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Merced C, Pratcorona L, Higueras T, Vargas M, Del Barco E, Solà J, Carreras E, Goya M. 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. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100305. [PMID: 38595705 PMCID: PMC11001768 DOI: 10.1016/j.eurox.2024.100305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024] Open
Abstract
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.
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Affiliation(s)
- Carme Merced
- Department of Obstetrics, Hospital Universitari de Vic, Consorci Hospitalari de Vic. Barcelona, Spain
| | - Laia Pratcorona
- Department of Obstetrics, Hospital Germans Trias I Pujol. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Higueras
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Vargas
- Department of Obstetrics, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain
| | - Esther Del Barco
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Judit Solà
- Data Analysis and Modeling Research Group, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, Spain
| | - Elena Carreras
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Goya
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
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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. [PMID: 38698597 DOI: 10.1055/s-0044-1786175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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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Hessami K, D'Alberti E, Mascio DD, Berghella V. Universal cervical length screening and risk of spontaneous preterm birth: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101343. [PMID: 38479489 DOI: 10.1016/j.ajogmf.2024.101343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To evaluate the risk of spontaneous preterm birth with or without universal transvaginal ultrasound cervical length screening at the time of midtrimester scan. DATA SOURCES Medline, Embase, ClinicalTrials.gov, and Web of Science were systematically searched from the inception of the databases to November 12, 2023, using combinations of the relevant medical subject heading terms, key words, and word variants that were considered suitable for the topic. STUDY ELIGIBILITY CRITERIA Studies including individuals with singleton gestations at 16-25 weeks of gestation screened or not screened with universal transvaginal ultrasound cervical length screening were considered eligible. Primary outcome was spontaneous preterm birth <37 weeks; secondary outcomes were spontaneous preterm birth <34 and <32 weeks. METHODS Random effect head-to-head analyses were used to directly compare each outcome, expressing the results as summary odds ratio and relative 95% confidence interval. The quality of the included studies was independently assessed by 2 reviewers, using the Newcastle-Ottawa scale for cohort studies and the Cochrane risk-of-bias tool for randomized controlled studies. The study was registered on the prospective register of systematic reviews database (PROSPERO) (registration number: CRD42022385325). RESULTS Eight studies, including 447,864 pregnancies, were included in the meta-analysis (213,064 screened with transvaginal ultrasound cervical length and 234,800 unscreened). In the overall analysis, universal transvaginal ultrasound cervical length did not significantly decrease the spontaneous preterm birth rates <37 weeks (odds ratio, 0.92 [95% confidence interval, 0.84-1.01], P=.07) and <34 weeks (odds ratio, 0.87 [95% confidence interval, 0.73-1.04], P=.12), but was significantly associated with a lower risk of spontaneous preterm birth <32 weeks (odds ratio, 0.84 [95% confidence interval, 0.76-0.94], P=.002). Individuals without a prior spontaneous preterm birth had a significantly lower risk of spontaneous preterm birth <37 weeks (odds ratio, 0.88 [95% confidence interval, 0.79-0.97], P=.01) and a lower trend of spontaneous preterm birth <32 weeks (odds ratio, 0.82 [95% confidence interval, 0.66-1.01], P=.06) when screened with transvaginal ultrasound cervical length, compared with no screening. CONCLUSION Universal transvaginal ultrasound cervical length screening usually <24 weeks in singletons without a prior spontaneous preterm birth, is associated with a significant reduction in spontaneous preterm birth <37 weeks, compared with no screening.
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Affiliation(s)
- Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr Hessami)
| | - Elena D'Alberti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy (Drs D'Alberti and Di Mascio)
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy (Drs D'Alberti and Di Mascio)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA (Dr Berghella).
