft noise. Aust N Z J Public Health 1997;21(02):221–236
- Berglund B, Lindvall T, Schwela DH, et al. Guidelines for Commu- nity Noise. Geneva, Switzerland: WHO; 1999:1–141
- Petrikovsky BM. Cell phones: be aware of the risks to the fetus. Neonatal Intensive Care 2016;30(01):29–35
- Petrikovsky BM, Schifrin B, Diana L. The effect of fetal acoustic stimulation on fetal swallowing and amniotic fluid index. Obstet Gynecol 1993;81(04):548–550
- Hezelgrave NL, Whitty CJM, Shennan AH, Chappell LC. Advising on travel during pregnancy. BMJ 2011;342:d2506
- Brooks GA, Fahey TD, White TP, Baldwin KM. Exercise, atmo- spheric pressure, air pollution, and travel. In: Exercise Physiol- ogy: Human Bioenergetics and Its Applications. 3rd ed. Mountain View, CA: Mayfield Publishing Company; 2000:504–536