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van Gils L, de Boer MA, Bosmans J, Duijnhoven R, Schoenmakers S, Derks JB, Prins JR, Al-Nasiry S, Lutke Holzik M, Lopriore E, van Drongelen J, Knol MH, van Laar JOEH, Jacquemyn Y, van Holsbeke C, Dehaene I, Lewi L, van der Merwe H, Gyselaers W, Obermann-Borst SA, Holthuis M, Mol BW, Pajkrt E, Oudijk MA. Study protocol for two randomised controlled trials evaluating the effects of Cerclage in the reduction of extreme preterm birth and perinatal mortality in twin pregnancies with a short cervix or dilatation: the TWIN Cerclage studies. BMJ Open 2024; 14:e081561. [PMID: 38729756 PMCID: PMC11097875 DOI: 10.1136/bmjopen-2023-081561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/03/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Twin pregnancies have a high risk of extreme preterm birth (PTB) at less than 28 weeks of gestation, which is associated with increased risk of neonatal morbidity and mortality. Currently there is a lack of effective treatments for women with a twin pregnancy and a short cervix or cervical dilatation. A possible effective surgical method to reduce extreme PTB in twin pregnancies with an asymptomatic short cervix or dilatation at midpregnancy is the placement of a vaginal cerclage. METHODS AND ANALYSIS We designed two multicentre randomised trials involving eight hospitals in the Netherlands (sites in other countries may be added at a later date). Women older than 16 years with a twin pregnancy at <24 weeks of gestation and an asymptomatic short cervix of ≤25 mm or cervical dilatation will be randomly allocated (1:1) to both trials on vaginal cerclage and standard treatment according to the current Dutch Society of Obstetrics and Gynaecology guideline (no cerclage). Permuted blocks sized 2 and 4 will be used to minimise the risk of disbalance. The primary outcome measure is PTB of <28 weeks. Analyses will be by intention to treat. The first trial is to demonstrate a risk reduction from 25% to 10% in the short cervix group, for which 194 patients need to be recruited. The second trial is to demonstrate a risk reduction from 80% to 35% in the dilatation group and will recruit 44 women. A cost-effectiveness analysis will be performed from a societal perspective. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Committees in the Netherlands on 3/30/2023. Participants will be required to sign an informed consent form. The results will be presented at conferences and published in a peer-reviewed journal. Participants will be informed about the results. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05968794.
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Affiliation(s)
- Lissa van Gils
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Judith Bosmans
- Department of Health Sciences, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Ruben Duijnhoven
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan B Derks
- Department of Obstetrics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, The Netherlands
| | - Margo Lutke Holzik
- Department of Obstetrics and Gynecology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Neonatology and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud Universiteit, Nijmegen, The Netherlands
| | - Marieke H Knol
- Department of Obstetrics and Gynaecology, Isala Zwolle, Zwolle, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics & Gynaecology, Máxima Medical Center, Veldhoven, The Netherlands
| | | | | | | | - Liesbeth Lewi
- Fetal Medicine Unit, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Hannes van der Merwe
- Fetal Medicine Unit, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynecology, Hospital Oost-Limburg, Genk, Belgium
| | | | - Mayella Holthuis
- Patient organization 'Extreme Vroeggeboorte', Amsterdam, The Netherlands
| | - Ben W Mol
- department of obstetrics and gynaecology, school of medicine, Monash University, Melbourne, Victoria, Australia
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
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Goodell M, Leechalad L, Soti V. Are Cervical Pessaries Effective in Preventing Preterm Birth? Cureus 2024; 16:e51775. [PMID: 38187016 PMCID: PMC10771609 DOI: 10.7759/cureus.51775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/06/2024] [Indexed: 01/09/2024] Open
Abstract
Preterm births are a significant concern, as they can have serious consequences for both infants and mothers. It is crucial to identify risk factors associated with preterm birth and to implement effective interventions, such as progesterone, cervical pessary, and cervical cerclage, to prevent it. This systematic review aims to evaluate the efficacy of cervical pessary in reducing spontaneous preterm delivery. However, cervical pessaries have limited research and conflicting findings when compared to other interventions for preventing preterm labor. Therefore, this review seeks to analyze various studies to evaluate their overall effectiveness and better understand their role in treating this vulnerable population. The literature search was conducted using PubMed between January and September 2023, and the systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results of this review highlight the importance of continued research into mitigation strategies for preterm birth. There is some evidence that indicates that using cervical pessaries before 34 weeks can be effective. While some studies have reported positive outcomes when cervical pessaries are combined with other treatments like progesterone, there is no solid statistical evidence to support this claim. Furthermore, additional research is needed to comprehend the impact of singleton pregnancies and long-term outcomes for both mothers and infants.
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Affiliation(s)
- Morgan Goodell
- Obstetrics and Gynecology, Lake Erie College of Osteopathic Medicine, Elmira, USA
| | - Leilani Leechalad
- Internal Medicine, Lake Erie College of Osteopathic Medicine, Elmira, USA
| | - Varun Soti
- Pharmacology and Therapeutics, Lake Erie College of Osteopathic Medicine, Elmira, USA
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Ahmed B, Abushama M, Konje JC. Prevention of spontaneous preterm delivery – an update on where we are today. J Matern Fetal Neonatal Med 2023; 36:2183756. [PMID: 36966809 DOI: 10.1080/14767058.2023.2183756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
Spontaneous preterm birth (delivery before 37 completed weeks) is the single most important cause of perinatal morbidity and mortality. The rate is increasing world-wide with a great disparity between low, middle and high income countries. It has been estimated that the cost of neonatal care for preterm babies is more than 4 times that of a term neonate admitted into the neonatal care. Furthermore, there are high costs associated with long-term morbidity in those who survive the neonatal period. Interventions to stop delivery once preterm labor starts are largely ineffective hence the best approach to reducing the rate and consequences is prevention. This is either primary (reducing or minimizing factors associated with preterm birth prior to and during pregnancy) or secondary - identification and amelioration (if possible) of factors in pregnancy that are associated with preterm labor. In the first category are optimizing maternal weight, promoting healthy nutrition, smoking cessation, birth spacing, avoidance of adolescent pregnancies and screening for and controlling various medical disorders as well as infections prior to pregnancy. Strategies in pregnancy, include early booking for prenatal care, screening and managing medical disorders and their complications, and identifying predisposing factors to preterm labor such as shortening of the cervix and timely instituting progesterone prophylaxis or cervical cerclage where appropriate. The use of biomarkers such as oncofetal fibronectin, placental alpha-macroglobulin-1 and IGFBP-1 where cervical screening is not available or to diagnosis PPROM would identify those that require close monitoring and allow the institution of antibiotics especially where infection is considered a predisposing factor. Irrespective of the approach to prevention, timing the administration of corticosteroids and where necessary tocolysis and magnesium sulfate are associated with an improved outcome. The role of genetics, infections and probiotics and how these emerging dimensions help in the diagnosis of preterm birth and consequently prevention are exciting and hopefully may identify sub-populations for targeted strategies.
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Creswell L, Rolnik DL, Lindow SW, O’Gorman N. Preterm Birth: Screening and Prediction. Int J Womens Health 2023; 15:1981-1997. [PMID: 38146587 PMCID: PMC10749552 DOI: 10.2147/ijwh.s436624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/13/2023] [Indexed: 12/27/2023] Open
Abstract
Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.
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Affiliation(s)
- Lyndsay Creswell
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
| | - Daniel Lorber Rolnik
- Department of Obstetrics and Gynecology, Monash University, Melbourne, VIC, Australia
| | - Stephen W Lindow
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
| | - Neil O’Gorman
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
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Kumari P, Kumar M, Joseph T, Kumari M, Yadav B, Beck MM. Comparing Obstetric and Perinatal Outcomes Following Elective and Emergency Cervical Cerclage in Singleton and Multiple Pregnancies in a Tertiary Care Perinatal Centre. J Obstet Gynaecol India 2023; 73:213-221. [PMID: 38143986 PMCID: PMC10746619 DOI: 10.1007/s13224-023-01845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/19/2023] [Indexed: 12/26/2023] Open
Abstract
Objective To compare the success, failure rates and perinatal outcomes following emergency and elective cervical cerclage in singleton and twin pregnancies at a tertiary care perinatal centre over half a decade. Methods All pregnant women, both with singleton and twin pregnancies, who had cervical cerclage between June 2014 and May 2019 were included in the retrospective study. Success rates, failure rates, maternal complications and perinatal outcomes were compared in both groups. Results There were 129 women enrolled in the study, 48 in the emergency and 81 in the elective group. A significantly greater number of multiparous women were in the elective group (97.5% versus 68.7%; p-value < 0.001). Twins were nearly four times more in the emergency group as compared to the elective group. The mean cervical length at time of cerclage was 2.05 cm and 1.5 cm; (p-value < 0.001) respectively in the elective and emergency groups. Almost half of the women in the emergency group had bulging membranes. (52.2%). Following cerclage, mean gestational age at delivery was similar in both groups. However, more women in the elective group delivered at or beyond 34 weeks in comparison to the emergency groups (71% versus 53.3%. P-value 0.05). Preterm labour leading to preterm births was almost twice in the emergency group than elective group (49% versus 22%, P-value 0.002). Rates of maternal chorioamnionitis were similar in both groups. The overall live birth rates were comparable (81.3% versus 84.4% P-value 0.85) in both the groups. These results were also seen on doing subgroup analysis of elective versus emergency cerclage in singleton pregnancies only. Failure rates were also similar in both groups (18.7% versus 15.6%, P-value 0.85) Composite neonatal morbidity was more in the emergency group than in the elective group (35.5 versus 14%, P-value 0.01). Conclusion Live birth rates and failure rates were comparable following elective and emergency cerclage both overall and in singleton pregnancies. Maternal chorioamnionitis and neonatal sepsis rates were similar in both the groups. However, composite neonatal morbidity was higher in the emergency cerclage group.
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Affiliation(s)
- Pushplata Kumari
- Obstetrics and Gynecology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Manish Kumar
- Department of Neonatology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Treasa Joseph
- Department of Reproductive Medicine and Surgery Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Minakshi Kumari
- Obstetrics and Gynecology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical and Hospital, Vellore, Tamil Nadu 632004 India
| | - Manisha Madhai Beck
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
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Wharton LK, Anumba DOC. Techniques for detecting cervical remodeling as a predictor for spontaneous preterm birth: current evidence and future research avenues in patients with multiple pregnancies. J Matern Fetal Neonatal Med 2023; 36:2262081. [PMID: 37778754 DOI: 10.1080/14767058.2023.2262081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Spontaneous preterm birth occurs more frequently in multiple pregnancies. This syndrome has multiple triggers that result in a unified downstream pathway of cervical remodeling, uterine activity, and progressive cervical dilatation. Whilst the triggers for labor in multiple pregnancy may be different from singletons, the downstream changes will be the same. Identifying patients at risk of preterm birth is a priority as interventions to delay delivery and optimize the fetus can be initiated. Methods for screening for risk of preterm birth which focus on the detection of cervical remodeling may therefore have potential in this population. METHODS This review explores the evidence for the predictive utility for preterm birth of several published techniques that assess the physical, biomechanical, and optical properties of the cervix, with a focus on those which have been studied in multiple pregnancies and highlighting targets for future research in this population. RESULTS Fifteen techniques are discussed which assess the physical, biomechanical, and optical properties of the cervix in pregnancy. Of these, only three techniques that evaluated the predictive accuracy of a technique in patients with multiple pregnancies were identified: uterocervical angle, cervical consistency index, and cervical elastography. Of these, measurement of the uterocervical angle has the strongest evidence. Several techniques have shown predictive potential in singleton pregnancies, but have not yet been studied in multiple pregnancies, which would be a logical expansion of research. CONCLUSION Research on techniques with predictive utility for PTB in patients with multiple pregnancies is limited but should be a research priority. Overall, the theory supports the investigation of cervical remodeling as a predictor of PTB, and there are numerous techniques in development that may have potential in this field.
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Affiliation(s)
- L K Wharton
- Academic Unit of Reproductive and Developmental Medicine, Faculty of Medicine Dentistry and Health, The University of Sheffield, Sheffield, UK
| | - D O C Anumba
- Academic Unit of Reproductive and Developmental Medicine, Faculty of Medicine Dentistry and Health, The University of Sheffield, Sheffield, UK
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Olisova K, Sao CH, Lussier EC, Sung CY, Wang PH, Yeh CC, Chang TY. Ultrasonographic cervical length screening at 20-24 weeks of gestation in twin pregnancies for prediction of spontaneous preterm birth: A 10-year Taiwanese cohort. PLoS One 2023; 18:e0292533. [PMID: 37797073 PMCID: PMC10553282 DOI: 10.1371/journal.pone.0292533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/21/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Shortened cervical length is one of the primary predictors for spontaneous preterm deliveries in twin pregnancies. However, there is lack of consensus regarding cut-off values. Recent evidence highlights that established cut-offs for cervical length screening might not always apply across different populations. This study aims to present the distribution of cervical length in Taiwanese twin pregnancies and to assess its predictive value for spontaneous preterm birth during mid-trimester screening. MATERIALS AND METHODS This retrospective analysis of cervical length screening in Taiwan evaluated 469 twin pregnancies between 20-24 weeks of gestation. Outcome data were obtained directly from the medical records of the delivery hospital. The study explored the predictive value of cervical length screening for spontaneous preterm birth and the characteristics of cervical length distribution in Taiwanese twin pregnancies. RESULTS The average gestational age at screening was 22.7 weeks. Cervical length values displayed a non-normal distribution (p-value <0.001). The median, 5th and 95th centiles were 37.5 mm 25.1 mm, and 47.9 mm, respectively. Various cut-off values were assessed using different methods, yielding positive [negative] likelihood ratios for spontaneous preterm births between 32-37 weeks of gestational age (GA) (1.3-30.1 and [0.51-0.92]) and for very preterm births between 28-32 weeks GA (5.6-51.1 and [0.45-0.64]). CONCLUSIONS The findings from our analysis of Taiwanese twin pregnancies uphold the moderate predictive potential of cervical length screening, consistent with prior investigations. The presented likelihood ratios for predicting preterm birth at different gestational ages equip clinicians with valuable tools to enhance their diagnostic rationale and resource utilization. By fine-tuning screening parameters according to the spontaneous preterm birth prevalence and clinical priorities of the particular population, healthcare providers can enhance patient care. Our data implies that a cervical length below 20 mm might provide an optimal balance between minimizing false negatives and managing false positives when predicting spontaneous preterm birth.
