Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening

Cervical elastography in predicting spontaneous preterm birth in singleton pregnancy with a short cervix receiving progesterone treatment at 18 to 24 weeks' gestation

BACKGROUND

A short cervix in the second trimester is known to increase the risk of preterm birth, which can be reduced with the administration of vaginal progesterone. However, some studies have suggested that a significant number of cases still experience preterm birth despite progesterone treatment.

OBJECTIVE

This study was aimed to investigate the potential value of transvaginal cervical elasticity measured by E-Cervix as a predictor for spontaneous preterm birth (sPTB) in singleton pregnancies receiving progesterone treatment for a short cervix (CL ≤ 2.5 cm) diagnosed at 18 to 24 weeks' gestation.

STUDY DESIGN

This prospective study was conducted at a single center premature high-risk clinic from January 2020 to July 2022. Singleton pregnancies with a short cervix at 18 to 24 weeks' gestation were enrolled. Cervical elastography using E-Cervix was performed, and maternal and neonatal demographic characteristics, cervical length (CL), elasticity contrast index (ECI), cervical hardness ratio, mean internal os strain (IOS), and mean external os strain (EOS) were compared before and after progesterone treatment in sPTB and term birth groups. Multivariate logistic regression was used to analyze the association between elasticity parameters and spontaneous preterm birth. The screening performance of CL and optimal cervical elasticity parameters in predicting sPTB was evaluated using receiver-operating characteristic (ROC) curve analysis.

RESULTS

A total of 228 singleton pregnant women were included in the study, among which 26 (11.4%) had sPTB. There were no significant differences in maternal characteristics and gestational age at enrollment between women with and without sPTB. At the start of progesterone treatment, there were no significant differences in cervical elasticity parameters between the two groups. After two weeks of progesterone treatment, women who had sPTB showed significantly higher levels of ECI, IOS, EOS (p = 0.0108, 0.0001, 0.016), and lower hardness ratio (p = 0.011) compared to those who had a full-term birth. Cervical length did not show significant differences between the two groups, regardless of whether progesterone treatment was administered before or after. Among the post-treatment cervical elasticity parameters, IOS and EOS were associated with a 3.38-fold and 2.29-fold increase in the risk of sPTB before 37 weeks (p = 0.032, 0.047, respectively). The AUROC of the combined model including CL, IOS, and EOS (0.761, 95% CI0.589-0.833) was significantly higher than the AUROC of CL alone (0.618, 95% CI 0.359-0.876). At a fixed false-positive of 13%, the addition of IOS and EOS in the CL model increased sensitivity from 34.6% to 57.6%, PPV from 25.7% to 36.5%, and NPV from 91.1% to 94.1%.

CONCLUSION

When assessing the risk of sPTB in singleton pregnancies with a short cervix receiving progesterone therapy, relying solely on cervical length is insufficient. It is crucial to also evaluate cervical stiffness, particularly the strain of the internal and external os, using cervical elastography.

SMFM Consult Series #70: Management of short cervix in individuals without a history of spontaneous preterm birth

Most deliveries before 34 weeks of gestation occur in individuals with no previous history of preterm birth. Midtrimester cervical length assessment using transvaginal ultrasound is one of the best clinical predictors of spontaneous preterm birth. This Consult provides guides for the diagnosis and management of a short cervix in an individual without a history of preterm birth. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that all cervical length measurements used to guide therapeutic recommendations be performed using a transvaginal approach and in accordance with standardized procedures as described by organizations, such as the Perinatal Quality Foundation or the Fetal Medicine Foundation (GRADE 1C); (2) we recommend using a midtrimester cervical length of ≤25 mm to diagnose a short cervix in individuals with a singleton gestation and no previous history of spontaneous preterm birth (GRADE 1C); (3) we recommend that asymptomatic individuals with a singleton gestation and a transvaginal cervical length of ≤20 mm diagnosed before 24 weeks of gestation be prescribed vaginal progesterone to reduce the risk of preterm birth (GRADE 1A); (4) we recommend that treatment with vaginal progesterone be considered at a cervical length of 21 to 25 mm based on shared decision-making (GRADE 1B); (5) we recommend that 17-alpha hydroxyprogesterone caproate, including compounded formulations, not be prescribed for the treatment of a short cervix (GRADE 1B); (6) in individuals without a history of preterm birth who have a sonographic short cervix (10-25 mm), we recommend against cerclage placement in the absence of cervical dilation (GRADE 1B); (7) we recommend that cervical pessary not be placed for the prevention of preterm birth in individuals with a singleton gestation and a short cervix (GRADE 1B); and (8) we recommend against routine use of progesterone, pessary, or cerclage for the treatment of cervical shortening in twin gestations outside the context of a clinical trial (GRADE 1B).

Cerclage plus Adjuvant Vaginal Progesterone for Preterm Birth Prevention in Patients with a Short or Dilated Cervix without Prior Preterm Birth

OBJECTIVE

 The primary objective was to determine if vaginal progesterone following cerclage for cervical length <10 mm or cervical dilation in patients without a history of spontaneous preterm birth (sPTB) decreased the risk of preterm birth at <34 weeks' gestation compared with cerclage alone. Secondary objectives were to determine if vaginal progesterone following cerclage (1) decreased the risk of preterm birth at <24, <28, and <37 weeks' gestation and (2) increased the latency period from cerclage placement to delivery compared with treatment with cerclage alone.

STUDY DESIGN

 Multicenter retrospective cohort study from 2015 to 2020 of singleton pregnancies, without prior sPTB, who had cerclage placement <24 weeks' gestation for cervical length <10 mm or cervical dilation. Exposure defined as cerclage plus vaginal progesterone postoperatively (dual therapy) and unexposed as cerclage alone (monotherapy), based on surgeon preference.

RESULTS

 We included 122 patients, 78 (64%) treated with dual therapy and 44 (36%) treated with monotherapy. In the crude analysis, dual therapy was associated with a lower risk of delivery at <28 weeks' gestation (13%) compared with monotherapy (34%; crude risk ratio: 0.38 [95% confidence interval, CI: 0.19-0.75]). When adjusted for preoperative vaginal progesterone, results were attenuated (adjusted risk ratio: 0.45 [95% CI: 0.20-1.01]). In both the crude and adjusted analyses, the risk of sPTB was not statistically different at <24, <34 or <37 weeks' gestation. Dual therapy was associated with a greater pregnancy latency from cerclage to delivery (16.3 vs. 14.4 weeks; p = 0.04), and greater gestational age at delivery (37.3 vs. 35.8 weeks' gestation; p = 0.02) compared with monotherapy.

CONCLUSION

 While not statistically significant, the risk of sPTB was lower at all gestational ages studied in patients treated with dual therapy compared with monotherapy. Dual therapy was associated with longer pregnancy latency and greater gestational age at delivery compared with monotherapy.

KEY POINTS

· Dual therapy did not decrease preterm birth risk compared with monotherapy.. · Dual therapy prolonged pregnancy compared with monotherapy.. · Dual therapy can be considered but further studies are needed..

Validating staging criteria for sonographic and physical examination for cervical changes at <24 weeks' gestation to predict preterm birth

BACKGROUND

Preterm birth represents a significant clinical challenge, and the ability to predict it effectively is a priority in obstetrics. The cervix undergoes specific changes during pregnancy, and staging these changes may offer a valuable predictive model for preterm birth, particularly among women with a midtrimester short cervical length.

OBJECTIVE

The study aimed to validate a proposed staging model for asymptomatic women with midtrimester short cervical length and to evaluate its potential for predicting preterm birth. The integration of cervical examination and inspection with cervical length measurement was a novel approach to be assessed.

STUDY DESIGN

This was a multicenter, retrospective cohort study that included 925 pregnant women with a singleton fetus and a midtrimester cervical length measurement of ≤25 mm. Cervical conditions were assessed using ultrasonography, a speculum, and a physical examination and were classified into 1 of 5 cervical stages to correlate with the likelihood of preterm birth. Statistical analyses included Kaplan-Meier survival analysis to illustrate the time-to-event characteristics across the 5 stages and density plot evaluation to visualize the distribution of the gestational ages within the stages.

