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Hart JM, Macharia A, Modest AM, Johnson KM, Lauring J, Nicasio E, Hacker MR, Spiel MH. Cerclage Plus Adjuvant Vaginal Progesterone for Preterm Birth Prevention in Patients with a Short or Dilated Cervix without Prior Preterm Birth. Am J Perinatol 2024; 41:1595-1603. [PMID: 38698597 DOI: 10.1055/s-0044-1786175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
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..
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Affiliation(s)
- Jessica M Hart
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Annliz Macharia
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Katherine M Johnson
- Department of Obstetrics and Gynecology, University of Massachusetts Memorial Health, Worcester, Massachusetts
- Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Julianne Lauring
- Department of Obstetrics and Gynecology, University of Massachusetts Memorial Health, Worcester, Massachusetts
- Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Erica Nicasio
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Melissa H Spiel
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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Hanke K, Fortmann MI, Auerswald GH, Härtel C, Olbertz D, Roll C, Grüttner B, Wieg C, Breunig S, Rody A, Felderhoff-Müser U, Herting E, Göpel W, Bossung V. Use and Impact of Pessary, Cerclage, and Progesterone for the Secondary Prevention of Preterm Birth: Data from the German Neonatal Network. Z Geburtshilfe Neonatol 2024; 228:246-254. [PMID: 38228167 DOI: 10.1055/a-2217-9463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND To evaluate the use and effect of cervical stitch cerclage, pessary, and progesterone on pregnancy outcome in mothers of very low birth weight infants (VLBWI) born<32 weeks of gestation in the German Neonatal Network (GNN). METHODS The GNN is a population-based cohort study enrolling VLBWI since 2009. We included 575 neonates from 424 mothers into our analysis, who were born between 2015 and 2019, after prenatal intervention with cerclage, pessary, progesterone or a combination between 20/0 to 25/0 weeks of gestation to prevent preterm birth. Median intervention-to-birth interval was the primary endpoint. RESULTS 231 of 424 pregnant women had a cerclage only (54.5%), 76 women a pessary only (17.9%), and 27 were prescribed progesterone only (15.3%). The most common combination treatment (>1 intervention group) was cerclage plus progesterone (n=27), followed by cerclage plus pessary (n=13). The median intervention-to-birth interval for the whole cohort was 24 days (IQR 19.0 days). The earlier the intervention was started, the longer the intervention-to-birth interval lasted: When started at 20 weeks, the interval was 34 days in contrast to 11.5 days, when started at 25 weeks. The >1 group was born at a significantly higher median GA with 27.0 weeks (IQR 2.9 weeks) and a higher median birth weight of 980 g (IQR 394 g) accordingly. CONCLUSION We propose that the earliest possible start of intervention leads to the most efficient pregnancy prolongation.
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Affiliation(s)
- Kathrin Hanke
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Mats Ingmar Fortmann
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Gesa Henrike Auerswald
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Christoph Härtel
- Department of Pediatrics, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Dirk Olbertz
- Department of Neonatology, University of Rostock, Rostock, Germany
| | - Claudia Roll
- Neonatology and Paediatric Intensive Care, Vestische Kinder- und Jugendklinik Datteln, Datteln, Germany
| | | | - Christian Wieg
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau gGmbH, Aschaffenburg, Germany
| | - Stephanie Breunig
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau gGmbH, Aschaffenburg, Germany
| | - Achim Rody
- Department of Obstetrics and Gynaecology, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | | | - Egbert Herting
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Verena Bossung
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland and 15 -University of Zurich, Zurich, Switzerland
