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Soto-Torres EE, Hernandez-Andrade E, Huntley ES, Blackwell SC. Maternal and obstetrical factors associated with short cervical length at midtrimester in women with no history of preterm delivery. J Matern Fetal Neonatal Med 2023; 36:2228448. [PMID: 37385780 DOI: 10.1080/14767058.2023.2228448] [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: 01/15/2021] [Revised: 03/23/2023] [Accepted: 06/18/2023] [Indexed: 07/01/2023]
Abstract
AIM To evaluate associations between maternal characteristics and a short cervix in patients without history of preterm delivery, and to determine if these characteristics can predict the presence of a short cervix. MATERIALS AND METHODS This is a retrospective cohort study that included 18,592 women with singleton pregnancies without history of previous preterm deliveries who underwent universal transvaginal cervical length (TVCL) screening between 18 + 0 and 23 + 6 weeks/days of gestation. A short cervix was defined as a cervical length (CL) ≤25 mm, ≤20 mm, and ≤15 mm. Associations between maternal age, weight, height, body mass index (BMI), previous term deliveries, and history of previous miscarriages, with a short cervix were evaluated using logistic regression models. RESULTS The prevalence of a short cervix in our population was: CL ≤25 mm, 2.2% (n = 403); CL ≤20 mm, 1.2% (n = 224); and CL ≤15 mm, 0.9% (n = 161). Women with BMI >30 and/or previous abortions constituted 45.5% of the total population (8463/18,582). Significant associations with short cervix were observed for women with BMI ≥30, and for women with at least one previous abortion (p < .001). Parous women had a significantly lower association with a short cervix than nulliparous women (p < .001). Maternal age or height were not associated with a short cervix. Prediction of short cervix based on presence of any of the following: BMI ≥ 30 or previous abortions showed sensitivities of 55.8% (≤25 mm), 61.6% (≤20 mm), and 63.4% (≤15 mm) with similar specificity (50.1-54.6%) and likelihood ratio positive (1.2-1.5); and prediction based on BMI ≥ 30 and previous abortions showed sensitivities of 11.1% (≤25 mm), 14.7% (≤20 mm), and 16.7% (≤15 mm) with specificity 93%. CONCLUSIONS Among low risk women for spontaneous preterm delivery, those with a BMI ≥30 and/or previous miscarriages had a significantly increased risk for a short cervix at 18 + 0 and 23 + 6 weeks/days of gestation. Despite these significant associations, screening by maternal risk factors in a low risk population of pregnant women should not be an alternative to mid-trimester universal CL measurement.
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Affiliation(s)
- Eleazar E Soto-Torres
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
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Morales-Roselló J, Loscalzo G, Martínez-Varea A, Álamo BND, Nieto-Tous M. Primary prevention with vaginal chlorhexidine before 16 weeks reduces the incidence of preterm birth: results of the Preterm Labor Prevention Using Vaginal Antiseptics study. AJOG GLOBAL REPORTS 2023; 3:100277. [PMID: 38107249 PMCID: PMC10724831 DOI: 10.1016/j.xagr.2023.100277] [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] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Preterm labor is one of the leading causes of perinatal death and is currently considered a syndrome with many causes. One of the most important causes of preterm birth is ascending infection from bacterial vaginosis. Chlorhexidine has proven to be effective against bacterial vaginosis and against bacterial biofilms without affecting gestation. OBJECTIVE We aimed to evaluate the effectiveness of a universal primary prevention strategy for preterm birth using intravaginal chlorhexidine applied before 16 weeks (Preterm Labor Prevention Using Vaginal Antiseptics study). STUDY DESIGN We performed a prospective observational study with 2 cohorts of pregnant women that were assigned either to prevention of preterm birth by means of intravaginal chlorhexidine (Cum Laude Chlorhexidine, chlorhexidine digluconate 0.2%) before 16 weeks (n=413), or to no treatment following the usual hospital protocol (n=704). Primary outcomes were the incidence of spontaneous preterm birth before 34 and 37 weeks; the incidence of preterm birth before 34 and 37 weeks, including inductions for premature rupture of membranes; and the incidence of preterm birth before 34 and 37 weeks, including any indication for termination of pregnancy. Both cohorts were compared using Mann-Whitney and Fisher tests. Finally, a multivariable analysis, including the odds ratio was performed, adjusting for clinical parameters, to evaluate the importance of the different determinants in the prediction of preterm birth. RESULTS In pregnancies treated with chlorhexidine, the incidences of spontaneous preterm birth; preterm birth, including induction for premature rupture of membranas; and preterm birth, including any indication for termination of pregnancy were at 34 and 37 weeks: 0% and 0%, 0.24% and 1.69, and 2.90% and 3.15%, respectively; whereas in nontreated pregnancies, these incidences were 9% and 11%, 12% and 23%, and 35% and 43%, respectively. According to the multivariable analysis, the incidence of preterm birth among women treated with chlorhexidine before 16 weeks was halved (Odds ratio, 0.52; P<.05). CONCLUSION Universal treatment with vaginal chlorhexidine before 16 weeks reduces the incidence of preterm birth, especially before 34 weeks.
