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Objective To evaluate whether increasing body mass index (BMI) alters the efficacy of ultrasound-directed cerclage in women with a history of preterm birth. Methods This was a planned secondary analysis of a multicenter trial in which women with a singleton gestation and prior spontaneous preterm birth (17 to 33 + 6 weeks' gestation) were screened for a short cervix by serial transvaginal ultrasound evaluations between 16 and 22 + 6 weeks. Women with a short cervix (cervical length < 25 mm) were randomly assigned to cerclage or not. Linear and logistic regression were used to assess the relationship between BMI and continuous and categorical variables, respectively. Results Overall, in the screened women (n = 986), BMI was not associated with cervical length (P = 0.68), gestational age at delivery (P = 0.12) or birth at 47 kg/m2. Conclusion In women at high risk for recurrent preterm birth, BMI was not associated with cervical length or gestational age at birth. BMI did not appear to adversely affect ultrasound-indicated cerclage. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Objective: The objective of this study was to determine whether there are any indication-specific variations in risk reduction for fetal Down syndrome after a normal genetic sonogram. Study Design: A second-trimester genetic sonogram was offered to all pregnant women who were at increased risk for fetal Down syndrome (≥1:274) because of either advanced maternal age (≥35 years), an abnormal triple screen, or both. Outcome information included the results of genetic amniocentesis (if performed), the results of pediatric assessment, and follow-up after birth. Normal genetic sonography was defined as the absence of all ultrasound aneuploidy markers. Results: The overall prevalence of fetal Down syndrome in the tested population was 1.41% (53/3753 pregnancies); however, in the presence of normal genetic sonography, the overall prevalence of fetal Down syndrome was 0.21% (7/3291 pregnancies). The overall risk reduction for fetal Down syndrome in the presence of normal genetic sonography was 6.64-fold (95% CI, 3.01-14.62); the overall negative likelihood ratio was 0.15 (95% CI, 0.07-0.33). In the presence of normal genetic sonography, the risk for fetal Down syndrome was reduced by 83% in patients with advanced maternal age, 88% in patients with abnormal triple screen, 89% in patients with abnormal triple screen who were Conclusion: There were no significant variations in the risk reduction for fetal Down syndrome in the presence of normal genetic sonography. Regardless of the indication for testing, the likelihood for fetal Down syndrome was reduced by 83% to 89%. This information will be useful in counseling pregnant women who are at high risk for fetal Down syndrome and who prefer to undergo genetic sonography before deciding about genetic amniocentesis. (Am J Obstet Gynecol 2002;187:1226-9.)

Objective To construct an institution-specific nomogram of fetal abdominal circumference measurements and determine whether previously published nomograms correctly categorize our population's outer centiles. Design Using cross-sectional data from a database of sonographic circumference measurements, a nomogram for abdominal circumference measurements was created by modeling the mean and standard deviation separately. The adequacy of the nomogram was confirmed by assessing the normal distribution of data, verifying goodness-of-fit, and checking residuals. Outer centiles were compared with those from other published nomograms. Results The new nomogram for fetal abdominal circumference measurements from 10 070 fetuses provided sufficient data to derive values for the 5th, 10th, 50th, 90th and 95th centiles based on gestational age. Comparisons with other published nomograms indicated that the false-negative rates for classifying our population as 90th centile ranged from 11.3% to 90.5% and from 0 to 66.4%, respectively. Conclusion Institution-specific nomograms of fetal abdominal circumference measurements are important to avoid incorrect categorization of outer centiles. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

