Intra-amniotic debris linked to Preterm Birth independent of Cervical Funnel

Amniotic fluid ‘‘sludge’’ (A) with normal cervix (B) with short cervix
courtesy:https://www.researchgate.net/figure

Presence of Intra-amniotic debris or sludge identified by sonography is linked to increased risk of Preterm Birth(PTB) before 34 weeks of pregnancy in nulliparous women with a cervical length less than 30 mm, reports the results of a secondary cohort study accepted for publication in Journal Ultrasound in Obstetrics and Gynecology.

This secondary analysis of multicentric trial was funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network.

The exact composition of amniotic fluid debris is not known. They may be formed of hemorrhage, meconium or a mixture of bacteria and inflammatory cells, that is encased in a biofilm that is resistant to antibiotics. They are probably a sign of placental senescence, and preterm delivery seems to be a protective phenomenon to shuttle the fetus out of the already compromised environment.

The initial trial was conducted to study the effect of progesterone injections to prevent preterm birth in nulliparous women with a short cervix.

A total of 657 women between 16 and 22 weeks of gestation were randomized to progesterone or placebo. All of them had a transvaginal ultrasound by a certified sonologist, 78 were found to have intra-amniotic debris, 112 women had cervical funnel on ultrasound.

A significant number of women with debris had a preterm labor (35% vs. 23%), as also women who cervical funnel (37% vs.21%).

After multivariate analysis, only amniotic fluid debris was found to be significantly associated with preterm birth prior to 34 or 32 weeks (aOR 1.85, 95% CI 1.00-3.44; aOR 2.78, 95% CI 1.42-5.45) respectively.

Earlier study have also shown that Amniotic fluid debris or ‘‘sludge’’ (AFS) is an independent risk factor for preterm delivery in women with CL< 25 mm. During Ultrasound it is recognized as a hyperechogenic matter in the amniotic fluid close to the uterine cervix and its prevalence is 22.3% in patients with preterm labor.

Abstract

SMFM issues guidelines for managing patients with third trimester bleeding between 34 0/7-36 6/7 weeks.

Third trimester bleeding is not so uncommon and nearly 1 in 10 women will experience vaginal bleeding during this period. It may present as just spotting or may be heavier. It could be just due to softening and opening of cervix or a sign of more serious obstetric nightmare like placenta previa or abruption.

Optimal management of third trimester bleeding depends on accurate identification of the cause and the gestational age window.

The earlier Society for Maternal-Fetal Medicine (SMFM) recommendations were not specific to the gestational age. The recommendations were published electronically in October in American Journal of Obstetrics and Gynecology.

Recommendations: 

If a patient with placenta previa is stable and have no other obstetric complications, deliver her at 36–37 6/7 weeks of gestation. If this episode is mild and self-limiting, but there is history of previous bleeding episodes < 34 weeks, deliver her to avoid risk of major bleeding episode in future. (Grade 1B)

Routine cervical length screening for women with placenta previa is not indicated in the late preterm period because of a lack of data on an appropriate management strategy (Grade 2C)

A stable woman with placenta accreta, schedule a planned delivery between 34 and 37 weeks of gestation.  (Grade 1C)

A stable woman with vasa previa, schedule a planned delivery between 34 and 37 weeks of gestation.  (Grade 1C)

Recommendations are less clear about ideal time of delivery in placental abruption for women who are hemodynamically stable along with the fetus. Delivery may be prolonged with close monitoring of mother and fetus. If the women with abruptio is hemorrhaging profusely, she should undergo delivery.

If a woman is bleeding profusely, do not defer delivering her for the purpose of administering corticosteroids.  (Grade 1B)

Fetal lung maturity testing is not indicated in late preterm period, when a indication for delivery is already present.  (Grade 1B)

Administer antenatal corticosteroids to women who are eligible, stable and are being managed expectantly and delivery is expected within 7 days, the gestational age is between 34 and 36 6/7 weeks of gestation, and antenatal corticosteroids has not previously been given (Grade 1A).

Clinical Considerations:

For placenta previa, vasa previa or accreta, cesarean section should be performed. For other clinical situation, in absence of contraindications to vaginal delivery and fetus in stable condition, a vaginal delivery might be attempted.

Very small amount of vaginal bleeding, that resolves by the time the patient presents in the hospital, can be managed expectantly provided the patient and fetus are stable and patient has access to emergency care 24/7.

Perform an ultrasound for evaluation of cause of bleeding and location of placenta before doing a digital examination. For suspected placenta previa vaginal ultrasound is a better choice and pulsed-wave doppler may help identify a fetal arterial vessel (with FH rate) or fetal vessels with venous flow in vasa previa.

In cases of placenta accreta, ultrasound can be performed but the sensitivity and specificity is less than for placenta previa and vasa previa.

In cases of placental abruption, always rely on clinical acumen as sonography can miss the diagnosis in 20-50% of cases.

MRI is contraindicated in women with active bleeding in third trimester.

Abstract

First US baby born after uterine transplant delivered in Texas

Dr showing the baby to mother. Courtesy Baylor University Medical Center at Dallas

The first birth as a result of  uterine transplant in the United States took place on Friday in Texas at the Baylor University Medical Center in Dallas. The women had undergone a live donor transplant and have received her uterus from Taylor Siler, 36, a registered nurse in the Dallas area.

The boy delivered by elective cesarean section is just named “baby number 9, as he is the 9th person in the world to be born out of transplanted uterus. 

“We’ve been preparing for this moment for a very long time,” says Dr. Liza Johannesson, an ob-gyn and uterus transplant surgeon at Baylor. “I think everyone had tears in their eyes when the baby came out. I did for sure.” The woman and her husband asked that their identity not be revealed in order to protect their privacy.

This is the first baby born as a part of hospital’s ongoing uterus transplant clinical trial, being conducted by Baylor Scott & White Research Institute. Uterine transplant is offered to patients with absolute uterine factor infertility (AUI). Most of the women in the trial have a condition called Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

The trial is expected to enroll 10 patients and will end in January 2026. So far, there are 8 women enrolled in the study who have received a uterine transplant. Out of which 3 have failed and there is an additional ongoing pregnancy in a woman who received a live donor transplant.  

A similar trial was conducted in Sweden for women with uterine factor infertility, which resulted in seven uterine transplants and four live births. In September 2014, Mats Brännström and colleagues report the first successful birth of a child following uterus transplantation. The recipient, a 35-year-old woman lacking a uterus (Rokitansky syndrome), received a cryopreserved embryo 1 year after transplantation, leading to a livebirth by caesarean section.

Giuliano Testa, MD, principal investigator of the uterine transplant clinical trial at Baylor University Medical Center at Dallas said, “This first live birth to a uterus transplant recipient in the United States was a milestone in our work to solve absolute uterine factor infertility; but, more importantly, a beautiful moment of love and hope for a mother who had been told she would never be able to carry her own child.”