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Affiliation(s)
- José Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain (Prof. Morales-Roselló, Dr Loscalzo, Dr Martínez-Varea, Dr Novillo-Del Alamo and Dr Nieto-Tous)
- Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain (Prof Morales-Roselló)
| | - Gabriela Loscalzo
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain (Prof. Morales-Roselló, Dr Loscalzo, Dr Martínez-Varea, Dr Novillo-Del Alamo and Dr Nieto-Tous)
| | - Alicia Martínez-Varea
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain (Prof. Morales-Roselló, Dr Loscalzo, Dr Martínez-Varea, Dr Novillo-Del Alamo and Dr Nieto-Tous)
| | - Blanca Novillo-Del Álamo
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain (Prof. Morales-Roselló, Dr Loscalzo, Dr Martínez-Varea, Dr Novillo-Del Alamo and Dr Nieto-Tous)
| | - Mar Nieto-Tous
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain (Prof. Morales-Roselló, Dr Loscalzo, Dr Martínez-Varea, Dr Novillo-Del Alamo and Dr Nieto-Tous)
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Soto EE, Hernandez-Andrade E, Huntley ES, Blackwell SC. Implementing a Universal Cervical Length Screening Program in a Large Hospital System, it Takes Some Time to Achieve Consistent Results. Gynecol Obstet Invest 2022; 87:124-132. [PMID: 35354147 DOI: 10.1159/000524361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe changes in the acceptance of transvaginal (TV) cervical length (CL) measurements, and in the variance of CL measurements among operators, after implementation of universal TV-CL measurements at 18+0-23+6 weeks/days of gestation. STUDY DESIGN Retrospective cohort study Participants/Materials, Setting, Methods This study was performed after universal TV-CL screening was implemented at the University of Texas Health Science Center in Houston, Texas, for all women undergoing an anatomy ultrasound (US) between 18 0/6 and 23 6/7 weeks of gestation. Pregnant women carrying singletons without prior history of preterm delivery who underwent anatomy ultrasound evaluation between September 2017 and March 2020 (30 months) were included. The complete study period was divided in five epochs of six months each. Changes in patient's acceptance for the TV scan, in CL distribution, in the prevalence of short cervix defined as ≤15, ≤20, or ≤25 mm, and in the performance of ultrasound operators across the five epochs were evaluated. For this analysis, success rate was defined as the percentage of TV-CL measurements obtained in relation to the number of second trimester anatomy scans. RESULTS A total of 22,207 low risk pregnant women evaluated by 36 trained sonographers were analyzed. Overall, the acceptance for TV-CL measurement was 82.3% (18,289/22,207), increasing from 76.7% in the first epoch to 82.8% (p<0.0001) in the last epoch. The mean CL did not significantly change from 38.6 mm in the first epoch to 38.5 mm in the last epoch (p=0.7); however, the standard deviation decreased from 7.9 mm in the first epoch to 7.04 mm in the last epoch (p=<0.01). The prevalence of a short cervix ≤25 mm was 2.2% (n=399/18,289), ≤20 mm was 1.2% (224/18,289), and ≤15 mm was 0.9% (162/18,289). This prevalence varied only for CL ≤25 mm from 3.02% (88/2,907) in the first epoch to 1.77% (64/3,615) in the last epoch (p=0.0009). There was a variation in CL measurements among operators (mean 3.3 mm). Sonographers with less than one year of experience had a lower success rate for completing TV-CL examinations than more experienced sonographers (80.8% vs. 85.8%; p <0.03). In general 77% (27/35) of operators had a success rate ≥80% for completing TV-SL scans. LIMITATIONS Characteristics of individuals who accepted versus those who declined TV-CL were not compared; CL values were not correlated with clinical outcomes. CONCLUSIONS During the first six months after implementation of a universal cervical length screening program, there was greater variation in CL measurements, lower acceptance for a TV ultrasound, and a higher number of women diagnosed with a CL ≤25 mm, as compared to subsequent epochs. After the first six months, these metrics improved and remained stable. Most operators improved their performance over time; however, there were a few with a low success rate for TV-CL, and others who systematically over or under estimate CL measurements.