Objectives To assess the role of cervical sonography and to compare various sonographic cervical parameters in their ability to predict spontaneous preterm birth in high-risk singleton gestations. Design A prospective cohort of 469 high-risk gestations were longitudinally evaluated between 15 and 24 weeks' gestation on 1265 occasions with transvaginal cervical sonography and transfundal pressure. The cervical parameters obtained were funnel width and length, cervical length, percent funneling and cervical index. The information obtained was used for patient management. Restriction of physical activities was initiated at cervical lengths of ≤ 2.5 cm with cerclage as an option for cervical lengths of ≤ 2.0 cm. Results Receiver operating characteristic curve analyses showed that a cervical length of ≤ 2.5 cm between 15 and 24 weeks' gestation was equal to the other sonographic cervical parameters in its ability to predict spontaneous preterm birth. The sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation were 94%, 91%, 83% and 76%, respectively, while the negative predictive values were 99%, 99%, 98% and 96%, respectively. The placement of a cerclage did not influence the positive and negative predictive values. In comparison to women with other risk factors, cervical length was best in the prediction of preterm birth in women with a prior mid-trimester loss; an optimal cut-off of ≤ 1.5 cm had sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation of 100%, 100% 92% and 81%, respectively. The rate of preterm delivery at < 34 weeks' gestation increased dramatically when the cervical length was ≤ 1.5 cm. Cervical length was the only independent variable that entered the logistic regression model for the prediction of preterm delivery at < 34 weeks' gestation. Conclusions In high-risk singleton gestations a cervical length of ≤ 2.5 cm was equal to other sonographic cervical parameters in its ability to predict spontaneous preterm birth and was better for the prediction of earlier forms of prematurity (at < 28 and < 30 weeks) than later forms (at < 32 and < 34 weeks). The optimal cervical lengths and their performance for predicting prematurity may be influenced by obstetric risk factors. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations.This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at28 weeks' gestation,30 weeks' gestation,32 weeks' gestation, and34 weeks' gestation.The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length ofor =2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value ofor =2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at28,30,32, and34 weeks' gestation, respectively. The positive predictive values for delivery at32 and34 weeks' gestation were 80% and 100%, respectively. Between 21 and 24 weeks' gestation a cervical length ofor =2.0 cm had specificities of 84%, 84%, 85%, and 86% and negative predictive values of 99%, 99%, 94%, and 87% for delivery at28,30,32, and34 weeks' gestation, respectively. Between 25 and 28 weeks' gestation cervical length had excellent negative predictive values of 99%, 98%, 95%, and 93% for delivery at28,30,32, and34 weeks' gestation, respectively.In twin gestations a cervical length ofor =2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity.

Objective: This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations. Study Design: This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at Results: The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length of ≤2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value of ≤2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at Conclusions: In twin gestations a cervical length of ≤2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity. (Am J Obstet Gynecol 2000;183:1103-7.)

Objective To compare pregnancy outcomes in women at risk for pregnancy loss treated with elective versus ultrasound-indicated placement of cerclage. Methods A retrospective cohort study was performed on two groups of patients with singleton gestations. The first group consisted of women at risk for pregnancy loss who were treated with an elective cerclage, while the second group was managed conservatively and followed with serial transvaginal cervical sonography and transfundal pressure. An emergency cerclage was placed in women in the second group when the endocervical canal length shortened to < 20 mm, either spontaneously or in response to transfundal pressure. The two groups were compared with respect to maternal demographics, obstetric and gynecological history, and gestational age, both at time of cerclage placement and delivery. Results A total of 138 patients were identified. Eighty-one patients were treated with an elective cerclage and 57 with an ultrasound-indicated cerclage. Patients treated with elective cerclages were older (32 versus 27 years, p = 0.0003), more commonly white (56.8% versus 38.6%, p = 0.0380), less commonly nulliparous (23.5% versus 43.9%, p = 0.0063), and more often private patients (92.6% versus 28.1%, p < 0.0001). A history of previous treatment with cerclage (45.7% versus 10.5%, odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1–0.4) and one prior midtrimester loss (53.1% versus 33.3%, OR 0.4, 95% CI 0.2–0.9) were also more common in the elective versus ultrasound-indicated cerclage group. However, there was no difference in the rates of previous preterm delivery, two midtrimester losses, two terminations of pregnancy, in utero diethylstilbestrol exposure, uterine anomalies, history of cone biopsy or parity. As expected, gestational age at placement of cerclage was significantly earlier in the elective group (13.0 versus 20.0 weeks, p < 0.0001). The median (range) gestational age at delivery (37 (15–41) versus 37 (17–41) weeks, p = 0.90), the number of early (< 25 weeks) losses (9.9% versus 8.8%, OR 1.6, 95% CI 0.3–7.9), and preterm deliveries (< 37 weeks) (35.8% versus 36.8%, OR 1.1, 95% CI 0.4–3.2) were similar in the elective and ultrasound-indicated cerclage patients, respectively. Conclusion In patients at risk for pregnancy loss, placement of cervical cerclages in response to ultrasono-graphically detected shortening of the endocervical canal length is a medically acceptable alternative to the use of elective cerclage. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