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Hsieh MH, Chen CP, Sun FJ, Chen YY, Wang LK, Chen CY. Changes in cervical elastography, cervical length and endocervical canal width after cerclage for cervical insufficiency: an observational ultrasound study. BMC Pregnancy Childbirth 2023; 23:750. [PMID: 37875844 PMCID: PMC10594665 DOI: 10.1186/s12884-023-06071-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/16/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND We previously demonstrated that pregnant women with a history of cervical insufficiency had a softer anterior cervical lip, shorter cervical length and wider endocervical canal in the first trimester. The aim of this study was to investigate changes in cervical elastography, cervical length, and endocervical canal width in the second trimester after cerclage, and further discuss whether these ultrasound parameters are predictive of preterm delivery. METHODS This was a secondary analysis of cervical changes in singleton pregnancies after cerclage from January 2016 to June 2018. Cervical elastography, cervical length, and endocervical canal width were measured during the second trimester in the cervical insufficiency group and control group without cervical insufficiency. Strain elastography under transvaginal ultrasound was used to assess cervical stiffness and presented as percentage (strain rate). RESULTS Among the 339 pregnant women enrolled, 24 had a history of cervical insufficiency and underwent cerclage. Both anterior and posterior cervical lips were significantly softer in the cervical insufficiency group even though they received cerclage (anterior strain rate: 0.18 ± 0.06% vs. 0.13 ± 0.04%; P = 0.001; posterior strain rate: 0.11 ± 0.03% vs. 0.09 ± 0.04%; P = 0.017). Cervical length was also shorter in the cervical insufficiency group (36.3 ± 3.6 mm vs. 38.3 ± 4.6 mm; P = 0.047). However, there was no significant difference in endocervical canal width between the two groups (5.4 ± 0.7 mm vs. 5.6 ± 0.7 mm; P = 0.159). Multivariate logistic regression analysis also revealed significant differences in anterior cervical lip strain rate (adjusted odds ratio [OR], 7.32, 95% confidence interval [CI], 1.70-31.41; P = 0.007), posterior cervical lip strain rate (adjusted OR, 5.22, 95% CI, 1.42-19.18; P = 0.013), and cervical length (adjusted OR, 3.17, 95% CI,1.08-9.29; P = 0.035). Among the four ultrasound parameters, softer anterior cervical lip (P = 0.024) and shorter cervical length (P < 0.001) were significantly related to preterm delivery. CONCLUSIONS Cervical cerclage can prevent widening of the endocervical canal, but not improve cervical elasticity or cervical length. Measuring anterior cervical elastography and cervical length may be valuable to predict preterm delivery.
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Affiliation(s)
- Meng-Hsuen Hsieh
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Chie-Pein Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Liang-Kai Wang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Chen-Yu Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan.
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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Keshtmandi H, Mirmohammadkhani M, Rahmanian M. Adjuvant Treatment with Oral Dydrogesterone in the Prevention of Preterm Labor: A Randomized, Double-Blinded, Placebo-Controlled Trial. Reprod Sci 2023; 30:3037-3045. [PMID: 37166606 DOI: 10.1007/s43032-023-01249-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/23/2023] [Indexed: 05/12/2023]
Abstract
We conducted a double-blind, randomized, placebo-controlled clinical trial to evaluate the efficacy of oral dydrogesterone (DG) on maternal and neonatal consequences in the treatment of preterm labor. We included 100 nulliparous mothers (24-34 weeks) with normal pregnancy who had preterm labor pain. Participants who received magnesium sulfate were randomly assigned to the investigation group (DG 30 mg/day) or placebo group. Maternal and neonatal outcomes were compared between the two groups. Recurrent uterine contraction (UC) rates (92% vs. 88%, P = 0.862) and the incidence of preterm delivery (66% vs. 58%, P = 0.834) were not different in the DG and placebo groups. No significant differences were observed in terms of gestational age at delivery (33.5 ± 3.5 vs. 34.2 ± 3.2, P = 0.281), latency period (5.53 ± 2.29 days vs. 5.59 ± 2.57 days, P = 0.622), cervical dilation (1.82 ± 0.26 cm vs. 1.84 ± 0.29 cm, P = 0.281), and effacement (53 ± 4.47% vs. 57.21 ± 6.27%, P = 0.622) between the placebo and DG groups. The percentage of neonates with a 1-min Apgar score < 7 was higher in the placebo group compared with that of the DG group (12% vs. 0%, P = 0.0001). However, both groups were similar in the frequency of a 5-min Apgar score < 7. No differences in the term of adverse effects of medications were recorded. Our results showed that DG adjuvant to magnesium sulfate could not be effective in improving the incidence of preterm labor, rate of recurrent UC, latency period, pregnancy outcomes, and maternal and neonatal outcomes when compared with the placebo group.
