This is a typical case of cervical incompetence (and this patient has conization as a risk factor). This pathology consists of dilatation of the cervix in the absence of contractions, requiring cerclage to prevent miscarriage or immature delivery. The cerclage is ideally performed electively, programmed, and not when the patient arrives at the ER "in extemis" (which are also done, but with a lower success rate... the ideal is to do them cold).

A 32-year-old woman requests preconception counseling. The patient reports that she underwent cervical conization for a high-grade intraepithelial lesion (H-SIL) and subsequently had three miscarriages between 20 and 22 weeks gestation. She has no living children. On all three occasions she came to the emergency department with a feeling of weight in the hypogastrium, where she was found to be 8 cm dilated and with prominent amniotic membranes. She had never felt contractions before, what advice would you give her for the next pregnancy?

I would prescribe oral atosiban prophylaxis throughout the pregnancy.

I would offer lung maturation with corticosteroids from 19-20 weeks of gestation.

I would recommend a cervical cerclage at 14 weeks gestation.

I would advise her not to attempt any more pregnancies because of the high risk of recurrence.

I would recommend resorting to assisted reproductive techniques.

Prevention of spontaneous preterm birth: Guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF).

In France, 60,000 neonates are born preterm every year (7.4%), half of them after the spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated with decreased prematurity (level of evidence [LE]1). It is therefore recommended (Grade A). Routine screening and treatment of vaginal bacteriosis is not recommended in the general population (Grade A). The only population for which vaginal progesterone is recommended is that comprising asymptomatic women with singleton pregnancies, no history of preterm delivery, and a short cervix at 16-24 weeks of gestation (Grade B). A history-indicated cerclage is not recommended for women with only a history of conization (Grade C), uterine malformation (professional consensus), isolated history of preterm delivery (Grade B), or twin pregnancies for primary (Grade B) or secondary (Grade C) prevention of preterm birth. A history-indicated cerclage is recommended for a singleton pregnancy with a history of at least 3 late miscarriages or preterm deliveries (Grade A). Ultrasound cervical length screening is recommended between 16 and 22 weeks for women with a singleton previously delivered before 34 weeks gestation, so that cerclage can be offered if cervical length <25mm before 24 weeks (Grade C). A cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with twin pregnancies (Grade A) or in populations of asymptomatic women with a short cervix (professional consensus). Although the implementation of universal screening by transvaginal ultrasound for cervical length at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In cases of preterm labor, (i) it is not possible to recommend any one of the several methods (ultrasound of the cervical length, vaginal examination, or fetal fibronectin assay) over any other to predict preterm birth (Grade B); (ii) routine antibiotic therapy is not recommended (Grade A); (iii) prolonged hospitalization (Grade B) and bed rest (Grade C) are not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (Grade B), unlike beta-agonists (Grade C), can be used for tocolysis in spontaneous preterm labor without preterm premature rupture of membranes. Maintenance tocolysis is not recommended (Grade B). Antenatal corticosteroid administration is recommended for all women at risk of preterm delivery before 34 weeks of gestation (Grade A). After 34 weeks, the evidence is insufficiently consistent to justify recommending systematic antenatal corticosteroid treatment (Grade B), but a course of this treatment might be indicated in clinical situations associated with high risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (Grade C). Repeated courses of antenatal corticosteroids are not recommended (Grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 weeks (Grade A). Cesareans are not recommended for fetuses in vertex presentation (professional consensus). Both planned vaginal and elective cesarean delivery are possible for breech presentations (professional consensus). Delayed cord clamping may be considered if the neonatal or maternal state allows (professional consensus).

[Prevention of spontaneous preterm birth (excluding preterm premature rupture of membranes): Guidelines for clinical practice - Text of the Guidelines (short text)].

To determine the measures to prevent spontaneous preterm birth (excluding preterm premature rupture of membranes)and its consequences. The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. In France, premature birth concerns 60,000 neonates every year (7.4 %), half of them are delivered after spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated to a decrease of prematurity (level of evidence [LE] 1). This is therefore recommended (grade A). Routine screening and treatment of vaginal bacteriosis in general population is not recommended (grade A). Asymptomatic women with single pregnancy without history of preterm delivery and a short cervix between 16 and 24 weeks is the only population in which vaginal progesterone is recommended (grade B). A history-indicated cerclage is not recommended in case of only past history of conisation (grade C), uterine malformation (Professional consensus), isolated history of pretem delivery (grade B) or twin pregnancies in primary (grade B) or secondary (grade C) prevention of preterm birth. A history-indicated cerclage is recommended for single pregnancy with a history of at least 3 late miscarriages or preterm deliveries (grade A).). In case of past history of a single pregnancy delivery before 34 weeks gestation (WG), ultrasound cervical length screening is recommended between 16 and 22 WG in order to propose a cerclage in case of length<25mm before 24 WG (grade C). Cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with a twin pregnancy (grade A) and in populations of asymptomatic women with a short cervix (Professional consensus). Although the implementation of a universal transvaginal cervical length screening at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In case of preterm labor, (i) it is not possible to recommend one of the methods over another (ultrasound of the cervical length, vaginal examination, fetal fibronectin) to predict preterm birth (grade B); (ii) routine antibiotic therapy is not recommended (grade A); (iii) prolonged hospitalization (grade B) and bed rest (grade C) is not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (grade B), contrary to betamimetics (grade C), can be used for tocolysis in spontaneous preterm labour without preterm premature rupture of membranes. Maintenance tocolysis is not recomended (grade B). Antenatal corticosteroid administration is recommended to every woman at risk of preterm delivery before 34 weeks of gestation (grade A). After 34 weeks, evidences are not consistent enough to recommend systematic antenatal corticosteroid treatment (grade B), however, a course might be indicated in the clinical situations associated with the higher risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (grade C). Repeated courses of antenatal corticosteroids are not recommended (grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended to women at high risk of imminent preterm birth before 32WG (grade A). Cesarean is not recommended in case of vertex presentation (Professional consensus). Both planned vaginal or elective cesarean delivery is possible in case of breech presentation (Professional consensus). A delayed cord clamping may be considered if the neonatal or maternal state so permits (Professional consensus). Except for antenatal corticosteroid and magnesium sulfate administration, diagnostic tools or prenatal pharmacological treatments implemented since 30 years to prevent preterm birth and its consequences have not matched expectations of caregivers and families.

Obstentrics_Williams

Afecting approximately 1 percent of fertile couples, recurrent pregnancy loss (RPL) is classically deined as three or more consecutive pregnancy losses <20 weeks' gestation or with a fetal weight < 500 g. Mindful of this threshold, data from two large studies showed the risk for a subsequent miscarriage to be similar whether following two or three prior pregnancy losses (Bhattacharya, 2010; Brigham, 1999). And, the American Society for Reproductive Medicine (2013) now deines RPL as two or more failed pregnancies conirmed by sonographic or histopathological examination. Primary PL refers to multiple losses in a woman who has never delivered a liveborn, and secondary PL refers to multiple pregnancy losses in a patient with a prior live birth. Remarkably, the chances for a successful pregnancy arei> 50 percent even after five losses (Table 18-4). TABLE 18-4. Predicted Success Rate of Subsequent Pregnancy According to Age and Number of Previous Miscarriages

Early Accreta and Uterine Rupture in the Second Trimester.