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Affiliation(s)
- Eleazar E Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, Texas, USA
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Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol 2021; 138:e65-e90. [PMID: 34293771 DOI: 10.1097/aog.0000000000004479] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Preterm birth is among the most complex and important challenges in obstetrics. Despite decades of research and clinical advancement, approximately 1 in 10 newborns in the United States is born prematurely. These newborns account for approximately three-quarters of perinatal mortality and more than one half of long-term neonatal morbidity, at significant social and economic cost (1-3). Because preterm birth is the common endpoint for multiple pathophysiologic processes, detailed classification schemes for preterm birth phenotype and etiology have been proposed (4, 5). In general, approximately one half of preterm births follow spontaneous preterm labor, about a quarter follow preterm prelabor rupture of membranes (PPROM), and the remaining quarter of preterm births are intentional, medically indicated by maternal or fetal complications. There are pronounced racial disparities in the preterm birth rate in the United States. The purpose of this document is to describe the risk factors, screening methods, and treatments for preventing spontaneous preterm birth, and to review the evidence supporting their roles in clinical practice. This Practice Bulletin has been updated to include information on increasing rates of preterm birth in the United States, disparities in preterm birth rates, and approaches to screening and prevention strategies for patients at risk for spontaneous preterm birth.
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Almeida JPRFPD, Bartosch CMM, Macedo AMPCC. The Impact of Routine Transvaginal Ultrasound Measurement of the Cervical Length on the Prediction of Preterm Birth: A Retrospective Study in a Tertiary Hospital. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:264-274. [PMID: 33979887 PMCID: PMC10183866 DOI: 10.1055/s-0041-1726053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Preterm birth (PTB) is a major obstetric problem associated with high rates of neonatal morbidity and mortality. The prevalence of PTB has not changed in the last decade; thus, the establishment of a screening test and effective treatment are warranted. Transvaginal ultrasound measurement of the cervical length (TUCL) has been proposed as an effective method to screen pregnant women at a higher risk of experiencing PTB. OBJECTIVE To evaluate the applicability and usefulness of second-trimester TUCL to predict PTB in a cohort of Portuguese pregnant women. METHODS Retrospective cross-sectional cohort study including all singleton pregnant women who performed their second-trimester ultrasound (between weeks 18 and 22 + 6 days) from January 2013 to October 2017 at Centro Hospitalar Universitário São João. RESULTS Our cohort included 4,481 women. The prevalence of spontaneous PTB was of 4.0%, with 0.7% occurring before the 34th week of gestation. The mean TUCL was of 33.8 mm, and percentiles 3, 5 and 10 corresponded to TUCLs of 25.0 mm, 27.0 mm and 29.0 mm respectively. The multiple logistic regression analysis, including maternal age, previous PTB and cervical surgery showed a significant negative association between TUCL and PTB, with an odds ratio (OR) of 0.92 (95% confidence interval [95%CI]: 0.90-0.95; p < 0.001). The use of a TUCL of 20 mm is the best cut-off, when compared with the 25-mm cut-off, improving the prediction of risk. CONCLUSION The present study showed an inverse association between TUCL and PTB, and that the inclusion of other risk factors like maternal age, previous PTB and cervical surgery can improve the screening algorithm. Furthermore, it emphasizes that the TUCL cut-off that defines short cervix can differ according to the population.