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Affiliation(s)
- Ksenia Olisova
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
| | - Chih-Hsuan Sao
- Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eric C. Lussier
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
| | - Chan-Yu Sung
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
| | - Peng-Hui Wang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Obstetrics and Gynecology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Female Cancer Foundation, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chang-Ching Yeh
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Obstetrics and Gynecology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Yao Chang
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
- Department of Fetal Medicine, Taiji Clinic, Taipei, Taiwan
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Tan H. The use of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation: a twelve-year retrospective cohort study. BMC Pregnancy Childbirth 2023; 23:700. [PMID: 37773110 PMCID: PMC10540472 DOI: 10.1186/s12884-023-06013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND To identify the effect and optimal time of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation. METHODS This observational retrospective study enrolled all women with asymptomatic twin pregnancies who were diagnosed with asymptomatic cervical shortening or dilation at the Second Affiliated Hospital of Wenzhou Medical University between 2010 and 2022. Women included were allocated into the cerclage group (n = 36) and the no cerclage group (n = 22). The cerclage group was further divided into the cerclage group (< 24 weeks group) and the cerclage group (24-28 weeks group) according to the time of cerclage. The no cerclage group was further divided into no cerclage group (< 24 weeks group) and no cerclage group (24-28 weeks group) according to the time of ultrasound-indicated or physical exam indicated cerclage. The rates of PTB < 24, 28, 32 and 34 weeks of gestation, maternal and neonatal outcomes were compared among the groups. RESULTS The gestational age (GA) at delivery was higher (P = 0.005) and the interval time between the presentation of the indicated cerclage and delivery was longer in the cerclage group (P < 0.001). The rates of PTB before 28, 32, and 34 weeks of gestation, caesarean section and stillbirth were lower in the cerclage group (P < 0.05). The birthweight of the twins was higher in the cerclage group (P = 0.012). Admissions to the NICU were more frequent in pregnancies with no cerclage (P = 0.008). Subgroup analysis showed that the interval time between the presentation and delivery was longer in the cerclage group (< 24 weeks) (P < 0.001). The GA at delivery and the birthweight of the twins were significantly higher in the cerclage group (< 24 weeks) (P < 0.001). No differences were found in the GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight between the cerclage group (24-28 weeks group) and the control group (24-28 weeks group) (P > 0.05). CONCLUSIONS Cerclage appears to prolong the GA at delivery and the interval time between the presentation to delivery, and may reduce the incidence of PTB before 28, 32 and 34 weeks of gestation and adverse perinatal outcomes in asymptomatic twin pregnancies with cervical shortening or dilation. Cerclage before 24 weeks of gestation showed longer GA at delivery, longer interval time between the presentation to delivery and higher birthweight of the twins. The GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight in women with cerclage at 24-28 weeks were similar to those in women without cerclage at 24-28 weeks.
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Affiliation(s)
- Hongying Tan
- Zhejiang College of Security Technology, 325027, Wenzhou, China.
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
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Hughes K, Ford H, Thangaratinam S, Brennecke S, Mol BW, Wang R. Diagnosis or prognosis? An umbrella review of mid-trimester cervical length and spontaneous preterm birth. BJOG 2023; 130:866-879. [PMID: 36871557 PMCID: PMC10953024 DOI: 10.1111/1471-0528.17443] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/04/2022] [Accepted: 01/16/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Cervical length is widely used to assess a woman's risk of spontaneous preterm birth (SPTB). OBJECTIVES To summarise and critically appraise the evidence from systematic reviews on the prognostic capacity of transvaginal sonographic cervical length in the second trimester in asymptomatic women with singleton or twin pregnancy. SEARCH STRATEGY Searches were performed in Medline, Embase, CINAHL and grey literature from 1 January 1995 to 6 July 2021, including keywords 'cervical length', 'preterm birth', 'obstetric labour, premature', 'review' and others, without language restriction. SELECTION CRITERIA We included systematic reviews including women who did not receive treatments to reduce SPTB risk. DATA COLLECTION AND ANALYSIS From 2472 articles, 14 systematic reviews were included. Summary statistics were independently extracted by two reviewers, tabulated and analysed descriptively. The ROBIS tool was used to evaluate risk of bias of included systematic reviews. MAIN RESULTS Twelve reviews performed meta-analyses: two were reported as systematic reviews of prognostic factor studies, ten used diagnostic test accuracy methodology. Ten systematic reviews were at high or unclear risk of bias. Meta-analyses reported up to 80 combinations of cervical length, gestational age at measurement and definition of preterm birth. Cervical length was consistently associated with SPTB, with a likelihood ratio for a positive test of 1.70-142. CONCLUSIONS The ability of cervical length to predict SPTB is a prognostic research question; systematic reviews typically analysed diagnostic test accuracy. Individual participant data meta-analysis using prognostic factor research methods is recommended to better quantify how well transvaginal ultrasonographic cervical length can predict SPTB.
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Affiliation(s)
- Kelly Hughes
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - Heather Ford
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Women's Health, Institute of Translational MedicineUniversity of BirminghamBirminghamUK
| | - Shaun Brennecke
- Department of Obstetrics and GynaecologyThe University of MelbourneMelbourneVictoriaAustralia
- Department of Maternal‐Fetal Medicine & Pregnancy Research CentreRoyal Women's HospitalMelbourneVictoriaAustralia
| | - Ben W. Mol
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Rui Wang
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
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Berger R, Abele H, Bahlmann F, Doubek K, Felderhoff-Müser U, Fluhr H, Garnier Y, Grylka-Baeschlin S, Hayward A, Helmer H, Herting E, Hoopmann M, Hösli I, Hoyme U, Kunze M, Kuon RJ, Kyvernitakis I, Lütje W, Mader S, Maul H, Mendling W, Mitschdörfer B, Nothacker M, Olbertz D, Ramsell A, Rath W, Roll C, Schlembach D, Schleußner E, Schütz F, Seifert-Klauss V, Stubert J, Surbek D. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/025, September 2022) - Part 1 with Recommendations on the Epidemiology, Etiology, Prediction, Primary and Secondary Prevention of Preterm Birth. Geburtshilfe Frauenheilkd 2023; 83:547-568. [PMID: 37152544 PMCID: PMC10159718 DOI: 10.1055/a-2044-0203] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/22/2023] [Indexed: 05/09/2023] Open
Abstract
Aim This revised guideline was coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). It aims to improve the prediction, prevention, and management of preterm birth, based on evidence from the current literature, the experience of members of the guidelines commission, and the viewpoint of self-help organizations. Methods The members of the contributing professional societies and organizations developed recommendations and statements based on international literature. The recommendations and statements were presented and adopted using a formal process (structured consensus conferences with neutral moderation, written Delphi vote). Recommendations Part 1 of this short version of the guideline presents statements and recommendations on the epidemiology, etiology, prediction, and primary and secondary prevention of preterm birth.
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Affiliation(s)
- Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Harald Abele
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Franz Bahlmann
- Frauenklinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | | | - Ursula Felderhoff-Müser
- Klinik für Kinderheilkunde I/Perinatalzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Herbert Fluhr
- Frauenklinik, Universitätsklinikum Graz, Graz, Austria
| | - Yves Garnier
- Frauenklinik, Klinikum Osnabrück, Osnabrück, Germany
| | - Susanne Grylka-Baeschlin
- Zürcher Hochschule für angewandte Wissenschaften, Institut für Hebammenwissenschaft und reproduktive Gesundheit, Zürich, Switzerland
| | | | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Hoopmann
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Udo Hoyme
- Frauenklinik, Ilm-Kreis-Kliniken, Arnstadt, Germany
| | - Mirjam Kunze
- Frauenklinik, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Ruben-J. Kuon
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Wolf Lütje
- Frauenklinik, Evangelisches Amalie Sieveking-Krankenhaus Hamburg, Hamburg, Germany
| | - Silke Mader
- European Foundation for the Care of Newborn Infants, München, Germany
| | - Holger Maul
- Frauenklinik, Asklepios Kliniken Hamburg, Hamburg, Germany
| | - Werner Mendling
- Frauenklinik, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | | | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Berlin, Germany
| | - Dirk Olbertz
- Klinik für Neonatologie, Klinikum Südstadt Rostock, Rostock, Germany
| | | | - Werner Rath
- Emeritus, Universitätsklinikum Aachen, Aachen, Germany
| | - Claudia Roll
- Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln/Berlin Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | | | - Florian Schütz
- Frauenklinik, Diakonissen-Stiftungs-Krankenhaus Speyer, Speyer, Germany
| | | | | | - Daniel Surbek
- Universitätsklinik für Frauenheilkunde, Inselspital Bern, Universität Bern, Bern, Switzerland
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11
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Impis Oglou M, Tsakiridis I, Mamopoulos A, Kalogiannidis I, Athanasiadis A, Dagklis T. Cervical length screening for predicting preterm birth: A comparative review of guidelines. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:472-478. [PMID: 36170160 DOI: 10.1002/jcu.23354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/24/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
A cervical length (CL) assessment may predict preterm birth (PTB). This study aimed to analyze and compare the recommendations of guidelines on the role of CL in the prediction of PTB. There is no consensus regarding universal screening of asymptomatic women without a history of prior spontaneous PTB (sPTB), using CL. On the other hand, CL assessment is recommended in cases with a history of sPTB due to the high recurrence rate. Finally, there is discrepancy regarding CL assessment in asymptomatic women with multiple pregnancy. Although far from perfect, CL measurement remains the best available method to predict PTB.
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Affiliation(s)
- Mechmet Impis Oglou
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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12
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Khalil A, Prasad S. Screening and prevention of preterm birth in twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2022; 84:179-193. [DOI: 10.1016/j.bpobgyn.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/02/2022]
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13
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Sahin E, Madendag Y, Eraslan Sahin M, Col Madendag I, Kirlangic MM. New ultrasonographic midtrimester scoring method for predicting spontaneous preterm birth in uncomplicated asymptomatic twin pregnancies. J Perinat Med 2022; 50:567-572. [PMID: 35146974 DOI: 10.1515/jpm-2021-0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/24/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of the present study was to evaluate a new ultrasonographic scoring method that could predict spontaneous preterm birth (sPTB) in uncomplicated twin pregnancies during routine anomaly screening in the midtrimester. METHODS This prospective study included women with a monochorionic diamniotic (MCDA) or dichorionic diamniotic (DCDA) twin pregnancy gestational ages from 170/7 through 226/7. A new ultrasonographic score between 0 and 5 points was calculated using cervical length (CL), uterocervical angle (UCA), and cervical dilatation status during routine anomaly screening in the midtrimester. The primary outcome of the study was the prediction of sPTB < 32 and <34 gestational weeks. RESULTS A total of 118 pregnant women with twins were evaluated, 31 of whom delivered before 34 gestational weeks an 87 of whom delivered after 34 gestational weeks. The sensitivity and specificity values were separately calculated for scores of 3.5 and 2.5 for predicting sPTB < 32 gestational weeks. The cut-off value of 3.5 provided a sensitivity of 80% and a specificity of 82%. When the score was 2.5, the sensitivity and specificity were 86 and 71%, respectively. To determine a score for predicting sPTB < 34 gestational week cut-off value of 3.5 provided a sensitivity of 80% and a specificity of 90%. When the score value was 2.5, the sensitivity and specificity of the method were 83 and 81%, respectively. CONCLUSIONS Our results indicated that the midtrimester new scoring is a simple technique that can be easily used as an improved tool for predicting the risk of sPTB in women with a twin pregnancy.
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Affiliation(s)
- Erdem Sahin
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Yusuf Madendag
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | | | - Ilknur Col Madendag
- Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Turkey
| | - Mehmet Mete Kirlangic
- Department of Obstetrics and Gynecology, Tuzla Government Hospital, Istanbul, Turkey
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14
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Wolf HM, Romero R, Strauss JF, Hassan SS, Latendresse SJ, Webb BT, Tarca AL, Gomez-Lopez N, Hsu CD, York TP. Study protocol to quantify the genetic architecture of sonographic cervical length and its relationship to spontaneous preterm birth. BMJ Open 2022; 12:e053631. [PMID: 35301205 PMCID: PMC8932269 DOI: 10.1136/bmjopen-2021-053631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION A short cervix (cervical length <25 mm) in the midtrimester (18-24 weeks) of pregnancy is a powerful predictor of spontaneous preterm delivery. Although the biological mechanisms of cervical change during pregnancy have been the subject of extensive investigation, little is known about whether genes influence the length of the cervix, or the extent to which genetic factors contribute to premature cervical shortening. Defining the genetic architecture of cervical length is foundational to understanding the aetiology of a short cervix and its contribution to an increased risk of spontaneous preterm delivery. METHODS/ANALYSIS The proposed study is designed to characterise the genetic architecture of cervical length and its genetic relationship to gestational age at delivery in a large cohort of Black/African American women, who are at an increased risk of developing a short cervix and delivering preterm. Repeated measurements of cervical length will be modelled as a longitudinal growth curve, with parameters estimating the initial length of the cervix at the beginning of pregnancy, and its rate of change over time. Genome-wide complex trait analysis methods will be used to estimate the heritability of cervical length growth parameters and their bivariate genetic correlation with gestational age at delivery. Polygenic risk profiling will assess maternal genetic risk for developing a short cervix and subsequently delivering preterm and evaluate the role of cervical length in mediating the relationship between maternal genetic variation and gestational age at delivery. ETHICS/DISSEMINATION The proposed analyses will be conducted using deidentified data from participants in an IRB-approved study of longitudinal cervical length who provided blood samples and written informed consent for their use in future genetic research. These analyses are preregistered with the Center for Open Science using the AsPredicted format and the results and genomic summary statistics will be published in a peer-reviewed journal.