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Affiliation(s)
- Hengameh Keshtmandi
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Majid Mirmohammadkhani
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Mojgan Rahmanian
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Sciences, Semnan, Iran.
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Aubin AM, McAuliffe L, Williams K, Issah A, Diacci R, McAuliffe JE, Sabdia S, Phung J, Wang CA, Pennell CE. Combined vaginal progesterone and cervical cerclage in the prevention of preterm birth: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101024. [PMID: 37211087 DOI: 10.1016/j.ajogmf.2023.101024] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- Anne-Marie Aubin
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia (Drs Aubin, L. McAuliffe, and Sabdia)
| | - Liam McAuliffe
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia (Drs Aubin, L. McAuliffe, and Sabdia)
| | - Kimberley Williams
- Western Australian Country Health Service, Western Australia, Australia (Dr Williams)
| | - Ashad Issah
- Northern Adelaide Local Health Network, South Australia, Australia (Dr Issah)
| | - Rosanna Diacci
- Central Coast Health District, New South Wales, Australia (Dr Diacci)
| | - Jack E McAuliffe
- University of Adelaide, South Australia, Australia (Mr J. McAuliffe)
| | - Salma Sabdia
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia (Drs Aubin, L. McAuliffe, and Sabdia)
| | - Jason Phung
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia (Dr Phung, Ms Wang, and Professor Pennell); Mothers and Babies Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia (Dr Phung, Ms Wang, and Dr Pennell); Maternity and Gynaecology John Hunter Hospital, New Lambton Heights, New South Wales, Australia (Drs Phung and Pennell)
| | - Carol A Wang
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia (Dr Phung, Ms Wang, and Professor Pennell); Mothers and Babies Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia (Dr Phung, Ms Wang, and Dr Pennell)
| | - Craig E Pennell
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia (Dr Phung, Ms Wang, and Professor Pennell); Mothers and Babies Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia (Dr Phung, Ms Wang, and Dr Pennell); Maternity and Gynaecology John Hunter Hospital, New Lambton Heights, New South Wales, Australia (Drs Phung and Pennell).
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Hulshoff CC, Bosgraaf RP, Spaanderman MEA, Inthout J, Scholten RR, Van Drongelen J. The efficacy of emergency cervical cerclage in singleton and twin pregnancies: a systematic review with meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100971. [PMID: 37084870 DOI: 10.1016/j.ajogmf.2023.100971] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/31/2023] [Accepted: 04/09/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because of cervical insufficiency. This study aimed to investigate the effectiveness of an emergency cerclage in both singleton and twin pregnancies in the prevention of extreme premature birth. DATA SOURCES We performed a systematic literature search in PubMed and Embase from inception to June 2022 for transvaginal cervical emergency cerclages. STUDY ELIGIBILITY CRITERIA All studies on transvaginal cervical emergency cerclages with at least 5 patients and reporting survival were included. METHODS Included studies were assessed for quality and risk of bias with an adjusted Quality In Prognosis Studies tool. Random-effects meta-analyses and meta-regressions were performed for the primary outcome: survival. RESULTS Our search yielded 96 studies, incorporating 3239 women, including 14 studies with an expectant management control group, incorporating 746 women. Overall survival after cervical emergency cerclage was 74%, with a fetal survival of 88% and neonatal survival of 90%. Singleton and twin pregnancies showed similar survival, with a pregnancy prolongation of 52 and 37 days and a gestational age at delivery of 30 and 28 weeks, respectively. Meta-regression analyses indicated a significant inverse association between mean gestational age at diagnosis and pregnancy prolongation and no association between dilatation or gestational age at diagnosis and gestational age at delivery. Compared with expectant management, emergency cerclage significantly increased overall survival by 43%, fetal survival by 17% and neonatal survival by 22%, along with a significant pregnancy prolongation of 37 days and reduction in delivery at <28 weeks of gestation of 55%. These effects were more profound in singleton pregnancies than in twin pregnancies. CONCLUSION This systematic review indicates that, in pregnancies threatened by extreme premature birth because of cervical insufficiency, emergency cerclage leads to significantly higher survival, accompanied by significant pregnancy prolongation and reduction in delivery at <28 weeks of gestation, compared with expectant management. The mean gestational age at delivery was 30 weeks, independent of dilatation or gestational age at diagnosis. Survival was similar for singleton and twin pregnancies, implying that emergency cerclage should be considered in both.
