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Fox N.S.,Maternal Fetal Medicine Associates PLLC | Saltzman D.H.,Gynecology and Reproductive science | Saltzman D.H.,Carnegie Imaging for Women PLLC | Roman A.S.,Gynecology and Reproductive science | And 3 more authors.
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2011

Background There are a number of agents used for cervical ripening prior to the induction of labour. Two commonly used agents are intravaginal misoprostol and a transcervical Foley catheter. Objective To review the evidence comparing misoprostol and transcervical Foley catheter placement for induction of labour, and perform a meta-analysis comparing these two induction agents. Search strategy We conducted database searches of PubMed, Embase, the Cochrane Library Database, and the ClinicalTrials.gov website. Bibliographies of all relevant articles were reviewed. Selection criteria Prospective, randomised trials comparing the use of intravaginal misoprostol and transcervical Foley catheter for the purpose of cervical ripening and induction of labour were included. We excluded studies in which the patients in these two intervention groups also received other induction agents concurrently, such as oral misoprostol, oxytocin, or other prostaglandins. Data collection and analysis The primary outcomes selected were time to delivery, and the rates of caesarean section, uterine tachysystole, and chorioamnionitis. Random-effects generalised linear models with a poisson distribution and log link function were used to compare the two induction agents across the studies. Main results Nine studies (1603 patients) were identified as eligible to be included in this meta-analysis. There were no significant differences in the mean time to delivery (mean difference 1.08 ± 2.19 hours shorter for misoprostol, P = 0.2348), the rate of caesarean delivery (RR 0.991; 95% CI 0.768, 1.278), or in the rate of chorioamnionitis (RR 1.130; 95% CI 0.611, 2.089) between women who received misoprostol compared with transcervical Foley catheter. Patients who received misoprostol had significantly higher rates of tachysystole compared with women who received a transcervical Foley catheter (RR 2.844; 95% CI 1.392, 5.812). Conclusions Intravaginal misoprostol and transcervical Foley catheter have similar effectiveness as induction agents. Transcervical Foley catheter is associated with a lower incidence of tachysystole. © 2011 RCOG.


Roman A.S.,Carnegie Imaging for Women PLLC | Roman A.S.,New York University | Saltzman D.H.,Carnegie Imaging for Women PLLC | Fox N.,Carnegie Imaging for Women PLLC | And 6 more authors.
American Journal of Perinatology | Year: 2013

Objective To determine if prophylactic cerclage improves pregnancy outcomes in women with twin pregnancies without a history of cervical insufficiency. Study Design Women with twin pregnancies who received outpatient preterm labor surveillance services between January 1990 and May 2004 for ≥1 day beginning at < 28.0 weeks' gestation were identified from a database. Patients with previous preterm delivery or a diagnosis of cervical incompetence in a previous or in the index pregnancy were excluded. Twin pregnancies managed with prophylactic cerclage were compared with twin pregnancies in which cerclage was not placed. The primary outcome was incidence of preterm birth prior to 32 weeks. Groups were compared using Fisher exact and Mann-Whitney U test statistics. Results Overall, 8,218 twin pregnancies met inclusion criteria, of which 146 women (1.8%) received prophylactic cerclage. Patients who received prophylactic cerclage had a significantly higher incidence of preterm birth before 32 weeks and infants with lower mean birth weight and longer nursery stays. No significant difference was seen in mean gestational age at delivery. This study had 80% power to detect a 7% reduction in the primary outcome. Conclusion Prophylactic cerclage was not associated with a lower risk of preterm birth and adverse neonatal outcomes in twin pregnancies without history of cervical insufficiency. 2013 by Thieme Medical Publishers, Inc.


Fox N.S.,Mount Sinai School of Medicine | Fox N.S.,Maternal Fetal Medicine Associates PLLC | Rebarber A.,Maternal Fetal Medicine Associates PLLC | Roman A.S.,Carnegie Imaging for Women PLLC | And 2 more authors.
Ultrasound in Obstetrics and Gynecology | Year: 2012