We tested the accuracy of a mathematical model based on computer analysis of the fetal heart rate tracing in predicting umbilical artery pH at birth. In a previous report based on data on 38 growth-restricted fetuses, the second-order polynomial regression equation, umbilical artery pH = 7,28 + 0.002 (duration of episodes of low variation in minutes) + 0.00009 (duration of episodes of low variation in minutes)2, was retrospectively found to be the best model for the prediction of umbilical artery pH at birth. In the present study, this formula was prospectively tested in 29 growth restricted fetuses between 26 and 37 weeks of gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. Computer analysis of the fetal heart rate tracing of 1 hour duration was performed within 1.5–6 hours of cesarean birth prior to the onset of labor. Umbilical artery cord blood was collected at birth with pH determined within 5 minutes of collection. Acidemia was defined as umbilical artery ...

The object was to determine whether there is a correlation between the obstetric history and the ultrasonographically determined endocervical canal length between 15 and 24 weeks gestation. A retrospective cohort study was performed in singleton pregnancies of multigravidas with normal and abnormal obstetric histories. They underwent sonographic evaluation for the determination of the endocervical canal length between 15 and 24 weeks gestation. The shortest endocervical canal length measurements between 15 and 20 weeks and also between 21 and 24 weeks of gestation were recorded. An ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to > 2 cm or a single endocervical canal length measurement > 2 cm. A multivariable general linear regression model was used to correlate the relationship between endocervical canal lengths at 15–20 weeks and 21–24 weeks gestation in the current pregnancy with the earliest gestational age at delivery of prior pre...

Objective: To determine the utilization rate of second-trimester genetic sonogram and its role in influencing the decision for amniocentesis in women at increased risk for fetal trisomy 21. Methods: From November 1, 1993, to December 31, 1996, a second-trimester genetic sonogram or only genetic amniocentesis (as a first choice) were offered to pregnant women referred to our institution who were at increased risk for fetal trisomy 21. Results: During the study period, 2089 women were referred to our unit for genetic prenatal diagnosis; of these, 1426 (68%) chose only genetic amniocentesis, and 663 (32%) chose a genetic sonogram as their first option. The yearly utilization rates of genetic sonogram were two of 477 or 0.4% for 1993, 82 of 495 or 16.6% for 1994, 251 of 523 or 48.0% for 1995, and 328 of 594 or 55.2% for 1996. Adjusting for potential confounders, multivariable logistic regression analysis showed that the most important factors associated with the women's decision to undergo genetic amniocentesis were three or more ultrasound markers present (relative risk [RR] 189.5, 95% confidence interval [CI] 37.1, 980.0), two ultrasound markers present (RR 47.2, 95% CI 9.8, 267.8), one ultrasound marker present (RR 12.7, 95% CI 5.5, 29.7), and abnormal serum biochemistry (RR 3.0, 95% CI 1.0, 8.9). Conclusion: The increasing utilization trend, in conjunction with the fact that an abnormal sonogram was the most influential factor in women's decision to undergo genetic amniocentesis, suggests that genetic sonogram services for detection of trisomy 21 should be added to the armamentarium of all prenatal diagnostic centers.