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Affiliation(s)
- Hope M Wolf
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Human and Molecular Genetics, Virginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
- Detroit Medical Center, Detroit, Michigan, USA
| | - Jerome F Strauss
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sonia S Hassan
- Office of Women's Health, Wayne State University, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Shawn J Latendresse
- Department of Psychology and Neuroscience, Baylor University, Waco, Texas, USA
| | - Bradley T Webb
- GenOmics, Bioinformatics, and Translational Research Center, Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina, USA
- Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA
| | - Adi L Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Timothy P York
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Human and Molecular Genetics, Virginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Sun J, Li N, Jian W, Cao D, Yang J, Chen M. Clinical application of cervical shear wave elastography in predicting the risk of preterm delivery in DCDA twin pregnancy. BMC Pregnancy Childbirth 2022; 22:202. [PMID: 35287624 PMCID: PMC8919632 DOI: 10.1186/s12884-022-04526-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Limited studies have used cervical shear wave elastography (SWE) as a tool to investigate the predictive effect of cervical changes on preterm delivery (PTD) in twin pregnancy. This study is aimed to predict the risk of PTD by cervical SWE in dichorionic diamniotic (DCDA) twin pregnancy. Methods A total of 138 women with dichorionic diamniotic (DCDA) twins were included in this prospective study. The mean SWE value of the cervix was obtained from the inner, middle and outer regions of the anterior and posterior cervical lips using a transvaginal ultrasound transducer and measured consecutively across three different gestations (20–23+ 6 weeks, 24–27+ 6 weeks, and 28–32 weeks). Follow-up was performed on all subjects, and we compared the mean SWE value between the PTD and term delivery (TD) groups. Results A total of 1656 cervical mean SWE data were collected for analysis. Among the 138 twin pregnant women, only 92 women completed the three elastography examinations; PTD occurred in 58.7% (54/92), and TD in 41.3% (38/92). The mean (SD) maternal age was 33.1 ± 4.1 years, and the mean (SD) body mass index was 21.1 ± 2.6 kg/m2. As gestational age increased, the mean SWE value of each part of the cervix decreased. The cervical mean SWE value was lower in the preterm group than in the term group in all three gestations, except for the anterior cervical lip at 28–32 weeks. Receiver operating characteristics (ROC) curves showed the sensitivity of mean SWE value of the anterior cervical lip was 83.3% (95% CI, 70.7–92.1) with a specificity of 57.9% (95% CI, 40.8–73.7) for predicting PTD at a cutoff value of 7.94 kPa. The positive likelihood ratio (LR+) was 1.67 (95% CI, 1.19–2.34), and the negative likelihood ratio (LR–) was 0.33 (95% CI, 0.17–0.64). Conclusions There is a significant negative correlation between cervical stiffness and gestational age in DCDA twin pregnancy. SWE is a potential tool for assessing cervical stiffness and predicting PTD in DCDA twin pregnancy. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04526-0.
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Affiliation(s)
- Jimei Sun
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Nan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Wei Jian
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Dingya Cao
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Junying Yang
- Global UIS Academic Department, Shenzhen Mindray Bio-Medical Electronics Co., Ltd, Shenzhen, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China.
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16
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Wu FT, Chen YY, Chen CP, Sun FJ, Chen CY. Outcomes of ultrasound-indicated cerclage in twin pregnancies with a short cervical length. Taiwan J Obstet Gynecol 2021; 59:508-513. [PMID: 32653121 DOI: 10.1016/j.tjog.2020.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To investigate the outcomes of ultrasound-indicated cerclage in dichorionic-diamniotic (DCDA) twin pregnancies with a short cervical length. MATERIALS AND METHODS This was a retrospective cohort study of DCDA twin pregnancies with a short cervical length (≤25 mm) from January 2000 to July 2017 to compare maternal and neonatal outcomes. Additional sub-analysis was performed by dividing the patients into two subgroups by a cervical length ≤15 mm and between 16 and 25 mm. RESULTS One hundred and eight women were initially diagnosed with twin pregnancies and cervical insufficiency. After excluding cases not meeting the study criteria, 46 women were recruited for analysis, of whom 33 underwent ultrasound-indicated cerclage. The delivery age of the cerclage group was significantly later than the non-cerclage group (34.85 ± 3.91 versus 31.08 ± 5.25 weeks, p = 0.011), and the latency was significantly longer in the cerclage group than in the non-cerclage group (86.09 ± 41.32 versus 52.31 ± 33.24 days, p = 0.014). Sub-analysis revealed that these benefits were significant in the subgroup of a cervical length ≤15 mm. Both first twin (twin A) and second twin (twin B) had a significantly decreased rate of neonatal intensive care unit admission in the cerclage group. However, twin A had more promising outcomes with significantly decreased rates of neonatal respiratory distress syndrome (6.7% versus 50.0%, p = 0.004) and sepsis (0% versus 25.0%, p = 0.019). CONCLUSION Ultrasound-indicated cerclage in DCDA twin pregnancies can decrease preterm birth and prolong the latency. It also decreases neonatal morbidity, and is especially beneficial for twin A.
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Affiliation(s)
- Fang-Tzu Wu
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ying-Yu Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chie-Pein Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chen-Yu Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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Cervical Assessment for Predicting Preterm Birth-Cervical Length and Beyond. J Clin Med 2021; 10:jcm10040627. [PMID: 33562187 PMCID: PMC7915684 DOI: 10.3390/jcm10040627] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 02/07/2023] Open
Abstract
Preterm birth is considered one of the main etiologies of neonatal death, as well as short- and long-term disability worldwide. A number of pathophysiological processes take place in the final unifying factor of cervical modifications that leads to preterm birth. In women at high risk for preterm birth, cervical assessment is commonly used for prediction and further risk stratification. This review outlines the rationale for cervical length screening for preterm birth prediction in different clinical settings within existing and evolving new technologies to assess cervical remodeling.
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Rosta K, Al-Bibawy K, Al-Bibawy M, Temsch W, Springer S, Somogyi A, Ott J. Vaginal Progesterone Has No Diabetogenic Potential in Twin Pregnancies: A Retrospective Case-Control Study on 1686 Pregnancies. J Clin Med 2020; 9:jcm9072249. [PMID: 32679847 PMCID: PMC7408737 DOI: 10.3390/jcm9072249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/01/2020] [Accepted: 07/13/2020] [Indexed: 01/02/2023] Open
Abstract
Background: In this study, we aimed to investigate the incidence of gestational diabetes mellitus (GDM) in women who carried twin pregnancies and received vaginal progesterone. Methods: In this retrospective cohort study, 203 out of 1686 women with twin pregnancies received natural progesterone (200 mg/day between gestational weeks 16 + 0 and 36 + 0) vaginally for ≥ 4 weeks. The control group consisted of 1483 women with twin pregnancies without progesterone administration. Pearson’s Chi squared test, Fisher’s exact test, and Student’s t-test was used to compare differences between the control and the progesterone-treated groups. A multivariate binary logistic regression was performed to assess relative independent associations on the dependent outcome of GDM incidence. Results: Vaginal progesterone treatment in twin pregnancies had no significant influence on developing GDM (p = 0.662). Higher pre-pregnancy BMI (OR 1.1; p < 0.001), GDM in previous pregnancy (OR 6.0; p < 0.001), and smoking during pregnancy (OR 1.6; p = 0.014) posed an increased risk for developing GDM. Conclusion: In twin pregnancies, the use of vaginal progesterone for the prevention of recurrent preterm delivery was not associated with an increased risk of GDM.
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Affiliation(s)
- Klara Rosta
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna 1090, Austria; (K.R.); (K.A.-B.); (M.A.-B.); (S.S.)
| | - Katharina Al-Bibawy
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna 1090, Austria; (K.R.); (K.A.-B.); (M.A.-B.); (S.S.)
| | - Maria Al-Bibawy
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna 1090, Austria; (K.R.); (K.A.-B.); (M.A.-B.); (S.S.)
| | - Wilhelm Temsch
- Center for Medical Statistic and Informatic and Intelligent Systems, Medical University of Vienna, Vienna 1090, Austria;
| | - Stephanie Springer
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna 1090, Austria; (K.R.); (K.A.-B.); (M.A.-B.); (S.S.)
| | - Aniko Somogyi
- 2nd Department of Internal Medicine, Semmelweis University, 1085 Budapest, Hungary;
| | - Johannes Ott
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna 1090, Austria; (K.R.); (K.A.-B.); (M.A.-B.); (S.S.)
- Correspondence: ; Tel.: +43-140-4002-8160
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Pergialiotis V, Bellos I, Antsaklis A, Loutradis D, Daskalakis G. Presence of amniotic fluid sludge and pregnancy outcomes: A systematic review. Acta Obstet Gynecol Scand 2020; 99:1434-1443. [PMID: 32367525 DOI: 10.1111/aogs.13893] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Several studies acknowledge that the presence of amniotic fluid sludge (AFS) is an independent predictive factor for preterm birth. In the present systematic review, we summarize research that focuses on the comparison of pregnancy outcomes among women with and without AFS. MATERIAL AND METHODS Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were systematically searched from inception. Both observational and randomized controlled studies were considered eligible provided that they reported data on pregnancy outcomes among women with and without AFS. Outcomes were not meta-analyzed because of the high heterogeneity in terms of selected population and outcome reporting. RESULTS Seventeen studies of 2432 women were included in this review. Six studies evaluated women at high risk for preterm birth. Pregnancies complicated by AFS had a lower gestational age at delivery and increased incidence of preterm delivery at <37 weeks. Neonatal death rates and admission to the Neonatal Intensive Care Unit were also increased. Evidence in low-risk women, those with signs of preterm labor, in those carrying twins, and in women with cervical cerclage or Arabin pessary was extremely limited. CONCLUSIONS Women with AFS seem to deliver at an earlier gestational age, and preterm birth rates are also increased. Limited data seem to point to neonatal morbidity and mortality being increased. However, the presence of a direct association should not be assumed because the evidence is not adjusted for the presence of confounders.
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Affiliation(s)
- Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece.,1st department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Aris Antsaklis
- 1st department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- 1st department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Daskalakis
- 1st department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Cervical pessary for preterm twin pregnancy in women with a short cervix. Obstet Gynecol Sci 2020; 63:231-238. [PMID: 32489967 PMCID: PMC7231939 DOI: 10.5468/ogs.2020.63.3.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 11/08/2022] Open
Abstract
Objective We aimed to evaluate the effectiveness of cervical pessary for extending twin pregnancy in women with a short cervix. Methods Between January 2014 and March 2019, the use of a cervical pessary for twin pregnancy in women with a cervical length of ≤15 mm was investigated between 16 and 28 weeks of gestation. We included women with a shortened cervix after a cerclage procedure and visible fetal membranes and cervical dilatation. Thirteen patients underwent pessary insertion and were matched with a control group of 15 patients. Pregnancy and neonatal outcomes were compared between the groups. We excluded women with major fetal anomalies discovered before or after birth and known placenta previa. Results Women who underwent pessary insertion were diagnosed with a short cervix (0.65±0.47 vs. 0.66±0.51 cm in the pessary and control groups, respectively; P=0.957) at a gestational age similar to that of the controls (23.29 vs. 25.14 weeks, P=0.294). There was no significant difference in gestational age at delivery between them (33.29 vs. 27.29 weeks in the pessary and control groups, respectively, P=0.058). The pessary group had a longer interval between the diagnosis and delivery than the control group (60.7±28.3 vs. 22.6±24.5 days, P=0.001). The number of adverse neonatal outcomes was significantly lower in the pessary group (n=7; 28.0%) than in the control group (n=14; 58.3%; P=0.032). Conclusion The use of a cervical pessary may prolong gestation in twin pregnancies in women with an extremely short cervix until viable gestational age.
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Berger R, Abele H, Bahlmann F, Bedei I, Doubek K, Felderhoff-Müser U, Fluhr H, Garnier Y, Grylka-Baeschlin S, Helmer H, Herting E, Hoopmann M, Hösli I, Hoyme U, Jendreizeck A, Krentel H, Kuon R, Lütje W, Mader S, Maul H, Mendling W, Mitschdörfer B, Nicin T, Nothacker M, Olbertz D, Rath W, Roll C, Schlembach D, Schleußner E, Schütz F, Seifert-Klauss V, Steppat S, Surbek D. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 1 with Recommendations on the Epidemiology, Etiology, Prediction, Primary and Secondary Prevention of Preterm Birth. Geburtshilfe Frauenheilkd 2019; 79:800-812. [PMID: 31423016 DOI: 10.1055/a-0903-2671] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 12/13/2022] Open
Abstract
Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recent scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods Based on the international literature, the members of the participating medical societies and organizations developed Recommendations and Statements. These were adopted following a formal process (structured consensus conference with neutral moderation, voting was done in writing using the Delphi method to achieve consensus). Recommendations Part I of this short version of the guideline lists Statements and Recommendations on the epidemiology, etiology, prediction and primary and secondary prevention of preterm birth.
