Susan C. Olmstead

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	A fascinating debate at the 2017 ACOG clinical and scientific meeting delved in to the history, utility, and relevance of a longstanding obstetrical diagnosis.

	The term “cervical insufficiency” describes a mysterious phenomenon, and its diagnosis is one of exclusion, using patient history, ultrasound, and the physical exam as criteria. ACOG practice bulletin #142 defines cervical insufficiency as “the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester.”

	“Should We Abandon the Diagnosis of Cervical Insufficiency?” was the title of the Morton and Diane Stenchever lecture, held Monday at the 2017 ACOG Annual Clinical and Scientific Meeting. Arguing against doing so was Dr John Owen of the University of Alabama at Birmingham. Noting that cerclage is the primary treatment, and treatment indications, like the diagnosis, depend on history, ultrasound, and the physical exam, Dr Owen reviewed studies of effectiveness of cerclage by each indication. Noting that actual placement of a cerclage is very safe, he concluded that the diagnosis is valid “despite some problems.”

	Dr Jay Iams of Ohio State University, arguing for “a paradigm shift in thinking about preterm parturition,” made it clear that he does not disagree with the treatment for cervical insufficiency, but rather with the diagnosis itself. Cervical competence is not a continuum, he pointed out, and the woman with the weakest cervix will benefit most from cerclage. He insisted, “the 20-week line between miscarriage and preterm birth is a fraud,” and “the 20-week line between cervical insufficiency and premature labor is a fraud.”

	Asking the question, “Why haven’t we dumped the 20-week boundary between ‘miscarriage’ and ‘premature birth’?” he listed 4 reasons: “1) It’s historical, even biblical. Change is hard. 2) It’ll be a major headache to track births at 16–20 weeks. No one does that, do they? 3) It’s a sociopolitical nightmare. If births >16 weeks are called births and counted, then … 4) We haven’t thought of births at 16–20 weeks as the obstetrical equivalent to advanced ovarian cancer.” While epithelial ovarian cancer is aggressively documented and actively researched, he said, births at this gestational age are poorly documented and actively ignored.

	Results of a retrospective cohort study presented at the 65

 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists suggest that human papillomavirus (HPV) is associated with an increased risk of preterm premature rupture of membranes (PPROM). Maternal infection does not, however, independently increase risk of adverse neonatal outcomes, according to researchers from the University of Virginia.

	Included in the study were singleton deliveries from 2010 to 2015 to 2,153 women. Of the cohort, 38.5% were HPV positive and 3.4% had premature rupture of membranes (PROM). The authors found a significant association between PROM and HPV infection (

	After adjustment for history of PROM, cervical conization, drug use or smoking, ethnicity and insurance, HPV infection was still associated with PROM (odds ratio [OR] 2.0, 95% confidence interval [CI]: 1.21-3.55). Adjusting for those covariates, HPV infection was associated with PPROM but not PROM (OR=2.23, 95% CI 1.12-4.43 versus OR=1.87, 95% CI 0.81-4.34). In univariate but not multivariable analysis, HPV infection was associated with preterm delivery. It also had a univariate association with newborn septicemia (

=0.01), neonatal intensive care unit admission (

	Dudley D, Ferguson J, Pettit K, Boyle A. Maternal human papillomavirus infection increases the risk of premature rupture of membranes. Poster 19M. Presented Monday, May 8, 2017 at the 65

 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists in San Diego, CA.

Articles

A debate at ACOG 2017 looks at whether cervical insufficiency should be abandoned as a diagnosis. Plus: A study presented at ACOG 2017 examines whether human papillomavirus is linked to preterm birth?

Is cervical insufficiency a true diagnosis?

	Maternal anti-Lea antibodies, red cell antibodies not usually thought to be a risk factor for adverse pregnancy outcomes, were found to increase the risk of stillbirth in a 

 performed in Sweden and published in 2014. Rh and K-red blood cell antibodies also were found to increase the risk of both preterm birth and stillbirth. The study was published in the 

	In a study sample consisting of 1,022,569 singleton pregnancies from 668,952 mothers in Sweden during 1987–2002, 1.3% were alloimmunized. The researchers ran adjusted logistic regression models and, compared with having no antibodies, alloimmunization with anti-D, anti-E, anti-C and anti-c was associated with increased risk of both stillbirth and preterm birth. In addition, anti-Kell was associated with increased risk of preterm birth and anti-Lea with increased risk of stillbirth. Compared with firstborns, children of subsequent births had a higher risk of preterm birth.

	The researchers claimed that this study was the largest as of 2014 to look at both Rhesus and non-Rhesus maternal alloimmunization and called for further investigation of the consequences of non-anti-D alloimmunization. They noted, “In our study sample, anti-D antibody occurred at a frequency comparable to other antibodies (e.g. anti-Lea, anti-E) that are not as well studied and which do not have prophylactic treatments. However, the relative risk of stillbirth and preterm birth associated with these less well-known antibodies was of similar magnitude to that found for anti-D.”

Relative risk of stillbirth and preterm birth associated with less well-known antibodies was of similar magnitude to that found for anti-D.