Objective: To evaluate the effect of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate (FHR) tracings as measured by computer analysis.Methods: We studied 37 women with uncomplicated pregnancies at term with reactive FHR tracings. The women were randomized to receive epidural anesthesia with either bupivicaine with fentanyl or bupivicaine alone. One-hour FHR tracings were obtained before epidural anesthesia. Thirty minutes after the initial bolus of the epidural a repeat computer analysis of 60-minute FHR tracing was obtained. Median values are reported for FHR parameters with statistical analysis performed by the Mann-Whitney U and Wilcoxon signed rank tests where appropriate. A power calculation was performed using a power of 90% to determine a required sample size of 28 patients. Statistical significance was set at P

For several decades, visual analysis of the antepartum fetal heart rate tracing has been a primary mode of fetal surveillance despite lack of proof from randomized trials that its use leads to a reduction in perinatal mortality in high risk pregnancies. A meta-analysis of these trials offered the same conclusion. The trials were performed in the early 1980's with fetal monitors with poor signal to noise ratios and poorer testing schemes in comparison to today. Therefore the results may no longer be pertinent, however, it is unlikely that these trials will be repeated because of present medico-legal constraints. Nonetheless, the use of non-stress testing alone is an accepted mode of fetal surveillance because of associated low fetal death rates within 1 week of a normal test; 1.9 to 3.2/1000 patients tested. The expense associated with this low fetal death rate is a low positive predictive value of 25% to 50%. Interrelated with this inefficiency, is the considerable inter- and intra-observer variation in the interpretation of antepartum fetal heart rate tracings. Variation in the interpretation of antepartum fetal heart rate tracings continues to exist despite the increase in experience and knowledge of fetal heart rate monitoring and improvement in fetal heart rate monitors. The end result is a form of fetal surveillance that is of questionable value and inefficient, requiring frequent back up testing to clarify fetal condition.

The objective of this study was to determine the effects of removal of amniotic fluid in cases of symptomatic severe polyhydramnios on Doppler waveform indices of the uterine and umbilical arteries and flow velocities of the uterine arteries. Nine women underwent therapeutic amniocentesis during ten pregnancies for symptomatic polyhydramnios due to Beckwith-Wiedemann Syndrome (n = 1), esophageal atresia (n = 2), chorioangioma (n = 1), twin-twin transfusion syndrome (n = 3), a presumed autosomal recessive syndrome (n = 2), and an unbalanced double translocation (n = 1; partial dup 3q and partial del 9p syndrome). An average of 2.78 +/- 0.9 (range 1-4) 1 of fluid were removed at each procedure between the gestational ages of 18 and 34 weeks (mean of 28 weeks). The systolic/diastolic (S/D) ratio, pulsitility index (PI), and resistance index (RI) of the uterine and umbilical arteries were obtained before and after the procedure using color and pulsed Doppler. After angle correction, the peak systolic velocity (PSV) and mean velocity (MV) in centimeters/second (cm/s) of the uterine arteries were also determined. The presence or absence of a uterine artery waveform notch was determined. Dominant uterine arteries were defined as those with lower impedance indices or higher flow velocities. Statistical analysis was performed with the Wilcoxon signed-rank test. Significance was set at P0.05. There was a significant increase in the median value of the uterine artery MV (43.8 vs. 81.1 cm/s, P = 0.005) and PSV (74.2 vs. 125.5 cm/s, P = 0.007) after amniocentesis. The uterine S/D (3.0 vs. 1.84, P = 0.007), PI (1.12 vs. 0.68, P = 0.008), and RI (0.60 vs. 0.45, P = 0.005) impedance indices significantly decreased following amniocentesis. When uterine arteries were categorized as dominant vs. nondominant, there were greater improvements in impedance indices and flow velocities in the nondominant uterine arteries. There were three cases of unilateral and one case of bilateral early diastolic notches of the uterine artery waveforms which either resolved (n = 4) or improved (n = 1). There was no effect on the umbilical artery impedance indices. Therapeutic amniocentesis significantly improved uterine artery impedance indices and resulted in improved flow velocities, while there was no effect on umbilical artery waveform indices. The procedure resulted in the disappearance or improvement of the uterine waveform notch. Our findings suggest that in cases of severe polyhydramnios abnormal uterine artery velocimetry may not be due to lack of trophoblastic invasion of the spiral arteries but to increased intrauterine pressure secondary to polyhydramnios.