Objectives To estimate the association between the cervical length (CL) measurement at 30-32 weeks and the mode of delivery in twin pregnancies. Methods This was a retrospective study of a cohort, from 2005-2010, of 265 twin pregnancies with a CL measurement at 30-32 weeks. We compared the CL measurement at 30-32 weeks based on mode of delivery. We then analyzed our data across four subgroups, based on the CL measurement quartiles at 30-32 weeks. We performed this analysis in all patients, and also performed a planned subgroup analysis of 130 patients who attempted a vaginal delivery. Results In all patients, including those who attempted a vaginal delivery, the mean CL at 30-32 weeks was significantly shorter in women who delivered vaginally compared with women who had a Cesarean section. The likelihood of Cesarean delivery increased significantly with increasing CL measurement across the groups defined by measurement quartiles. On adjusted analysis controlling for maternal age, race, in-vitro fertilization, chorionicity, induction of labor and prior vaginal delivery, the CL measurement at 30-32 weeks was independently associated with mode of delivery. Conclusions In twin pregnancies, the CL at 30-32 weeks is significantly associated with the likelihood of Cesarean delivery. A longer CL may represent underdevelopment of the uterus, leading to a higher risk of Cesarean delivery in labor at term. Copyright © 2012 ISUOG.


Fox N.S.,Maternal Fetal Medicine Associates PLLC | Fox N.S.,Carnegie Imaging for Women PLLC | Fox N.S.,Mount Sinai School of Medicine | Rebarber A.,Maternal Fetal Medicine Associates PLLC | And 11 more authors.
Journal of Maternal-Fetal and Neonatal Medicine | Year: 2012

Objective: To estimate the association between fetal fibronectin (fFN), cervical length (CL), and spontaneous preterm birth (SPTB) in asymptomatic women with triplet pregnancies. Study design: A cohort of 39 consecutive women with triplet pregnancies managed in one Maternal-Fetal medicine practice from 20052011 was analyzed. Combined fFN and CL testing was performed every 2 weeks from 2232 weeks. A short CL was defined as ≤20 mm. Results: A positive fFN was significantly associated with SPTB <28 weeks, <30 weeks, <32 weeks, and <34 weeks. A short CL was significantly associated with SPTB <32 weeks. On combined testing, having both tests positive was associated with the highest likelihood of SPTB at all gestational ages. As a screening test for SPTB <32 weeks, having both a positive fFN and a short CL had a sensitivity of 62.5%, specificity of 90%, positive predictive value of 62.5%, negative predictive value of 90%, positive likelihood ration of 2.98 and negative likelihood ratio of 0.88. Combined fFN and CL outperformed fFN alone, CL alone, or either test being positive alone. Conclusions: In asymptomatic women with triplet pregnancies, fFN and CL are each significantly associated with SPTB. For the prediction of SPTB, combined fFN and CL testing outperforms either test alone. © 2012 Informa UK, Ltd.


Fox N.S.,Mount Sinai School of Medicine | Fox N.S.,Maternal Fetal Medicine Associates PLLC | Rebarber A.,Mount Sinai School of Medicine | Rebarber A.,Maternal Fetal Medicine Associates PLLC | And 4 more authors.
American Journal of Perinatology | Year: 2012

To estimate the risk of preterm birth in asymptomatic women with twin pregnancies with a normal cervical length (CL) and a positive fetal fibronectin (fFN), we reviewed a retrospective cohort of twin pregnancies delivered in our practice from 2005 to 2010. Patients were screened from 22 to 32 weeks with CL and fFN at 2- to 4-week intervals. We examined 244 patients with twin pregnancies and a normal CL (>25 mm) between 22 and 32 weeks and compared outcomes based on the fFN result. Fourteen (5.7%) patients had a positive fFN and 230 (94.3%) patients had a negative fFN. Positive fFN was associated with an increased the risk of spontaneous preterm birth < 37 weeks (85.7% versus 38.3%, p=0.001), < 35 weeks (50% versus 11.8%, p< 0.001), < 34 weeks (35.7% versus 6.9%, p< 0.001), and < 32 weeks (21.4% versus 2.2%, p< 0.001). On adjusted analysis, a positive fFN was independently associated with preterm birth < 32 weeks (odds ratio 6.8, 95% confidence interval 1.42, 32.2) and gestational age at delivery (p=0.001). In the setting of a normal CL, a positive fFN is significantly associated with preterm birth in asymptomatic twin pregnancies. Contingency model screening of fFN in asymptomatic twin pregnancies solely based on CL evaluation may fail to identify a cohort of at-risk patients. © 2012 by Thieme Medical Publishers, Inc.

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