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Abstract
Progestogens (vaginal progesterone and intramuscular 17-hydroxyprogesterone acetate) are widely recommended for women at high risk of preterm birth. Typical regimens include 17-hydroxyprogesterone caproate (250 mg intramuscularly weekly), starting at 16-20 gestational weeks until 36 weeks or delivery for women with a singleton gestation and a history of spontaneous preterm birth, or vaginal progesterone (90-mg vaginal gel or 200-mg micronized vaginal soft capsules) for women with a short cervix (typically ≤25 mm). Although some randomized trials support this approach, neither of the largest trials (PROLONG for 17-hydroxyprogesterone acetate or OPPTIMUM for vaginal progesterone) demonstrated efficacy. There are almost no data on long-term effects, and none that shows benefit beyond the neonatal period. Although some analyses suggest the cost-effectiveness of the approach, a cervical length screening program followed by progesterone for those with a short cervix will reduce preterm birth rates by less than 0.5%. The present review assesses evidence on the efficacy, likely impact, and long-term effects of implementing the recommendations for progestogens in full. Clinicians and pregnant women can look forward to resolution of the conflicting views on efficacy once the Patient-Centered Outcomes Research Initiative (PCORI)-funded individual patient data meta-analysis is published.
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Affiliation(s)
- Jane E. Norman
- Faculty of Health SciencesUniversity of BristolBristolUK
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Lamont RF, Richardson LS, Boniface JJ, Cobo T, Exner MM, Christensen IB, Forslund SK, Gaba A, Helmer H, Jørgensen JS, Khan RN, McElrath TF, Petro K, Rasmussen M, Singh R, Tribe RM, Vink JS, Vinter CA, Zhong N, Menon R. Commentary on a combined approach to the problem of developing biomarkers for the prediction of spontaneous preterm labor that leads to preterm birth. Placenta 2020; 98:13-23. [PMID: 33039027 DOI: 10.1016/j.placenta.2020.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Globally, preterm birth has replaced congenital malformation as the major cause of perinatal mortality and morbidity. The reduced rate of congenital malformation was not achieved through a single biophysical or biochemical marker at a specific gestational age, but rather through a combination of clinical, biophysical and biochemical markers at different gestational ages. Since the aetiology of spontaneous preterm birth is also multifactorial, it is unlikely that a single biomarker test, at a specific gestational age will emerge as the definitive predictive test. METHODS The Biomarkers Group of PREBIC, comprising clinicians, basic scientists and other experts in the field, with a particular interest in preterm birth have produced this commentary with short, medium and long-term aims: i) to alert clinicians to the advances that are being made in the prediction of spontaneous preterm birth; ii) to encourage clinicians and scientists to continue their efforts in this field, and not to be disheartened or nihilistic because of a perceived lack of progress and iii) to enable development of novel interventions that can reduce the mortality and morbidity associated with preterm birth. RESULTS Using language that we hope is clear to practising clinicians, we have identified 11 Sections in which there exists the potential, feasibility and capability of technologies for candidate biomarkers in the prediction of spontaneous preterm birth and how current limitations to this research might be circumvented. DISCUSSION The combination of biophysical, biochemical, immunological, microbiological, fetal cell, exosomal, or cell free RNA at different gestational ages, integrated as part of a multivariable predictor model may be necessary to advance our attempts to predict sPTL and PTB. This will require systems biological data using "omics" data and artificial intelligence/machine learning to manage the data appropriately. The ultimate goal is to reduce the mortality and morbidity associated with preterm birth.