We report the prenatal diagnosis of mid shaft hypospadias and describe the sonographic features of fetal hypospadias including an abnormal urethral canal, ventral curvature of the distal penis, extension of the penile glans beyond the prepuce, and fetal micturation in a plane perpendicular to the penile shaft. An accurate family history is an essential part of the evaluation of the milder degrees of fetal hypospadias.

The objective of this study was to determine whether vacuum extraction is associated with umbilical cord blood acid-base changes when used electively or in the presence of suspected fetal distress. Data from 1,428 patients from a previously published randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify differences in umbilical cord blood acid-base measurements associated with the elective use of vacuum extraction (patients with duration of second stage of labor 60 min or less) and also in the presence of suspected fetal distress during the second stage of labor. When used electively, vacuum extraction was associated with lower pH (in both umbilical cord artery and vein), lower venous base excess, and higher venous carbon dioxide tension (PCO2), as compared to normal spontaneous vaginal delivery. After correcting for duration of second stage of labor, elective vacuum delivery was significantly associated only with a decrease in cord venous pH and increase in venous PCO2. However, these cord blood acid-base changes were not accompanied by any differences in perinatal morbidity and mortality or in the number of neonates born with acidemia (cord arterial pH < 7.15 or < 7.10). In cases of suspected fetal distress, the use of vacuum extraction was not associated with any detectable cord blood acid-base changes as compared to normal spontaneous vaginal delivery. These data support the continued use of vacuum extraction, especially in cases of suspected fetal distress during the second stage of labor.

We present a case of congenital cystic adenomatoid malformation (CCAM) of the lung diagnosed at 17 weeks and 6 days of gestation, initially classified as a type II lesion and reclassified as a type I lesion at 19 weeks, which shows that the natural evolution of CCAM of the lung can include cyst enlargement leading to reclassification. At 22 weeks of gestation ascites developed. The second successful in-utero treatment of hydrops secondary to this condition hy serial simple aspiration is described.

To assess cerclage benefit in women with short cervix also receiving 17-α-hydroxyprogesterone caproate (17P) to prevent recurrent preterm birth (PTB).Secondary analysis of a multicenter trial of ultrasound-indicated cerclage for shortened cervical length (CL). Women with prior spontaneous PTB at 16-33 6/7 weeks, singleton gestation and CL25 mm between 16 and 22 6/7 weeks were counseled on use of 17P and randomized to cerclage or no cerclage. Outcomes of women who received 17P were analyzed by randomization group. Primary outcome was PTB35 weeks.99 women received 17P: 47 cerclage; 52 no cerclage. Rates of PTB35 weeks were similar, 30% for cerclage and 38% for no cerclage (aOR 0.64 (0.27-1.52)). In women with CL15 mm, PTB35 weeks was reduced for the cerclage group (17% vs. 75%, p = 0.02). However, this difference was nullified after controlling for total progesterone doses received (p = 0.40).Cerclage was shown not to offer additional benefit for the prevention of recurrent PTB in women with short CL25 mm receiving 17P, but the sample size is insufficient for a definite conclusion given the 36% nonsignificant decrease in the odds of PTB35 weeks. Cerclage may further offer substantial benefit to women with very short CL15 mm and further study is needed.

We present a case of continuous abnormal fetal breathing which was associated with a severely asphyxiated neonate. The period of apnea was fixed at approximately 3 s and the breathing activity consisted of a single inspiratory and expiratory movement. The depth of each breath appeared similar. No movement or tone was observed. This “picket fence” fetal breathing pattern, which has been described in fetal lambs as a preterminal event, has not been reported previously in humans.