The differential diagnosis of third trimester bleeding can range from placenta abruptia to placenta previa to uterine rupture and the placenta accreta spectrum (PAS). However, patients with risk factors such as multiple cesarean sections (c-sections), advanced maternal age (AMA), grand multiparity, and single-layer uterine closure are at greater risk of developing these complications earlier than we would traditionally expect. This case recounts a 38-year-old gravida 6 preterm 3 term 1 abortus 1 live 4 (G6P3114) at 23 weeks and five days gestational age (GA) with a past medical history of preterm pregnancy, pre-eclampsia, chronic abruptia, three previous c-sections, and low-lying placenta who presented to the emergency department (ED) with vaginal bleeding. Initial workup revealed placenta accreta and possible percreta. The patient was placed on intramuscular (IM) corticosteroids in anticipation of preterm delivery. As soon as the patient was stable, she was discharged home. She presented to a different hospital the next day with the same complaints. Imaging was consistent with accreta and her presentation with abruption. During the hospital stay, the patient went into threatened preterm labor (PTL). At first, we suspected preterm premature rupture of membranes (PPROM) due to apparent pooling of amniotic fluid in the vaginal canal. Upon further work up, the diagnosis was consistent with chronic abruption oligohydramnios sequence (CAOS). Before this could be investigated, her hospital course was complicated by acute abruption and Category III/nonreassuring fetal heart rate (FHR) tracing. The patient underwent an emergency c-section at 26 weeks GA as well as a planned supracervical hysterectomy for desired permanent sterilization. During the operation, the patient suffered a postpartum hemorrhage (PPH) of 4500 mL. She was later discharged home on postoperative day (POD) eight.

Standard term of pregnancy.

What is it? This question arose early this year during a discussion with my doula partner, who lived in Great Britain for 20 years, and one of the midwives I work with, who attends only homebirths, which is very rare in France. The mom whose case we were discussing was late going into labor but not postdated according to the official pregnancy term here in France (37-42 WA--"weeks of amenorrhea"). The midwife expressed her discomfort with waiting. My doula partner and I felt differently, but we knew we were influenced by American and British midwives' practices. I had been shocked the previous December by the position of the chief of the maternity department in a private hospital (a small unit with no residents, in which nurse-midwives attend "normal" births and obstetricians are called in case of complications only). This OB explained to my client and me that if she didn't go into labor naturally, she would be called at 41 + 1 for a vaginal exam to check her cervix and would be induced at 41 + 2. Waiting until 42 weeks requires daily checks, for which he has neither the room nor personnel. He clearly stated that it was a matter of management of time and finances. A month later one of our clients reported the story of her brother and sister-in-law's planned homebirth in London. Their doctors had put a lot of pressure on the mother during her pregnancy with gestational diabetes regarding her length of term. They started to talk about induction. The parents didn't feel comfortable with this, and at that point our client had asked me to refer them to someone who could help them there. We referred them to the National Childbirth Trust and to the sweetest doula we know there. This doula (Liliana Lammers) and her famous doctor partner (Dr. Michel Odent) were a good match. The doctor advised waiting, on the condition that the health of the baby and the amount of fluid be checked daily at the local hospital. The mother had already been waiting several weeks past what was supposed to be her term. Finally, she went naturally into labor at home. The doctor and the doula came and, after some hours of observation, decided it would be wiser for the mother to deliver in the hospital. The doctor and doula were not comfortable with the prolonged prelabor, when, at nearly 44 weeks, the health of the baby and the amount of fluid had not been checked for five days. The mother finally had a vaginal birth without drugs at the hospital. After hearing this story, I suggested it would be interesting to collect the official lengths of term and the different routines in other countries as a learning tool and in order to give us something other than French protocol on which to base our practice. So I sent the question to every midwife for whom I had an e-mail address from the last Midwifery Today conference in Paris. Beyond this motivation was my own curiosity regarding the relationship between the official term in each country and its uses and routines. The most significant (because the most unique) answer, in my opinion, is from The Netherlands, where physiology is a priority.

[What should you tell a patient with a history of cervical incompetence in the first trimester?].

Data is now more than ever available to inform couples at risk of second trimester miscarriage or preterm delivery. We are able to give customized information according to the obstetrical history and to the evolution of the cervix during the second trimester although the level of scientific evidence is limited or poor. Elective cerclage can be proposed to patients with a history of at least 3 second trimester miscarriages or preterm deliveries. There is no clear consensus on which patients could benefit from therapeutic cerclage. Indications would have to be motivated by a short cervix on ultrasound measurements and the cerclage performed before 24 weeks of gestation.

First case of vaginal radical trachelectomy in a pregnant Japanese woman.

A diagnosis of cervical cancer during pregnancy poses difficult management and ethical problems. Survival of the patient is the foremost concern, but fetal viability and well-being must also be addressed. Radical trachelectomy (RT) has recently begun to be performed as a possible treatment modality for early stage invasive uterine cervical cancer in pregnant patients who would like to continue their pregnancy. A 32-year-old Japanese woman visited a local hospital for prenatal care, and was diagnosed with a FIGO I B1 adenocarcinoma of the uterine cervix. She had a strong desire to avoid pregnancy termination, so she was admitted to our hospital for fertility-preserving surgery. After extensive counseling, vaginal radical trachelectomy with abdominal pelvic lymphadenectomy was performed in the 16th gestational week. The excised uterine cervix and lymph nodes were pathologically negative for cancer. To maintain her pregnancy, daily vaginal disinfection with povidone iodine, bed rest, and administration of ritodrine and an ulinastatin vaginal suppository were continued until the delivery. At 34 weeks' gestation, an emergency cesarean section was performed because of sudden premature rupture of the membranes. A baby girl was born weighing 2112 g, with Apgar score of 8/9. The mother remains without evidence of recurrence at the time of this report. This is the first case of successful pregnancy and delivery in Japan after vaginal RT.

Obstentrics_Williams

Prevention of preterm birth remains an elusive goal. Still, may be achievable. Of options, cerclage placement may be used to prevent pre term birth in at least three circumstances. First, the procedure may beneit women who have a history of recurrent midtrimester losses and who are diagnosed with cervical insuiciency. A second instance is the woman identiied during sonographic examination to have a short cervix. The third indication is a "rescue" cerclage, done emergently when cervical incompetence is recognized in women with threatened preterm labor.

Successful cervical cerclage in a dichorionic diamniotic twin pregnancy: A case report.

A 26-year-old primigravid woman presented with a dichorionic diamniotic twin pregnancy after 7 years of infertility. No formal ultrasound was performed until a morphology check at 19 weeks and 4 days of gestation, at which time a shortened cervix was identified. The patient was already on vaginal progesterone pessaries from conception, as per her infertility specialist, and was advised to change to a rectal route of administration. At 20 weeks and 5 days, progesterone pessaries were increased to twice daily. A repeat scan at 21 weeks and 4 days showed a funnelled cervix 29 mm in length, a closed portion of 4-6 mm and bulging membranes. A speculum examination at this time showed a shortened cervix, 5 mm open, with visible membranes. A cervical cerclage was placed at 21 weeks and 5 days. The patient was given oral antibiotics for 1 week and was continued on progesterone pessaries. The patient was managed through the twins clinic and had serial ultrasound scans throughout the pregnancy. She went on to develop gestational diabetes and pre-eclampsia. She had a caesarean section at 33 weeks and 4 days due to pre-eclampsia, with abnormal doppler scans. Cervical cerclage was removed at the time of the caesarean section. Both twins were admitted to the nursery for prematurity and progressed well. This case report illustrates how a cervical cerclage can be utilised successfully in a primigravid dichorionic diamniotic twin pregnancy.

Breathlessness with pulmonary metastases: a multimodal approach.