RESULTS

The staging model included 5 stages based on cervical length, appearance, and dilatation. Among the 925 participants, 649 were classified as being stage 1, 245 as stage 2, 18 as stage 3, 10 as stage 4, and 3 as stage 5. The observed rates of preterm birth before 37 weeks for individuals classified in stages 1, 2, 3, 4, and 5 were 22.3%, 26.5%, 44.4%, 60%, and 66.7%, respectively (P=.005). The overall observed rates of preterm birth before 28, 32, 34, and 37 weeks' gestation were 5.5%, 9.9%, 12.2%, and 24.1%, respectively (P=.005).

CONCLUSION

This study validated the proposed staging criteria as an effective predictor of preterm birth caused by cervical insufficiency. The results demonstrate a significant increase in the preterm birth rate with advancing stage classification, indicating that the staging effectively stratified women based on their risk for preterm birth and highlighting the potential use for targeted interventions. Implementing these staging criteria can potentially improve the counseling and management of pregnant women at risk for preterm birth.

Nationwide status of progestogen treatment to prevent spontaneous preterm birth: A questionnaire survey for childbirth healthcare facilities in Japan

AIM

This study aimed to investigate the current status of progestogen treatment for pregnant women at a high risk for preterm birth (PTB) in childbirth healthcare facilities in Japan.

METHODS

A web-based nationwide questionnaire survey regarding progestogen use for prevention of PTB was conducted among childbirth healthcare facilities from 2019 to 2021.

RESULTS

Valid responses were obtained from 528 facilities (25.2% of those surveyed), including 155 tertiary perinatal facilities (making up 92.3% of all tertiary perinatal care facilities). In the survey period, progestogen treatment was implemented in 207 facilities (39.2%) for PTB prevention. Regarding types of progestogens, 17α-hydroxyprogesterone caproate was used in 170 facilities (82.1%), with a low dose (125 mg/week) administered in 62.9% of the facilities to comply with the regulations of the national health insurance system, although 250 mg/week is considered the best dose. Vaginal progesterone was used in 36 facilities (17.4%), although the cost of vaginal progesterone was not covered by health insurance. Of the facilities not administering progestogen treatment, approximately 40% expressed that vaginal progesterone would be their first choice for PTB prevention in daily practice if it would be covered by health insurance in the future.

CONCLUSIONS

Due to the current regulations of the Japanese health insurance system, 17α-hydroxyprogesterone caproate, rather than vaginal progesterone, was mainly used for PTB prevention. Despite global evidence supporting vaginal progesterone as the approach with the highest efficacy, only a limited number of facilities have utilized it due to the current drug use regulations in Japan.

Reduction in cervical length after vaginal progesterone in women with short cervix is significantly associated with preterm delivery at ≤ 34 weeks and < 37 weeks of gestation

OBJECTIVE

To evaluate the association between changes in cervical length (CL) after vaginal progesterone treatment and preterm delivery (PTD).

METHODS

This was a retrospective cohort study that included 197 singleton pregnancies without (n = 178) and with (n = 19) a history of PTD which were found to have a short cervix (≤ 25 mm) between 18 + 0 and 23 + 6 weeks' gestation with a follow-up transvaginal CL measurement taken at least 1 week after vaginal progesterone treatment started. Receiver-operating-characteristics (ROC)-curve analysis was performed and three CL shortening patterns were evaluated: (1) ≥ 10% reduction; (2) ≥ 20% reduction; and (3) ≥ 5 mm reduction relative to the first CL measurement. The predictive performance of each CL reduction cut-off and its association with PTD ≤ 34 weeks and PTD < 37 weeks were evaluated.

RESULTS

Overall, the rate of PTD ≤ 34 weeks was 16.8% (33/197) and that of PTD < 37 weeks was 36.5% (72/197). The area under the ROC curve of cervical shortening expressed in % for predicting PTD ≤ 34 weeks and PTD < 37 weeks was 0.703 and 0.608, respectively. Cervical shortening was observed in 60/197 (30.5%) patients, with 49/60 (81.7%) women showing ≥ 10% reduction, 32/60 (53.3%) ≥ 20% reduction and 27/60 (45.0%) ≥ 5 mm reduction in CL. Sensitivity and specificity for PTD ≤ 34 weeks were, respectively, 48.5% and 79.9% for ≥ 10% reduction; 36.4% and 87.8% for ≥ 20% reduction; and 27.3% and 89.0% for ≥ 5 mm reduction in CL. For PTD < 37 weeks, sensitivity and specificity were, respectively, 36.1% and 81.6% for ≥ 10% reduction; 27.8% and 90.4% for ≥ 20% reduction; and 20.8% and 90.4% for ≥ 5 mm reduction in CL. The highest positive likelihood ratios for PTD ≤ 34 and < 37 weeks were for ≥ 20% CL reduction (2.98 (95% CI, 1.62-5.49) and 2.89 (95% CI, 1.52-5.57), respectively). Despite significant differences in sensitivity among the different cut-offs for cervical shortening, favoring the ≥ 10% reduction cut-off, a reduction of ≥ 20% in CL showed the strongest association with PTD ≤ 34 weeks (odds ratio (OR), 4.11 (95% CI, 1.75-9.62)) and < 37 weeks (OR, 3.62 (95% CI, 1.65-7.96)), as compared with a less pronounced reduction in CL.

CONCLUSIONS

In women with a short cervix treated with vaginal progesterone, a reduction in CL on a subsequent ultrasound scan can predict PTD ≤ 34 and < 37 weeks. A ≥ 20% reduction in CL had the highest positive likelihood ratio and strongest association with PTD ≤ 34 and < 37 weeks compared with ≥ 10% or ≥ 5 mm reduction. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Cervical Cerclage vs. Pessary in Women with a Short Cervix on Ultrasound

PURPOSE

In the present study we sought to compare the efficacy of cervical pessary to that of cerclage in terms of reducing preterm birth rates among women with a short (<25 mm) or ultra-short (<15 and <10 mm) cervix during the ultrasonographic second-trimester assessment.

METHOD

We retrospectively searched the hospital records for singleton pregnancies diagnosed with cervical insufficiency during the second trimester of pregnancy. The McDonald cerclage using a 5mm Mersilene tape was used in all women. An Arabin pessary was used uniformly. In all cases 80 mg of vaginal progesterone gel were administered daily until 37 weeks of gestation.

RESULTS

Overall, 294 women (124 (42.2%) with a McDonald cerclage and 170 (57.8%) with placement of an Arabin pessary) were selected for analysis. Preterm birth rates <37 weeks were similar in both groups (C: 30/122 vs. P: 35:165, p=.581) as well as PTB <34 weeks (C: 16/122 vs. 15/150, p=.278). Admission to the NICU and need for CPAP were more prevalent in the cerclage group (p<.001). Analysis of cases with a cervix <15 mm and <10 mm indicated that preterm birth rates remained equal among the groups, while an increased risk of NICU admission was seen in cases with a cervical length <10 mm that were treated with cerclage.

DISCUSSION AND CONCLUSION

Cervical pessary may be an alternative to cervical cerclage for women with second-trimester cervical shortening and its effect may persist even among cases with an ultra-short cervix. Future randomized trials are needed to ascertain these findings.

Reassessing Preterm Birth Prevention After the Withdrawal of 17-α Hydroxyprogesterone Caproate

The U.S. Food and Drug Administration has recently withdrawn approval for 17-α hydroxyprogesterone caproate for prevention of recurrent preterm birth, and recent studies have called into question benefits of the pessary in the setting of a short cervix. Obstetric health care professionals are once again left with limited remaining options for preterm birth prevention. This narrative review summarizes the best current evidence on the use of vaginal progesterone, low-dose aspirin, and cerclage for the prevention of preterm birth; attempts to distill possible lessons learned from studies of progesterone and pessary, as well as their implementation into practice; and highlights areas where inroads into preterm birth prevention may be possible outside of the progesterone-aspirin-cerclage paradigm.

