Cervical modifications after pessary placement in singleton pregnancies with maternal short cervical length: 2D and 3D ultrasound evaluation

Antibiotics and indomethacin as perioperative management for cerclage: A systematic review and meta-analysis

OBJECTIVE

Prematurity complications remain the leading cause of perinatal morbidity and mortality. Although cerclage shows promise in preventing preterm birth, it remains unclear whether perioperative management, such as the use of antibiotics or indomethacin, offers any additional benefit.

STUDY DESING

We conducted a systematic review and random-effects meta-analysis comparing the use of indomethacin, antibiotics, and their combination as perioperative management for cerclage versus cerclage alone. Our research protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on June 9, 2024 (ID CRD42024552516).

RESULTS

Our systematic review encompassed ten studies, and 838 pregnant women submitted to cerclage for prevention of preterm birth. We found no association between perioperative management and preterm birth before 28 weeks (RR 1.03; 95 % CI 0.76-1.39; p = 0.86), or perinatal mortality (RR 0.81; 95 % CI 0.54-1.22; p = 0.32).

CONCLUSION

Antibiotics, indomethacin, and their combination may have no additional benefit to cerclage in risk reduction of preterm birth or perinatal mortality.

Risk factors of early spontaneous preterm birth despite carrying a cervical pessary in singleton pregnancies with a short cervix: Development of a risk prediction model

Introduction

We aimed to identify the incidence and risk factors of spontaneous preterm birth in pessary carriers with singleton pregnancies and a short cervix in the mid-trimester of pregnancy.

Material and Methods

Patient data were obtained from the PECEP Trial. We analyzed singleton pregnancies in pessary carriers with a short cervix (≤25 mm) between 18 and 22 gestational weeks. Demographics and obstetric history were compared to identify risk factors for spontaneous preterm birth < 34 gestational weeks. Each demographic and obstetric variable was compared between spontaneous preterm birth < 34 and ≥ 34 weeks of gestation.Regression analysis was used to identify risk factors. A risk score model was generated using the odds ratio for significant factors. The risk score model and spontaneous preterm birth risk were assessed using the receiver operating characteristic curve. Perinatal outcomes were compared by risk score.

Results

Among 190 pregnant individuals, 12 (6.3%) had spontaneous preterm birth < 34 gestational weeks. In the bivariate analysis, statistically significant differences between those with and without spontaneous preterm birth were only observed for mean cervical length at diagnosis and mean cervical length after pessary placement. By multiple logistic regression analysis, maternal age (OR 0.818; 95% CI 0.69-0.97; P 0.020), cervical length at diagnosis (OR 0.560; 95% CI 0.43-0.73; P < 0.001) and smoking status (OR 7.276; 95% CI 1.02-51.80; P 0.048) remained significantly associated with spontaneous preterm birth.The ROC curve from the multiple logistic regression analysis, including cervical length, maternal age and smoking status, had an area under the curve (AUC) of 0.952 (P < 0.001). The ROC curve for the risk score model incorporating all three variables had an AUC of 0.864 (95% CI 0.77-0.96; P < 0.001). A high-risk score was predictive of spontaneous preterm birth with a sensitivity of 75%, specificity of 84%, positive predictive value of 24%, and negative predictive value of 98%.Women with a high-risk score had a significantly reduced latency to delivery and poorer neonatal outcomes than those with a low-risk score.

Conclusions

Patients at a high risk for spontaneous preterm birth despite pessary therapy may be identified using cervical length at diagnosis added to maternal age and smoking status.

Prevention of Preterm Birth by Cervical Pessary Combined with Vaginal Progesterone: a Systematic Review and Meta-analysis with Trial Sequential Analysis