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Affiliation(s)
- R F Lamont
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Division of Surgery, Northwick Park Institute for Medical Research Campus, University College London, London, UK.
| | - L S Richardson
- Dept of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Dept. Electrical and Computer Engineering Texas A&M University, College Station, TX, USA
| | - J J Boniface
- Sera Prognostics, Inc., 2749 East Parleys Way, Suite 200, Salt Lake City, UT, 84109, USA
| | - T Cobo
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecología, Obstetrícia I Neonatología, Fetal i+D Fetal Medicine Research Center, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona. Barcelona. Spain, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - M M Exner
- Hologic, Inc., 10210 Genetic Center Dr, San Diego, CA, 92121, USA
| | | | - S K Forslund
- Experimental and Clinical Research Center, A Cooperation of Charité-Universitätsmedizin and the Max-Delbrück Center, Berlin, Germany
| | - A Gaba
- Department of Obstetrics and Maternal-fetal Medicine, Vienna Medical University, Austria
| | - H Helmer
- Department of Obstetrics and Maternal-fetal Medicine, Vienna Medical University, Austria
| | - J S Jørgensen
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Centre for Innovative Medical Technologies (CIMT), Odense University Hospital, Kløvervænget 8, 5000, Odense C, Denmark; Odense Patient Data Explorative Network (OPEN), Odense University Hospital/University of Southern Denmark, J. B. Winsløws Vej 9 a, 3. Floor, 5000, Odense C, Denmark
| | - R N Khan
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Room 4115, Medical School, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | | | - K Petro
- Hologic, Inc., 10210 Genetic Center Dr, San Diego, CA, 92121, USA
| | - M Rasmussen
- MIRVIE Inc., 820 Dubuque Ave., South San Francisco, CA, 94080, USA
| | - R Singh
- ARCEDI Biotech ApS, Aarhus, Denmark
| | - R M Tribe
- Dept. of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital Campus, London, SE1 7EH, UK
| | - J S Vink
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - C A Vinter
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - N Zhong
- New York State Institute for Basic Research in Developmental Disabilities, 105 Forest Hill Road, Staten Island, NY, 10314, USA
| | - R Menon
- Dept of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Dept. Electrical and Computer Engineering Texas A&M University, College Station, TX, USA.
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Rosenbloom JI, Raghuraman N, Temming LA, Stout MJ, Tuuli MG, Dicke JM, Macones GA, Cahill AG. Predictive Value of Midtrimester Universal Cervical Length Screening Based on Parity. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:147-154. [PMID: 31283038 DOI: 10.1002/jum.15091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/15/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To evaluate the effect of parity on performance characteristics of midtrimester cervical length (CL) in predicting spontaneous preterm birth (sPTB) before 37 weeks. METHODS This was a retrospective cohort study of 13,508 women with no history of sPTB undergoing universal transvaginal CL screening at 17 to 23 weeks' gestation from 2011 to 2016. Patients who declined screening or with unknown delivery outcomes were excluded. Areas under the receiver operator characteristic curves were used to assess and compare the predictive ability of CL screening for sPTB. The sensitivity, specificity, and positive and negative predictive values were estimated for specific CL cutoffs for prediction of sPTB. RESULTS There were 20,100 patients, of whom 2087 (10%) declined screening and 4505 (22%) did not meet inclusion criteria. Of the remaining 13,508 patients, 43% were nulliparous. The incidence rates of sPTB were 6.5% in nulliparas and 4.9% in multiparas (P < .001). The mean CLs were 39.9 mm in nulliparas and 41.8 mm in multiparas (P < .001), and those of the first percentiles were 19.0 mm in nulliparas and 24.0 mm in multiparas. Cervical length was significantly more predictive of sPTB in nulliparas (area under the curve, 0.67; 95% confidence interval, 0.63-0.70; versus 0.61, 95% confidence interval, 0.57-0.63; P = .008). At CL cutoffs of 10, 15, 20, and 25 mm or less, the sensitivity was lower in multiparas, and the specificity was comparable between the groups. CONCLUSIONS Midtrimester CL is less predictive of sPTB in multiparas compared to nulliparas. The poor predictive ability, especially in multiparas, calls into question the value of universal CL screening in this population.