Case Study  Sarah is a 58-year-old breast cancer survivor, social worker, and health-care administrator at a long-term care facility. She lives with her husband and enjoys gardening and reading. She has two grown children and three grandchildren who live approximately 180 miles away. SECOND CANCER DIAGNOSIS  One morning while showering, Sarah detected a painless quarter-sized lump on her inner thigh. While she thought it was unusual, she felt it would probably go away. One month later, she felt the lump again; she thought that it had grown, so she scheduled a visit with her primary care physician. A CT scan revealed a 6.2-cm soft-tissue mass in the left groin. She was referred to an oncologic surgeon and underwent an excision of the groin mass. Pathology revealed a grade 3 malignant melanoma. She was later tested and found to have BRAF-negative status. Following her recovery from surgery, Sarah was further evaluated with an MRI scan of the brain, which was negative, and a PET scan, which revealed two nodules in the left lung. As Sarah had attended a cancer support group during her breast cancer treatment in the past, she decided to go back to the group when she learned of her melanoma diagnosis. While the treatment options for her lung lesions included interleukin-2, ipilimumab (Yervoy), temozolomide, dacarbazine, a clinical trial, or radiosurgery, Sarah's oncologist felt that ipilimumab or radiosurgery would be the best course of action. She shared with her support group that she was ambivalent about this decision, as she had experienced profound fatigue and nausea with chemotherapy during her past treatment for breast cancer. She eventually opted to undergo stereotactic radiosurgery. DISEASE RECURRENCE  After the radiosurgery, Sarah was followed every 2 months. She complained of shortness of breath about 2 weeks prior to each follow-up visit. Each time her chest x-ray was normal, and she eventually believed that her breathlessness was anxiety-related. Unfortunately, Sarah's 1-year follow-up exam revealed a 2 cm × 3 cm mass in her left lung, for which she had a surgical wedge resection. Her complaints of shortness of breath increased following the surgery and occurred most often with anxiety, heat, and gardening activities, especially when she needed to bend over. Sarah also complained of a burning "pins and needles" sensation at the surgical chest wall site that was bothersome and would wake her up at night. Sarah met with the nurse practitioner in the symptom management clinic to discuss her concerns. Upon physical examination, observable signs of breathlessness were lacking, and oxygen saturation remained stable at 94%, but Sarah rated her breathlessness as 7 on the 0 to 10 Borg scale. The nurse practitioner prescribed duloxetine to help manage the surgical site neuropathic pain and to assist with anxiety, which in turn could possibly improve Sarah's breathlessness. Several nonpharmacologic modalities for breathlessness were also recommended: using a fan directed toward her face, working in the garden in the early morning when the weather is cooler, gardening in containers that are at eye level to avoid the need to bend down, and performing relaxation exercises with pursed lip breathing to relieve anxiety-provoked breathlessness. One month later, Sarah reported relief of her anxiety; she stated that the fan directed toward her face helped most when she started to feel "air hungry." She rated her breathlessness at 4/10 on the Borg scale. SECOND RECURRENCE: MULTIPLE PULMONARY NODULES  Sarah's chest x-rays remained clear for 6 months, but she developed a chronic cough shortly before the 9-month exam. An x-ray revealed several bilateral lung lesions and growth in the area of the previously resected lung nodule. Systemic therapy was recommended, and she underwent two cycles of ipilimumab. Sarah's cough and breathlessness worsened, she developed colitis, and she decided to stop therapy after the third cycle. In addition, her coughing spells triggered bronchospasms that resulted in severe anxiety, panic attacks, and air hunger. She rated her breathlessness at 10/10 on the Borg scale during these episodes. She found communication difficult due to the cough and began to isolate herself. She continued to attend the support group weekly but had difficulty participating in conversation due to her cough. Sarah was seen in the symptom management clinic every 2 weeks or more often as needed. No acute distress was present at the beginning of each visit, but when Sarah began to talk about her symptoms and fear of dying, her shortness of breath and anxiety increased. The symptom management nurse practitioner treated the suspected underlying cause of the breathlessness and prescribed oral lorazepam (0.5 to 1 mg every 6 hours) for anxiety and codeine cough syrup for the cough. Opioids were initiated for chest wall pain and to control the breathlessness. Controlled-release oxycodone was started at 10 mg every 12 hours with a breakthrough pain (BTP) dose of 5 mg every 2 hours as needed for breathlessness or pain. Sarah noted improvement in her symptoms and reported a Borg scale rating of 5/10. Oxygen therapy was attempted, but subjective improvement in Sarah's breathlessness was lacking. END OF LIFE  Sarah's disease progressed to the liver, and she began experiencing more notable signs of breathlessness: nasal flaring, tachycardia, and restlessness. Opioid doses were titrated over the course of 3 months to oxycodone (40 mg every 12 hours) with a BTP dose of 10 to 15 mg every 2 hours as needed, but her breathlessness caused significant distress, which she rated 8/10. The oxycodone was rotated to IV morphine continuous infusion with patient-controlled analgesia (PCA) that was delivered through her implantable port. This combination allowed Sarah to depress the PCA as needed and achieve immediate control of her dyspneic episodes. Oral lorazepam was also continued as needed. Sarah's daughter moved home to take care of her mother, and hospice became involved for end-of-life care. As Sarah became less responsive, nurses maintained doses of morphine for control of pain and breathlessness and used a respiratory distress observation scale to assess for breathlessness since Sarah could no longer self-report. A bolus PCA dose of morphine was administered by Sarah's daughter if her mother appeared to be in distress. Sarah died peacefully in her home without signs of distress.

[Cervical cerclage and evidence-based medicine: if, how and when].

Cervical cerclage has always been the main treatment option in cases of so-called cervical insufficiency, a condition that is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. We can distinguish between a prophylactic cerclage, to be performed electively, usually at 13-16 weeks gestation, only when the woman has a history extremely suggestive for cervical incompetence (3 or more mid-trimester abortions or preterm deliveries) and a therapeutic cerclage. This last cerclage is recommended either for women who have ultrasonographic changes consistent with a short cervix or the presence of funneling after the 16-20 weeks gestation (urgent cerclage) and for women who present the asymptomatic dilation of the uterine cervix of at least 2 cm and/or a prolapse of the amniochorial membranes (emergent cerclage). So far there is still a lack of controlled and randomized trials that can unquestionably demonstrate the advantages of the cervical cerclage in comparison with a ''wait and see'' aptitude. The cerclage can be performed either transvaginally, usually according to the McDonald technique, or transabdominally. This last approach is recommended when a transvaginal cerclage has to be avoided because of technical difficulties depending on the conditions of the cervix or when the pregnant woman has a history of one or more failed transvaginal cerclages. Interesting perspectives are currently offered by the laparoscopic cerclage, a method that has been effective and unexpectedly safe till now.

Chorioamnionitis caused by <i>Serratia marcescens</i> in a healthcare worker: A case report.