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Affiliation(s)
- Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Harald Abele
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Franz Bahlmann
- Frauenklinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - Ivonne Bedei
- Frauenklinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany
| | | | - Ursula Felderhoff-Müser
- Klinik für Kinderheilkunde I/Perinatalzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Herbert Fluhr
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Yves Garnier
- Frauenklinik, Klinikum Osnabrück, Osnabrück, Germany
| | | | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Hoopmann
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Udo Hoyme
- Frauenklinik, Ilm-Kreis-Kliniken, Arnstadt, Germany
| | | | - Harald Krentel
- Frauenklinik, Annahospital Herne, Elisabethgruppe Katholische Kliniken Rhein Ruhr, Herne, Germany
| | - Ruben Kuon
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Wolf Lütje
- Frauenklinik, Evangelisches Amalie Sieveking-Krankenhaus Hamburg, Hamburg, Germany
| | - Silke Mader
- European Foundation for the Care of the Newborn Infant
| | - Holger Maul
- Frauenklinik, Asklepios Kliniken Hamburg, Hamburg, Germany
| | - Werner Mendling
- Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe an der Frauenklinik, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | | | | | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Berlin, Germany
| | - Dirk Olbertz
- Abteilung Neonatologie und neonatologische Intensivmedizin, Klinikum Südstadt Rostock, Rostock, Germany
| | - Werner Rath
- Emeritus, Universitätsklinikum Aachen, Aachen, Germany
| | - Claudia Roll
- Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln/Berlin Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | | | - Florian Schütz
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Daniel Surbek
- Universitäts-Frauenklinik, Inselspital, Universität Bern, Bern, Switzerland
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Kuon RJ, Voß P, Rath W. Progesterone for the Prevention of Preterm Birth - an Update of Evidence-Based Indications. Geburtshilfe Frauenheilkd 2019; 79:844-853. [PMID: 31423019 PMCID: PMC6690740 DOI: 10.1055/a-0854-6472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/05/2019] [Accepted: 02/10/2019] [Indexed: 02/06/2023] Open
Abstract
The prevention and treatment of preterm birth remains one of the biggest challenges in obstetrics. Worldwide, 11% of all children are born prematurely with far-reaching consequences for the children concerned, their families and the health system. Experimental studies suggest that progesterone inhibits uterine contractions, stabilises the cervix and has immunomodulatory effects. Recent years have seen the publication of numerous clinical trials using progestogens for the prevention of preterm birth. As a result of different inclusion criteria and the use of different progestogens and their methods of administration, it is difficult to draw comparisons between these studies. A critical evaluation of the available studies was therefore carried out on the basis of a search of the literature (1956 to 09/2018). Taking into account the most recent randomised, controlled studies, the following evidence-based recommendations emerge: In asymptomatic women with singleton pregnancies and a short cervical length on ultrasound of ≤ 25 mm before 24 weeks of gestation (WG), daily administration of vaginal progesterone (200 mg capsule or 90 mg gel) up until 36 + 6 WG leads to a significant reduction in the preterm birth rate and an improvement in neonatal outcome. The latest data also suggest positive effects of treatment with progesterone in cases of twin pregnancies with a short cervical length on ultrasound of ≤ 25 mm before 24 WG. The study data for the administration of progesterone in women with singleton pregnancies with a previous preterm birth have become much more heterogeneous, however. It is not possible to make a general recommendation for this indication at present, and decisions must therefore be made on a case-by-case basis. Even if progesterone use is considered to be safe in terms of possible long-term consequences, exposure should be avoided where it is not indicated. Careful patient selection is crucial for the success of treatment.
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Affiliation(s)
- Ruben-J. Kuon
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Frauenklinik, Heidelberg, Germany
| | - Pauline Voß
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Frauenklinik, Heidelberg, Germany
| | - Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Merced C, Goya M, Pratcorona L, Rodó C, Llurba E, Higueras T, Cabero L, Carreras E. Cervical pessary for preventing preterm birth in twin pregnancies with maternal short cervix after an episode of threatened preterm labor: randomised controlled trial. Am J Obstet Gynecol 2019; 221:55.e1-55.e14. [PMID: 30826339 DOI: 10.1016/j.ajog.2019.02.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/24/2019] [Accepted: 02/15/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND No intervention has proved effective to date in reducing the spontaneous preterm birth rate in twin pregnancies following an episode of threatened preterm labor and with a short cervix remaining. This study was designed to ascertain whether cervical pessaries are useful in preventing spontaneous preterm birth in women with twin pregnancies and a short cervix remaining after a threatened preterm labor episode. STUDY DESIGN This open, randomized, controlled trial was conducted in 132 pregnant women who had not delivered 48 hours after a threatened preterm labor episode and had a short cervix remaining (≤20 mm between 240 and 296 weeks and ≤10 mm between 300 and 336 weeks). Patients were randomly assigned to cervical pessary (n = 67) or routine management (n = 65). The primary outcome was the spontaneous preterm birth rate before 34 weeks. Spontaneous preterm birth before 28 and 37 weeks and neonatal morbidity and mortality were also evaluated in an intention-to-treat analysis. RESULTS Significant differences were observed in the spontaneous preterm birth rate before 34 weeks between the pessary and routine management groups (11 of 67 [16.4%] in the pessary group vs 21 of 65 [32.3%] in the control group; relative risk, 0.51 [confidence interval, 0.27-0.97]; P = .03). No significant differences were observed in the preterm birth rate < 28 weeks or < 37 weeks between groups. The pessary group less frequently required readmission for new threatened preterm labor episodes (4 of 67 [5.6%] vs 14 of 65 [21.5%]; relative risk, 0.28 [confidence interval, 0.10-0.80]; P = .009). Significant reduction was observed in the number of neonates weighing less than 2500 g (17.9% [24 of 134] vs 70.8% [92 of 130]; relative risk, 0.25 [confidence interval, 0.15-0.43]; P < .0001). CONCLUSION Pessary use did significantly lower the spontaneous preterm birth rate before 34 weeks in twin pregnancies with maternal short cervix remaining after a threatened preterm labor episode. Pessary use also reduced the threatened preterm labor recurrence and neonates' weight less than 2500 g.
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Prevention of spontaneous preterm birth. Arch Gynecol Obstet 2019; 299:1261-1273. [DOI: 10.1007/s00404-019-05095-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
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Lynch TA, Szlachetka K, Seligman NS. Second trimester uterocervical angle and spontaneous preterm birth in twins. J Matern Fetal Neonatal Med 2019; 33:3125-3131. [PMID: 30714437 DOI: 10.1080/14767058.2019.1569615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To determine if there is an association between uterocervical angle (UCA) and spontaneous preterm birth (sPTB) < 37 weeks for women with twins.Materials and methods: Retrospective cohort study from 2014 to 2017 of twin pregnancies with cervical length (CL) screening between 15 0/7 and 24 6/7 weeks. Monochorionic-monoamniotic twins were excluded. Post-hoc UCA measurements were analyzed as a continuous variable and a wide UCA was also defined as an angle >95° and >110°. The primary outcome was sPTB < 37 weeks. Secondary outcomes were sPTB <34 weeks, <32 weeks, CL, and performance metrics for UCA. Binary logistic regression controlled for age, tobacco use, prior sPTB, CL, and gestational age at CL measurement.Results: A total of 114 women were studied. The rate of sPTB <37 weeks was 35.0%, <34 weeks was 21.4%, and <32 weeks was 17.1%. As a continuous variable, mean UCA was 117.9° (SD 27.1°) for delivery ≥37 weeks and 133.1° (SD 23.1°) <37 weeks (p = .002). A wider mean UCA was also associated with sPTB <34 weeks (sPTB ≥34 weeks: 120.9° [SD 26.5°] vs. <34 weeks: 133.0° [SD 22.8°], p = .025) and sPTB <32 weeks (sPTB ≥32 weeks: 121.2° [SD 25.9°] vs. <32 weeks: 135.0° [SD 24.0°], p = .018). However, after controlling for age, prior sPTB, tobacco use, CL measurement, and gestational age at CL measurement, UCA was not associated with sPTB <37 weeks, <34 weeks, or <32 weeks. UCA >110° was associated with sPTB <37 weeks after controlling for confounders (aOR 3.6 [95% CI 1.2-10.5], p = 0.02). There was no association between UCA >110° and sPTB <34 or <32 weeks. Furthermore, a UCA >95° was not associated with sPTB <37, <34, or <32 weeks. As a screening tool for sPTB <37 weeks, a UCA of >110° had a sensitivity of 85.7%, specificity of 43.1%, positive predictive value of 53.2%, negative predictive value of 80.0%, positive likelihood ratio of 1.5, and negative likelihood ratio of 0.3.Conclusions: In a cohort of dichorionic-diamniotic and monochroionic-diamniotic twins, UCA >110° was associated with sPTB <37 weeks. However, second trimester UCA had a low positive likelihood ratio and was not a robust marker for the prediction of sPTB in twins.
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Affiliation(s)
- Tara A Lynch
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kam Szlachetka
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, USA
| | - Neil S Seligman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, USA
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26
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Abstract
Preterm birth, defined as birth occurring prior to 37 weeks gestation, is a serious obstetric problem accounting for 11% of pregnancies worldwide. It is associated with significant neonatal morbidity and mortality. Predictive tests for preterm birth are incredibly important, given the huge personal, economic, and health impacts of preterm birth. They can provide reassurance for women who are unlikely to deliver early, but they are also important for highlighting those women at higher risk of premature delivery so that we can offer prophylactic interventions and help guide antenatal management decisions. Unfortunately, there is unlikely to be a single test for predicting preterm birth, but a combination of tests is likely to improve clinical prediction. This review explores the clinical utility of the currently marketed predictive tests for preterm birth in both singleton and multiple pregnancies, as well as discussing novel predictive tests that may be useful in the future.
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Affiliation(s)
- Natalie Suff
- Department of Women's Health, King's College London, St Thomas' Hospital, London, UK.
| | - Lisa Story
- Department of Women's Health, King's College London, St Thomas' Hospital, London, UK; Centre for the Developing Brain, King's College London, St Thomas' Hospital, London, UK
| | - Andrew Shennan
- Department of Women's Health, King's College London, St Thomas' Hospital, London, UK
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27
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Assessment of Uterocervical Angle Width as a Predictive Factor of Preterm Birth: A Systematic Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1837478. [PMID: 30687736 PMCID: PMC6327283 DOI: 10.1155/2018/1837478] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 10/29/2018] [Indexed: 11/17/2022]
Abstract
Background Uterocervical angle (UCA) has been recently proposed as a potential marker that could accurately predict preterm birth (PTB). The purpose of the present systematic review is to accumulate current evidence and provide directions for future research. Materials and Methods We used the Medline (1966–2018), Scopus (2004–2018), Clinicaltrials.gov (2008–2018), EMBASE (1980-2018), Cochrane Central Register of Controlled Trials CENTRAL (1999-2018), and Google Scholar (2004-2018) databases in our search. Results Eleven studies were finally included in the present systematic review that evaluated data from 3,018 women. The significant heterogeneity in terms of outcome reporting and outcome reporting measures (use of optimal cut-off values) precluded meta-analysis. However, existing data support that second trimester UCA measurement might be used as a predictive factor of PTB <34 weeks, as at least two studies in unselected singleton pregnancies and two studies in pregnancies with an ultrasonographically shortened cervix seem to support this hypothesis. The most commonly reported cut-off values were 105° and 95°. Conclusions UCA measurement during the second trimester of pregnancy may be a useful method of determining women at risk of delivering preterm. However, more studies are needed to assess the reproducibility of these findings and reach conclusive evidence.
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Ville Y, Rozenberg P. Predictors of preterm birth. Best Pract Res Clin Obstet Gynaecol 2018; 52:23-32. [PMID: 30309793 DOI: 10.1016/j.bpobgyn.2018.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/04/2018] [Indexed: 11/16/2022]
Abstract
Cervical length (CL) measured by transvaginal ultrasound examination (TVUE) best identifies the risk for preterm birth (PTB). It identifies women at risk who can benefit from corticosteroids or in utero transfer. Early screening improves effectiveness of tocolysis. It reduces iatrogenicity and cost. In preterm premature rupture of membranes (PPROM), CL is devoid of infectious risk and predicts duration of the latency phase but not the risk of perinatal sepsis. Asymptomatic women at risk should be screened at a 2-week interval starting from 16 to 18 weeks, up to 24 weeks. CLs <10th centile are at risk of PTB, especially with decrease in CL after 16 weeks. Repeat ultrasound improves predictive values. Stable CL calls for term delivery. Funneling does not improve predictivity of CL. In twin pregnancies, CL reduces unnecessary interventions. In symptomatic women, fetal fibronectin performs less than CL. Its combination with inconclusive CL has not emerged productive through randomized controlled trials (RCTs), and studies with homogeneous management for preterm labor (PTL) suggest that up to 15% of unjustified hospitalizations and treatment could be avoided.