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Affiliation(s)
- Joshua I Rosenbloom
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Lorene A Temming
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Molly J Stout
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Methodius G Tuuli
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Jeffery M Dicke
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - George A Macones
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Sinkey RG, Odibo AO. Vasa previa screening strategies: decision and cost-effectiveness analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:522-529. [PMID: 29786153 DOI: 10.1002/uog.19098] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 04/25/2018] [Accepted: 05/05/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To perform a decision and cost-effectiveness analysis comparing four screening strategies for the antenatal diagnosis of vasa previa in singleton pregnancies. METHODS A decision-analytic model was constructed comparing vasa previa screening strategies. Published probabilities and costs were applied to four transvaginal screening scenarios that were carried out at the time of mid-trimester ultrasound: no screening, ultrasound-indicated screening, screening only pregnancies conceived by in-vitro fertilization (IVF) and universal screening. Ultrasound-indicated screening was defined as performing transvaginal ultrasound at the time of the routine anatomy ultrasound scan in response to one of the following sonographic findings associated with an increased risk of vasa previa: low-lying placenta, marginal or velamentous cord insertion or bilobed or succenturiate lobed placenta. The primary outcome was cost per quality-adjusted life year (QALY) in US$. The analysis was performed from a healthcare system perspective with a willingness-to-pay threshold of $100 000 per QALY selected. One-way and multivariate sensitivity analysis (Monte-Carlo simulation) was performed. RESULTS This decision-analytic model demonstrated that screening pregnancies conceived by IVF was the most cost-effective strategy, with an incremental cost effectiveness ratio (ICER) of $29186.50/QALY. Ultrasound-indicated screening was the second most cost-effective, with an ICER of $56096.77/QALY. These data were robust to all one-way and multivariate sensitivity analyses performed. CONCLUSIONS Within the baseline assumptions, transvaginal ultrasound screening for vasa previa appears to be most cost-effective when performed among IVF pregnancies. However, both IVF and ultrasound-indicated screening strategies fall within contemporary willingness-to-pay thresholds, suggesting that both strategies may be appropriate to apply in clinical practice. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R G Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A O Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
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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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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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Abstract
Preterm birth (PTB) remains a major obstetric healthcare problem and a significant contributor to perinatal morbidity, mortality, and long-term disability. Over the past few decades, the perinatal outcomes of preterm neonates have improved markedly through research and advances in neonatal care, whereas rates of spontaneous PTB have essentially remained static. However, research into causal pathways and new diagnostic and treatment modalities is now bearing fruit and translational initiatives are beginning to impact upon PTB rates. Successful PTB prevention requires a multifaceted approach, combining public health and educational programs, lifestyle modification, access to/optimisation of obstetric healthcare, effective prediction and diagnostic modalities, and the application of effective, targeted interventions. Progress has been made in some of these areas, although there remain areas of controversy and uncertainty. Attention is now being directed to areas where greater gains can be achieved. In this mini-review, we will briefly and selectively review a range of PTB prevention strategies and initiatives where progress has been made and where exciting opportunities await exploitation, evaluation, and implementation.