Healthcare workers (HCWs) are at an increased risk for exposure to infections. <iSerratia marcescens</i (<iS</i. <imarcescens</i) is a gram-negative, opportunistic and nosocomial pathogen belonging to the Enterobacterieae family. A few case reports have been published of chorioamnionitis caused by <iS. marcescens</i infection. Immunological changes during pregnancy can also affect the risk of infection. However, few studies have examined hospital-acquired bacterial infection in pregnant HCWs. A 33-year-old woman, a resident in anesthesiology, was admitted at 14 wk gestation for fever with chills. She had no medical history other than contact dermatitis of both hands that started from the beginning of the trainee. There was no obvious infection focus and no bacterial growth in blood cultures. She was discharged after 1 wk of empirical antibiotic treatment. At three weeks before the fever started, she had a blister on the site of contact dermatitis on both hands, she applied antibiotic ointment for three days and the blisters had healed. At 19 wk gestation, she had a high fever and was readmitted. Physical examination and image studies were nonspecific and the patient had no other symptoms. <iS. marcescens</i grew in blood cultures at 19 wk gestation. Treatment with intravenous antibiotics was started. However, she suffered a miscarriage at 22<sup4/7</sup wk gestation. Pathologically, the amniotic membrane showed chorioamnionitis with a focal infarct. Subsequently, a placenta tissue culture grew <iS. marcescens</i. HCWs can be exposed to pathogens that can cause opportunistic infections such as <iS. marcescens</i. Pregnancy affects the immune system, making it susceptible to opportunistic infections. Therefore, pregnant HCWs may require more preventive measures, including hand hygiene and avoid risk factors (ex. wrapping the skin).

Elective abortion: Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF).

The number of elective abortions has been stable for several decades. Many factors explain women's choice of abortion in cases of unplanned pregnancies. Early initiation of contraceptive use and a choice of contraceptive choices appropriate to the woman's life are associated with lower rates of unplanned pregnancies. Reversible long-acting contraceptives should be favored as first-line methods for adolescents because of their effectiveness (grade C). Ultrasound scan before an elective abortion must be encouraged but should not be obligatory (professional consensus). As soon as the embryo appears on the ultrasound scan, the date of pregnancy is estimated by measuring the crown-rump length (CRL) or, from 11 weeks on, by measuring the biparietal diameter (BPD) (grade A). Because reliability of these parameters is ±5 days, the abortion may be done if measurements are respectively less than 90 mm for CRL and less than 30 mm for BPD (professional consensus). A medically induced abortion, performed with a dose of 200 mg mifepristone combined with misoprostol, is effective at any gestational age (Level of Evidence (LE) 1). Before 7 weeks, mifepristone should be followed 24-48 h later by misoprostol, administered orally, buccally, sublingually, or even vaginally followed if needed by a further dose of 400 μg after 3 h, to be renewed if needed after 3 h (LE 1, grade A). After 7 weeks, administration of misoprostol by the vaginal, sublingual, or buccal routes is more effective and better tolerated than by the oral route (LE 1). Cervical preparation is recommended for systematic use in surgical abortions (professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 μg (grade A). Vacuum aspiration is preferable to curettage (grade B). A uterus perforated during surgical aspiration should not routinely be considered to be scarred (professional consensus). An elective abortion is not associated with a higher risk of subsequent infertility or ectopic pregnancy (LE 2). The medical consultation before an elective abortion generally does not affect the decision to end or continue the pregnancy, and most women are sufficiently certain about their choice at this time. Women appear to find the method used most acceptable and to be most satisfied when they were able to choose the method (grade B). Elective abortions are not associated with an increased rate of psychiatric disorders (LE 2). However, women with psychiatric histories are at a higher risk of psychological disorders after the occurrence of an unplanned pregnancy than women with such a history (LE 2). For surgical abortions, combined hormonal contraceptives - oral or transdermal - should be started on the day of the abortion, while the vaginal ring should be inserted 5 days afterwards (grade B). For medical abortions, the vaginal ring should be inserted in the week after mifepristone administration, while the combined contraceptives should begin the same day as the misoprostol or the day after (grade C). Contraceptive implants should be inserted on the same day as a surgical abortion, and may be inserted the day the mifepristone is administered for medical abortions (grade B and C respectively). In case of medical abortion, the implant can be inserted the same day the mifepristone is administered (grade C). Both the copper IUDs and levonorgestrel intrauterine system should be inserted on the day of the surgical abortion (grade A). After medical abortions, an IUD can be inserted in 10 days after mifepristone administration, after ultrasound scan verification of the absence of an intrauterine pregnancy (grade C).

Mode of Delivery in the Setting of Repeated Vitreous Hemorrhages in Proliferative Diabetic Retinopathy: A Case Report and Review of the Literature.

The state of pregnancy affects all organ systems including the eyes. Progression of diabetic retinopathy (DR) is a known association. In proliferative DR, there is an increased risk of vitreous hemorrhage (VH) during spontaneous vaginal delivery (SVD) due to the Valsalva maneuver. A 30-year-old female with poorly controlled type I diabetes and hypothyroidism on treatment was following up with the antenatal services at our hospital. This was her second pregnancy having had a previous miscarriage. Three months into her pregnancy, our Ophthalmology service was consulted to assess her and give our advice regarding the safest mode of delivery for her. Questioning revealed that she was following regularly elsewhere for proliferate DR with previous interventions and history of multiple and repeated VHs. When she was seen in our Ophthalmology clinic, she was anxious about the mode of delivery that was best suited for her with regard to her ocular condition. On examination, her visual acuity (VA) without correction was 20/40 in both eyes, improving to 20/20 in the right eye and 20/30 in the left eye after refraction. Her intra-ocular pressure was normal. A dilated fundus examination (DFE) showed changes of high-risk proliferative DR in both eyes and a VH in the right eye. Subsequent follow-up did not reveal any new complaints or concerns. She required one session of pan-retinal photocoagulation (PRP) in her first-trimester visit. DFE showed improvement in VH when compared to her initial examination. After discussing her condition with her obstetrician, it was decided to offer the patient a cesarean section (C/S) delivery, as her risk of developing VH during SVD was greater than normal. At 38 weeks of gestation, she delivered a healthy boy following an uneventful elective C/S. There were no visual complaints throughout her admission for the procedure or thereafter. During the reproductive age, DR is a leading cause of decreased vision. Pregnancy is an independent risk factor for progression of DR, with the stage of DR prior to conception being another. If not managed well, proliferative DR can result in VH, with the risk also existing in relation to SVD due to recurrent Valsalva maneuvers during labor. Our patient who initially presented with proliferative DR in both eyes and a VH in the right eye received one session of PRP to both eyes in the first trimester and was closely followed up throughout her pregnancy thereafter. When her due date neared, it was decided that the safest and most suitable mode of delivery was an elective C/S due to her increased risk of VH related to Valsalva maneuvers during SVD, especially since this was to be her first delivery.

[Prevention of preterm birth by uterine cervical cerclage].