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Affiliation(s)
- Yves Ville
- Université Paris Descartes, EHU-PACT, Department of Obstetrics and Fetal Medicine, Hôpital Necker Enfants-Malades, 149 rue de Sèvres, 75015, Paris, France.
| | - Patrick Rozenberg
- Université Versailles Saint-Quentin, Department of Obstetrics and Gynecology, Hôpital Intercommunal de Poissy, France
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Conde-Agudelo A, Romero R, Da Fonseca E, O'Brien JM, Cetingoz E, Creasy GW, Hassan SS, Erez O, Pacora P, Nicolaides KH. Vaginal progesterone is as effective as cervical cerclage to prevent preterm birth in women with a singleton gestation, previous spontaneous preterm birth, and a short cervix: updated indirect comparison meta-analysis. Am J Obstet Gynecol 2018; 219:10-25. [PMID: 29630885 DOI: 10.1016/j.ajog.2018.03.028] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND An indirect comparison meta-analysis published in 2013 reported that both vaginal progesterone and cerclage are equally efficacious for preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic short cervix. The efficacy of vaginal progesterone has been challenged after publication of the OPPTIMUM study. However, this has been resolved by an individual patient-data meta-analysis (Am J Obstet Gynecol. 2018;218:161-180). OBJECTIVE To compare the efficacy of vaginal progesterone and cerclage in preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix. DATA SOURCES MEDLINE, EMBASE, LILACS, and CINAHL (from their inception to March 2018); Cochrane databases, bibliographies, and conference proceedings. STUDY ELIGIBILITY CRITERIA Randomized controlled trials comparing vaginal progesterone to placebo/no treatment or cerclage to no cerclage in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic cervical length <25 mm. STUDY APPRAISAL AND SYNTHESIS METHODS Updated systematic review and adjusted indirect comparison meta-analysis of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. The primary outcomes were preterm birth <35 weeks of gestation and perinatal mortality. Pooled relative risks (RRs) with 95% confidence intervals were calculated. RESULTS Five trials comparing vaginal progesterone vs placebo (265 women) and 5 comparing cerclage vs no cerclage (504 women) were included. Vaginal progesterone, compared to placebo, significantly reduced the risk of preterm birth <35 and <32 weeks of gestation, composite perinatal morbidity/mortality, neonatal sepsis, composite neonatal morbidity, and admission to the neonatal intensive care unit (RRs from 0.29 to 0.68). Cerclage, compared to no cerclage, significantly decreased the risk of preterm birth <37, <35, <32, and <28 weeks of gestation, composite perinatal morbidity/mortality, and birthweight <1500 g (RRs from 0.64 to 0.70). Adjusted indirect comparison meta-analyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Vaginal progesterone and cerclage are equally effective for preventing preterm birth and improving perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix. The choice of treatment will depend on adverse events and cost-effectiveness of interventions and patient/physician's preferences.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Eduardo Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual "Francisco Morato de Oliveira" and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - John M O'Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
| | - Elcin Cetingoz
- Department of Obstetrics and Gynecology, Turkish Red Crescent Altintepe Medical Center, Maltepe, Istanbul, Turkey
| | - George W Creasy
- Center for Biomedical Research, Population Council, New York, NY
| | - Sonia S Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences. Ben-Gurion University of the Negev, Beersheba, Israel
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Kypros H Nicolaides
- Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, United Kingdom
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Kyvernitakis I, Maul H, Bahlmann F. Controversies about the Secondary Prevention of Spontaneous Preterm Birth. Geburtshilfe Frauenheilkd 2018; 78:585-595. [PMID: 29962517 PMCID: PMC6018068 DOI: 10.1055/a-0611-5337] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/28/2018] [Accepted: 04/17/2018] [Indexed: 02/07/2023] Open
Abstract
Preterm birth is one of the major global health problems and part of the Millennium Development goals because of the associated high number of perinatal or neonatal mortality and long-term risks of neurodevelopmental and metabolic diseases. Transvaginal sonography has meanwhile been established as a screening tool for spontaneous preterm birth despite its relatively low sensitivity when considering only the cervical length. Vaginal progesterone has been shown to reduce prematurity rates below 34 weeks in a screening population of singleton pregnancies. Up to now, no positive long-term effect could be demonstrated after 2 years. It seems to have no benefit to prolong pregnancies after a period of preterm contractions and in risk patients without cervical shortening. Meta-analyses still demonstrate conflicting results dependent on quality criteria used for selection. A cerclage is only indicated in singleton pregnancies with previous spontaneous preterm birth and a combined cervical shortening in the current pregnancy. Nevertheless, the short- and long-term outcome has never been evaluated, whereas maternal complications may be increased. There is no evidence for a prophylactic cervical cerclage in twin pregnancies even in cases with cervical shortening. Emergency cerclage remains an indication after individual counseling. The effect of a cervical pessary in singleton pregnancy seems to be more pronounced in studies where a few investigators with increasing experience have treated and followed the patients at risk for preterm birth. Mainly in twin pregnancies, pessary treatment seems to be promising compared to other treatment options of secondary prevention when the therapy is started at early stages of precocious cervical ripening. At present, several international trials with the goal to reduce global rates of prematurity are in progress which will hopefully allow to specify the indications and methods of intervention for certain subgroups. When trials are summarized, prospective meta-analyses carry a lower risk of bias than the meanwhile uncontrolled magnitude of retrospective meta-analyses with conflicting results.
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Affiliation(s)
- Ioannis Kyvernitakis
- Dpt. of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt a. M., Dr. Senckenberg Foundation and Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Holger Maul
- Dpt. of Obstetrics and Prenatal Medicine, Asklepios Kliniken Barmbek and Nord-Heidberg, Hamburg, Germany
| | - Franz Bahlmann
- Dpt. of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt a. M., Dr. Senckenberg Foundation and Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
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31
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Romero R, Conde-Agudelo A, Da Fonseca E, O'Brien JM, Cetingoz E, Creasy GW, Hassan SS, Nicolaides KH. Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix: a meta-analysis of individual patient data. Am J Obstet Gynecol 2018; 218:161-180. [PMID: 29157866 PMCID: PMC5987201 DOI: 10.1016/j.ajog.2017.11.576] [Citation(s) in RCA: 281] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/13/2017] [Accepted: 11/13/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The efficacy of vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix has been questioned after publication of the OPPTIMUM study. OBJECTIVE To determine whether vaginal progesterone prevents preterm birth and improves perinatal outcomes in asymptomatic women with a singleton gestation and a midtrimester sonographic short cervix. STUDY DESIGN We searched MEDLINE, EMBASE, LILACS, and CINAHL (from their inception to September 2017); Cochrane databases; bibliographies; and conference proceedings for randomized controlled trials comparing vaginal progesterone vs placebo/no treatment in women with a singleton gestation and a midtrimester sonographic cervical length ≤25 mm. This was a systematic review and meta-analysis of individual patient data. The primary outcome was preterm birth <33 weeks of gestation. Secondary outcomes included adverse perinatal outcomes and neurodevelopmental and health outcomes at 2 years of age. Individual patient data were analyzed using a 2-stage approach. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology. RESULTS Data were available from 974 women (498 allocated to vaginal progesterone, 476 allocated to placebo) with a cervical length ≤25 mm participating in 5 high-quality trials. Vaginal progesterone was associated with a significant reduction in the risk of preterm birth <33 weeks of gestation (relative risk, 0.62; 95% confidence interval, 0.47-0.81; P = .0006; high-quality evidence). Moreover, vaginal progesterone significantly decreased the risk of preterm birth <36, <35, <34, <32, <30, and <28 weeks of gestation; spontaneous preterm birth <33 and <34 weeks of gestation; respiratory distress syndrome; composite neonatal morbidity and mortality; birthweight <1500 and <2500 g; and admission to the neonatal intensive care unit (relative risks from 0.47-0.82; high-quality evidence for all). There were 7 (1.4%) neonatal deaths in the vaginal progesterone group and 15 (3.2%) in the placebo group (relative risk, 0.44; 95% confidence interval, 0.18-1.07; P = .07; low-quality evidence). Maternal adverse events, congenital anomalies, and adverse neurodevelopmental and health outcomes at 2 years of age did not differ between groups. CONCLUSION Vaginal progesterone decreases the risk of preterm birth and improves perinatal outcomes in singleton gestations with a midtrimester sonographic short cervix, without any demonstrable deleterious effects on childhood neurodevelopment.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eduardo Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual "Francisco Morato de Oliveira" and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - John M O'Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
| | - Elcin Cetingoz
- Department of Obstetrics and Gynecology, Turkish Red Crescent Altintepe Medical Center, Maltepe, Istanbul, Turkey
| | - George W Creasy
- Center for Biomedical Research, Population Council, New York, NY
| | - Sonia S Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Kypros H Nicolaides
- Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, United Kingdom
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Murray SR, Stock SJ, Cowan S, Cooper ES, Norman JE. Spontaneous preterm birth prevention in multiple pregnancy. THE OBSTETRICIAN & GYNAECOLOGIST : THE JOURNAL FOR CONTINUING PROFESSIONAL DEVELOPMENT FROM THE ROYAL COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS 2018; 20:57-63. [PMID: 30008614 PMCID: PMC6034359 DOI: 10.1111/tog.12460] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/21/2023]
Abstract
KEY CONTENT Twin pregnancies are associated with a three-fold greater perinatal mortality than singleton pregnancies. Prematurity is a main contributor, with 50% of twin pregnancies delivering before 37 weeks and 10% delivering before 32 weeks of gestation.The aetiology of preterm delivery in twin pregnancies is likely multifactorial and different from that of singletons.Cervical cerclage reduces preterm birth rates in singletons but has mixed results in twins with some studies showing harm.The use of progesterone to prevent preterm birth in singletons has conflicting results and has not been proven to prevent preterm birth in twins. Studies continue to determine whether the cervical pessary is effective in preventing preterm birth in multiple pregnancies.There is a paucity of data available on the prevention of preterm birth in triplets/higher order multiples but similar principles to twin pregnancy apply. LEARNING OBJECTIVES To review the burden of preterm birth in multiple pregnancy.To understand the methods available for preventing preterm birth in multiple pregnancies and the evidence surrounding the use of each one.To be aware of the use of the Arabin pessary.
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Affiliation(s)
- Sarah R Murray
- MRC Centre for Reproductive HealthQueen's Medical Research InstituteUniversity of EdinburghEdinburghEH16 4TJUK
| | - Sarah J Stock
- MRC Centre for Reproductive HealthQueen's Medical Research InstituteUniversity of EdinburghEdinburghEH16 4TJUK
| | - Shona Cowan
- Royal Infirmary EdinburghEdinburghEH16 4SAUK
| | | | - Jane E Norman
- MRC Centre for Reproductive HealthQueen's Medical Research InstituteUniversity of EdinburghEdinburghEH16 4TJUK
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Park JW, Park KH, Jung EY, Cho SH, Jang JA, Yoo HN. Short cervical lengths initially detected in mid-trimester and early in the third trimester in asymptomatic twin gestations: Association with histologic chorioamnionitis and preterm birth. PLoS One 2017; 12:e0175455. [PMID: 28399138 PMCID: PMC5388475 DOI: 10.1371/journal.pone.0175455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 03/27/2017] [Indexed: 12/04/2022] Open
Abstract
Objective To determine whether short cervical lengths (≤20 mm) that were initially detected in mid-trimester and early in the third trimester are independently associated with increased risks of subsequent histologic chorioamnionitis and spontaneous preterm birth (SPTB, defined as a delivery before 34 weeks) in asymptomatic women with twin pregnancies. Material and methods This is a prospective study including 292 consecutive asymptomatic women with twin gestations. Cervical length measurements were carried out at 20 to 24 weeks’ gestation and at 28 to 32 weeks’ gestation. Both placentas of each twin pair were examined histologically after delivery. The generalized estimation equations models and logistic regression analysis were used for statistical analyses. Results Multivariable generalized estimation equations analysis revealed that short cervical length at mid-trimester was independently associated with an increased risk for subsequent histologic chorioamnionitis, whereas short cervical length initially detected early in the third trimester was not. By using the likelihood of SPTB as an outcome variable, multivariable logistic regression analysis indicated that short mid-trimester cervical length and histologic chorioamnionitis were independently associated with a greater risk for SPTB. Similarly, based on the multivariable analysis, a short third trimester cervical length was independently and significantly associated with a greater risk for SPTB. Conclusions In asymptomatic women with twin pregnancies, a short mid-trimester cervical length is independently associated with an increased risk of both subsequent histologic chorioamnionitis and SPTB, whereas a short cervical length initially detected early in the third trimester is independently associated with preterm delivery, but not subsequent histologic chorioamnionitis.