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Berghella V. Universal cervical length screening: yes! Am J Obstet Gynecol MFM 2024; 6:101347. [PMID: 38582652 DOI: 10.1016/j.ajogmf.2024.101347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
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Zhang Y, Edwards SA, House M. Cerclage prevents ascending intrauterine infection in pregnant mice. Am J Obstet Gynecol 2024; 230:555.e1-555.e8. [PMID: 37816485 PMCID: PMC10999506 DOI: 10.1016/j.ajog.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND The treatment for cervical insufficiency is cerclage surgery. Although cerclage is a common therapy for prevention of preterm birth, there is no consensus about its mechanism of efficacy. Previous investigators have hypothesized that cerclage prevents preterm birth by improving the cervical barrier to ascending infection. However, this hypothesis is difficult to study in human pregnancy. OBJECTIVE In a mouse model of ascending infection, we hypothesized that a cerclage improves the cervical barrier leading to decreased ascending intrauterine infection and inflammation. An abdominal cerclage was studied because a vaginal cerclage is not feasible in mice. STUDY DESIGN To perform an abdominal cerclage, laparotomy was performed on timed, pregnant C57BL/6 mice on gestational day 10 (E10). A 6-0 silk suture was placed around the cervix just below the junction of the 2 uterine horns. Sham controls received the same surgery, but no cerclage was placed. To track ascending infection nonpathogenic E coli K12 was genetically modified to express bioluminescence. On E15, bioluminescent E coli K12 (20 μL of 1×109 bacteria) was inoculated into the vagina. Whole-body bioluminescence imaging was performed 0.5 hours and 24 hours after inoculation. To assess intrauterine inflammation, pathogenic E coli K1 was used. On E15, bacterial inoculums of E coli K1 (20 μL of 1×104 bacteria) were vaginally administered. Samples of uterus, placenta, and fetal membranes were collected 24 hours after inoculation. Gene expression of inflammation-related proteins was compared between 3 groups: (1) sham control surgery + inoculation of phosphate-buffered saline (PBS), (2) sham control surgery + inoculation of E coli K1, and (3) cerclage surgery + inoculation of E coli K1. RESULTS Abdominal cerclage was well tolerated. No cases of preterm birth were seen following abdominal cerclage. Whole-body bioluminescent imaging performed 0.5 hours post inoculation showed a strong luminescence signal in the vaginal region of mice in both control and experimental groups indicating successful bacteria inoculation. Twenty-four hours after inoculation, bioluminescent signal was seen ascending into the uterine horns in all control mice. However, in mice with abdominal cerclages, no bioluminescent signal was seen after 24 hours. When the reproductive tissues were imaged separately in control mice, strong bioluminescence signal was detected in the placenta, fetal membranes, and uterus. Gene expression studies showed that cerclage significantly decreased the expression of inflammatory proteins induced by E coli K1 in the uterus, placenta, and fetal membranes. CONCLUSION In this mouse model of ascending intrauterine infection, abdominal cerclage prevented ascending infection of E coli. In addition, abdominal cerclage prevented expression of inflammatory cytokines in the uterus, placenta, and membranes of mice. The study provides evidence for a potential mechanism of cerclage success in human pregnancy.
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Affiliation(s)
- Yali Zhang
- Mother Infant Research Center, Tufts Medical Center, Boston, MA
| | - Skye A Edwards
- Department of Biomedical Engineering, Tufts University, Medford, MA
| | - Michael House
- Mother Infant Research Center, Tufts Medical Center, Boston, MA; Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA.
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Gavra-Shlissel H, Porat S, Tadmor O, Bitton E, Lipschuetz M, Kabiri D. Validating staging criteria for sonographic and physical examination for cervical changes at <24 weeks' gestation to predict preterm birth. Am J Obstet Gynecol MFM 2024; 6:101211. [PMID: 37926146 DOI: 10.1016/j.ajogmf.2023.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/21/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Hadar Gavra-Shlissel
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Gavra-Shlissel, Porat, Bitton, Lipschuetz, and Kabiri)
| | - Shay Porat
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Gavra-Shlissel, Porat, Bitton, Lipschuetz, and Kabiri)
| | - Offer Tadmor
- Maccabi Health Services, Jerusalem, Israel (Dr Tadmor)
| | - Elyasaf Bitton
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Gavra-Shlissel, Porat, Bitton, Lipschuetz, and Kabiri)
| | - Michal Lipschuetz
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Gavra-Shlissel, Porat, Bitton, Lipschuetz, and Kabiri)
| | - Doron Kabiri
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel (Drs Gavra-Shlissel, Porat, Bitton, Lipschuetz, and Kabiri).
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Hernandez-Andrade E, Huntley ES, Sibai B, Blackwell SC, Soto-Torres EE. 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. Ultrasound Obstet Gynecol 2024; 63:644-649. [PMID: 37916641 DOI: 10.1002/uog.27527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/05/2023] [Accepted: 10/19/2023] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- E Hernandez-Andrade
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E S Huntley
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - B Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E E Soto-Torres
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
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Saccone G, Maruotti GM, Morlando M, Visentin S, De Angelis C, Sarno L, Cosmi E, Torcia F, Costanzi F, Gragnano E, Bartolini G, La Verde M, Borelli F, Savoia F, Schiatterella A, De Franciscis P, Locci M, Guida M. Randomized trial of screening for preterm birth in low-risk women - the preterm birth screening study. Am J Obstet Gynecol MFM 2024; 6:101267. [PMID: 38642994 DOI: 10.1016/j.ajogmf.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 04/22/2024]
Abstract
BACKGROUND Preterm birth is a major cause of perinatal morbidity and mortality. It is unclear whether the introduction of a universal transvaginal ultrasound cervical length screening program in women at low risk for preterm delivery is associated with a reduction in the frequency of preterm birth. OBJECTIVE To test the hypothesis that the introduction of a midtrimester universal transvaginal ultrasound cervical length screening program in asymptomatic singleton pregnancies without prior preterm delivery would reduce the rate of preterm birth at <37 weeks of gestation. STUDY DESIGN This study was a multicenter nonblinded randomized trial of screening of asymptomatic singleton pregnancies without prior spontaneous preterm birth, who were randomized to either cervical length screening program (ie, intervention group) or no screening (ie, control group). Participants were randomized at the time of their routine anatomy scan between 18 0/7 and 23 6/7 weeks of gestation. Women randomized in the screening group received cervical length measurement. Those who were found to have cervical length ≤25 mm were offered 200 mg vaginal progesterone daily along with cervical pessary. The primary outcome was preterm birth at <37 weeks. The risk of primary outcome was quantified by the relative risk with 95% confidence interval, and was based on the intention-to-screen principle. RESULTS A total of 1334 asymptomatic women with singleton pregnancies and without prior preterm birth, were included in the trial. Out of the 675 women randomized in the transvaginal ultrasound cervical length screening group, 13 (1.9%) were found to have transvaginal ultrasound cervical length ≤25 mm during the screening. Preterm birth at <37 weeks of gestation occurred in 48 women in the transvaginal ultrasound cervical length screening group (7.5%), and 54 women in the control group (8.7%) (relative risk, 0.86; 95% confidence interval, 0.59-1.25). Women randomized in the transvaginal ultrasound cervical length screening group had no significant differences in the incidence of preterm birth at less than 34, 32, 30, 28, and 24 weeks of gestation. CONCLUSION The introduction of a universal transvaginal ultrasound cervical length screening program at 18 0/6 to 23 6/7 weeks of gestation in singleton pregnancies without prior spontaneous preterm birth, with treatment for those with cervical length ≤25 mm, did not result in significant lower incidence of preterm delivery than the incidence without the screening program.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida).