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Affiliation(s)
- Cecile C Hulshoff
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen).
| | - Remko P Bosgraaf
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen); Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands (Dr Bosgraaf)
| | - Marc E A Spaanderman
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen); Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands (Dr Spaanderman)
| | - Joanna Inthout
- Health Evidence (Dr Inthout), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ralph R Scholten
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen)
| | - Joris Van Drongelen
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen)
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Booker WA, Reed EG, Power ML, Schulkin J, Gyamfi-Bannerman C, Manuck T, Berghella V, Vink J. OBGYN practice patterns regarding combination therapy for prevention of preterm birth: A national survey. Eur J Obstet Gynecol Reprod Biol 2021; 266:23-30. [PMID: 34560330 PMCID: PMC9812028 DOI: 10.1016/j.ejogrb.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Our objective was to examine if US obstetrician-gynecologists (OBGYNs) practice outside of evidenced-based guidelines and use a combination of interventions to prevent spontaneous preterm birth (sPTB). STUDY DESIGN An electronic survey was distributed to members of the Pregnancy-Related Care Research Network (PRCRN), and also to members of the Society of Maternal-Fetal Medicine (SMFM). The survey consisted of questions regarding physician demographics, and the use of interventions to prevent sPTB in women with 1) a prior sPTB, 2) an incidental short cervix (no prior sPTB), and 3) a history of cervical insufficiency. RESULTS The PRCRN response rate was 58.6% (283/483) with an additional 143 responses from SMFM members. Among PRCRN responders, 82.7% were general OBGYNs and 17.3% were Maternal-Fetal Medicine subspecialists. Respondents were from all geographic regions of the country; most practiced in a group private practice (42.6%) or academic institution (31.4%). In women with prior sPTB, 45.2% of respondents would consider combination therapy, most commonly weekly intramuscular progesterone (IM-P) and serial cervical length (CL) measurements. If the patient then develops a short cervix, 33.7% would consider adding an ultrasound-indicated cerclage. In women with an incidental short cervix, 66.8% of respondents were likely to recommend single therapy with daily vaginal progesterone (VP). If a patient developed an incidentally dilated cervix, 40.8% of PRCRN respondents would recommend dual therapy, most commonly cerclage + VP, whereas 64.3% of SMFM respondents were likely to continue with VP only. In women with a history of cervical insufficiency, 47% of PRCRN respondents indicated they would consider a combination of IM-P, history-indicated cerclage and serial CL measurements. CONCLUSION Although not currently supported by evidence-based medicine, combination therapy is commonly being used by U.S. OBGYNs to prevent sPTB in women with risk factors such as prior sPTB, short or dilated cervix or more than one of these risks.
