In the name of God. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth...
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In the name of God
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Vaginal progesterone, cerclage or cervical pessary for
preventing preterm birth in asymptomatic singleton pregnant women with a
history of preterm birth and a sonographic short cervix
Published online 17 January 2013 in Wiley online libraryUltrasound Obstet Gynecol 2013;41
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Preterm birth remains the leading cause of perinatal morbidity & mortality worldwide soPreventive strategies required to minimize burden of prematurity
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Shortened Cx length in TVS is powerful predictor of spontaneous preterm birth
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Vaginal progesterone for asymptomatic pregnant women with short Cx ≤ 25mm In comparison with placebo reduces:O Preterm birth rates before 33 weeks
GAO Neonatal mortality/morbidity
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In a Cochrane review : cerclage in comparison with no treatment for preterm birth prevention in singleton pregnancy reported a less marked, but statistically significant
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In meta-analysis Benefit of cerclage for women with singleton pregnancy is highlighted in:O Short CxO Previous preterm birth
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Cx pessary versous expectant management in a recent multicenter study in spain:380 pregnant women with Hx of preterm birth &Cx length ≤25mm
Significant reduction in:Preterm birth <34 w GA (6.3% vs 26.8%)Neonatal morbidity (4.2% vs 22.1%)
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Aim of this study
Compare outcom of pregnancy in singleton pregnancy with Hx of preterm bith & Cx length ≤25mm in cerclage, vaginal progesterone or cervical pessary
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Method:
3 different cohort of singleton pregnant women with a Hx of at least one spontaneous preterm birth< 34 & short cx on sono:142 treated with cerclage in USA59 vaginal progesterone UK42 cervical pessary Spain
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cerclage15 clinical center in the USA 2003-2007:Singleton pregnant women with previous histoty of preterm birth at 17W <GA<33+6 if Cx length <25mm cerclage done if Cx length 25-29mm serial transvaginal
scan at 16<GA<21+6 fortnightly or weekly screen for Neisseria gonorrhoeae & chlamydia trachomatis that treat with positive culture
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Post cerclage managementO Recommendation for pelvic restO Abstinence from sexual activityO No douchingO No tamponsO Physical activity restrictions, no prolonged
standing for >4 hO No heavy physical work involving lifting >20
pounds or strainingO No valsalva
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Cerclage removingO 37 W GA in NL pregnancyO Early removing in : chorioamnion rupture labor hemorrhage
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Vaginal progesterone
59 high risk Singleton pregnant women with:O Spontaneous preterm birthO Preterm ROMO Significant cervical surgery
referred to the weekly outpatient clinic
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Short cervix
Cervical length < 3rd centileO 30.5mm at 16 WO 24.5mm at 23W
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O Serial transvaginal scan from 16W every 1-4 W (depended on initial cervical length & GA of prior preterm birth )
O 200mg vaginal progesteron at night (restriction in activity & prolonged standing but no advise for sexual activity)
O If significant Cx shortening do cerclage (<15mm in women that was > 15mm or further shortening >50% in <15mm cervical length in initial treatment)
O Vaginal swab were taken only for symptomatic pt
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Cervical pessary
42 singleton pregnant women with pior preterm birth <34 in Spain 2007-2010Serial TVS from 16W continued 1-4 W Cervical & vaginal swab if infection proved appropriate treatment then with 1 week delay pessary inserted but not removing for infection after insertion
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Removing pessary
In NL pregnancy 37W GABefore 37W in:O Active vaginal bleedingO Threat of preterm labor with
persistant contractions, despite tocolysis, or sever pt discomfort
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resultsCerclage Vaginal
progesterone Cervical pessary
Maternal age 26 ± 5 30 ± 6 31± 7
Racial origineAfro-caribbean CaucasianOther
75(53)51(36)16(11)
3(5)53(89)3(5)
1(2)35(83)6(14)
Smoker 23(16) 21(36) 11(26)
BMI 30±8 25±6 27±6
Prior birth<34 2(1-3) 1(1-3) 1(1-3)
GA in initiation of treatment
19±2 21±3 21±2
Cx length in initiation of treatment
18.4±6.3 21.1±8.1 19.3±5.1
cerclage 142(100) 6(10) 0
Progesterone 54(38) 59(100) 0
Cx pessary 0 1(2) 42(100)
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Clinical outcom
Cerclage(A)
Vaginal progesterone(B)
Cervical pessary (c)
A vs B A vs c B vs c
Pregnancy outcom
Birth< 37w 63(44)
27(46)
19(45) 0.97 (0.69-1.35)
0.98 (0.67-1.43) 1.01 (0.66-1.56)
Birth<34w 40(28)
19(32)
5(12) 0.87 (0.56-1.38)
2.37 (1.00-5.61) 2.70 (1.10-6.67)
Birth <28w 20(14)
8(14) 3(7) 1.04 (0.48-2.22)
1.97(0.62-6.31) 1.90 (0.53-6.74)
C/s 43(30)
12(20)
10(24) 1.49 (0.85-2.61)
1.23 (0.70-2.31) 0.85 (0.41-1.79)
Neonatal outcom
Perinatal loss 12(8) 5(8) 1(2) 0.99 (0.37-2.71)
3.55 (0.47-26.51) 3.56 (0.43-29.37)
Serious ICH 0 1(2) 0
Serious respiratory morbidity
12(8) 6(10) 2(4) 0.83(0.33-2.11) 1.77 (0.41-7.62) 2.14 (0.45-10.07)
Necrotizing entrocolitis
2(1) 0 1(2)
Retinopathy of prematurity
3(2) 0 0
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Clinical outcom in cervical lenght<25 irrespective of GA
PRIMARY THERAPY FOR SHORT CERVIX
Relative risk(95 CI)
Cerclage (142)
Vaginal progesterone (38)
Cx pessary (42)
A vs B A vs C B vs c
Birth <34
40(28) 10(26) 5(12) 1.07 (0.59-1.94)
2.37 (0.99-5.61)
2.21 (0.83-5.98)
Perinatal loss
12(8) 5(13) 1(2) 0.64 (0.24-1.71)
3.55 (0.47_26.51)
5.53 (0.68-45.21)
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Discussion
Similar effectiveness of currently available treatment strategies for women with singleton pregnancy who has one prior preterm birth and shortened cervical length on TVS
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Smoking & ethnicity are confounders known to be associated with preterm birth however in short Cx it is low
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Infection screeningO USA study: N.gonorrhoeae &
C.trachomatisO Spanish: vaginal bacteriosisO Uk: screen symptomatic womenNumber of women who received AB is low so effectiveness of AB to prevent preterm birth remains unproven…
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Progressive cervical shortening & CX length< 15mm increased benefit with cerclage despite treatment with progesteron
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recommendationO Trials should be less invasine and
cheaper treatment and need to be even larger studies
O Choose cerclage, vaginal progesterone or cervical pessary for women with short cervix on sono or prior preterm birth is reasnable
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Thanks for your attention
Thanks for your
attention