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492 Cervical cerclage: Risks versus benefits

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380 SPO Abstracts

490 INTRAMUSCULAR (1M) RITODRINE (R) FOR INITIAL TOCOL YSIS. Isabelle Wilkins, Bernard Gonik, Thomas J Benedetti, Robert H. Hayashi, H. Jack Adams', Robert K. Creasy. Univ of Texas, Houston, TX; UnlV of WaShington, Seattle, W A:, Univ of Michigan, Ann Arbor, MI; Astra Pharmaceuticals, Westborough, MA.

A prospective, open-label study of 94 panents was undertaken in 3 centers to examine the role of 1M R as interim therapy for tocolysis Previous work has demonstrated 1M R to be safe and efficacious, this dosage form may be preferable to the clinician who infrequently uses tocolysis during transport to a tertiary center. All subjects had smgleton pregnancies between 20 and 36 wks gestatIOn, preterm labor (contractions ~4Ihr, cervical change or initial exam of ~2 cm or ~80% effacement), and intact membranes. Panents were treated with 5-10 mg of 1M R mltially and every 2 hrs x 3 doses. N R was subsequently administered x 6 hrs or until 12 hrs of uterine quiescence. Oral tocolytics were used after parenteral therapy. Successful therapy was defined as completion of the protocol and institution of oral tocolysls with delay of delivery >7 days Qualified success included patients who required a change in protocol at any lime after the 3 1M doses of R but with delivery delay >7 days. Failures mcluded adverse effects which halted therapy, continued contractions during the 1M phase of treatment, and all deliveries <7 days Eight patients were excluded because of lethal anomalies or improper entry, although Side effects were recorded 72/86 (84%) had effective tocolysls (49/86 (57%) success, and 23/86 (27%) qualified success); 14/86 (16%) were treatment failures. Five patients on 1M and 6 on IV had R stopped due to significant side effects These results compare favorably with other tocolytlc regimens and warrant consideratIOn, particularly if patient transport is necessary.

491 THE PREDICTABILITY OF UTERINE CONTRACTILITY PATTERNS IN WOMEN WITH MINOR RISK FACTORS FOR PRETERM BIRTH. 'Lois E Brustman, 'Jose L Reyes, XMartln L Oslson Our Lady of Mercy MedICal Center, Bronx, NY and Health Oyne, Atlanta, GA.

It 15 generally accepted that women With multiple gestations, previous preterm births, and a current episode of preterm labor are at a significant risk for a preterm delivery (PTO) In contrast to this, there is conflICting Information in the literature regarding the Influence minor risk factors (i e , minor multiple abortions, 2nd trimester bleeding, placental abnormalities, urinary tract infections, etc.) have on subsequent PTO. Previously, we demonstrated that uterine contractility patterns could be used as a predICtor of PTO In women With a major risk factor for preterm labor Therefore, in this study we attempted to answer the question, if baseline uterine contractility data could be used to identify women With minor risk factors who would have a PTO Between July, 1989 and Oecember, 1989, 36 women were Identified with minor risk factors and participated in this prospective study from the 24th week of gestation. Uterine activity was monitored for 1 hour twice a day In an ambulatory setting PTO was defined as a delivery before the completion of the 37th week of gestation Analysis of the data revealed: 1) 44% (16/36) of the women delivered preterm; 2) the most predictive uterine contractility pattern for PTO was 2: 3 contractions per hour on at least 3 occasions between 24·25 weeks gestation This had a sensitivity of 75%, specificity of 85%, positive predictive value was 81% and negative predictive value was 80% Therefore, our data suggests that In women with minor fISk factors for preterm delivery, uterine contractility patterns can be used to Identify the subset of women at risk for a preterm birth This screening test may allow the cliniCian to offer an indiVidualization of preterm birth prevention measures to women With a positive screening test, thus, offering a practical and cost effective approach to prenatal care in thiS risk group

.J.muan 1991 Am.J Obstct (;, newl

492 CERVICAL CERCLAGE: RISKS VERSUS BENEFITS. James BalducCi MP, Michael Drews, MDx, Keith Rawlinson, MDx,

Arnold N. Fenton, MDx. North Shore University Hospital, ~3nhasset, New York.

A four year retrospective review of the experience with cervical cerclage was conducted at North Shore Unlversrty Hospital. During this time period, 17,470 patients delivered and a total of 213 cerclage procedures were performed (frequency of 1/82.) The patients were analyzed in two groups; the routine suture group, suture placed electively under controlled circumstances at 12-15 weeks (192 cases) and the late-emergent group, suture placed in emergent situation for cerVical dilatation occurring late in the second trimester 18-24 weeks (21 cases). Chorloamnlonltls complicated the routine suture group less frequently than the late­emergent suture group 6.8"10 (13/182) versus 85.7"10 (18121) respectively (p<.OOl). Eight of 21 (38"10) patients With late­emergent sutures ended In pregnancy loss Within 2 weeks of suture placement as compared to 2 of 192 (1.5"10) patients With routine sutures (p < .001). Patients In the routine suture group who were treated perioperatively with ampicillin (41 patients) had an infection rate of 9.8"10 versus 6.6% (151 patients) when antibiotics were not used. The use of prophylactic antibiotics Within the routine suture group did not lower the incidence of chonoamnlonltls. The placement of cervical cerclage in DES exposed patients who had prevIous preterm birth did not alter the length of gestation when compared to the previous pregnancy. The benefits of the late· emergent suture as well as those of the routine cerclage In DES exposed patients with a previous history of prevIous preterm births are brought into question.


Serial examination of the cervix for dilation and/or effacement has been proposed as a component of preterm birth prevention efforts. Examination by palpation is subject to variability and its value for detecting subtle or early cervical change is limited. Ultrasonographic and other biophysical techniques remain investigational and the need persists for a more quantitative "early warning" approach. We describe a new technique using computerized colposcopy to serially visualize and precisely measure the perimeter of the dilated internal os. The system consists of a photocolposcope, coupled device camera, computer, digital filter, storage device, and software that processes magnified images. The cervix is examined with the colposcope which may require the endocervical speculum for exposure of the internal os. The image is computer enhanced to facilitate visualization and accurate measurement. Early experience with the technique employed sequentially over several weeks serendipitously demonstrated its ability to quantitate subtle cervical change prior to clinical signs and symptoms of advanced preterm labor in a patient at risk. The cervix had been unchanged by vaginal exams performed concomitantly in a blinded fashion until less than a week before delivery. A broad prospective evaluation of the technique to determine its role in preterm labor risk prediction is underway.