How to screen the cervix and reduce the risk of spontaneous preterm birth in asymptomatic women without a prior preterm birth

Preterm birth (PTB) is a leading cause of perinatal morbidity and mortality globally. PTB rates have increased in South Korea despite reduction in birth rates. A history of PTB is a strong predictor of subsequent PTB and screening of cervical length between 16 0/7 weeks and 24 0/7 weeks of gestation is recommended in women with a singleton pregnancy and a prior spontaneous PTB. However, the prediction and prevention of spontaneous PTBs in women without a prior PTB remain a matter of debate. The scope of this review article comprises cervical screening and prevention strategies for PTB in asymptomatic women without a prior PTB, based on recent evidence and guidelines.

Combined vaginal progesterone and cervical cerclage in the prevention of preterm birth: a systematic review and meta-analysis

OBJECTIVE

Vaginal progesterone and cervical cerclage are both effective interventions for reducing preterm birth. It is currently unclear whether combined therapy offers superior effectiveness than single therapy. This study aimed to determine the efficacy of combining cervical cerclage and vaginal progesterone in the prevention of preterm birth.

DATA SOURCES

We searched Medline (Ovid), EMBASE (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Cochrane Library (Wiley), and Scopus (from their inception to 2020).

STUDY ELIGIBILITY CRITERIA

The review accepted randomized and pseudorandomized control trials, nonrandomized experimental control trials, and cohort studies. High risk patients (shortened cervical length <25mm or previous preterm birth) who were assigned cervical cerclage, vaginal progesterone, or both for the prevention of preterm birth were included. Only singleton pregnancies were assessed.

METHODS

The primary outcome was birth <37 weeks. Secondary outcomes included birth <28 weeks, <32 weeks and <34 weeks, gestational age at delivery, days between intervention and delivery, preterm premature rupture of membranes, cesarean delivery, neonatal mortality, neonatal intensive care unit admission, intubation, and birthweight. Following title and full-text screening, 11 studies were included in the final analysis. Risk of bias was assessed using the Cochrane Collaboration tool for assessing the risk of bias (ROBINS-I and RoB-2). Quality of evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) tool.

RESULTS

Combined therapy was associated with lower risk of preterm birth at <37 weeks than cerclage alone (risk ratio, 0.51; 95% confidence interval, 0.37-0.79) or progesterone alone (risk ratio, 0.75; 95% confidence interval, 0.58-0.96). Compared with cerclage only, combined therapy was associated with preterm birth at <34 weeks, <32 weeks, or <28 weeks, decreased neonatal mortality, increased birthweight, increased gestational age, and a longer interval between intervention and delivery. Compared with progesterone alone, combined therapy was associated with preterm birth at <32 weeks, <28 weeks, decreased neonatal mortality, increased birthweight, and increased gestational age. There were no differences in any other secondary outcomes.

CONCLUSION

Combined treatment of cervical cerclage and vaginal progesterone could potentially result in a greater reduction in preterm birth than in single therapy. Further, well-conducted and adequately powered randomized controlled trials are needed to assess these promising findings.

Unraveling the Efficacy of Therapeutic Interventions for Short Cervix: Insights from a Retrospective Study for Improved Clinical Management

Background and Objectives: Preterm birth (PTB) is associated with important neonatal mortality and morbidity. The aim of this study was to retrospectively evaluate the average treatment effects on the treated and the efficacity of various therapeutic interventions for PTB in a cohort of patients with singleton pregnancies and short cervical lengths. Materials and Methods: This observational retrospective study included 1146 singleton pregnancies at risk of PTB that were segregated into the following groups: intravaginal progesterone (group 1), Arabin pessary (group 2), McDonald cerclage (group 3), intravaginal progesterone and Arabin pessary (group 4), and intravaginal progesterone and cerclage (group 5). Their treatment effects were evaluated and compared. Results: All evaluated therapeutic interventions significantly reduced the occurrence of late and early preterm births. The risk of late and early PTB was lowered for those pregnant patients who received progesterone and pessaries or progesterone and cerclage in comparison with those who received only progesterone. The extremely PTB risk of occurrence was significantly lowered only by the administration of progesterone in association with cervical cerclage in comparison with progesterone monotherapy. Conclusions: The combined therapeutic interventions had the highest efficacy in preventing preterm birth. An individualized evaluation is needed to establish the best therapeutic approach in particular cases.

Incidentally Found Midtrimester Shortened Cervical Length: Practice Patterns among American Maternal-Fetal Medicine Specialists

OBJECTIVE

The management of incidentally found short cervical length (CL) without prior spontaneous preterm birth (PTB) can vary. While most agree on starting vaginal progesterone, management after CL shortens <10 mm varies. The purpose of this study was to elucidate current practice patterns amongst maternal-fetal medicine (MFM) specialists.

STUDY DESIGN

We conducted an online survey of MFM attending physicians and fellows in the United States from May 2019 to April 2020. The primary outcome was management of varying CL based on gestational age. Variations in management were assessed descriptively.

RESULTS

There were 236 respondents out of 400 eligible surveyed, with a response rate of 59.2%. Universal CL screening was reported by 93.6% (49.6% abdominal and 44.1% transvaginal). Management of short CL varied based on CL measurement, rather than gestational age at presentation. At CL <10 mm, management included cerclage (17.4-18.7%), vaginal progesterone (41.3-41.7%), or cerclage plus vaginal progesterone (43.4%). Between CL of 10 to 20 mm, the majority (77.4-91.9%) would start vaginal progesterone. At CL 21 to 25 mm, management varied between expectant management (45.5-48.5%) or vaginal progesterone (51.1-52.8%). Suture material used was ethylene terephthalate (47.4%) or polypropelene (31.2). Preoperative antibiotic use was reported by 22.3%, while 45.5% used them only if the amniotic membranes were exposed, and 32.2% reported no antibiotic use. Postoperative tocolytic use varied with 19.3% reporting no use, 32.6% using it always, 8.2% only after significant cervical manipulation, 22.7% after the patient is experiencing symptoms, and 17.6% using it only if the cervix is dilated on exam. After cerclage placement, 44.5% continued CL surveillance.

CONCLUSION

Substantial differences of opinion exist among MFM physicians regarding management of incidentally found short CL in patients without history of PTB. The differences in responses obtained highlight the need for evidence-based guidelines for managing this clinical scenario.

KEY POINTS

· There is lack of consensus on the management of incidentally found shortened CL.. · The purpose of this study was to elucidate current trends in CL screening and management.. · Substantial differences of opinion exist regarding management of incidentally found short CL..

The introduction of a universal transvaginal cervical length screening program is associated with a reduced preterm birth rate

BACKGROUND

Midtrimester sonographic short cervix is a good predictor of preterm birth in singleton pregnancies.

OBJECTIVE

This study aimed to assess the impact of implementing a universal transvaginal cervical length screening program on preterm birth rate.

STUDY DESIGN

This study consisted of 2 parts: a before-and-after multicenter study and a study on the ECHOCOL ("echo"="ultrasound" and "col"="cervix" in French) prospective cohort. We compared the rate of preterm birth before and after the introduction of universal cervical length screening at the time of midtrimester anatomy ultrasound. The multicenter before-and-after regional study included all women with a singleton pregnancy who gave birth after 24 weeks' gestation in the South East of France from January 1, 2012 to April 30, 2018. In parallel, the ECHOCOL cohort study was prospectively conducted from May 2015 to July 2018, including 17 maternity hospitals in the South East region of France. In case of asymptomatic short cervix <25 mm, treatments offered included 200 mg of vaginal progesterone, or cerclage, or a pessary until 34 weeks' gestation.