To review the scientific literature on cervical insufficiency and indications of cervical cerclage cervix. The PubMed database, the Cochrane Library and the recommendations from the French and international obstetrical societies between 1972 and June 2016 have been consulted. Cervical insufficiency is a pathophysiological concept and to date no consensual definition is available: the diagnosis is clinical and discussed retrospectively in case of patients with a history of late miscarriages and/or spontaneous preterm delivery, with asymptomatic dilatation of the cervix (professional consensus). The risk of preterm birth is higher in case of surgical cold-knife conisation as compared to loop electrosurgical excision (LE3) and laser vaporization has a negligible impact (LE3). In patients with a history of late pregnancy loss or preterm birth, investigations for the diagnosis of uterine malformation are recommended (grade C). No investigation is recommended for the diagnosis of a cervical insufficiency (professional consensus). A history-indicated cerclage is not recommended in case of only past history of conisation (grade C), uterine malformation (professional consensus), isolated history of preterm delivery (grade B) or twin pregnancies in primary (grade B) or secondary (grade C) prevention of preterm birth. A history-indicated cerclage is recommended for single pregnancy with a history of at least three late miscarriages or preterm deliveries (grade A). In case of history of one or two late miscarriages or preterm deliveries, there are not sufficient arguments to recommend a history-indicated cerclage (professional consensus). Further studies are needed. The ultrasound-indicated cerclage is not recommended in case of short cervical length during the 2nd trimester of single pregnancy without past history of gynecologic or obstetrical event (grade B). In case of past history of a single pregnancy delivery before 34 weeks gestation (WG), ultrasound cervical length screening is recommended between 16 and 22 WG in order to propose a cerclage in case of length<25mm before 24 WG (grade C). Ultrasound-indicated cerclage is not recommended for multiple pregnancy with a short cervix (grade B). Emergency cerclage using the MacDonald technique is recommended during the second trimester of pregnancy in case of major changes of the cervix, with or without protrusion of the fetal membranes, but without premature rupture of membranes or chorioamnionitis (grade C). Tocolysis and antibiotics during cerclage should be considered individually (professional consensus). There is no reason to recommend a period of expectative before considering an emergency cerclage (professional consensus). A maximum gestational age to perform a cerclage cannot be recommended (professional consensus). A cervico-isthmic cerclage can be discussed in case of failure of MacDonald cerclage (professional consensus). Scientific data are insufficient to recommend or not a vaginal bacteriological analysis before performing a cerclage (professional consensus). The use of double cerclage does not improve perinatal outcome (NP3) and is not recommended (grade C). There is insufficient scientific argument to recommend a type of stitch over another (grade C). The available data are not in favor of a superiority of the Shirodkar cerclage in case of history- or ultrasound-indicated cerclage and the MacDonald cerclage is firstly recommended because technically easier and less risky (grade C). Overall, complications of cerclage are rare but potentially serious. The occurrence of complications is no different between the history-indicated and echo-indicated cerclage (LE4). There is no scientific evidence on the benefit of bed rest and adjuvant treatments (antibiotics or indomethacin) during history or ultrasound-indicated cerclage (professional consensus). Available data in the literature about cervical cerclage are generally of low level of evidence.

Obstentrics_Williams

3. Nullpara-a woman who has never completed a pregnancy beyond 20 weeks' gestation. She may not have been pregnant or may have had a spontaneous or elective abortion(s) or an ectopic pregnancy. 4. Primipara-a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimated length of gestation of 20 or more weeks. In the past, a 500-g birthweight threshold was used to define parity. his threshold is now controversial because many states still use this weight to diferentiate a stillborn fetus from an abortus (Chap. 1, p. 3). However, the survival of neonates with birthweights < 500 g is no longer uncommon.

Preconception counseling for preventable risks.

A healthy woman of reproductive age complained that when she saw me before pregnancy I did not advise her that she could check her varicella immunity and get vaccinated. She contracted chickenpox and endured unnecessary anxiety. This led me to think that it would be useful to have a summary of all the preconception counseling advice we should give to our patients to ensure the best pregnancy outcomes possible. Could Motherisk provide such a summary? Although favourable pregnancy outcomes cannot be guaranteed, when a pregnancy is planned, many risk factors can be reduced and modified to enhance pregnancy outcomes. In the summary provided we will discuss optimization of diet, weight, and exercise; discontinuation of smoking and drinking; controlling chronic medical conditions; starting supplementation with multivitamins and folic acid; and ensuring proper immunization.

Obstentrics_Williams

Stoddard A, Eisenberg DL: Controversies in family planning: timing of ovulation after abortion and the conundrum of postabortion intrauterine device insertion. Contraception 84(2):119, 2011 Stoval N, Sibai B, Habli M: Is there a role for cerclage in twin gestation with short cervical length (CL)? Single center experience. Abstract No. 143, Am ] Obstet Gynecole208(1 Suppl):S73, 2013 Stubbleield PG, Altman M, Goldstein SP: Randomized trial of one versus two days of laminaria treatment prior to late midtrimester abortion by uterine evacuation: a pilot study. Am] Obstet GynecoI143(4):481, 1982 Sugibayashi S, Aeby T, Kim D, et al: Amniotic luid arborization in the diagnosis of previable preterm premature rupture of membranes. ] Reprod Med 57(3-4):136,e2012 Sullivan E, Silver M, LaCoursiere DY, et al: Recurrent fetal aneuploidy and recurrent miscarriage. Obstet Gynecol 104:784,e2004

Endoscopic transabdominal cervical cerclage replacement after recurrent late miscarriage.

Transabdominal cerclage (TAC) is a recognised treatment for recurrent spontaneous late miscarriage or preterm birth due to cervical weakness. This can be performed via an open procedure before and during pregnancy, or a laparoscopic technique preconception. Complications include cerclage failure and suture migration. We present a case highlighting these complications where laparoscopic removal of an open TAC and replacement led to two successful term deliveries. A woman in her thirties with a fibroid uterus, adenomyosis and a history of three spontaneous mid-trimester losses, had an open TAC at 13 weeks of gestation. Preterm premature rupture of the membranes occurred shortly after and at 18 weeks of gestation she underwent surgical evacuation of the uterus. Subsequent hysteroscopy confirmed migration of the cerclage through the cervical canal. We demonstrate the application of endoscopic gynaecological surgery to remove and replace the TAC with two successful term births by Caesarean section in the ensuing pregnancies.

[Analysis of the effect of modified cervical cerclage in the treatment of cervical insufficiency].

<bObjective:</b To discuss the surgical effect of modified cervical cerclage for the treatment of pregnant women with cervical insufficiency. <bMethods:</b The clinical data of 225 pregnant women who underwent modified cervical cerclage in Qilu Hospital (Qingdao) were selected for retrospective analysis from April 2014 to June 2020. Surgical success rate, full-term birth rate, preterm birth rate, prolonged pregnancy weeks and newborn birth weight were compared between singleton and twin pregnancies, preventive cerclage and emergency cerclage, surgery before and after 18 weeks, naturally and in vitro fertilization and embryo transfer (IVF-ET) conceived pregnant women respectively. <bResults:</b Among the 225 pregnant women, the gestational weeks of surgery were 14-24<sup+5</sup weeks, mean gestational weeks of delivery were 38<sup+2</sup weeks (35<sup+5</sup-39<sup+3</sup weeks), the number of prolonged gestation were (20.3±5.2) weeks, and the newborn birth weight was (3 065±735) g; the overall surgical success rate was 92.9% (209/225), and the miscarriage rate was 7.1% (16/225); among the surviving newborns, the full-term birth rate was 73.7% (154/209), and the preterm birth rate was 26.3% (55/209). All cases had no intraoperative complications. Among the 225 pregnant women, 202 (89.8%, 202/225) cases were singleton pregnancies, and 23 (10.2%, 23/225) cases were twin pregnancies; 201 (89.3%, 201/225) cases underwent preventive cervical cerclage, and 24 (10.7%, 24/225) cases underwent emergency cervical cerclage; 190 (84.4%, 190/225) cases underwent the surgery before 18 weeks, and 35 (15.6%, 35/225) cases underwent the surgery after 18 weeks; 49 (21.8%, 49/225) cases were conceived by IVF-ET. There was no statistically significant difference in the overall surgical success rate of single and twin group (<iP0.05). The full-term birth rate, newborn birth weight and prolonged pregnancy weeks of single group were higher than those of twin group (<iP</i<0.05). There were no statistical differences between preventive and emergency cerclage in overall surgical success rate, full-term birth rate, preterm birth rate, and newborn birth weight (all <iP0.05). The pregnancy prolonged weeks of preventive cerclage was higher than that of emergency cerclage (<iP</i<0.05). There were no statistically significant differences in the overall surgical success rate, full-term birth rate, preterm birth rate and birth weight of newborns at different surgical timings (all <iP0.05). The pregnancy prolonged week for those who underwent surgery before 18 weeks was higher than that of surgery after 18 weeks (<iP</i<0.05). The premature birth rate of IVF-ET was higher than that of naturally conceived pregnant women (<iP</i<0.05). <bConclusion:</b The modified cervical cerclage could effectively prolong the gestational weeks of delivery, reduce the rate of preterm birth, and the operation is simple and easy to promote. It could be used as a surgical option for patients with cervical insufficiency.