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Affiliation(s)
- Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA; The Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA.
| | - Eda G Reed
- Smithsonian National Zoological Park and Conservation Biology Institute, Washington, DC, USA; Bloomberg School of Public Health and Carey Business School, Johns Hopkins University, Baltimore, MD, USA
| | - Michael L Power
- Smithsonian National Zoological Park and Conservation Biology Institute, Washington, DC, USA; American College of Obstetricians and Gynecologists, Washington, DC, USA
| | - Jay Schulkin
- American College of Obstetricians and Gynecologists, Washington, DC, USA; University of Washington School of Medicine, Seattle, WA, USA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA; The Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Tracy Manuck
- Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joy Vink
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA; The Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA
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Diacci RC, Issah A, Williams KP, McAuliffe L, Aubin AM, McAuliffe JE, Phung J, Wang CA, Pennell CE. Effectiveness of combined vaginal progesterone and cervical cerclage in preventing preterm birth: a systematic review and meta-analysis protocol. BMJ Open 2021; 11:e050086. [PMID: 34172552 PMCID: PMC8237739 DOI: 10.1136/bmjopen-2021-050086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/24/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Preterm birth (PTB) is the leading cause of death in children under 5 years. Preventive therapies targeted towards women with risk factors such as a prior PTB or a short cervix reduce the rate of PTB. Cervical cerclage, vaginal progesterone and a combination of the two have been used with no consensus as to whether combined treatment is more effective than any single treatment alone. The objective of this review is to determine the efficacy of combined treatment compared with cerclage alone and combined treatment compared with progesterone alone. METHODS AND ANALYSIS Studies will be sourced from the electronic databases Medline (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Scopus, CINAHL (EBSCOhost) and Cochrane Library (Wiley) and reference lists. We will not exclude any papers due to publication date. Randomised control trials (RCTs), non-RCTs and cohort studies assessing single therapy (either progesterone or cerclage) versus combined therapy in women with a singleton pregnancy will be included. Two independent reviewers will conduct study screening (at abstract and full-text level), data extraction and risk of bias assessment with disagreements resolved by an experienced researcher. Random or fixed effects models will be used depending on data heterogeneity and data will be presented as risk ratio for dichotomous data or mean difference for continuous data with a CI of 95% used for all outcomes. ETHICS AND DISSEMINATION Not applicable due to nature of the study type. PROSPERO REGISTRATION NUMBER CRD42020195975.
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Affiliation(s)
- Rosanna C Diacci
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Ashad Issah
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Kimberley P Williams
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Liam McAuliffe
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Anne-Marie Aubin
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Jack E McAuliffe
- Department of Engineering, Computing and Mathematical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Jason Phung
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Carol A Wang
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Craig E Pennell
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
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Park JY, Oh KJ, Lee S, Kim NK, Lee YE, Park YH, Hong JS. A new quantification system for assessing the degree of acute cervical insufficiency based on physical and sonographic examination. Eur J Obstet Gynecol Reprod Biol 2020; 256:372-378. [PMID: 33278713 DOI: 10.1016/j.ejogrb.2020.11.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Sukjeong Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Nam-Kyeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Young-Eun Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ye Hyon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
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10
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Eleje GU, Eke AC, Ikechebelu JI, Ezebialu IU, Okam PC, Ilika CP. Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies. Cochrane Database Syst Rev 2020; 9:CD012871. [PMID: 32970845 PMCID: PMC8094629 DOI: 10.1002/14651858.cd012871.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- George U Eleje
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, PMB 5001, Nnewi, Nigeria
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph I Ikechebelu
- Department of Obstetrics/Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Ifeanyichukwu U Ezebialu
- Department of Obstetrics and Gynaecology, Faculty of Clinical medicine, College of Medicine, Anambra State University Amaku, Awka, Nigeria