RESULTS

We observed a significant decrease rate of preterm birth between periods A and B after multivariate analysis. (respectively, 5.8% vs 5.6%; adjusted odds ratio, 0.92; 95% confidence interval, 0.89-0.95; P<.0001). In parallel, the percentage of cervical length screening significantly increased from 28.9% in period A to 52.9% in period B (odds ratio, 2.76; 95% confidence interval, 2.71-2.80; P<.0001). Among the 3468 patients of the ECHOCOL prospective cohort, 38 (1.1%) asymptomatic short cervices were detected, and 192 patients gave birth prematurely (11 with an asymptomatic short cervix and 181 without). In the ECHOCOL cohort, a marked but statistically insignificant tendency toward a reduced rate of preterm birth before 37 weeks of gestation was observed (from 5.8% to 5.5%; adjusted odds ratio, 0.72; 95% confidence interval, 0.51-1.03; P=.068).

CONCLUSION

This study showed a significantly lower rate of preterm birth after the implementation of a universal cervical length screening and treating policy during the second trimester of pregnancy. The clinical trial was registered under NCT02598323.

Proposed staging criteria for sonographic and physical exam for cervical changes at <24 weeks gestation to predict preterm birth

Asymptomatic cervical changes, such as cervical length shortening and dilation, which often occur before spontaneous preterm birth, have been described well in singleton pregnancies with or without history of preterm birth. The current screening strategies available to identify patients at increased risk of spontaneous preterm birth include use of transvaginal ultrasound for cervical length assessment and for detection of a short cervical length (≤25 mm) before 24 weeks of gestation. Whether an additional evaluation of the cervix (ie, via speculum or manual exam) is indicated is often pondered by clinicians and may depend on how short the cervical length is and if there is a history of preterm birth. Based on expert opinion, we developed a novel staging system of asymptomatic cervical changes including the following: cervical length measurement, cervical and membrane appearance on speculum exam, and cervical dilation by manual exam. This staging system, if proven accurate, may aid in standardizing definitions for purposes of patient prognosis, evaluation of intervention efficacy, and clinical management.

Pre-Cerclage cervical length predicts long-term pregnancy sustenance: A case-control study

Background

This study aimed to assess a predictor of long-term pregnancy sustenance post cervical cerclage in women with or without a medical history of cervical insufficiency.

Materials and methods

We included pregnant women who underwent cerclage at 12–25 weeks gestation in four perinatal medical centers between January 2009 and December 2010. We classified the cerclage modality as ultrasound-indicated cervical cerclage if the pre-cerclage CL was <25 mm because the prophylactic and therapeutic cerclage definitions varied among institutions. The procedure was deemed successful if the pregnancy continued for more than 13 weeks post cerclage. We compared the outcomes of women who underwent successful and unsuccessful cerclage and investigated whether the pre-cerclage CL could predict pregnancy outcomes in women who underwent successful cerclage using receiver-operating characteristic curves.

Results

We screened 114 pregnant women; 91 met the inclusion criteria. Pre-cerclage CL was a moderately accurate predictor of long-term pregnancy sustenance in the successful group (optimal cut-off value: 17 mm; area under the curve: 0.76; P = 0.0016). Approximately 87% of patients with a pre-cerclage CL ≥ 17 mm sustained their pregnancies for more than 13 weeks post cerclage; however, 64% of patients with a pre-cerclage CL < 17 mm did not.

Conclusion

We speculate that the use of other treatment options in addition to cerclage in women with a pre-cerclage CL < 17 mm may result in a successful pregnancy.

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Cervical cerclage encompasses many indications and specific techniques.

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Pre-cerclage cervical length (CL) predicts long-term pregnancy sustenance.

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87% women (pre-cerclage, CL ≥ 17 mm) sustained their pregnancy for >13 weeks.

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64% women (pre-cerclage, CL < 17 mm) did not sustain their pregnancy for >13 weeks.

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Cerclage can be considered in women with a pre-cerclage CL < 17 mm.

The clinical utility of ongoing sonographic cervix length surveillance in pregnancies prescribed vaginal progesterone therapy

BACKGROUND

Vaginal progesterone therapy significantly reduces preterm birth (PTB) rates in those high-risk pregnancies with a sonographic short cervix (≤25 mm) and/or a history of spontaneous PTB. Cervical length (CL) is routinely measured at the midtrimester morphology scan; however, CL surveillance thereafter is not currently recommended. Progesterone's precise mechanism of action remains unknown, though if it indeed influences CL, shortening after treatment initiation could indicate therapeutic failure and risk of PTB.

AIMS

The aim was to explore the utility of serial transvaginal ultrasound (TVU) measurement of CL at 16, 19 and 22 weeks for predicting PTB in high-risk pregnancies prescribed progesterone therapy.

METHODS

A retrospective cohort study was conducted involving women who attended the King Edward Memorial Hospital PTB Prevention Clinic from 2015 to 2019 and were prescribed progesterone therapy. CL was measured at 16, 19 and 22 weeks by TVU. CL change across three time points was assessed using linear mixed models; then relationships between CL change between 16-19 and 19-22 weeks and PTB were analysed using logistic regression models.

RESULTS

Term birth was most likely when CL did not decrease across both time periods. The addition of 16-19 week decrease in CL to a model, including CL at 19 weeks alone, for predicting PTB increased sensitivity from 43.2 to 56.3%, specificity from 73.2 to 77.4%, and overall accuracy from 61.7 to 70.2%.

CONCLUSION

For high-risk women prescribed vaginal progesterone therapy, serial measurement of the cervix at 16 and 19 weeks improves clinical ability to predict PTB from current recommendations of 19-week measurement alone.

Management of an incompetent mid-second (mid-2nd) trimester absent ecto-cervix: a case series. Cervical amplification pre-cerclage insertion

BACKGROUND

Cervical cerclage is a treatment for an incompetent cervix, the latter being a contributor to spontaneous preterm birth. There is significant difficulty with a transvaginal cerclage insertion for the absent vaginal or ecto-cervix in the mid-2nd trimester period resulting in a higher risk of late miscarriages, extremely preterm labour with increased neonatal morbidity and mortality.

METHODS

A retrospective review of 5 consecutive cases managed by a surgical technique-modified high vaginal cerclage insertion at 18-20 weeks-and adjunct protocols which included vaginal progesterone use, serial infection screening and lifestyle advice, over a 12-month period ending in August 2021, is presented. Inclusion criteria included minimal or absent ecto-cervix, singleton pregnancies with an incompetent cervix attending for a vaginal cerclage whilst exclusion criteria were the usual contraindications to a cerclage insertion. Primary outcome was delivery after 34 weeks whilst seconday outcomes included maternal hemorrhage, bowel/bladder injury, chorioamnionitis and neonatal admission.

RESULTS

A increased gestational latency of 13 gestational weeks (range 12-18). Mean gestational age at delivery was 36 weeks +1 (253 days) with a range of 241-264 days. Delivery after 34 weeks gestational age was 100% with no maternal surgical complications and corresponding neonatal outcomes.

CONCLUSION

There is a potential therapeutic benefit of this technique and adjunct management, in managing an incompetent mid-2nd trimester absent ecto-cervix.

Outcomes following Placement and Removal of Transvaginal Cerclage in at Risk Pregnancies: A Single Center Experience

Objective

The objective of this study was to estimate the time between removal of cerclage and delivery, stratified by indication for cerclage placement (elective or non-elective). Additionally, delivery within 72 hours after cerclage removal was compared between elective and non-elective cerclage placement, as well as between ultrasound-indicated and physical examination-indicated cerclage placement.

Design

A single-center retrospective cohort study. Participants/Materials, Setting, and Methods. Clinical information of 72 pregnant women who underwent transvaginal cerclage over a 4-year period was obtained. Comparisons were made between elective (history-indicated) and non-elective (ultrasound or physical examination-indicated) cerclage placement. Comparisons were also made between physical examination-indicated and ultrasound-indicated cerclage.