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Affiliation(s)
- Jeong Woo Park
- Department of Obstetrics and Gynecology, Inje University College of Medicine, Ilsan-Paik Hospital, Gyeonggi, Republic of Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyo Hoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- * E-mail:
| | - Eun Young Jung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soo-Hyun Cho
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji Ae Jang
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ha-Na Yoo
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Romero R, Conde‐Agudelo A, El‐Refaie W, Rode L, Brizot ML, Cetingoz E, Serra V, Da Fonseca E, Abdelhafez MS, Tabor A, Perales A, Hassan SS, Nicolaides KH. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:303-314. [PMID: 28067007 PMCID: PMC5396280 DOI: 10.1002/uog.17397] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 12/23/2016] [Accepted: 12/29/2016] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To assess the efficacy of vaginal progesterone for the prevention of preterm birth and neonatal morbidity and mortality in asymptomatic women with a twin gestation and a sonographic short cervix (cervical length ≤ 25 mm) in the mid-trimester. METHODS This was an updated systematic review and meta-analysis of individual patient data (IPD) from randomized controlled trials comparing vaginal progesterone with placebo/no treatment in women with a twin gestation and a mid-trimester sonographic cervical length ≤ 25 mm. MEDLINE, EMBASE, POPLINE, CINAHL and LILACS (all from inception to 31 December 2016), the Cochrane Central Register of Controlled Trials, Research Registers of ongoing trials, Google Scholar, conference proceedings and reference lists of identified studies were searched. The primary outcome measure was preterm birth < 33 weeks' gestation. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated. RESULTS IPD were available for 303 women (159 assigned to vaginal progesterone and 144 assigned to placebo/no treatment) and their 606 fetuses/infants from six randomized controlled trials. One study, which included women with a cervical length between 20 and 25 mm, provided 74% of the total sample size of the IPD meta-analysis. Vaginal progesterone, compared with placebo/no treatment, was associated with a statistically significant reduction in the risk of preterm birth < 33 weeks' gestation (31.4% vs 43.1%; RR, 0.69 (95% CI, 0.51-0.93); moderate-quality evidence). Moreover, vaginal progesterone administration was associated with a significant decrease in the risk of preterm birth < 35, < 34, < 32 and < 30 weeks' gestation (RRs ranging from 0.47 to 0.83), neonatal death (RR, 0.53 (95% CI, 0.35-0.81)), respiratory distress syndrome (RR, 0.70 (95% CI, 0.56-0.89)), composite neonatal morbidity and mortality (RR, 0.61 (95% CI, 0.34-0.98)), use of mechanical ventilation (RR, 0.54 (95% CI, 0.36-0.81)) and birth weight < 1500 g (RR, 0.53 (95% CI, 0.35-0.80)) (all moderate-quality evidence). There were no significant differences in neurodevelopmental outcomes at 4-5 years of age between the vaginal progesterone and placebo groups. CONCLUSION Administration of vaginal progesterone to asymptomatic women with a twin gestation and a sonographic short cervix in the mid-trimester reduces the risk of preterm birth occurring at < 30 to < 35 gestational weeks, neonatal mortality and some measures of neonatal morbidity, without any demonstrable deleterious effects on childhood neurodevelopment. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- R. Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health, Department of Health and Human ServicesBethesda, MD and DetroitMIUSA
- Department of Obstetrics and GynecologyUniversity of MichiganAnn ArborMIUSA
- Department of Epidemiology and BiostatisticsMichigan State UniversityEast LansingMIUSA
- Center for Molecular Medicine and GeneticsWayne State UniversityDetroitMIUSA
| | - A. Conde‐Agudelo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health, Department of Health and Human ServicesBethesda, MD and DetroitMIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - W. El‐Refaie
- Department of Obstetrics and Gynecology, Mansoura University HospitalsMansoura UniversityMansouraEgypt
| | - L. Rode
- Center of Fetal Medicine and Pregnancy, Department of ObstetricsCopenhagen University HospitalRigshospitaletCopenhagenDenmark
- Department of Clinical BiochemistryHerlev and Gentofte HospitalHerlevDenmark
| | - M. L. Brizot
- Department of Obstetrics and GynecologySão Paulo University Medical SchoolSão PauloBrazil
| | - E. Cetingoz
- Department of Obstetrics and GynecologyZeynep Kamil Women and Children Diseases Education and Research HospitalUskudarIstanbulTurkey
| | - V. Serra
- Maternal‐Fetal Medicine Unit, Instituto Valenciano de InfertilidadUniversity of ValenciaValenciaSpain
- Department of Pediatrics, Obstetrics and GynecologyUniversity of ValenciaValenciaSpain
| | - E. Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual ‘Francisco Morato de Oliveira’ and School of MedicineUniversity of São PauloSão PauloBrazil
| | - M. S. Abdelhafez
- Department of Obstetrics and Gynecology, Mansoura University HospitalsMansoura UniversityMansouraEgypt
| | - A. Tabor
- Center of Fetal Medicine and Pregnancy, Department of ObstetricsCopenhagen University HospitalRigshospitaletCopenhagenDenmark
- University of CopenhagenFaculty of Health SciencesCopenhagenDenmark
| | - A. Perales
- Department of Pediatrics, Obstetrics and GynecologyUniversity of ValenciaValenciaSpain
- Department of ObstetricsUniversity Hospital La FeValenciaSpain
| | - S. S. Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health, Department of Health and Human ServicesBethesda, MD and DetroitMIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - K. H. Nicolaides
- Harris Birthright Research Centre for Fetal MedicineKing's College HospitalLondonUK
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Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SJ, Romero R, Barrett J. Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations? Am J Obstet Gynecol 2016; 215:616.e1-616.e14. [PMID: 27365003 PMCID: PMC5086275 DOI: 10.1016/j.ajog.2016.06.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical length at midtrimester is a powerful predictor of preterm birth in twin gestations. However, given the fact that, in some cases, cervical shortening may become evident only later during the second trimester, it seems reasonable that serial monitoring of cervical length may improve the detection of preterm birth in women with twins. However, data in support of such a practice are limited and conflicting. The contradictory results may be related to the fact that in most of these studies, the analysis of the predictive value of serial measurements of cervical length was limited to data derived from only two sequential measurements of cervical length, while data on the predictive value of multiple (>2) measurements are scarce. OBJECTIVE We sought to determine whether serial measurements of cervical length can improve the prediction of preterm birth in asymptomatic women with twin gestations compared with a single measurement of cervical length at midgestation. STUDY DESIGN This was a retrospective cohort study of women with twin pregnancies followed up in a tertiary medical center from 2012 through 2014. All participants underwent routine measurement of cervical length at midgestation and every 2-3 weeks thereafter until 28-32 weeks. For each patient, cervical length was determined at the following time periods: 18+0 to 21+6 weeks (period 1, routine exam), 22+0 to 24+6 weeks (period 2), 25+0 to 27+6 weeks (period 3), and 28+0 to 32+0 weeks (period 4). Measurements of cervical length at periods 2-4 were analyzed in the form of either absolute length (in millimeters) or percent shortening relative to cervical length at period 1. The performance of a stepwise algorithm that incorporated serial measurements of cervical length for the prediction of preterm birth was compared to that achieved with a single measurement of cervical length at period 1. RESULTS Overall, 441 women with twin pregnancies who were eligible for the study underwent a total of 2374 cervical length measurements. The association of a short cervix (<10th percentile) with preterm birth at <32 weeks persisted in each of the 4 periods of gestation [odds ratio (95% confidence interval): 7.2 (3.1-16.5), 15.3 (6.4-36.7), 10.3 (4.4-24.3), and 23.1(8.3-64.1), respectively]. Compared with a single measurement of cervical length at midgestation (period 1), a stepwise algorithm integrating serial cervical length measurements from all 4 successive gestational age periods resulted in a significant increase in the area under the receiver operating characteristic curve (0.917 vs 0.613, P < .001). Similarly, when a target false-positive rate of 5% was used, the same stepwise algorithm was associated with a higher detection rate (69% vs 28%, P < .001), higher positive likelihood ratio (14.54 vs 5.12), and lower negative likelihood ratio (0.32 vs 0.76) for preterm birth at <32 weeks compared with a single measurement of cervical length at period 1. CONCLUSION Integration of serial measurements of cervical length using a stepwise algorithm in asymptomatic women with twin gestations can improve the detection of women at risk of preterm birth. Prospective studies are needed to validate these findings, and to investigate whether improved risk assessment performance is sufficient to offset the additional costs associated with serial cervical length measurements.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
| | - Alex Pittini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Steven J Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SS, Romero R, Barrett J. Serial cervical length determination in twin pregnancies reveals 4 distinct patterns with prognostic significance for preterm birth. Am J Obstet Gynecol 2016; 215:476.e1-476.e11. [PMID: 27207277 PMCID: PMC5045791 DOI: 10.1016/j.ajog.2016.05.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women with a twin gestation are at increased risk for preterm birth (PTB), and sonographic cervical length (CL) is a powerful predictor for spontaneous PTB. Obstetricians frequently monitor CL in multiple gestations; yet, the optimal method to integrate and interpret the results of serial sonographic CL has not been determined. OBJECTIVE We sought to determine whether there are different patterns of cervical shortening in twin gestations, and whether such patterns are related to the risk of PTB. STUDY DESIGN We conducted a retrospective study of all women with twins followed up in a single tertiary referral center during 2012 through 2014. All women underwent serial measurements of CL every 2-3 weeks starting from 14-18 weeks and until 28-32 weeks of gestation. Changes in CL were analyzed and classified into distinct patterns that were initially identified by visual inspection of all individual cases. Each pattern was then characterized by several parameters including information about when cervical shortening began, the rate of shortening, and whether a plateau was observed. Locally weighted regression mean profiles were generated to describe each pattern of CL over time. The association of these patterns with spontaneous PTB was determined. The specific characteristics of each pattern that further determined the risk of PTB were identified using multivariable logistic regression analysis. RESULTS We studied 441 women who had a total of 2826 measurements of CL done. Overall, 4 main patterns of change in CL were identified: pattern I, stable cervix (n = 196); pattern II, early and rapid shortening (n = 18); pattern III, late shortening (n = 109); and pattern IV, early shortening with a plateau (n = 118). The rate of PTB at <34 weeks was lowest in cases of pattern I (11.7%), followed by pattern IV (14.4%) and pattern III (20.2%), and was highest for women with pattern II (44.4%) (P < .001). In cases with pattern III (late shortening), the most important factors affecting the risk of PTB were the shortening rate, the gestational age at the onset of cervical shortening, and the initial plateau of CL. In the case of pattern IV (early shortening with a plateau), it was only the new plateau at which cervical shortening stopped that was associated with the risk of PTB. CONCLUSION Changes in sonographic CL over time in twin gestations can be classified into 4 patterns, each associated with a different risk of PTB.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
| | - Alex Pittini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven S Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Romero R, Nicolaides KH, Conde-Agudelo A, O'Brien JM, Cetingoz E, Da Fonseca E, Creasy GW, Hassan SS. Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:308-17. [PMID: 27444208 PMCID: PMC5053235 DOI: 10.1002/uog.15953] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/19/2016] [Accepted: 04/25/2016] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To evaluate the efficacy of vaginal progesterone administration for preventing preterm birth and perinatal morbidity and mortality in asymptomatic women with a singleton gestation and a mid-trimester sonographic cervical length (CL) ≤ 25 mm. METHODS This was an updated systematic review and meta-analysis of randomized controlled trials comparing the use of vaginal progesterone to placebo/no treatment in women with a singleton gestation and a mid-trimester sonographic CL ≤ 25 mm. Electronic databases, from their inception to May 2016, bibliographies and conference proceedings were searched. The primary outcome measure was preterm birth ≤ 34 weeks of gestation or fetal death. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated. RESULTS Five trials involving 974 women were included. A meta-analysis, including data from the OPPTIMUM study, showed that vaginal progesterone significantly decreased the risk of preterm birth ≤ 34 weeks of gestation or fetal death compared to placebo (18.1% vs 27.5%; RR, 0.66 (95% CI, 0.52-0.83); P = 0.0005; five studies; 974 women). Meta-analyses of data from four trials (723 women) showed that vaginal progesterone administration was associated with a statistically significant reduction in the risk of preterm birth occurring at < 28 to < 36 gestational weeks (RRs from 0.51 to 0.79), respiratory distress syndrome (RR, 0.47 (95% CI, 0.27-0.81)), composite neonatal morbidity and mortality (RR, 0.59 (95% CI, 0.38-0.91)), birth weight < 1500 g (RR, 0.52 (95% CI, 0.34-0.81)) and admission to the neonatal intensive care unit (RR, 0.67 (95% CI, 0.50-0.91)). There were no significant differences in neurodevelopmental outcomes at 2 years of age between the vaginal progesterone and placebo groups. CONCLUSION This updated systematic review and meta-analysis reaffirms that vaginal progesterone reduces the risk of preterm birth and neonatal morbidity and mortality in women with a singleton gestation and a mid-trimester CL ≤ 25 mm, without any deleterious effects on neurodevelopmental outcome. Clinicians should continue to perform universal transvaginal CL screening at 18-24 weeks of gestation in women with a singleton gestation and to offer vaginal progesterone to those with a CL ≤ 25 mm. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- R Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA.
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA.
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA.
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Conde-Agudelo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA
| | - J M O'Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY, USA
| | - E Cetingoz
- Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Uskudar, Istanbul, Turkey
| | - E Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual 'Francisco Morato de Oliveira' and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - G W Creasy
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - S S Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Abstract
Preterm birth is a major concern in modern obstetrics, and an important source of morbidity and mortality in newborns. Among twin pregnancies, especially, preterm birth is highly prevalent, and it accounts for almost 50% of the complications observed in this obstetrical population. In this article, we review the existing literature regarding the prediction and prevention of preterm birth in both symptomatic and asymptomatic twin pregnancies. In asymptomatic twin pregnancies, the best two predictive tests were cervical length (CL) measurement and cervicovaginal fetal fibronectin (fFN) testing. A single measurement of transvaginal CL at 20-24 weeks of gestation <20 mm or <25 mm is a good predictor of spontaneous preterm birth at <28, <32, and <34 weeks of gestation. A CL beyond 25 mm is associated with a 2% risk for birth before 28 weeks and with a 65% chance for a term pregnancy. Cervicovaginal fFN may be slightly less accurate than CL; however, it has a high negative predictive value in women presenting with threatened preterm labor, as <2% of these women will deliver within one week if the fFN is negative. In symptomatic twin pregnancies, no tests have proven accurate in predicting the risk of preterm birth. For the prevention of preterm birth in asymptomatic twins, regardless of CL, no treatment including bed rest, limitation of home activities, prophylactic tocolysis, progesterone, or cerclage has been shown to reduce the rate of preterm birth. Cervical pessaries might be of interest in cases where there is a short cervix (<25 mm and <38 mm, respectively) but these results need to confirmed in future trials.