Persistent vs Recurrent Cushing's Disease Diagnosed Four Weeks Postpartum.

Cushing's disease (CD) recurrence in pregnancy is thought to be associated with estradiol fluctuations during gestation. CD recurrence in the immediate postpartum period in a patient with a documented dormant disease during pregnancy has never been reported. <iCase Report</i. A 30-year-old woman with CD had improvement of her symptoms after transsphenoidal resection (TSA) of her pituitary lesion. She conceived unexpectedly 3 months postsurgery and had no symptoms or biochemical evidence of recurrence during pregnancy. After delivering a healthy boy, she developed CD 4 weeks postpartum and underwent a repeat TSA. Despite repeat TSA, she continued to have elevated cortisol levels that were not well controlled with medical management. She eventually had a bilateral adrenalectomy. <iDiscussion</i. CD recurrence may be higher in the peripartum period, but the link between pregnancy and CD recurrence and/or persistence is not well studied. Potential mechanisms of CD recurrence in the postpartum period are discussed below. We describe the first report of recurrent CD that was quiescent during pregnancy and diagnosed in the immediate postpartum period. Understanding the risk and mechanisms of CD recurrence in pregnancy allows us to counsel these otherwise healthy, reproductive-age women in the context of additional family planning.

[Report on 8 years' experience in the prenatal diagnosis of genetic defects. III. Outcome of pregnancy].

The courses of 997 pregnancies out of 1113 prenatal diagnoses were analysed. The total rate of all fetal and neonatal losses is 11.6 per cent inclusively the therapeutically induced abortions. Peculiarities of our material are the shift to higher ages and the inclusion of pregnancies following amniofetography and fetoscopy. Without the last ones the perinatal mortality is 18.9 per thousand, the abortion rate is 2.6 per cent, the rate of premature deliveries (till the 37th gestational week) is 10.2 per cent and the rate of low birth weight babies below 2500 g is 6.1 per cent in connection with a frequency of caesarean sections of 9 per cent. 91 per cent of the newborns had Apgarscore of 8 to 10. The most favourable courses with an abortion rate of 2.2 per cent, a perinatal mortality of 11.8 per cent and a rate of low birth weight babies of 5.7 per cent are to be found following uncomplicated amniocentesis. Perinatal mortality is increased about the factor 10 combined with an threefold raise of prematurity in cases of brownish amniotic fluid. If the amniotic fluid was bloody and the repeated insertions during amniocentesis abortion rate is 10 per cent and perinatal mortality 44.4 per thousand. --3.2 per cent of pregnancies after fetoscopy are terminated by abortions. Perinatal mortality is 33.3 per thousand, the rate of low birth weight babies 26.7 per cent. Pregnancies following amniofetography have a most unfavourable course. The abortion rate is elevated to 11.2 per cent, perinatal mortality to 139.2 per thousand with a rate of low birth weight babies of 41.8 per cent. Following amniofetography every fourth newborn has a birth weight below 1500 grams.(ABSTRACT TRUNCATED AT 250 WORDS)

[Management of Cervical Cancer Stage I B during Pregnancy].

Management and treatment of stage I B1 cervical cancer during pregnancy depends on the estimated gestational age and personal desires. We report 4 cases of stage I B1 cervical cancer during pregnancy that were treated differently. Case 1: A 29- year-old woman, primipara, visited our hospital at 7 weeks' gestation. She was diagnosed with a stage I B1 cervical cancer by using conization at 12 weeks' gestation. She strongly desired childbirth and therefore was treated at 29 weeks' gestation with a simultaneous cesarean section and radical surgery. Case 2: A 26-year-old woman, para 1, was diagnosed with stage I B1 cervical cancer at 23 weeks' gestation. She was treated at 28 weeks' gestation with a simultaneous cesarean section and radical surgery. Case 3: A 36-year-old woman, para 7, at 18 weeks' gestation, visited our hospital because of a stage I A cervical cancer. She chose to undergo abortion and radical surgery, which were performed simultaneously at 21 weeks' gestation. After the surgery, she was diagnosed with a stage I B1 cervical cancer pathologically. Case 4: A 33-year-old woman, para 2, was diagnosed with a stage I B2 cervical cancer at 30 weeks' gestation and was treated with a simultaneous cesarean section and radical surgery at 31 weeks' gestation.

[Induced abortion: Guidelines for clinical practice - Text of the Guidelines (short text)].

Develop recommendations for the practice of induced abortion. The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted. The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman's life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being±5 days, IA could be done if measurements are respectively less than 90mm for CRL and less than 30mm for BIP (Professional consensus). A medical IA performed with a dose of 200mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C). The implementation of these guidelines may promote a better and more homogenous care for women requesting IA in our country.

Twin pregnancies treated with emergency or ultrasound-indicated cerclage to prevent preterm births.

<bIntroduction:</b Multiple gestations are high-risk pregnancies associated with an increased risk of neonatal morbidity and mortality, mainly due to preterm births. Numerous interventions have been attempted in order to delay the time of delivery and subsequently, prevent preterm births in twin gestations. To date, no really effective intervention has been found. Use of cerclage in twin pregnancies has been controversial. Recently, however, small retrospective cohort studies have shown a potentially positive effect with the use of cerclage in twin pregnancies. The aim of this study was to evaluate pregnancies and neonatal outcomes in twin gestations with a short cervix treated with cervical cerclage at a single University Hospital.<bMethods:</b This retrospective cohort study included all women - with twin gestation and a short cervix - who had an ultrasound indicated or emergency cervical cerclage at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark between January 1999 and May 2017. Cervical cerclage was offered to women before 26 weeks of gestation if: (1) the cervix at ultrasound was ≤20 mm without cervical dilatation (ultrasound-indicated cerclage), or (2) the cervix at ultrasound was ≤20 mm with cervical dilatation (emergency cerclage). Women with history-indicated cerclage placement or multifetal embryo reduction were excluded. A total of 65 women participated in the study.<bResults:</b The median gestational age at cerclage placement was 22.6 weeks with a median cervical length of 10 mm (range 0-20 mm). The frequency of preterm delivery before 32 weeks of gestation was 41.5% and 27.7% before 28 weeks. Median pregnancy latency was 77 days (range 4-148) and the median gestational age at delivery was 33.0 weeks. Gestational age at delivery was significantly lower among women with cervical dilatation and visible membranes than among women with a short cervix only (27.7 versus 33.6 weeks, <ip</i < .01) and so was the median pregnancy latency (48 versus 81 days, <ip</i < .05). Overall, neonatal survival was 91.5%.<bConclusion:</b Cervical cerclage in twin pregnancies may prolong pregnancy even when placed on a very short or dilated cervix. In our study, the procedure was safe and without any serious complications. The overall neonatal survival rate was high.

Recurrent miscarriage.