Results

Compared to those who had a non-elective cerclage, women undergoing elective cerclage were more likely to have history of cervical treatment (44% vs. 15%, p = 0.02), and spontaneous preterm delivery (92% vs. 61%, p = 0.003). There was no difference in the rate of delivery ≤72 hours following cerclage removal between women who had elective cerclage and those who had non-elective cerclage (46% vs. 58%, p = 0.47). Women who had an elective cerclage were more likely to have elective cerclage removal ≥36 weeks (71.8% vs. 39.4%, p = 0.01), compared to those who had undergone non-elective cerclage. The rate of delivery ≤72 hours following removal of cerclage was greater in women who had a physical examination-indicated cerclage compared to women who had ultrasound-indicated cerclage (80% vs. 39%, p = 0.04). Among women who had an elective cerclage, there was no difference in the rate of delivery at ≤72 hours between those who had elective cerclage removal at 36 weeks compared to those electively removed at 37 weeks (31% vs. 58%, p = 0.30). No complications such as fetal demise, iatrogenic amniotic membrane rupture, hemorrhage, or cervical laceration were reported within this cohort.

Conclusion

Cerclage indication should be considered prior to scheduling elective cerclage removal. Women who had an elective cerclage are most likely to get it electively removed at 36 weeks compared to their counterparts who had a non-elective cerclage. Furthermore, women who had a physical examination-indicated cerclage are most likely to deliver within 72 hours of cerclage removal.

Effects of vaginal microecology and immunity on the pregnancy outcome of cervical cerclage

Objective

To investigate the effects of vaginal microecology and immune status on the pregnancy outcome of cervical cerclage.

Methods

The clinical data of 125 patients with cervical incompetence who underwent transvaginal cervical cerclage in our hospital from January 2018 to January 2021 were collected, based on which the associations of vaginal microecology and related immune cytokines (IL-1β, IL-6, IL-8 and TNF-α) with the cervical cerclage outcome were explored.

Results

All of the 125 patients had singleton pregnancies, who were aged 20–43 years, with a mean of (32.34 ± 5.17) years. The surgery was successful in 104 patients (full-term delivery or survival of premature infants), while unsuccessful in 21 patients (late miscarriage or death of premature infants), revealing a success rate of 83.20%. There were 70 full-term deliveries, 34 premature deliveries (28 survived while 6 died), and 15 late miscarriages. Univariate analysis revealed statistically significant differences in the timing of surgery, gestational age of cerclage, preoperative cervical canal length, genital tract infections and preoperative invasive procedures between the successful and unsuccessful groups (P < 0.05). Insignificant differences were found in the pre-pregnancy body mass index (BMI) (P > 0.05). According to the multivariate analysis results, cerclage timing and genital tract infections were independent risk factors for postoperative pregnancy failure (P < 0.05). The pathogen detection rates in the two groups of pregnant women were analyzed, finding significantly higher incidence of bacterial vaginosis (BV) in the unsuccessful group than in the successful group (P < 0.05). Inter-group comparison revealed that the positive rates for vaginal microenvironmental factors (LE, NAG, SNA, H₂O₂ and pH) were all significantly higher in the unsuccessful group than in the successful group (P < 0.05). Besides, the immune cytokine levels in the cervicovaginal secretions were also all significantly higher in the unsuccessful group than in the successful group (P < 0.05).

Conclusion

The pregnancy outcome of patients undergoing cervical cerclage is associated with the imbalance of vaginal microecology and the levels of IL-1β, IL-6, IL-8 and TNF-α in cervicovaginal secretions.

Perinatal care for the extremely preterm infant

Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (20^0/7-25^6/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.

Controversies in treatment practices of the mother-infant dyad at the limit of viability

In the setting of threatened extreme preterm birth, balancing maternal and fetal risks and benefits in order to choose the best available treatment options is of utmost importance. Inconsistency in treatment practices for infants born between 22 and 24 weeks of gestatotional age may account for inter-hospital variation in survival rates with and without impairment. Most importantly, non-biased and accurate information must be presented to the family as soon as extremely preterm birth is suspected, including counseling on morbidities and mortality associated with delivery at the limits of viability. This review will focus on different therapeutic medical and surgical practices available for threatened extremely preterm birth to improve fetal and maternal outcomes while highlighting the importance of patient-centered approaches.

Cerclage in singleton gestations with an extremely short cervix (≤10 mm) and no history of spontaneous preterm birth

BACKGROUND

Data regarding the efficacy of a cervical cerclage for preterm birth prevention in patients with a short cervix and no history of spontaneous preterm birth are limited and inconclusive.

OBJECTIVE

This study aimed to determine whether cervical cerclage is associated with an increased time interval to delivery in asymptomatic patients with singleton pregnancies with an extremely short cervical length (≤10 mm) and no history of spontaneous preterm birth.

STUDY DESIGN

This was a multicenter retrospective cohort study of asymptomatic patients with singleton pregnancies with a cervical length of ≤10 mm between 16 and 23 weeks' gestation from January 2014 to December 2019. Patients with previous spontaneous preterm birth, symptoms of preterm labor, cervical dilation of >1 cm, pessary, major fetal structural malformations, or missing data were excluded from the study. The primary outcome of time interval from diagnosis to delivery was compared between those who had a cervical cerclage after diagnosis and those who did not. The secondary outcomes included gestational age at delivery and adverse neonatal outcomes. Moreover, a subgroup analysis of all outcomes in patients already being treated with vaginal progesterone in each group was performed. Statistical analysis included chi-square and Wilcoxon rank-sum tests and a multivariate Cox proportional hazard regression for time interval to delivery.

RESULTS

Of the 90 patients included in the study, 52 (57.8%) had cervical cerclage, of which 35 (67.3%) were already being treated with progesterone. Moreover, 38 patients (42.2%) did not have cervical cerclage, of which 21 (55.3%) were already being treated with progesterone. Patients in the cervical cerclage group had an earlier gestational age (21.0 vs 22.0 weeks' gestation; P≤.001) and shorter cervical length (5 vs 7 mm; P=.002) at the diagnosis of a short cervix (cervical length≤10 mm) than those who did not have a cerclage. Cervical cerclage was associated with a longer time interval to delivery (17.0 vs 15.0 weeks; P=.02) and lower hazard of earlier delivery after diagnosis (adjusted hazard ratio, 0.61; 95% confidence interval, 0.38-0.99; P=.04) than no cerclage, after accounting for gestational age and cervical length at diagnosis. In patients already treated with progesterone, cervical cerclage was also associated with a longer time interval to delivery (17.0 vs 13.1 weeks; P=.01) and a lower hazard of earlier delivery after diagnosis (adjusted hazard ratio, 0.49; 95% confidence interval, 0.27-0.87; P=.02) compared to those with no cerclage. Late preterm birth was less common in patients with a cervical cerclage compared with those with no cervical cerclage (11.5% vs 31.6%; P=.03).

CONCLUSION

Cervical cerclage should be considered in asymptomatic patients with an extremely short cervical length (≤10 mm) and no history of spontaneous preterm birth.

Painless cervical dilation with "hourglass membranes". Conservative management: our experience

BACKGROUND

Cervical competence is currently conceived as a continuous biological process with progressive degrees of insufficiency, this substituting the traditional vision of cervical competence as being present or absent. The most extreme expression of cervical insufficiency is known as "hourglass membranes". Currently no consensus exists regarding the treatment of pregnancies complicated by the protrusion of amniotic membranes; however, the majority of authors agree on recommending bed rest and performing cervical cerclage, known as "emergent cerclage".

METHODS

We describe a series of clinical cases corresponding to second-trimester pregnancies with cervical dilation and prolapsed amniotic membranes that were admitted to our hospital,managed with conservative treatment. All patients received the same basic treatment: intravenous fluid therapy for hydration, a single-oral-dose of azithromycin and intravenous antibiotic therapy for 7 days, vaginal micronized progesterone and indomethacin administrated orally.

RESULTS

Mean gestational age at diagnosis was 22,5 weeks with an extension of pregnancy between 2.1 and 16 weeks, with eight patients (72.72%) who extended their pregnancy for more than 8 weeks. In all cases, live fetuses were obtained, with favourable evolution.

CONCLUSIONS

Despite our limited experience, resulting from the low number of cases presenting, our results encourage us to propose conservative management in pregnancies complicated with a dilated cervix and membranes protruding into the vagina, as a reasonable alternative to surgical emergency cervical cerclage, which is currently considered the therapy of choice when extreme cervical shortening occurs in the second trimester of pregnancy.