| | - Princeston C Okam
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Chito P Ilika
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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11
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Ali MK, Ahmed SE, Sayed GH, Badran EY, Abbas AM. Effect of adjunctive vaginal progesterone after McDonald cerclage on the rate of second-trimester abortion in singleton pregnancy: a randomized controlled trial. Int J Gynaecol Obstet 2020; 149:370-376. [PMID: 32246762 DOI: 10.1002/ijgo.13148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/17/2019] [Accepted: 03/27/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the effect of adjunctive use of vaginal progesterone after McDonald cerclage on the rate of second-trimester abortion in singleton pregnancy. METHODS A randomized controlled trial at Woman's Health Hospital, Assiut University, Egypt, between April 2017 and March 2019 enrolled women eligible for McDonald cerclage. After cerclage, participants were randomly assigned to receive progesterone (400 mg pessary) once daily until 37 weeks or no progesterone. The primary outcome was rate of abortion before 28 weeks. Secondary outcomes included gestational age at delivery, preterm delivery, mean birthweight, Apgar score, and admission to the neonatal intensive care unit (NICU). RESULTS The rate of spontaneous abortion was higher in the no-progesterone group (P=0.016). Mean gestational age and mean birthweight was higher in the progesterone group (P<0.001 and P=0.002, respectively). The frequency of preterm neonates, neonates with Apgar score less than 7, and admission to NICU was higher in the progesterone group than in the no-progesterone group (P=0.005, P=0.008, and P=0.044, respectively). CONCLUSION Adjunctive use of vaginal progesterone after McDonald cerclage was found to decrease the frequency of second-trimester abortion and to improve perinatal outcomes in singleton pregnancy. Clinicaltrials.gov: NCT02846909.
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Affiliation(s)
- Mohammed K Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sameh E Ahmed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Gamal H Sayed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa Y Badran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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12
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Park JY, Jung YM, Kook SY, Jeon SJ, Oh KJ, Hong JS. The effect of postoperative vaginal progesterone in ultrasound-indicated cerclage to prevent preterm birth. J Matern Fetal Neonatal Med 2019; 34:2473-2480. [PMID: 31558069 DOI: 10.1080/14767058.2019.1668371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To compare pregnancy outcomes according to the use of postoperative vaginal progesterone in patients who underwent ultrasound-indicated cerclage. METHODS This was a retrospective cohort study of 86 consecutive asymptomatic singleton pregnancies who had undergone cerclage because of incidentally found short cervical length under 20 mm through transvaginal ultrasound between 16°/7 and 246/7 weeks' gestational age. Outcomes were compared according to the use of vaginal progesterone after cerclage. Primary outcome measure was preterm delivery < 34 weeks of gestation. RESULTS (1) The frequency of preterm delivery < 34 weeks of gestation was significantly lower in patients with postoperative vaginal progesterone than those without (2.2 versus 18.4%, p = .021); (2) the median gestational age at delivery in the postoperative vaginal progesterone group was significantly longer than the control group (38.3 weeks (interquartile range, 37.5-39.1 weeks) versus 37.3 weeks (interquartile range 33.9-38.6 weeks), p = .020); (3) Multivariable logistic regression analysis demonstrated the use of vaginal progesterone after cerclage was found to be independently associated with decrease in preterm delivery before 34 weeks (Odds ratio 0.10; 95% confidence interval, 0.01-0.93) and 37 weeks (Odds ratio 0.24; 95% confidence interval, 0.07-0.85). CONCLUSIONS The use of vaginal progesterone was associated with lower rates of preterm birth before 34 and 37 weeks of gestation in women who underwent ultrasound-indicated cerclage placement.
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Affiliation(s)
- Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Young Mi Jung
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Song-Yi Kook
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Se Jeong Jeon
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
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13
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Roman AR, Da Silva Costa F, Araujo Júnior E, Sheehan PM. Rescue Adjuvant Vaginal Progesterone May Improve Outcomes in Cervical Cerclage Failure. Geburtshilfe Frauenheilkd 2018; 78:785-790. [PMID: 30140107 PMCID: PMC6102116 DOI: 10.1055/a-0637-9324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/04/2018] [Accepted: 06/03/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction
Aim of the study was to evaluate the effect of rescue adjuvant vaginal progesterone in women with ongoing, transvaginal ultrasound (TVUS)-confirmed cervical shortening despite cervical cerclage.