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Affiliation(s)
- F Fuchs
- Departement de Gynécologie-Obstétrique, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin Bicêtre, France; INSERM, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, Villejuif, France; Université Paris-Sud, UMRS 1018, Villejuif, France
| | - M-V Senat
- Departement de Gynécologie-Obstétrique, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin Bicêtre, France; INSERM, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, Villejuif, France; Université Paris-Sud, UMRS 1018, Villejuif, France.
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Cervical Pessary and Vaginal Progesterone in Twin Pregnancies With a Short Cervix. Obstet Gynecol 2016; 127:625-630. [DOI: 10.1097/aog.0000000000001300] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Conde-Agudelo A, Romero R. Vaginal progesterone to prevent preterm birth in pregnant women with a sonographic short cervix: clinical and public health implications. Am J Obstet Gynecol 2016; 214:235-242. [PMID: 26450404 PMCID: PMC5703061 DOI: 10.1016/j.ajog.2015.09.102] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/18/2015] [Accepted: 09/23/2015] [Indexed: 12/20/2022]
Abstract
Vaginal progesterone administration to women with a sonographic short cervix is an efficacious and safe intervention used to prevent preterm birth and neonatal morbidity and mortality. The clinical and public health implications of this approach in the United States have been critically appraised and compared to other therapeutic interventions in obstetrics. Vaginal progesterone administration to women with a transvaginal sonographic cervical length (CL) ≤25 mm before 25 weeks of gestation is associated with a significant and substantial reduction of the risk for preterm birth from <28 to <35 weeks of gestation, respiratory distress syndrome, composite neonatal morbidity and mortality, admission to the neonatal intensive care unit, and mechanical ventilation. These beneficial effects have been achieved in women with a singleton gestation, with or without a history of spontaneous preterm birth, and did not differ significantly as a function of CL (<10 mm, 10-20 mm, or 21-25 mm). The number of patients required for treatment to prevent 1 case of preterm birth or adverse neonatal outcomes ranges from 10-19 women. The number needed to screen for the prevention of 1 case of preterm birth before 34 weeks of gestation is 125 women, and 225 for the prevention of 1 case of major neonatal morbidity or neonatal mortality. Several cost-effectiveness and decision analyses have shown that the combination of universal transvaginal CL screening and vaginal progesterone administration to women with a short cervix is a cost-effective intervention that prevents preterm birth and associated perinatal morbidity and mortality. Universal assessment of CL and treatment with vaginal progesterone for singleton gestations in the United States would result in an annual reduction of approximately 30,000 preterm births before 34 weeks of gestation and of 17,500 cases of major neonatal morbidity or neonatal mortality. In summary, there is compelling evidence to recommend universal transvaginal CL screening at 18-24 weeks of gestation in women with a singleton gestation and to offer vaginal progesterone to those with a CL ≤25 mm, regardless of the history of spontaneous preterm birth, with the goal of preventing preterm birth and neonatal morbidity and mortality.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
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Gordon MC, McKenna DS, Stewart TL, Howard BC, Foster KF, Higby K, Cypher RL, Barth WH. Transvaginal cervical length scans to prevent prematurity in twins: a randomized controlled trial. Am J Obstet Gynecol 2016; 214:277.e1-277.e7. [PMID: 26363481 DOI: 10.1016/j.ajog.2015.08.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 08/26/2015] [Accepted: 08/28/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Twin pregnancies are associated with an increased risk of perinatal morbidity and mortality primarily due to spontaneous preterm deliveries. The mean gestational age for delivery is 35.3 weeks and twins account for 23% of preterm births <32 weeks. A number of strategies have been proposed to prevent preterm deliveries: tocolytics, bed rest, hospitalization, home uterine activity monitoring, cerclage, and most recently, progesterone. Unfortunately, none have proven effective. Recent metaanalyses and reviews suggest that transvaginal cervical length (TVCL) ultrasound in the second trimester is a powerful predictor of preterm birth among asymptomatic women. Indeed, TVCL has the highest positive and negative predictive values for determining the risk of spontaneous preterm delivery in twin pregnancies. It follows that TVCL assessment may allow identification of a subset of twin pregnancies that re better candidates for interventions intended to prevent prematurity. OBJECTIVE We sought to determine whether use of TVCL prolongs gestation in twin pregnancies. STUDY DESIGN This is a multicenter, randomized, controlled trial of 125 dichorionic or monochorionic/diamniotic twin pregnancies without prior preterm birth <28 weeks. The study group (n = 63) had TVCL and digital exams monthly from 16-28 weeks and were managed with a standard algorithm for activity restriction and cerclage. The control group (n = 62) had monthly digital cervical examinations but no routine TVCL ultrasound examinations. The primary outcome was gestational age at delivery. Secondary outcomes included percentage of deliveries <35 weeks, and maternal and neonatal outcomes. RESULTS The mean gestational age at delivery was 35.7 weeks (95% confidence interval [CI], 35.2-36.2) among those managed with TVCL and 35.5 weeks (95% CI, 34.7-36.4) among the control patients. The Kaplan-Meier estimates of deliveries <38 weeks were not significantly different between groups. This was true whether we compared curves with a log-rank test (P = .67), Breslow test (P = .67), or Tarone-Ware test (P = .64). The percentage of deliveries <35 0/7 weeks did not differ: 27.4% for subjects managed with routine TVCL and 28.6% for control subjects (relative risk, 0.96; 95% CI, 0.60-1.54). Our study had an 80% power to detect a 12-day difference in the gestational age at delivery with 95% confidence. CONCLUSION The overall mean length of gestation and the percentage of women delivering <35 weeks did not differ between twin gestations managed with TVCL and digital exams monthly from 16-28 weeks with a standard algorithm for activity restriction and cerclage and controls who had monthly digital cervical examinations but no routine TVCL. Routine second-trimester transvaginal ultrasound assessment of cervical length is not associated with improved outcomes when incorporated into the standard management of otherwise low-risk twin pregnancies.
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Goya M, de la Calle M, Pratcorona L, Merced C, Rodó C, Muñoz B, Juan M, Serrano A, Llurba E, Higueras T, Carreras E, Cabero L. Cervical pessary to prevent preterm birth in women with twin gestation and sonographic short cervix: a multicenter randomized controlled trial (PECEP-Twins). Am J Obstet Gynecol 2016; 214:145-152. [PMID: 26627728 DOI: 10.1016/j.ajog.2015.11.012] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/28/2015] [Accepted: 11/12/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spontaneous preterm birth (SPB) is the leading cause of perinatal morbidity and mortality. In twins, the rate of preterm birth is higher than in singletons; interventions to prevent preterm birth are needed in this high-risk population. OBJECTIVE We sought to test whether a cervical pessary reduces the preterm birth rate in twin pregnancies with sonographic short cervix. STUDY DESIGN A prospective, open-label, multicenter, randomized clinical trial was conducted in 5 hospitals in Spain. The ethics committees of all participating hospitals approved the protocol. The trial was registered as ClinicalTrials.gov, number NCT01242410. Eligible women were scanned in Spain. The primary outcome was SPB <34 weeks of gestation. Neonatal morbidity and mortality were also evaluated. RESULTS Cervical length was measured in 2287 women; 137 pregnant women with a sonographic cervical length ≤25 mm (of 154 detected with a short cervix) were randomly assigned to receive a cervical pessary or expectant management (1:1 ratio). SPB <34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (11/68 [16.2%] vs 26/66 [39.4%]; relative risk, 0.41; 95% confidence interval, 0.22-0.76). Pessary use was associated with a significant reduction in the rate of birthweight <2500 g (P = .01). No significant differences were observed in composite neonatal morbidity outcome (8/136 [5.9%] vs 12/130 [9.1%]; relative risk, 0.64; 95% confidence interval, 0.27-1.50) or neonatal mortality (none) between the groups. No serious adverse effects associated with the use of a cervical pessary were observed. CONCLUSION The insertion of a cervical pessary was associated with a significant reduction in the SPB rate. We propose the use of a cervical pessary for preventing preterm birth in twin pregnancies of mothers with a short cervix.
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Affiliation(s)
- Maria Goya
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona.
| | | | - Laia Pratcorona
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Carme Merced
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Carlota Rodó
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | | | | | | | - Elisa Llurba
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Teresa Higueras
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Elena Carreras
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Luis Cabero
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
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Conde-Agudelo A, Romero R. Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol 2015; 213:789-801. [PMID: 26070703 DOI: 10.1016/j.ajog.2015.06.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 05/29/2015] [Accepted: 06/04/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine the accuracy of changes in transvaginal sonographic cervical length over time in predicting preterm birth in women with singleton and twin gestations. DATA SOURCES PubMed, Embase, Cinahl, Lilacs, and Medion (all from inception to June 30, 2015), bibliographies, Google scholar, and conference proceedings. Cohort or cross-sectional studies reporting on the predictive accuracy for preterm birth of changes in cervical length over time. STUDY APPRAISAL AND SYNTHESIS METHODS Two reviewers independently selected studies, assessed the risk of bias, and extracted the data. Summary receiver-operating characteristic curves, pooled sensitivities and specificities, and summary likelihood ratios were generated. RESULTS Fourteen studies met the inclusion criteria, of which 7 provided data on singleton gestations (3374 women) and 8 on twin gestations (1024 women). Among women with singleton gestations, the shortening of cervical length over time had a low predictive accuracy for preterm birth at <37 and <35 weeks of gestation with pooled sensitivities and specificities, and summary positive and negative likelihood ratios ranging from 49% to 74%, 44% to 85%, 1.3 to 4.1, and 0.3 to 0.7, respectively. In women with twin gestations, the shortening of cervical length over time had a low to moderate predictive accuracy for preterm birth at <34, <32, <30, and <28 weeks of gestation with pooled sensitivities and specificities, and summary positive and negative likelihood ratios ranging from 47% to 73%, 84% to 89%, 3.8 to 5.3, and 0.3 to 0.6, respectively. There were no statistically significant differences between the predictive accuracies for preterm birth of cervical length shortening over time and the single initial and/or final cervical length measurement in 8 of 11 studies that provided data for making these comparisons. In the largest and highest-quality study, a single measurement of cervical length obtained at 24 or 28 weeks of gestation was significantly more predictive of preterm birth than any decrease in cervical length between these gestational ages. CONCLUSIONS Change in transvaginal sonographic cervical length over time is not a clinically useful test to predict preterm birth in women with singleton or twin gestations. A single cervical length measurement obtained between 18 and 24 weeks of gestation appears to be a better test to predict preterm birth than changes in cervical length over time.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Molecular Obstetrics and Genetics, Wayne State University, Detroit, MI.
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van de Mheen L, Schuit E, Liem SMS, Lim AC, Bekedam DJ, Goossens SMTA, Franssen MTM, Porath MM, Oudijk MA, Bloemenkamp KWM, Duvekot JJ, Woiski MD, de Graaf I, Sikkema JM, Scheepers HCJ, van Eijk J, de Groot CJM, van Pampus MG, Mol BWJ. Second-trimester cervical length as risk indicator for Cesarean delivery in women with twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:579-584. [PMID: 25402630 DOI: 10.1002/uog.14727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 10/30/2014] [Accepted: 11/02/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To determine whether second-trimester cervical length (CL) in women with a twin pregnancy is associated with the risk of emergency Cesarean section. METHODS This was a secondary analysis of two randomized trials conducted in 57 hospitals in The Netherlands. We assessed the univariable association between risk indicators, including second-trimester CL in quartiles, and emergency Cesarean delivery using a logistic regression model. For multivariable analysis, we assessed whether adjustment for other risk indicators altered the associations found in univariable (unadjusted) analysis. Separate analyses were performed for suspected fetal distress and failure to progress in labor as indications for Cesarean section. RESULTS In total, 311 women with a twin pregnancy attempted vaginal delivery after 34 weeks' gestation. Emergency Cesarean delivery was performed in 111 (36%) women, of which 67 (60%) were performed owing to arrest of labor. There was no relationship between second-trimester CL and Cesarean delivery (adjusted odds ratio (aOR): 0.97 for CL 26(th) -50(th) percentiles; 0.71 for CL 51(st) - 75(th) percentiles; and 0.92 for CL > 75(th) percentile, using CL ≤ 25(th) percentile as reference). In multivariable analysis, the only variables associated with emergency Cesarean delivery were maternal age (aOR, 1.07 (95% CI, 1.00-1.13)), body mass index (BMI) (aOR, 3.99 (95% CI, 1.07-14.9) for BMI 20-23 kg/m(2) ; 5.04 (95% CI, 1.34-19.03) for BMI 24-28 kg/m(2) ; and 3.1 (95% CI, 0.65-14.78) for BMI > 28 kg/m(2) ) and induction of labor (aOR, 1.92 (95% CI, 1.05-3.5)). CONCLUSION In nulliparous women with a twin pregnancy, second-trimester CL is not associated with risk of emergency Cesarean delivery.