The efficacy of therapeutic cervical cerclage in singleton pregnancies: a retrospective study

OBJECTIVES

We compared the pregnancy prolongation effect attributable to cervical cerclage to that achieved by conservative management, and determined the cervical length for which cervical cerclage is effective.

METHODS

We retrospectively examined medical records of 281 women admitted to our hospital between January 2013 and December 2017 for management of threatened preterm birth at 22-28 weeks of gestation. Obstetricians determined suitability for cervical cerclage, which was performed using the McDonald procedure in all cases. Of the 281 subjects, 71 underwent cervical cerclage (cerclage group); the other 210 received conservative therapy (non-cerclage group). We recorded maternal and neonatal characteristics of all patients. The two groups were compared in terms of length of extension of pregnancy and weeks of gestation at delivery. Multivariate analysis was performed to identify factors associated with extension of time to delivery.

RESULTS

Our analyses revealed that the cerclage group was hospitalized earlier in pregnancy than the non-cerclage group (23.7 ± 1.5 weeks vs. 26.4 ± 1.9 weeks, p < .001) and had shorter cervixes (6.0 ± 9.4 mm vs. 16.9 ± 13.0 mm, p < .001). The two groups did not differ significantly in terms of gestational weeks at delivery. Multivariate analysis regarding extension of pregnancy revealed significant differences in extension of pregnancy related with cervical cerclage (26.65 days, 95% CI 17.0 - 36.3, p < .001) and cervical length <10 mm (-27.4 days, 95% CI -36.0--18.8, p < .001). While the time to delivery was extended by cervical cerclage in women with short cervixes (<25 mm), the two groups did not differ when cervical length was ≥15 mm.

CONCLUSIONS

Cervical cerclage was a significant positive factor and short cervix was a significant negative factor for elongating pregnancy. In primigravida and multigravida women with no history of preterm birth, when the cervix is short (<10 mm), cervical cerclage should be recommended.

Current Approaches to Risk Assessment and Prevention of Preterm Birth-A Continuing Public Health Crisis

Background: Preterm birth remains a major cause of neonatal morbidity and mortality. Several potential pathways and pathophysiologic processes can lead to preterm birth, complicating efforts to screen for the risk of preterm birth and making implementation of prevention strategies difficult.

Methods: Based on a review of the literature, this article addresses screening strategies for preterm birth risk stratification and interventions for preterm birth prevention.

Results: In women with a history of a prior spontaneous preterm birth, cervical cerclage placement in the setting of short cervix reduces the rate of recurrent spontaneous preterm birth. Weekly injections of 17-hydroxyprogesterone caproate (17-P) have been used as standard treatment for the prevention of recurrent preterm birth since 2011. However, results of a replication study of 17-P published in 2020 have raised questions regarding the effectiveness of this drug, and it is under review by the US Food and Drug Administration. Among women with no history of preterm birth, cervical length appears to be the best predictor of risk for preterm birth in asymptomatic women. In women with a cervical length <25 mm, vaginal progesterone has been demonstrated to reduce the risk of preterm birth.

Conclusion: Strategies including cervical length screening, vaginal progesterone administration, cervical cerclage placement, and, potentially, 17-P administration may help reduce rates of preterm birth when used in the appropriate patient populations. Development of protocols for patient evaluation and risk stratification will help identify patients at highest risk for preterm birth and allow use of the best available therapeutic interventions.

A new quantification system for assessing the degree of acute cervical insufficiency based on physical and sonographic examination

OBJECTIVES

Acute cervical insufficiency accounts for 10-25 % of all mid-trimester pregnancy losses. However, the definition and description for the degree of acute cervical insufficiency were obscure and different among the many studies. The aim of this study was to suggest a new 4-digit quantification system and to evaluate the outcome according to the new system in women with acute cervical insufficiency.

STUDY DESIGN

A retrospective cohort study was conducted in patients with acute cervical insufficiency who underwent physical examination indicated cervical cerclage. Acute cervical insufficiency was defined as painless external os dilation with prolapsed and/or visible membranes on speculum examination. The status of fetal membranes was described using two values: 1) size of the prolapsed membrane (P, measured using ultrasound); and 2) size of visible fetal membranes (M, evaluated by speculum examination). The status of cervix was described using two values: 1) dilatation of the narrowest os (O, measured by ultrasound); and 2) functional cervical length (C, measured by ultrasound). The patients were divided into 3 groups as follows: Stage I, patients with visible fetal membranes (M > 0) but with a remaining functional cervix (C > 0) (N = 7); stage II, those with visible fetal membranes (M > 0) and a functional cervical length of 0 but without prolapsed membranes (P = 0) (N = 33); and stage III, those with prolapsed membranes (P > 0) (N = 40).

RESULTS

1) Patients who delivered before 34 weeks of gestation had a significantly lower median gestational age at cerclage operation and a significantly higher median P, M, C values than those who delivered at or beyond 34 weeks of gestation(P < 0.01 for gestational age at operation, P and M values; P < 0.05 for C value); 2) The higher the stage based on PMOC quantification system, the greater the risk of preterm delivery before <24, <32, <34, and <37 weeks of gestation (P < 0.001 for all); 3) The neonatal survival rate was 100 % (7/7) for stage I, 93.9 % (31/33) for stage II, and 60 % (24/40) for stage III.

CONCLUSION

The PMOC system was a simple method to describe the individualized conditions and to predict the risk of preterm births in all spectrums of acute cervical insufficiency.

Controversies in the prevention of spontaneous preterm birth in asymptomatic women: an evidence summary and expert opinion

Preterm birth prevention is multifaceted and produces many nuanced questions. This review addresses six important clinical questions about preterm birth prevention as voted for by members of the UK Preterm Clinical Network. The questions cover the following areas: preterm birth prevention in 'low-risk' populations; screening for asymptomatic genital tract infection in women at high risk of preterm birth; cervical length screening with cerclage or vaginal pessary in situ; cervical shortening whilst using progesterone; use of vaginal progesterone in combination with cervical cerclage; and optimal advice about intercourse for women at high risk of preterm birth.

Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies

BACKGROUND

Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments.

OBJECTIVES

To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout.

MAIN RESULTS

We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.

Prevention of preterm birth: Proactive and reactive clinical practice-are we on the right track?

Preterm birth remains the major cause of death and disability among children under the age of five. In developing countries antenatal preterm birth prevention clinics are set up to provide cervical length surveillance and/or treatment modalities such as cerclage or progesterone for those women with identified risk factors such as previous cervical treatment or preterm birth. However, 85% of women have no risk factors for PTB and currently there is no biomarker to screen women early in pregnancy. Women will present unexpectedly in threatened preterm labour and we have no choice but to adopt a re-active approach to their care by using predication and preparation strategies such as fetal fibronectin, tocolytic therapy and steroids. Despite these strategies approximately 15-20% of these women will give birth preterm before 34 weeks. There is a urgent need to re-design primary, secondary and tertiary prevention strategies for spontaneous preterm labour (sPTL) in singleton pregnancies aimed at identifying and addressing key gaps in clinical practice and research.

Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis

BACKGROUND

Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting results.

OBJECTIVE

To evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women.

DATA SOURCES

MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth.

STUDY APPRAISAL AND SYNTHESIS METHODS

The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth <34 weeks of gestation. Secondary outcomes included adverse pregnancy, maternal, and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology.