We sought to assess pregnancy outcome along a continuum of cervical lengths (CLs) ≥25 mm.We conducted planned secondary analysis of a randomized cerclage trial of women with prior spontaneous preterm birth 17(0)-34(6/7) weeks. Outcomes of women who maintained CLs ≥25 mm were analyzed. Women with CLs25 mm randomized to no cerclage comprised an internal comparison group.Of 1014 screened, 153 had CL25 mm, and 672 had CL ≥25 mm. Birth35 weeks occurred in 16% of the ≥25 mm cohort. The relationship between CLs ≥25 mm and birth gestational age was null (P = .15). In the25 mm group, progressively shorter CLs predicted birth35 weeks (P.001); this relationship was null in the ≥25 mm group (P = .17).The continuum of CLs ≥25 mm measured between 16(0/7)-22(6/7) weeks does not predict gestational length in women with prior spontaneous preterm birth.

Objective To compare pregnancy outcomes in women at risk for pregnancy loss treated with elective versus ultrasound-indicated placement of cerclage. Methods A retrospective cohort study was performed on two groups of patients with singleton gestations. The first group consisted of women at risk for pregnancy loss who were treated with an elective cerclage, while the second group was managed conservatively and followed with serial transvaginal cervical sonography and transfundal pressure. An emergency cerclage was placed in women in the second group when the endocervical canal length shortened to < 20 mm, either spontaneously or in response to transfundal pressure. The two groups were compared with respect to maternal demographics, obstetric and gynecological history, and gestational age, both at time of cerclage placement and delivery. Results A total of 138 patients were identified. Eighty-one patients were treated with an elective cerclage and 57 with an ultrasound-indicated cerclage. Patients treated with elective cerclages were older (32 versus 27 years, p = 0.0003), more commonly white (56.8% versus 38.6%, p = 0.0380), less commonly nulliparous (23.5% versus 43.9%, p = 0.0063), and more often private patients (92.6% versus 28.1%, p < 0.0001). A history of previous treatment with cerclage (45.7% versus 10.5%, odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1–0.4) and one prior midtrimester loss (53.1% versus 33.3%, OR 0.4, 95% CI 0.2–0.9) were also more common in the elective versus ultrasound-indicated cerclage group. However, there was no difference in the rates of previous preterm delivery, two midtrimester losses, two terminations of pregnancy, in utero diethylstilbestrol exposure, uterine anomalies, history of cone biopsy or parity. As expected, gestational age at placement of cerclage was significantly earlier in the elective group (13.0 versus 20.0 weeks, p < 0.0001). The median (range) gestational age at delivery (37 (15–41) versus 37 (17–41) weeks, p = 0.90), the number of early (< 25 weeks) losses (9.9% versus 8.8%, OR 1.6, 95% CI 0.3–7.9), and preterm deliveries (< 37 weeks) (35.8% versus 36.8%, OR 1.1, 95% CI 0.4–3.2) were similar in the elective and ultrasound-indicated cerclage patients, respectively. Conclusion In patients at risk for pregnancy loss, placement of cervical cerclages in response to ultrasono-graphically detected shortening of the endocervical canal length is a medically acceptable alternative to the use of elective cerclage. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

Background: Reported cases of uterine rupture diagnosed by ultrasound have shown fetal membranes ballooning through uterine rupture sites, or adjacent areas of hemorrhage. Case: A 27-year-old gravida 3, para 2 had open fetal surgery to repair a fetal myelomeningocele at 28 weeks’ gestation. Her postoperative course was complicated by threatened preterm labor and anhydramnios. At 33 weeks’ gestation, with maternal symptoms of bowel obstruction, ultrasound showed a fetal leg and section of umbilical cord protruding through the uterine wall. Conclusion: Even in the presence of anhydramnios, uterine wall rupture was identified, because ultrasound evaluation of the uterine wall showed prolapsed fetal parts and umbilical cord. Persistent anhydramnios after open fetal surgery should prompt a search for uterine rupture.