Materials and Methods
A retrospective case control study was performed of women undergoing cervical surveillance following either history- or ultrasound-indicated cervical cerclage. We compared women managed with cervical cerclage and vaginal progesterone to women managed with cervical cerclage alone. Women with a singleton pregnancy who underwent cervical cerclage were identified from a database. Data on the concurrent use of vaginal progesterone, cervical length measurements, interventions and birth outcomes were collected from patient notes and clinical pathology notes. Patients from each intervention group were matched, based on exact shortest cervical length measurements obtained during surveillance and age of gestation when the measurement was obtained.
Results
66 women were matched and included in the study, based on exact shortest cervical length measurements. Each group had an identical mean shortest cervical length of 12.09 mm. The outcomes of 33 women who received both cervical cerclage and vaginal progesterone were compared to the outcomes of 33 women who were treated with cervical cerclage alone. The administration of vaginal progesterone to women with ongoing cervical shortening despite cervical cerclage was found to significantly prolong the pregnancy (36.36 weeks vs. 32.63 weeks; p = 0.0036) compared to women treated with cerclage alone. This use of rescue adjuvant vaginal progesterone was also associated with higher birth weights (2829 g vs. 2134 g; p = 0.0065) compared to women who had cervical cerclage alone; however, there was no difference in Apgar scores, composite neonatal morbidity or neonatal intensive care admission.
Conclusion
Women with cervical shortening despite the presence of cervical cerclage may benefit from further TVUS cervical length surveillance and the administration of vaginal progesterone if further cervical shortening occurs. Despite both groups having clinically significant shortened cervical lengths and cervical cerclage in situ, adjunct vaginal progesterone treatment resulted in older gestational age at birth and higher birth weight. Further investigation and confirmation of this finding in a larger prospective trial is warranted to explore this potential benefit for the management of preterm birth in future.
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Affiliation(s)
- Alina R Roman
- Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Fabricio Da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University and Monash Ultrasound for Women, Clayton, Victoria, Australia
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil
| | - Penelope M Sheehan
- Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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14
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Lee KN, Whang EJ, Chang KHJ, Song JE, Son GH, Lee KY. History-indicated cerclage: the association between previous preterm history and cerclage outcome. Obstet Gynecol Sci 2018; 61:23-29. [PMID: 29372146 PMCID: PMC5780317 DOI: 10.5468/ogs.2018.61.1.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Our hospital's policy is to perform history-indicated cerclage (HIC) for pregnant patients with 1 or more second-trimester pregnancy losses. Recently, the American College of Obstetricians and Gynecologists (ACOG) guideline regarding indications for HIC was changed from 3 or more previous second-trimester fetal losses to one or more. In this study, we aimed to evaluate the efficacy of the revised guideline and to investigate the association between previous preterm history and cerclage outcome. METHODS We conducted a retrospective observational study of cases of HIC in singleton pregnancies performed at our hospital between January 2007 and June 2016. We compared the perioperative complications and incidences of preterm delivery in patients with one previous second-trimester pregnancy loss against those in patients with ≥2 losses. RESULTS The incidence of preterm delivery (<32 weeks) was significantly lower in patients with one previous second-trimester pregnancy loss than in those with ≥2 losses (15/194 [8%] vs. 28/205 [14%]). In the 1 loss and ≥2 losses groups, the rates of preterm premature rupture of membranes (PPROM) were 7% and 8%, the rates of PPROM at <32 weeks 2.1% and 3.4%, and the ratios of neonatal intensive care unit admission 10% and 17%, respectively. CONCLUSION Comparison of HIC in one previous second-trimester pregnancy loss group with HIC in the 2 or more previous second-trimester pregnancy loss group found no difference in pregnancy outcome. This finding supports the amended ACOG guideline for HIC indications. Based on our results, we also propose development of a new protocol for HIC-related complications.
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Affiliation(s)
- Kyong-No Lee
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Eun-Jee Whang
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kylie Hae-Jin Chang
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Eun Song
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Ga-Hyun Son
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Keun-Young Lee
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
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