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Affiliation(s)
- Jeff A Keelan
- Division of Obstetrics & Gynaecology, School of Medicine, University of Western Australia King Edward Memorial Hospital, Perth, Australia
| | - John P Newnham
- Division of Obstetrics & Gynaecology, School of Medicine, University of Western Australia King Edward Memorial Hospital, Perth, Australia
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Variation in Coverage for Progesterone to Prevent Preterm Birth: A Survey of Medicaid Managed Care Organizations. Womens Health Issues 2017; 27:573-578. [PMID: 28687440 DOI: 10.1016/j.whi.2017.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/03/2017] [Accepted: 05/30/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Preterm birth is the leading cause of U.S. infant morbidity and mortality; Medicaid enrollees disproportionately experience preterm deliveries. Data suggest that progesterone-an evidence-based therapy for preventing preterm birth-is not accessible to all eligible Medicaid beneficiaries. This study aimed to identify variation in progesterone coverage guidelines in a sample of state Medicaid managed care organizations (MMCOs). MATERIAL AND METHODS Using a cross-sectional design, participation in a web-based survey was offered to 20 MMCO members of the Medicaid Health Plans of America. The survey assessed coverage guidelines for progesterone and associated interventions to prevent preterm birth. MMCOs identified key barriers in providing progesterone. Descriptive analyses were performed. RESULTS Analyses included data from 18 plans providing coverage in 31 of the 39 states with MMCOs (response rate, 90.0%). Responding MMCOs were diverse: 55.6% were multistate, 33.3% were nonprofit, and 31.2% covered more than 1,000,000 lives. Most respondents (87.5%) covered branded progesterone, and 81.3% covered compounded progesterone. Prior authorization was required by most plans for branded progesterone (86.7%) or compounded progesterone (75.0%). The MMCO gestational age restrictions for initiating progesterone varied from 22 to 37 weeks of gestation, even within the same state. MMCO-identified barriers to providing progesterone included cost, lack of clinician knowledge of indications and coverage, and variation in billing procedures. DISCUSSION Marked variation in MMCO coverage policies and procedures for progesterone and related interventions to prevent preterm birth was noted. IMPLICATIONS FOR PRACTICE AND POLICY Standardizing MMCO coverage policies may be one way to improve access to evidence-based interventions that prevent preterm birth.
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Rozenberg P. Universal cervical length screening for singleton pregnancies with no history of preterm delivery, or the inverse of the Pareto principle. BJOG 2016; 124:1038-1045. [DOI: 10.1111/1471-0528.14392] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/27/2022]
Affiliation(s)
- P Rozenberg
- Département d'Obstetrique et Gynecologie; Hôpital Poissy-Saint Germain; Université Versailles-St Quentin; Versailles France
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Crosby DA, Miletin J, Semberova J, Daly S. Is routine transvaginal cervical length measurement cost-effective in a population where the risk of spontaneous preterm birth is low? Acta Obstet Gynecol Scand 2016; 95:1391-1395. [PMID: 27623283 DOI: 10.1111/aogs.13021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 09/06/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A recent meta-analysis has suggested that routine measurement of the cervical length should be performed in conjunction with the anomaly scan to identify a group of women at increased risk of preterm delivery. We decided to investigate whether this recommendation is justifiable in a population where the risk of preterm birth is low. MATERIAL AND METHODS We reviewed 12 years of obstetric data from the Coombe Women and Infants University Hospital. Relative risks of adverse outcomes from the randomized controlled trial were applied and we extrapolated the possible numbers of women requiring intervention. We then used published neonatal data to estimate the cost of neonatal care and estimated the costs of providing the service. RESULTS Over 12 years from 2000 until 2011, there were 94 646 singleton deliveries, 1776 happening before 34 weeks. Spontaneous onset occurred in 882 (49.7%) of this group. These 882 births were studied. If we apply the figures from a randomized controlled trial, 1609 women (1.7% from our total population) would be expected to have a cervical length 15 mm. If we gave vaginal progesterone to all women with a sonographically short cervix, we would reduce the delivery rate before 34 weeks by 27.7%. The annual costs of providing the service were estimated to be €109 249 and the cost of immediate neonatal care was estimated to be €380 514. CONCLUSION Given the implications associated with preterm delivery, routine measurement of cervical length at the time of the anomaly scan may be justifiable from a cost point of view in a population where the risk of preterm birth is low.
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Affiliation(s)
- David A Crosby
- Department of Obstetrics and Gynecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Jan Miletin
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic.,UCD School of Medicine, Dublin, Ireland.,3rd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jana Semberova
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Sean Daly
- Department of Obstetrics and Gynecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,School of Medicine, Trinity College, Dublin, Ireland
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