RESULTS

Twelve studies (4687 women and 7167 fetuses/infants) met the inclusion criteria: 8 evaluated pessary vs no pessary in women with a short cervix, 2 assessed pessary vs no pessary in unselected multiple gestations, and 2 compared pessary vs vaginal progesterone in women with a short cervix. There were no significant differences between the pessary and no pessary groups in the risk of spontaneous preterm birth <34 weeks of gestation among singleton gestations with a cervical length ≤25 mm (relative risk, 0.80; 95% confidence interval, 0.43-1.49; 6 trials, 1982 women; low-quality evidence), unselected twin gestations (relative risk, 1.05; 95% confidence interval, 0.79-1.41; 1 trial, 1177 women; moderate-quality evidence), twin gestations with a cervical length <38 mm (relative risk, 0.75; 95% confidence interval, 0.41-1.36; 3 trials, 1128 women; low-quality evidence), and twin gestations with a cervical length ≤25 mm (relative risk; 0.72, 95% confidence interval, 0.25-2.06; 2 trials, 348 women; low-quality evidence). Overall, no significant differences were observed between the pessary and no pessary groups in preterm birth <37, <32, and <28 weeks of gestation, and most adverse pregnancy, maternal, and perinatal outcomes (low- to moderate-quality evidence for most outcomes). There were no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone in singleton gestations with a cervical length ≤25 mm (relative risk, 0.99; 95% confidence interval, 0.54-1.83; 1 trial, 246 women; low-quality evidence) and twin gestations with a cervical length <38 mm (relative risk, 0.73; 95% confidence interval, 0.46-1.18; 1 trial, 297 women; very low-quality evidence). Vaginal discharge was significantly more frequent in the pessary group than in the no pessary and vaginal progesterone groups (relative risks, ∼2.20; high-quality evidence).

CONCLUSION

Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations.

Management of pregnancy after fertility-sparing surgery for cervical cancer

Cervical cancer is increasingly diagnosed in women who have not yet completed their reproductive plans. For women with early-stage disease (FIGO stage IA1-IB1), fertility-sparing procedures, such as conization, trachelectomy or radical trachelectomy, represent the treatments of choice. However, women who undergo repeated conization or trachelectomy represent a challenge for obstetricians because they are at increased risk of infertility, mid-trimester miscarriage, preterm premature rupture of membranes and preterm delivery. So far, the evidence-based guidance on the management of these pregnancies is limited. This article reviews the literature discussing pregnancy management in women after fertility-sparing surgery for early cervical cancer. Although the evidence is limited, certain measures are desirable, including screening and treatment of asymptomatic bacteriuria, screening for cervical incompetence and progressive cervical shortening by transvaginal ultrasonography, and fetal fibronectin testing. Vaginal progesterone supplementation should be primary prevention for all women after trachelectomy. Women with a history of preterm delivery or late miscarriage may benefit from cervical cerclage. Elective delivery by cesarean section in the early-term period is desirable.

Very short cervix in low-risk asymptomatic singleton pregnancies: Outcome according to treatment and cervical length at diagnosis

INTRODUCTION

The aim of this study was to explore the outcome of low-risk singleton pregnancies with very short cervical length (CL ≤15 mm) according to method of treatment and CL at diagnosis.

MATERIAL AND METHODS

Retrospective study on singleton pregnancies devoid of risk factors for spontaneous preterm delivery identified in the course of universal screening programs by vaginal sonography at 20-24 weeks of gestation to have very short CL ≤ 15 mm.

RESULTS

The study group consisted of 233 pregnancies with CL ≤ 15 mm of which 88 had cervical cerclage inserted and the remaining 145 were treated with vaginal progesterone. Mean CL at diagnosis was significantly shorter in the cerclage group (5 mm) compared with the progesterone group (12 mm). Regardless of treatment there was no difference in the rate of spontaneous preterm delivery at <32 weeks of gestation in women with CL ≥ 9 mm at screening (11% and 12% in the cerclage and progesterone groups, respectively). In contrast, in the subgroup with CL ≤ 8 mm cervical cerclage resulted in significantly lower rates of spontaneous preterm delivery at <32 weeks of gestation compared with progesterone treatment (20% and 45%, respectively, P = .009) and the median gestational age at birth was significantly greater (37 weeks vs 36 weeks, respectively, P = .013).

CONCLUSIONS

The majority of asymptomatic singleton pregnancies with short CL will remain undelivered until 32 weeks of gestation whether treated with progesterone or cerclage. Women with extreme cervical shortening appear to benefit more from cervical cerclage.

The State of the Science of Preterm Birth: Assessing Contemporary Screening and Preventive Strategies

Preterm birth remains a leading cause of morbidity and mortality during the perinatal and neonatal periods. Now affecting approximately 1 in 10 births in the United States, preterm birth often occurs spontaneously and without a clear etiology. Careful assessment of risk factors, however, identifies vulnerable women allowing targeted interventions such as progestogen therapy and cerclage. This article is intended to highlight preterm birth risk factors and current predictive and preventive strategies for midwives, nurse practitioners, clinical nurse specialists, and perinatal nurses.

Progestogens for the prevention of preterm birth and risk of developing gestational diabetes mellitus: a meta-analysis

BACKGROUND

Several articles have implied that progestogen supplementation during pregnancy to reduce the risk of preterm birth may increase the risk for developing gestational diabetes mellitus.

OBJECTIVE

The purpose of the present meta-analysis was to accumulate existing evidence concerning this correlation.

DATA SOURCES

We searched Medline (1966-2019), Scopus (2004-2019), Clinicaltrials.gov (2008-2019), EMBASE (1980-2019), Cochrane Central Register of Controlled Trials CENTRAL (1999-2019), and Google Scholar (2004-2019) databases.

STUDY ELIGIBILITY CRITERIA

Randomized trials and observational studies were considered eligible for inclusion in the present meta-analysis. To minimize the possibility of article losses, we avoided language, country, and date restrictions.

STUDY APPRAISAL AND SYNTHESIS METHODS

The methodological quality of included studies was evaluated with the Cochrane risk of bias and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Meta-analysis was performed with the RevMan 5.3 and secondary analysis with the Open Meta-Analyst software. Trial sequential analysis was conducted with the trial sequential analysis program.

RESULTS

Overall, 11 studies were included in the present meta-analysis that recruited 8085 women. The meta-analysis revealed that women who received 17-alpha hydroxyprogesterone caproate had increased the risk of developing gestational diabetes mellitus (risk ratio, 1.73, 95% confidence interval, 1.32-2.28), whereas women who received vaginal progesterone had a decreased risk, although the effect did not reach statistical significance because of the unstable estimate of confidence intervals (risk ratio, 0.82, 95% confidence interval, 0.50-1.12). Meta-regression analysis indicated that neither the methodological rationale for investigating the prevalence of gestational diabetes mellitus (incidence investigated as primary or secondary outcome) (coefficient of covariance, -0.36, 95% confidence interval, -0.85 to 0.13, P = .154) nor the type of investigated study (randomized controlled trial/observational) (coefficient of covariance -0.361, 95% confidence interval, -1.049 to 0.327, P = .304) significantly altered the results of the primary analysis. Trial sequential analysis suggested that the meta-analysis concerning the correlation of 17-alpha hydroxyprogesterone caproate was of adequate power to reach firm conclusions, whereas this was not confirmed in the case of vaginal progesterone.

CONCLUSION

The results of the present meta-analysis clearly indicate that women who receive supplemental 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth have an increased risk of developing gestational diabetes mellitus. On the other hand, evidence concerning women treated with vaginal progesterone remains inconclusive.

The risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23-28 weeks' gestation

BACKGROUND

Asymptomatic short cervical length is an independent risk factor for spontaneous preterm birth. However, most studies have focused on the associated risk of a short cervical length when encountered between 16 and 23 weeks' gestation. The relationship between cervical length and risk of spontaneous preterm birth after 23 weeks is not well known.

OBJECTIVE

To evaluate the risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23-28 weeks' gestation.

MATERIALS AND METHODS

A retrospective cohort study of women with asymptomatic short cervix (cervical length ≤25 mm) at extreme prematurity, defined as 23-28 weeks' gestation, was performed at a single center from January 2015 to March 2018. Women with symptoms of preterm labor, multiple gestations, fetal or uterine anomalies, cervical cerclage, or those with incomplete data were excluded from the study. Demographic information as well as data on risk factors for spontaneous preterm birth were collected. Patients were divided into 4 groups based on the cervical length measurement (≤10 mm, 11-15 mm, 16-20 mm, and 21-25 mm). The primary outcome was time interval from enrollment to delivery. Secondary outcomes included delivery within 1 and 2 weeks of enrollment, gestational age at delivery, and delivery prior to 32, 34, and 37 weeks, respectively. Continuous variables were compared using Kruskal-Wallis test, whereas categorical variables were compared using the χ² or Fisher exact test as appropriate. The Wilcoxon test for difference in survival time was used to compare gestational age at delivery among the 4 cervical length groups, with data stratified based on gestational age at enrollment.

