Faculty Bibliography

OBJECTIVE: To describe a new technique for wound closure after endoscopic intrauterine procedures which prevents amniotic fluid leakage after the procedure. STUDY DESIGN: This is an observational study which reviews a new technique under an IRB-approved protocol. The rationale for this study was the increasing frequency of intrauterine endoscopic procedures. The most common complication of these procedures is persistent leakage of amniotic fluid from puncture sites, which can result in preterm labor and preterm delivery. Thus, these procedures carry a high morbidity rate that may overcome the benefit of the intervention. We have employed a new technique, which has successfully prevented amniotic fluid leakage following the procedure. The instruments used for the endoscopic procedures were no larger than 3.5 mm for all cases. A sealant of platelets was rapidly injected followed by injection of fibrin glue and powdered collagen slurry at each puncture site. Sonography for modified AFI, clinical examination for nitrazine and ferning, and pad count were performed after each procedure at three intervals: immediately after the procedure, 24 h and 48 h. RESULTS: Eight patients undergoing an endoscopic intrauterine procedure (either cord ligation for twin-twin transfusion syndrome or sealing of ruptured membranes after amniocentesis) were included. All patients were treated between 18 and 24 weeks of gestation. Sonography, clinical examination and pad count revealed no evidence of amniotic fluid leakage either intra-abdominally or vaginally in any of the patients. There was 1 patient who ruptured membranes 12 h after the procedure due to severe vomiting. Another patient elected to terminate the pregnancy 48 h after the procedure without evidence of leakage. The remaining patients continued for 8 weeks or more without fluid leakage. CONCLUSION: The technique described, immediate sealing of puncture wounds following endoscopic intrauterine procedures, is effective in preventing amniotic fluid loss after the procedure

OBJECTIVE: The study was undertaken to assess the validity of vaginal fetal fibronectin assay as a screening test for spontaneous preterm delivery in asymptomatic patients who have undergone multifetal pregnancy reduction (MFPR). STUDY DESIGN: A historic cohort of 63 patients who underwent MFPR between 10 and 14 weeks of gestation was identified. All patients underwent serial vaginal fetal fibronectin sampling every 2 to 3 weeks from 22 weeks of gestation until delivery or 32 weeks of gestation. The fetal fibronectin concentration was measured by enzyme-linked immunosorbent assay, with 50 ng/mL or greater indicating a positive result. Charts were reviewed for fetal fibronectin results and pregnancy outcome data. Groups were compared by use of Fisher exact test. RESULTS: There were 13 singleton and 50 twin gestations after MFPR. A median of 4 fetal fibronectin assays were performed per patient. A total of 234 fetal fibronectin assays were performed with 222 (94.9%) negative results and 12 (5.1%) positive results. Overall, 41.3% of gestations were delivered spontaneously before 37 weeks; 7.9% were delivered before 34 weeks. The mean interval between tests was 17.8 days (+/-7.2 days). For delivery within 2 and 3 weeks of a single test, fetal fibronectin had a sensitivity of 66.7% and 50%, a specificity of 95.7% and 96.1%, a positive predictive value of 16.7% and 25%, and a negative predictive value of 99.5% and 98.6%, respectively. CONCLUSION: The fetal fibronectin test has similar validity to predict spontaneous preterm delivery in these high-risk pregnancies as in previously published cohorts

OBJECTIVE: The purpose of this study was to assess the validity of vaginal fetal fibronectin as a screening test for spontaneous preterm birth in patients with cervical cerclage. STUDY DESIGN: A historic cohort of 117 patients who underwent cervical cerclage placement between 1996 and 2002 were identified. All patients were followed up in a maternal-fetal medicine faculty practice in a university setting. Serial fetal fibronectin samples of vaginal secretions were collected every 2 to 3 weeks, starting at 22 weeks of gestation and continuing until 32 weeks or delivery, whichever came first. RESULTS: There were 81 singleton, 23 twin, 12 triplet, and 1 quadruplet pregnancies. There were 61 ultrasound-indicated, 47 prophylactic, and 9 emergency cerclages that were placed. Most cerclages were of the modified Shirodkar type (95%) with a median gestational age at cerclage placement of 16.6 weeks. Overall, 33.3% of gestations were delivered spontaneously before 37 weeks of gestation; 17.1% of gestations were delivered spontaneously before 34 weeks. For deliveries within 2 weeks and 3 weeks of a single fetal fibronectin assessment, the test had a sensitivity of 50% and 48.3%, a specificity of 90% and 91.1%, a positive predictive value of 16.3% and 28.6%, and a negative predictive value of 97.9% and 96%, respectively. Subgroup analysis by number of fetuses (singleton, twin, and higher order multiple gestations) revealed similar values. For delivery before 34 weeks of gestation, fetal fibronectin had a sensitivity of 50%, a specificity of 78.4%, a positive predictive value of 33.3%, and a negative predictive value of 88%. CONCLUSION: This study is the first to evaluate the use of vaginal fetal fibronectin assessments to screen for preterm birth in patients who had undergone cervical cerclage procedures. We conclude that this test has similar validity to predict spontaneous preterm delivery in these high-risk pregnancies, as in previously published cohorts