On epidemiological evidence, the definition of recurrent miscarriage should be three or more consecutive pregnancy losses. Data should be collected to 28 weeks' gestation but analysis up to 20-22 weeks' or 500 g fetal weight should also be possible. General practitioners and gynaecologists should do what they feel is suitable for couples whose history does not meet these criteria but a diagnosis of recurrent miscarriage should not be made. Women meeting the definition can be subdivided into primary and secondary groups, respectively consisting of those who have lost all previous pregnancies and those who have had one successful pregnancy followed by consecutive losses.

Where no consent = death.

Men must be made to understand the value of family planning - particularly in societies where men hold the power of decision in the family.  Dr. Kotha Pannikar, chairman of the Kedah Family Planning Association (FPA) in Malaysia, illustrated this point in discussion which followed the Consultation of Medical and Communication Fieldworkers conference in Kuala Lumpur in August, with a story about 1 of her own patients.  When the girl, who had a rheumatic heart, was 16, Dr. Pannikar advised the parents that she needed cardiac surgery if she were to be a healthy wife and mother.  But the parents lived some distance from Dr. Pannikar's surgery and did not heed the advice.  The girl was married to a carpenter from a traditional Chinese family, in which "the man is lord and master." Her new home had no piped water, and in additional to normal domestic tasks she had to carry water from a source 1 1/2 miles agay.  In the 7th month of her 1st pregnancy, she went into cardiac failure.  After the 3rd pregnancy and a 3rd cardiac failure, Dr. Pannikar tried to arrange a sterilization "but we could not get consent - her husband refused to turn up at the hospital." When the girl was admitted to hospital 6 months into her 4th pregnancy, Dr. Pannikar got hold of her patient's mother-in-law.  "I told her if she wanted a servant in the house, it was easy to get one.  But no servant would look after her grandchildren the way their mother would.  I told her if she wanted to save the girl's life she had better speak to her son." During the 4th delivery, the girl went into cardiac arrest and spent 2 weeks in intensive care.  The mother-in-law prevailed upon her son to at least consent, and the girl was sterilized before she left hospital.  But "it was a very near thing," Dr. Pannikar recalls "and it wouldn't have happened if the husband had felt he was responsible in parenthood." The Kedah FPA makes special efforts to reach men.  Dr. Pannikar herself talks to men's organizations like the Lions and Rotary Clubs, and arranges education programs for trade unions and workers on the rubber estates.  She thinks women need to be told repeatedly that they have a basic human right to choose whether they want to have a baby, and when.  "Women feel," she says, "that their only function is to cook, wash clothes and feed the baby.  We need to tell them they have a part to play in the society of today because their children will be the citizens of tomorrow."o

[Clinical outcomes and influence factors of 435 singleton pregnancies with short cervix].

<bObjective:</b To investigate the clinical outcomes of different treatment options on singleton short cervix and its influence factors. <bMethods:</b Totally 435 cases of singleton pregnancies who were diagnosed with short cervix (≤25 mm) between 12 to 33<sup+6</sup gestational weeks in Peking University First Hospital from January 2018 to December 2018 were enrolled, including 21 cases with cervical length <10 mm, 414 cases with cervical length between 10 to 25 mm. The onset time was <24 gestational weeks in 106 cases, while 104 cases were at 24-29<sup+6</sup gestational weeks and 225 cases of ≥30 gestational weeks. Gestational outcomes including delivery before 37 weeks, delivery before 34 weeks, neonatal birth weight (NBW) and adverse neonatal outcome (ANO) were compared among three treatment groups: rest group, progesterone group and cerclage group. Influence factors were also investigated. <bResults:</b (1) The incidence of short cervix in pregnancy was 7.07% (435/6 155), while 106 cases were at <24 gestational weeks (1.72%, 106/6 155), 104 cases (1.69%, 104/6 155) at 24-29<sup+6</sup gestational weeks and 225 cases (3.66%, 225/6 155) at ≥30 gestational weeks. (2) In the group of cervical length <10 mm, rate of delivery before 37 and 34 weeks were 62% (13/21) and 57% (12/21) respectively. One case of progesterone treatment underwent miscarriage. Compared with rest group (<in</i=8), delivery weeks [28.5 (25.0-40.0) vs 37.0 (28.0-40.0), <iP</i=0.020] and NBW [1 245 g (630-3 830 g) vs 2 648 g (1 560-3 830 g), <iP</i=0.028] were higher in cerclage group (<in</i=9), while ANO was not statistically different (<iP0.05). (3) In the group of cervical length ≥10 mm before 24 gestational weeks, the delivery weeks, incidence of delivery before 34 weeks, adjusted incidence of delivery before 37 weeks, NBW and ANO were not statistically different (<iP0.05) among rest group (<in</i=36), progesterone group (<in</i=26) and cerclage group (<in</i=34). In vitro fertilization (<iOR</i=11.97, 95%<iCI</i: 1.88-76.44, <iP</i=0.009), infection (<iOR</i=46.03, 95%<iCI</i: 5.12-413.58, <iP</i=0.001), sludge on sonography (<iOR</i=9.87, 95%<iCI</i: 1.69-57.60, <iP</i=0.011) and history of short cervix (<iOR</i=7.24, 95%<iCI</i: 1.04-50.24, <iP</i=0.045) were independent risk factors of preterm birth. (4) In the group of cervical length ≥10 mm and gestational weeks between 24-29<sup+6</sup, the delivery weeks, incidence of delivery before 37 weeks, incidence of delivery before 34 weeks, NBW and ANO were not statistically different (<iP0.05) among rest group (<in</i=52), progesterone group (<in</i=34) and cerclage group (<in</i=9). Infection was an independent risk factor of preterm birth (<iOR</i=56.40, 95%<iCI</i: 4.67-680.61, <iP</i=0.002). (5) Outcomes of 223 cases were relatively good in the group of cervical length ≥10 mm beyond 30 gestational weeks. The incidence of delivery before 34 weeks was 6.3% (14/223). The delivery weeks, incidence of delivery before 37 and 34 weeks, NBW and ANO were not statistically different (<iP0.05) among 3 groups. Infection (<iOR</i=10.91, 95%<iCI</i: 2.21-53.96, <iP</i=0.003) and history of preterm birth (<iOR</i=8.63, 95%<iCI</i: 1.25-59.65, <iP</i=0.029) were independent risk factors of preterm birth. <bConclusions:</b Short cervix is a common complication of pregnancy. Cervical cerclage is related with better outcome for patients with cervical length <10 mm. Neither progesterone nor cervical cerclage improves pregnancy outcome for >10 mm cervical length patients comparing with rest. Infection, sludge, in vitro fertilization, history of short cervix and history of preterm birth are independent risk factors of preterm birth in short cervix pregnancies.

<i>Peptoniphilus indolicus</i> infection in a pregnant woman: a case report.

<iPeptoniphilus indolicus</i belongs is a gram-positive anaerobic coccus (GPAC), which can cause bacterial vaginitis. However, only a few studies have reported severe infection of <iP. indolicus</i. This study presented the first case of severe infection of <iP. indolicus</i during pregnancy. It aimed to help to fill the gap in the literature, find out the factors that accelerate infection and discuss the significance of the GPAC test. A 35-year-old woman was admitted due to unbearable abdominal pain with dilation of the cervical opening at 22+ weeks of gestation. A blood test revealed electrolyte disturbance and hypoproteinemia. A day before admission, the patient developed pain in the lower abdomen accompanied by yellow-green vaginal discharge. Two hours after admission, the patient suddenly presented with hyperpyrexia and chills. Timely and adequate antibiotic and cooling treatments were administered. After 14 h, the patient again developed chills that lasted for approximately 20 min, accompanied by uterine contractions and membrane rupture. After 3 h, she had a miscarriage and rapidly developed septic shock. She was transferred to the intensive care unit for further infection control, shock correction, and circulatory stabilization. The cultures of blood, secretion specimen, and amniotic fluid indicated <iP. indolicus</i infection using a matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, an advanced tool for bacterial species identification. <iP. indolicus</i is an opportunistic pathogen in pregnant women. Poor physical conditions and pregnancy may accelerate disease progression and lead to severe inflammation.