This study was to assess the effectiveness of cervical pessary combined with vaginal progesterone for the prevention of preterm birth (PTB). Ten studies about singleton [five randomized controlled trials (RCTs), vs vaginal progesterone; four cohorts, vs vaginal progesterone; two cohorts, vs cervical cerclage + vaginal progesterone] and two cohort studies about multiple pregnancies (vs vaginal progesterone) were included after searching electronic databases. For singleton pregnancies, the meta-analysis of three non-RCTs [relative risk (RR) = 0.41, p = 0.001] or total trials in non-Asian country (RR = 0.56, p = 0.03) revealed that compared with vaginal progesterone alone, cervical pessary + vaginal progesterone treatment had significant effectiveness on preventing PTB < 34 weeks, but not for five RCTs; meta-analysis of two trials showed that cervical pessary + vaginal progesterone had no significant prevention effects of PTB compared with cervical cerclage + vaginal progesterone. For multiple pregnancies, meta-analysis of two trials showed that compared with vaginal progesterone, cervical pessary + vaginal progesterone treatment increased neonatal birth weight (standardized mean difference = 0.50, p = 0.01). Trial sequential analysis implied additional studies were required. Four studies vs other controls (pessary, three-combined, tocolysis, conservative or no treatment; one study, each) were selected for systematic review. In conclusion, cervical pessary combined with vaginal progesterone may be safe and effective to prevent PTB in singleton pregnancies and increase neonatal birth weight in the multiple pregnancies compared with vaginal progesterone alone.

The role of obstetric pessary and micronized progesteron in early preterm birth prevention in patients with multiple pregnancy

Background. Multiple pregnancy is a well-established risk factor for preterm birth. Prevention of early termination of pregnancy is a priority problem in obstetric practice.The aim. To evaluate the role of an obstetric pessary and micronized progesterone in the prevention of early preterm labor in patients with multiple pregnancies.Materials and methods. A prospective controlled study was conducted with the inclusion of 146 pregnant women with multiple pregnancies, which, depending on the methods of treatment, were divided into three groups: Group I (n = 67) – pregnant women who received micronized progesterone in combination with an obstetric pessary; Group II (n = 57) included women who received micronized progesterone; Group III (n = 22) consisted of patients with multiple pregnancies without therapy.Results. In Group I, the complex of an obstetric pessary and micronized progesterone allowed to reduce the frequency of preterm birth by 2.3 times (p = 0.008) in comparison with Group III, the frequency of births at gestational age ≤ 34 weeks – by 8.1 times (p = 0.005) in compared with Group III and 2.7 times (p < 0.01) compared with Group II. In 70.4 % of pregnant women, the use of a complex of an obstetric pessary with micronized progesterone made it possible to prevent the formation of isthmiccervical insufficiency, which, according to sonography, was expressed in the dynamics of the utero-cervical angle towards a more obtuse one.Conclusion. The use of an obstetric pessary with micronized progesterone made it possible to reduce the risks of isthmic-cervical insufficiency by 7.7 % compared with patients who received only micronized progesterone therapy, and by 17.1 % compared with pregnant women who did not receive therapy.

The impact of cervical conization size with subsequent cervical length changes on preterm birth rates in asymptomatic singleton pregnancies

The study aimed to explore the impact of cervical conization size (CCS) with subsequent cervical length (USCL) changes on preterm birth (PTB) rates in asymptomatic singleton pregnancies as compared to pregnancy outcomes in healthy women with an intact cervix (ICG), and to estimate PTB prevention efficiency in patients with a short cervix. Pregnancy outcomes in populations of similar age, ethnicity, residency, education and harmful habits having undergone cervical conization (CCG) were retrospectively analyzed and compared to ICG and cervical conization sub-populations adjusted by USCL during pregnancy (adequate cervical length vs. a short cervix) and a progesterone-only group (POG) vs. a progesterone-pessary group (PPG). Cervical conization was not associated with an increased PTB risk (CCG vs. ICG) when parameters of CCS and USCL were not adjusted (p = NS). A significantly higher proportion of parous women was observed in the CCG population than in the ICG (p = 0.0019). CCS turned out to be a key PTB risk during pregnancy, the larger CCS being associated with a short cervix (p = 0.0001) and higher PTB risks (p = 0.0001) with a notably increased PTB rate (p = 0.0001) in nulliparous women (p = 0.0022), whereas smaller CCS with adequate cervical length and a lower PTB rate was predominantly observed in women with prior parity. An initial equal USCL size was to be considerably elongated in women with adequate cervical length (p < 0.0001), and shortened in those with a short cervix (p < 0.0001). USCL assessment during pregnancy proved to be the PTB risk-predicting tool, with CCS supplementation apt to increase its diagnostic value. No substantial impact on pregnancy outcomes could be linked to any particular PTB prevention mode (POG or PPV). However, during pregnancy, the USCL changes relating to CCS proved to be more critical in pregnancy outcomes.