RESULTS

Of the 126 pregnancies that met inclusion criteria, 22 (17.4%) had a cervical length of ≤10 mm, 23 (18.3%) had a cervical length of 11-15 mm, 37 (29.4%) had a cervical length of 16-20 mm, and 44 (34.9%) had a cervical length of 21-25 mm. Baseline characteristics were similar among all 4 groups. The shorter cervical length group was associated with a shorter time interval from enrollment to delivery (cervical length ≤10 mm, 10 weeks; cervical length 11-15 mm, 12.7 weeks; cervical length of 16-20 mm, 13 weeks; cervical length of 21-25 mm, 13.2 weeks; P = .006). Regardless of the cervical length measurement, delivery within 2 weeks was extremely uncommon (1 patient; 0.8%). The prevalence of spontaneous preterm birth at <32 weeks or <34 weeks was higher in women with a cervical length of ≤10 mm compared to those with a longer cervical length (P < .001).

CONCLUSIONS

The risk of spontaneous preterm birth in asymptomatic women with a sonographic short cervix increases as cervical length decreases. The risk is substantially higher in women with a cervical length of ≤10 mm. Women with a cervical length of ≤10 mm also had the shortest time interval to delivery. Nevertheless, delivery within 1 or 2 weeks is highly unlikely, regardless of the cervical length at the time of enrollment. Therefore, based on our data, we suggest that management decisions such as timing of administration of antenatal corticosteroids in asymptomatic patients with a cervical length of ≤25 mm at 23-28 weeks' gestation may be delayed until additional indications are present.

Evidence that antibiotic administration is effective in the treatment of a subset of patients with intra-amniotic infection/inflammation presenting with cervical insufficiency

BACKGROUND

Cervical insufficiency is a risk factor for spontaneous midtrimester abortion or early preterm birth. Intra-amniotic infection has been reported in 8-52% of such patients and intra-amniotic inflammation in 81%. Some professional organizations have recommended perioperative antibiotic treatment when emergency cervical cerclage is performed. The use of prophylactic antibiotics is predicated largely on the basis that they reduce the rate of complications during the course of vaginal surgery. However, it is possible that antibiotic administration can also eradicate intra-amniotic infection/inflammation and improve pregnancy outcome.

OBJECTIVE

To describe the outcome of antibiotic treatment in patients with cervical insufficiency and intra-amniotic infection/inflammation.

STUDY DESIGN

The study population consisted of 22 women who met the following criteria: (1) singleton pregnancy; (2) painless cervical dilatation of >1 cm between 16.0 and 27.9 weeks of gestation; (3) intact membranes and absence of uterine contractions; (4) transabdominal amniocentesis performed for the evaluation of the microbiologic and inflammatory status of the amniotic cavity; (5) presence of intra-amniotic infection/inflammation; and (6) antibiotic treatment (regimen consisted of ceftriaxone, clarithromycin, and metronidazole). Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and polymerase chain reaction for Ureaplasma spp. was performed. Intra-amniotic infection was defined as a positive amniotic fluid culture for microorganisms or a positive polymerase chain reaction for Ureaplasma spp., and intra-amniotic inflammation was suspected when there was an elevated amniotic fluid white blood cell count (≥19 cells/mm³) or a positive rapid test for metalloproteinase-8 (sensitivity 10 ng/mL). For the purpose of this study, the "gold standard" for diagnosis of intra-amniotic inflammation was an elevated interleukin-6 concentration (>2.6 ng/mL) using an enzyme-linked immunosorbent assay. The results of amniotic fluid interleukin-6 were not available to managing clinicians. Follow-up amniocentesis was routinely offered to monitor the microbiologic and inflammatory status of the amniotic cavity and fetal lung maturity. Treatment success was defined as resolution of intra-amniotic infection/inflammation or delivery ≥34 weeks of gestation.

RESULTS

Of 22 patients with cervical insufficiency and intra-amniotic infection/inflammation, 3 (14%) had microorganisms in the amniotic fluid. Of the 22 patients, 6 (27%) delivered within 1 week of amniocentesis and the remaining 16 (73%) delivered more than 1 week after the diagnostic procedure. Among these, 12 had a repeat amniocentesis to assess the microbial and inflammatory status of the amniotic cavity; in 75% (9/12), there was objective evidence of resolution of intra-amniotic inflammation or intra-amniotic infection demonstrated by analysis of amniotic fluid at the time of the repeat amniocentesis. Of the 4 patients who did not have a follow-up amniocentesis, all delivered ≥34 weeks, 2 of them at term; thus, treatment success occurred in 59% (13/22) of cases.

CONCLUSION

In patients with cervical insufficiency and intra-amniotic infection/inflammation, administration of antibiotics (ceftriaxone, clarithromycin, and metronidazole) was followed by resolution of the intra-amniotic inflammatory process or intra-amniotic infection in 75% of patients and was associated with treatment success in about 60% of cases.

Cervical Pessary versus Expectant Management for the Prevention of Delivery Prior to 36 Weeks in Women with Placenta Previa: A Randomized Controlled Trial

Objective  This multicenter randomized controlled trial compared cervical pessary (CP) versus expectant management (EM) in women with placenta previa between 22.0 and 32.0 in prolonging gestation until ≥ 36.0 weeks' gestation. Study Design  This study took place from November 2016 to June 2018. Women were randomized to receive either the Bioteque CP or EM. The pessary was removed at ≥ 36.0 weeks unless indicated. The primary outcome was gestational age (GA) at delivery, with secondary outcomes including need for transfusion, number and duration of antepartum admissions, type of delivery, and neonatal outcomes. A total of 140 patients were needed to show a 3-week prolongation of pregnancy in the pessary group; however, the trial was stopped early due to budgetary issues. Results  Of the 33 eligible women, 17 were enrolled. Although not statistically significant, the mean GA at delivery in the CP group was greater than women in the EM group (36.5 ± 1.23 vs. 36.0 ± 2.0; p  = 0.1673). The number and duration of antepartum admissions was greater in the EM group (2.7 ± 0.58 vs. 16.0 ± 22.76 days; p  = 0.1264) as well. Conclusion  Although the study was underpowered to determine the primary outcome, safety and feasibility of CP in pregnancies complicated with previa were demonstrated.

Efficacy of different cerclage suture materials in reducing preterm birth

Objective: To compare the efficacy of monofilament suture, braided polyester thread, and 5 mm tape suture in reducing preterm birth (PTB).Study design: Women who received a cerclage at Touro Infirmary, New Orleans, LA, USA, between 1 January, 2011 and 31 December, 2016 were identified using ICD-9/10 codes. All charts were reviewed for demographic and obstetrical variables including gestational age (GA) at delivery.Results: Of 145 women who received a cerclage, 36 were excluded due to incomplete charts leaving 109 for analysis. There was no significant difference in gestational age at cerclage placement or delivery among women with monofilament, braided, or 5 mm tape cerclages (p = .936 and p = .919, respectively) nor was there a difference in the proportion who delivered at ≥32, 34, or 37 weeks across groups with differing cerclage material (p = .270, p = .275, and p = .419, respectively). There was no difference in GA at delivery for patients who received 17-OHP compared to those who did not (p = .362). There were also no differences with respect to birth outcomes such as birthweight (p = .938), Apgar scores (p = .477, p = .430) or neonatal intensive care admission rates (NICU) (p = .304). Analysis revealed no difference in characteristics between groups including history of PTB or indication for removal (p = .371, p = .317).Conclusion: We found no difference in pregnancy prolongation when comparing different suture material used for indicated cerclages. We also found no differences with respect to rates of maternal infection or adverse neonatal outcomes among groups.RationaleThis study was conducted to evaluate the efficacy of different suture materials in increasing gestational age at delivery and reducing preterm birth.