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Affiliation(s)
- L van de Mheen
- Department of Obstetrics and Gynaecology, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - E Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
- Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - S M S Liem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - A C Lim
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - D J Bekedam
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - S M T A Goossens
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M T M Franssen
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The Netherlands
| | - M M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - M A Oudijk
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - M D Woiski
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - I de Graaf
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - J M Sikkema
- Department of Obstetrics and Gynaecology, Zorggroep Twente, Almelo, The Netherlands
| | - H C J Scheepers
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - J van Eijk
- Department of Obstetrics and Gynaecology, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - M G van Pampus
- Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - B W J Mol
- The Robinson Institute, School of Reproductive Health and Paediatrics, University of Adelaide, Adelaide, Australia
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Kindinger LM, Poon LC, Cacciatore S, MacIntyre DA, Fox NS, Schuit E, Mol BW, Liem S, Lim AC, Serra V, Perales A, Hermans F, Darzi A, Bennett P, Nicolaides KH, Teoh TG. The effect of gestational age and cervical length measurements in the prediction of spontaneous preterm birth in twin pregnancies: an individual patient level meta-analysis. BJOG 2015; 123:877-84. [PMID: 26333191 DOI: 10.1111/1471-0528.13575] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the effect of gestational age (GA) and cervical length (CL) measurements at transvaginal ultrasound (TVUS) in the prediction of preterm birth in twin pregnancy. DESIGN Individual patient data (IPD) meta-analysis. SETTING International multicentre study. POPULATION Asymptomatic twin pregnancy. METHODS MEDLINE and EMBASE searches were performed and IPD obtained from authors of relevant studies. Multinomial logistic regression analysis determined probabilities for birth at ≤28(+0) , 28(+1) to 32(+0) , 32(+1) to 36(+0) , and ≥36(+1) weeks as a function of GA at screening and CL measurements. MAIN OUTCOME MEASURES Predicted probabilities for preterm birth at ≤28(+0) , 28(+1) to 32(+0) , and 32(+1) to 36(+0) . RESULTS A total of 6188 CL measurements were performed on 4409 twin pregnancies in 12 studies. Both GA at screening and CL had a significant and non-linear effect on GA at birth. The best prediction of birth at ≤28(+0) weeks was provided by screening at ≤18(+0) weeks (P < 0.001), whereas the best prediction of birth between 28(+1) and 36(+0) weeks was provided by screening at ≥24(+0) weeks (P < 0.001). Negative prediction value of 100% for birth at ≤28(+0) weeks is achieved at CL 65 mm and 43 mm at ultrasound GA at ≤18(+0) weeks and at 22(+1) to 24(+0) weeks, respectively. CONCLUSION In twin pregnancies, prediction of preterm birth depends on both CL and the GA at screening. When CL is <30 mm, screening at ≤18(+0) weeks is most predictive for birth at ≤28(+0) weeks. Later screening at >22(+0) weeks is most predictive of delivery at 28(+1) to 36(+0) weeks. In twins, we recommend CL screening in twins to commence from ≤18(+0) weeks. TWEETABLE ABSTRACT An individual patient meta-analysis assessing gestation and CL in the prediction of preterm birth in twins.
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Affiliation(s)
- L M Kindinger
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.,Fetal Medicine Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - L C Poon
- Fetal Medicine Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.,Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London, UK
| | - S Cacciatore
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - D A MacIntyre
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - N S Fox
- Maternal Fetal Medicine Associates, PLLC, New York, NY, USA
| | - E Schuit
- Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - B W Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia
| | - S Liem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - A C Lim
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - V Serra
- Maternal-Fetal Medicine Unit, Instituto Valenciano de Infertilidad, University of Valencia, Valencia, Spain
| | - A Perales
- Department of Paediatrics, Obstetrics and Gynaecology, La FE, University and Polytechnic Hospital, University of Valencia, Valencia, Spain
| | - F Hermans
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - A Darzi
- Department of Academic Surgery, St Marys Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - P Bennett
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London, UK
| | - T G Teoh
- Fetal Medicine Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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van der Pol CB, McInnes MDF, Petrcich W, Tunis AS, Hanna R. Is quality and completeness of reporting of systematic reviews and meta-analyses published in high impact radiology journals associated with citation rates? PLoS One 2015; 10:e0119892. [PMID: 25775455 PMCID: PMC4361663 DOI: 10.1371/journal.pone.0119892] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 01/20/2015] [Indexed: 01/01/2023] Open
Abstract
Purpose The purpose of this study is to determine whether study quality and completeness of reporting of systematic reviews (SR) and meta-analyses (MA) published in high impact factor (IF) radiology journals is associated with citation rates. Methods All SR and MA published in English between Jan 2007–Dec 2011, in radiology journals with an IF >2.75, were identified on Ovid MEDLINE. The Assessing the Methodologic Quality of Systematic Reviews (AMSTAR) checklist for study quality, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for study completeness, was applied to each SR & MA. Each SR & MA was then searched in Google Scholar to yield a citation rate. Spearman correlation coefficients were used to assess the relationship between AMSTAR and PRISMA results with citation rate. Multivariate analyses were performed to account for the effect of journal IF and journal 5-year IF on correlation with citation rate. Values were reported as medians with interquartile range (IQR) provided. Results 129 studies from 11 journals were included (50 SR and 79 MA). Median AMSTAR result was 8.0/11 (IQR: 5–9) and median PRISMA result was 23.0/27 (IQR: 21–25). The median citation rate for SR & MA was 0.73 citations/month post-publication (IQR: 0.40–1.17). There was a positive correlation between both AMSTAR and PRISMA results and SR & MA citation rate; ρ=0.323 (P=0.0002) and ρ=0.327 (P=0.0002) respectively. Positive correlation persisted for AMSTAR and PRISMA results after journal IF was partialed out; ρ=0.243 (P=0.006) and ρ=0.256 (P=0.004), and after journal 5-year IF was partialed out; ρ=0.235 (P=0.008) and ρ=0.243 (P=0.006) respectively. Conclusion There is a positive correlation between the quality and the completeness of a reported SR or MA with citation rate which persists when adjusted for journal IF and journal 5-year IF.
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Affiliation(s)
| | - Matthew D. F. McInnes
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- * E-mail:
| | - William Petrcich
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Adam S. Tunis
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Ramez Hanna
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
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Precocious cervical ripening as a screening target to predict spontaneous preterm delivery among asymptomatic singleton pregnancies: a systematic review. Am J Obstet Gynecol 2015; 212:145-56. [PMID: 25017411 DOI: 10.1016/j.ajog.2014.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/23/2014] [Accepted: 07/03/2014] [Indexed: 11/23/2022]
Abstract
Routine second-trimester transvaginal ultrasonographic (TVU) screening for short cervical length (CL) predicts spontaneous preterm delivery (SPTD), albeit with limited sensitivity (35-40%) and a moderate positive likelihood ratio of 4-6. However, CL describes one of the multidimensional changes that are associated with precocious cervical ripening (PCCR) and that also include cervical softening, cervical funneling (CF), and dilation. PCCR, a precursor and a strong predictor for SPTD, was proposed as a potential screening target. We hypothesized that screening for composite measures of PCCR (eg, CL, CF, cervical consistency, and dilation) with the use of either digital examination or TVU would improve the prediction of SPTD compared with screening for short CL alone. We searched PubMed and EMBASE electronic databases for observational cohort studies to evaluate cervical screening in asymptomatic obstetric populations. Multidimensional composite cervical measures were assessed in 10 datasets (n = 22,050 pregnancies) and 12 publications. Appreciable heterogeneity in cervical measurements, data quality, and outcomes across studies prevented quantitative metaanalysis. Only one study reported intra- and interobserver reliability of cervical measurements. The prevalence of CF ranged from 0.7-9.1%. Five studies compared composite measures of PCCR (ie, CL and CF) with short CL alone and consistently reported improved screening performance. Among 3 TVU studies, gains in sensitivity ranged from 5-27%, and increases in positive likelihood ratio ranged from 3-16. Our findings suggest that composite measures of PCCR might serve as valuable screening targets. High-quality interdisciplinary studies that integrate epidemiologic approaches are needed to test this hypothesis and to accelerate the translation of advances in cervical pathophysiology into effective preventive interventions.
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Conde-Agudelo A, Romero R. Prediction of preterm birth in twin gestations using biophysical and biochemical tests. Am J Obstet Gynecol 2014; 211:583-95. [PMID: 25072736 DOI: 10.1016/j.ajog.2014.07.047] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 07/23/2014] [Accepted: 07/24/2014] [Indexed: 01/10/2023]
Abstract
The objective of this study was to determine the performance of biophysical and biochemical tests for the prediction of preterm birth in both asymptomatic and symptomatic women with twin gestations. We identified a total of 19 tests proposed to predict preterm birth, mainly in asymptomatic women. In these women, a single measurement of cervical length with transvaginal ultrasound before 25 weeks of gestation appears to be a good test to predict preterm birth. Its clinical potential is enhanced by the evidence that vaginal progesterone administration in asymptomatic women with twin gestations and a short cervix reduces neonatal morbidity and mortality associated with spontaneous preterm delivery. Other tests proposed for the early identification of asymptomatic women at increased risk of preterm birth showed minimal to moderate predictive accuracy. None of the tests evaluated in this review meet the criteria to be considered clinically useful to predict preterm birth among patients with an episode of preterm labor. However, a negative cervicovaginal fetal fibronectin test could be useful in identifying women who are not at risk for delivering within the next week, which could avoid unnecessary hospitalization and treatment. This review underscores the need to develop accurate tests for predicting preterm birth in twin gestations. Moreover, the use of interventions in these patients based on test results should be associated with the improvement of perinatal outcomes.
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Boyer A, Cameron L, Munoz-Maldonado Y, Bronsteen R, Comstock CH, Lee W, Goncalves LF. Clinical significance of amniotic fluid sludge in twin pregnancies with a short cervical length. Am J Obstet Gynecol 2014; 211:506.e1-9. [PMID: 24881831 DOI: 10.1016/j.ajog.2014.05.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 04/22/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of the study was to determine the clinical significance of amniotic fluid (AF) sludge in twin pregnancies with a short cervix. STUDY DESIGN We evaluated twin pregnancies with a short cervical length that had an ultrasound between 16 and 26 weeks (n = 78). Pregnancy outcomes in those with sludge (n = 27) and those without (n = 51) were compared. Outcome variables included gestational age at delivery, premature rupture of the membranes, chorioamnionitis, funisitis, composite neonatal morbidity, and perinatal death. For statistical analysis, the first-born (A) and second-born (B) twins were studied separately. RESULTS The prevalence of AF sludge was 34.6% (27 of 78). Pregnancies with sludge delivered earlier (27.2 ± 5.6 weeks vs 31.0 ± 4.05 weeks, P < .01) and had a higher rate of extreme prematurity (<26 weeks: 52.2% [12 of 23] vs 15.6% [5 of 32]; P < .01). Both twins had higher rates of histological chorioamnionitis (twin A, 50.0% [13 of 26] vs 12.8% [6 of 47]; P < .01; twin B, 42.3% [11 of 26] vs 13.3% [6 of 45]; P < .01) and neonatal death (twin A, 33.3% [9 of 27] vs 3.9% [2 of 51]; P < .01; twin B, 33.3% [9 of 27] vs 6.0% [3 of 50]; P = .01). Higher rates of funisitis (23.1% [6 of 26] vs 4.3% [2 of 47]; P = .02) and composite neonatal morbidity were observed for twin A only (66.7% [14 of 21] vs 37.5% [18 of 48]; P = .04). CONCLUSION The presence of AF sludge in twin pregnancies with a short cervix is a risk factor for extreme prematurity, histological chorioamnionitis, and perinatal death. Twin A had higher rates of funisitis and neonatal morbidity in the presence of AF sludge.
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El-Ardat MA, Gavrankapetanovic F, Abou El-Ardat KA, Dekovic S, Murtezic S, Mehmedbasic E, Hiros N. Ultrasound measurement of cervical length as predictor of threatened preterm birth: a predictive model. Acta Inform Med 2014; 22:306-8. [PMID: 25568578 PMCID: PMC4272850 DOI: 10.5455/aim.2014.22.306-308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 09/12/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The incidence of preterm delivery has been increasing even in developed countries and remains a serious problem for fetuses and neonates. Although many predictors for preterm delivery have been proposed, complete prediction and prevention have not yet been established. AIMS To examine the potential association between sonographic measurement of cervical length and threatened preterm birth (TPTB) in pregnant woman at 24-36 weeks of gestation. MATERIALS AND METHODS A cross-sectional study included a total of 360 pregnant woman at 24-36 weeks of gestation categorized in two groups: TPTB group (n=160) and non TPTB group (n=200). The study was carried out at the Department of Obstetrics and Gynecology of the Clinical Center University of Sarajevo (KCUS). Sociodemographic and clinical characteristics of patients were obtained from medical records and physical examination by gynecologist. Transvaginal sonography was carried out by GE Voluson 730. RESULTS There was a significant association between TPTB and sonographic measurement of cervical length <25 mm (P<0.001). The logistic regression model was statistically significant, x(2)(7) = 281.530, P<0. 001. The model explained 72.6% of the variance in TPTB and correctly classified 88.1% of cases. Sensitivity was 83.8%, specificity was 91.5%, positive predictive value was 88.7% and negative predictive value was 87.6%. Out of the 7 predictor variables only 5 were statistically significant: cervical length, cervical consistency, rupture of membranes, uterine contractions and amine odor test. CONCLUSION The findings of this study suggest association between sonographic measurement of cervical length and TPTB.
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Affiliation(s)
- Mohammad Abou El-Ardat
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Bosnia and Herzegovina1
| | - Fatima Gavrankapetanovic
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Bosnia and Herzegovina1
| | - Khalil A. Abou El-Ardat
- Institut fuer Klinische Genetik, Medizinische Fakultaet Carl Gustav Carus, Technische Universitaet Dresden, Dresden, Germany
| | - Sanjin Dekovic
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Bosnia and Herzegovina1
| | - Senad Murtezic
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Bosnia and Herzegovina1
| | - Eldar Mehmedbasic
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Bosnia and Herzegovina1
| | - Nadja Hiros
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Bosnia and Herzegovina1
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