Large study of maternal alloimmunization yields a surprise

	Panelists Leila V. Adamyan, MD, Alan H. DeCherney, MD, and Linda M. Nicoll, MD, went 1 for 2 during the “Stump the Professors” session at the 42

 AAGL Global Congress on Minimally Invasive Gynecology in Washington, DC.

	Jessica Shepherd, MD, MBA, chaired the session, which featured two clinical cases designed to challenge the diagnostic ability of the learned professors.  Case 1 was presented by Erika Mowers, MD, of the University of Michigan. Case 2 was presented by Olubunmi Olude, MD, of Eastern Virginia Medical School.

	The 20-year-old nulligravida in Case 1 presented to the Emergency Department (ED) on the third day of a course of Bactrim with a fever of 103.5°F, pain on urination, and pelvic pain. She reported a history of night sweats but neither sexually transmitted disease nor abnormal Pap smears.  For the past 2 years, while in a monogamous relationship, she had been taking oral contraceptives. Pelvic exam revealed a left-sided adnexal mass with tenderness. The patient’s pregnancy test was negative.

	The panelists suggested a differential of unilateral salpingitis or pelvic inflammatory disease (PID) but noted that those diagnoses were so common that they could not have been included in a Stump the Professors session.  Subsequent testing with ultrasound was revealed to have shown a mass in the left adnexa but the left ovary was not visualized. The woman’s fallopian tubes and ovaries were normal on laparoscopy. Cystoscopy showed pus within the bladder and a drain was placed for drainage. The patient remained febrile with continued drainage despite multiple changes in antibiotics.

	The final diagnosis-which stumped the professors-was retropubic abscess caused by an urachal anomaly, a condition more common in men than in women.

	The patient in Case 2 was a 30-year-old G5P5005 who presented to the ED with severe and worsening abdominal pain and fever. Eight days before, she had undergone an Essure procedure and her pain began 2 days after insertion. Physical examination revealed a distended abdomen and an umbilical hernia. The patient was 8 weeks postpartum and had not had a menstrual period since the vaginal delivery.

	The panel’s working diagnosis was PID or possibly perforation from Essure. Subsequent computed tomography of the abdomen and pelvis was revealed to have shown a large amount of fluid. The patient was started on broad-spectrum antibiotics and subsequently underwent laparoscopy, which revealed large amounts of pus but no evidence of tubal perforation.

	Although the panel members did not pin down the exact bacterium causing the infection, they had suggested calling for the appropriate tests, so Dr. Shepherd declared them unstumped.

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Panelists Leila V. Adamyan, MD, Alan H. DeCherney, MD, and Linda M. Nicoll, MD, went 1 for 2 during the “Stump the Professors” session at the 42nd AAGL Global Congress on Minimally Invasive Gynecology in Washington, DC.

AAGL Stump the Professors: 1 win and 1 loss

		The general public is misinformed about the causes of miscarriage, and miscarriage is still a source of guilt and shame for many women, according to a recent survey.

	The survey designers claim that this was the first national assessment of the general US population regarding causes of miscarriage and the impact of personal history on these perceptions. It consisted of an online questionnaire administered to 1083 adults in 48 states. Fifty-five percent were female and 15% reported a history of miscarriage.

	The researchers found that many respondents believed miscarriage to be far less common than it is: 55% of respondents believed that miscarriages occurred in fewer than 6% of all pregnancies.

	Although physicians are aware that most miscarriages are caused by chromosomal anomalies, among the respondents, many believed that miscarriage could be caused by a stressful event (76%), by lifting a heavy object (64%), or previous use of oral contraception (22%) or IUD (28%).

	Of those who had had a miscarriage, 40% felt that they had done something wrong to cause the miscarriage; 27% felt ashamed; 40% felt alone; and 47% felt guilty.

	“The false perceptions and lack of understanding about miscarriage … contribute to many women and couples feeling isolated and alone after suffering from a miscarriage,” said S. Zev Williams, MD, PhD, a coauthor of the study, in an Albert Einstein College of Medicine press release.

	Public disclosures of miscarriages by celebrities and public figures helped with feelings of isolation for 28% of respondents. Seventy-eight percent reported that they would want to know the cause of their miscarriage even if there were nothing that they could have done to prevent it. Women reported feeling less guilty about a miscarriage if a cause was found.

	“Miscarriage is perceived as a very emotionally painful but rare event and results in feelings of guilt and isolation,” the researchers noted in the study. “More open discussion of miscarriage and disclosures by celebrities and public figures would likely help in educating the public and ameliorate the secrecy and shame. Identifying a cause of miscarriage, even if no intervention is available, can be quite beneficial.”

	The results of the study were presented at the International Federation of Fertility Societies/American Society for Reproductive Medicine joint annual meeting in Boston on October 16.

		Bardos JD, Friedenthal J, Williams Z. Oral Session: Early Pregnancy II: Public perceptions of miscarriage: a national population based survey. Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.

A new survey reveals that the public is misinformed about the causes and prevalence of miscarriage.

Author | Susan C. Olmstead

Articles

Is cervical insufficiency a true diagnosis?

Large study of maternal alloimmunization yields a surprise

AAGL Stump the Professors: 1 win and 1 loss

Causes of miscarriage commonly misunderstood