Cervical Pessary Plus Progesterone for Twin Pregnancy with Short Cervix Compared to Unselected and Non-Treated Twin Pregnancy: A Historical Equivalence Cohort Study (EPM Twin Pessary Study)

OBJECTIVE

 The present study aims to determine if the use of cervical pessary plus progesterone in short-cervix (≤ 25 mm) dichorionic-diamniotic (DC-DA) twin pregnancies is equivalent to the rate of preterm births (PBs) with no intervention in unselected DC-DA twin pregnancies.

METHODS

 A historical cohort study was performed between 2010 and 2018, including a total of 57 pregnant women with DC-DA twin pregnancies. The women admitted from 2010 to 2012 (n = 32) received no treatment, and were not selected by cervical length (Non-Treated group, NTG), whereas those admitted from 2013 to 2018 (n = 25), were routinely submitted to cervical pessary plus progesterone after the diagnosis of short cervix from the 18th to the 27th weeks of gestation (Pessary-Progesterone group, PPG). The primary outcome analyzed was the rate of PBs before 34 weeks.

RESULTS

 There were no statistical differences between the NTG and the PPG regarding PB < 34 weeks (18.8% versus 40.0% respectively; p = 0.07) and the mean birthweight of the smallest twin (2,037 ± 425 g versus 2,195 ± 665 g; p = 0.327). The Kaplan-Meyer Survival analysis was performed, and there were no differences between the groups before 31.5 weeks. Logistic regression showed that a previous PB (< 37 weeks) presented an odds ratio (OR) of 15.951 (95% confidence interval [95%CI]: 1.294-196.557; p = 0.031*) for PB < 34 weeks in the PPG.

CONCLUSION

 In DC-DA twin pregnancies with a short cervix, (which means a higher risk of PB), the treatment with cervical pessary plus progesterone could be considered equivalent in several aspects related to PB in the NTG, despite the big difference between these groups.

Prediction of preterm birth and adverse perinatal outcomes after cervical pessary placement in singleton pregnancies with short cervical length

OBJECTIVES

To identify ultrasound-assessed cervical characteristics, modified after pessary placement, which could be predictive of spontaneous preterm birth (sPTB) at < 34 weeks of gestation (WG) or severe adverse perinatal outcomes (APO).

STUDY DESIGN

This prospective observational study conducted at Vall d'Hebron Universitary Hospital assessed multiple cervical characteristics in women with short cervical length (CL). All participants were examined by transvaginal ultrasound before and immediately after a cervical pessary was placed. Cervical assessment included CL, uterocervical angles (UCA), and cervical consistency indexes (cervical consistency index (CCI) and cervical length consistency index (CLCI)). Pregnancy outcomes were recorded to determine the capacity of these variables for predicting sPTB at < 34 WG and severe APO.

RESULTS

Thirty-one women with short CL, 17 (54.8%) with asymptomatic midtrimester short CL, and 14 (45.2%) after arrested threatened preterm labor were enrolled. After pessary placement, transvaginal ultrasound detected four participants in whom the pessary was not correctly placed around the cervix (12.9%); additionally, significant changes were observed in most cervical baseline characteristics, with CL, anterior UCA (A-UCA), CLCI, and intersegmentary angle (ISA) being predictive of sPTB at <34 WG and severe APO. Receiver operator curves were calculated to compare the predictive capacity of these variables, with CL and A-UCA after pessary placement being the best predictive parameters with an area under the curve of 0.88 and 0.87, respectively.

CONCLUSIONS

Transvaginal ultrasound after pessary placement detects incorrect pessary placement after pessary insertion and during follow-up. APO and sPTB can be predicted by measuring CL, A-UCA, CLCI, and ISA immediately after pessary placement, being CL and A-UCA more accurate and easier to be measured. Our results help to better identify women in whom the pessary is more likely to fail. Further research is required to assess the effectiveness of applying alternative, sequential or additional treatments to reduce prematurity and our results could be considered when designing such studies.