Maternal and fetal effects of COVID-19 virus on a complicated triplet pregnancy: a case report.

Coronavirus disease 2019 (COVID-19), the global pandemic that has spread throughout the world, is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Given the limited scientific evidence on the manifestations and potential impact of this virus on pregnancy, we decided to report this case. The patient was a 38 year-old Iranian woman with a triplet pregnancy and a history of primary infertility, as well as hypothyroidism and gestational diabetes. She was hospitalized at 29 weeks and 2 days gestational age due to elevated liver enzymes, and finally, based on a probable diagnosis of gestational cholestasis, she was treated with ursodeoxycholic acid. On the first day of hospitalization, sonography was performed, which showed that biophysical scores and amniotic fluid were normal in all three fetuses, with normal Doppler findings in two fetuses and increased umbilical artery resistance (pulsatility index [PI] > 95%) in one fetus. On day 4 of hospitalization, she developed fever, cough and myalgia, and her COVID-19 test was positive. Despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses leading to the rapid development of absent umbilical artery end-diastolic flow. Finally, 6 days later, the patient underwent cesarean section due to rapid exacerbation of placental insufficiency and declining biophysical score in two of the fetuses. Nasopharyngeal swab COVID-19 tests were negative for the first and third babies and positive for the second baby. The first and third babies died 3 and 13 days after birth, respectively, due to collapsed white lung and sepsis. The second baby was discharged in good general condition. The mother was discharged 3 days after cesarean section. She had no fever at the time of discharge and was also in good general condition. This was a complicated triplet pregnancy, in which, after maternal infection with COVID-19, despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses, and the third fetus had a positive COVID-19 test after birth. Therefore, in cases of pregnancy with COVID-19 infection, in addition to managing the mother, it seems that physicians would be wise to also give special attention to the possibility of acute placental insufficiency and subsequent fetal hypoxia, and also the probability of vertical transmission.

Prolonged and post-term pregnancies: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

The duration of pregnancy varies between 40(+0) and 41(+3) weeks. Conventionally, and essentially arbitrarily, a pregnancy is considered to be "prolonged" after 41(+0) weeks, but the infant is not considered "post-term" until 42(+0) weeks (Professional consensus). A term birth thus occurs during the period from 37(+0) to 41(+6) weeks. In France, prolonged pregnancies (≥41(+0)weeks) involve 15-20% of pregnant women, and post-term pregnancies (≥42(+0) weeks) approximately 1%. The frequency of post-term pregnancies is very heterogeneous: in Europe and the United States, it ranges from 0.5% to 10% according to country. In prolonged pregnancies, the cesarean section rate-especially the emergency cesarean rate-is multiplied by approximately 1.5 (grade B). From 37(0-6) to 43(0-6) weeks, the risk of perinatal mortality increases regularly, from 0.7‰ to 5.8‰. Meconium aspiration syndrome is responsible for substantial morbidity and mortality, and its incidence increases regularly between 38(+0) and 42(+6) weeks, from 0.24‰ to 1.42‰ (grade B). Similarly, the risks of neonatal acidosis (grade B), 5-min Apgar scores less than 7 (grade B) and admissions to neonatal intensive care (grade B) increase progressively between 38(+0) and 42(+6) weeks. These risks appear to double for post-term growth-restricted newborns (grade C). Ultrasound dating of the pregnancy makes it possible to reduce the risk that it will be incorrectly considered prolonged and that labor will therefore be induced unnecessarily. To harmonize practices, if the crown-rump length (CRL) is correctly measured (this measurement should be taken between 11(+0) and 13(+6) weeks, when CRL should measure from 45 to 84mm), ultrasound dating based on it should be used to determine the official date pregnancy began, regardless of its difference from the date assumed by the patient or estimated based on the date of the last menstrual period. This rule does not apply to pregnancies by IVF, for which the date pregnancy began is defined by the date of oocyte retrieval (Professional consensus). From 37(0-6) to 43(0-6) weeks, the risk of perinatal mortality increases regularly and there is no threshold at which a clear increase in perinatal mortality becomes visible. Fetal monitoring by cardiotocography (CTG) that begins at 41(+0) weeks would cover approximately 20% of women and reduce perinatal morbidity compared with monitoring that begins at 42(+0) weeks (grade C). The frequency recommended for this monitoring ranges between two and three times a week (Professional consensus). For ultrasonography assessment, measurement of the largest fluid pocket is recommended, because measurement of the amniotic fluid index (that is, the sum of the four quadrants) is accompanied by more diagnoses of oligohydramnios, inductions of labor, and cesareans for fetal distress without any improvement in neonatal prognosis (grade A). The practice of assessing the Manning biophysical score increases the number of diagnoses of oligohydramnios and fetal heart rage (FHR) abnormalities and generates an increase in the rates of inductions and cesareans without improving neonatal prognosis. The use of this biophysical score in monitoring prolonged pregnancies is therefore not recommended (grade B). In the absence of a specific disorder, induction of labor can be proposed in patients between 41(+0) and 42(+6) weeks (grade B). Nonetheless, the choice of prolongation beyond above 42(+0) weeks appears to involve an increase in fetal risk, which must be explained to the patient and balanced against the potential disadvantages of induction (Professional consensus). Stripping the membranes can reduce the duration of pregnancy by increasing the number of patients going into labor spontaneously during the week afterward (grade B). Compared to an expectant approach, it does not increase the cesarean section rate (grade A). It reduces recourse to induction by 41% at 41(+0) weeks and by 72% at 42(+0) weeks (grade B), without increasing the risk of either membrane rupture or maternal or neonatal infection (grade B). Used as a tampon or vaginal gel, prostaglandins E2 (PGE2) are an effective method of inducing labor (grade A). They can be used to induce labor successfully, regardless of cervical ripeness (grade A). If misoprostol is chosen, the lowest dose is to be preferred, starting with a vaginal dose of 25μg every 3-6h (grade A). For misoprostol, more powerful studies remain necessary for better defining the doses, routes of administration, tolerance and indications. Misoprostol at any dose is contraindicated in women with uterine scars (grade B). Placement of an intracervical Foley catheter is an effective mechanical means of inducing labor, with less uterine hyperstimulation than prostaglandins and no increase in the cesarean section rate (grade A). Nonetheless, as the risk of infection might be increased, this technique requires more robust evaluation before entering general practice (grade B). In cases of meconium-stained amniotic fluid, pharyngeal aspiration before delivery of the shoulders is not recommended (grade A). The team managing a post-term newborn with meconium-stained amniotic fluid at birth must know how to perform intubation and, if the intubation is not helpful, endotracheal aspiration (grade C) and ventilation with a mask. Routine endotracheal intubation of a vigorous newborn is not recommended (grade A).

Obstentrics_Williams

pregnancy continuation. For women facing a poor pregnancy prognosis due to cervical dilation at midgestation, it seems reasonable to ofer emergency or rescue cerclage with appropriate counseling. However, it is unclear if such interventions truly confer a beneit or merely increase the risk of membrane rupture and infection (Hawkins, 2017).