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
| | - Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy (Drs Morlando, La Verde, Savoia, Schiatterella and De Franciscis)
| | - Silvia Visentin
- Department of Woman's and Child's Health, University of Padua, Padua, Italy (Drs Visentin and Cosmi)
| | - Carlo De Angelis
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy (Drs De Angelis, Torcia, and Costanzi)
| | - Laura Sarno
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
| | - Erich Cosmi
- Department of Woman's and Child's Health, University of Padua, Padua, Italy (Drs Visentin and Cosmi)
| | - Francesco Torcia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy (Drs De Angelis, Torcia, and Costanzi)
| | - Flavia Costanzi
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy (Drs De Angelis, Torcia, and Costanzi)
| | - Elisabetta Gragnano
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
| | - Giorgia Bartolini
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy (Drs Morlando, La Verde, Savoia, Schiatterella and De Franciscis)
| | - Felice Borelli
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
| | - Fabiana Savoia
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy (Drs Morlando, La Verde, Savoia, Schiatterella and De Franciscis)
| | - Antonio Schiatterella
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy (Drs Morlando, La Verde, Savoia, Schiatterella and De Franciscis)
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy (Drs Morlando, La Verde, Savoia, Schiatterella and De Franciscis)
| | - Mariavittoria Locci
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
| | - Maurizio Guida
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone, Maruotti, and Sarno; Ms Gragnano; Drs Bartolini, Borrelli, Locci, and Guida)
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Reddy M, McGannon C, Mol BW. Looking back on preterm birth - The successes and failures. Acta Obstet Gynecol Scand 2024; 103:410-412. [PMID: 38356249 PMCID: PMC10867352 DOI: 10.1111/aogs.14730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Maya Reddy
- Monash Women'sMonash HealthClaytonVictoriaAustralia
| | | | - Ben W. Mol
- Monash Women'sMonash HealthClaytonVictoriaAustralia
- Department of Obstetrics and Gynaecology, School of Clinical SciencesMonash UniversityClaytonVictoriaAustralia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
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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. [PMID: 38228167 DOI: 10.1055/a-2217-9463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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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Abstract
Spontaneous preterm birth (delivery before 37 completed weeks) is the single most important cause of perinatal morbidity and mortality. The rate is increasing world-wide with a great disparity between low, middle and high income countries. It has been estimated that the cost of neonatal care for preterm babies is more than 4 times that of a term neonate admitted into the neonatal care. Furthermore, there are high costs associated with long-term morbidity in those who survive the neonatal period. Interventions to stop delivery once preterm labor starts are largely ineffective hence the best approach to reducing the rate and consequences is prevention. This is either primary (reducing or minimizing factors associated with preterm birth prior to and during pregnancy) or secondary - identification and amelioration (if possible) of factors in pregnancy that are associated with preterm labor. In the first category are optimizing maternal weight, promoting healthy nutrition, smoking cessation, birth spacing, avoidance of adolescent pregnancies and screening for and controlling various medical disorders as well as infections prior to pregnancy. Strategies in pregnancy, include early booking for prenatal care, screening and managing medical disorders and their complications, and identifying predisposing factors to preterm labor such as shortening of the cervix and timely instituting progesterone prophylaxis or cervical cerclage where appropriate. The use of biomarkers such as oncofetal fibronectin, placental alpha-macroglobulin-1 and IGFBP-1 where cervical screening is not available or to diagnosis PPROM would identify those that require close monitoring and allow the institution of antibiotics especially where infection is considered a predisposing factor. Irrespective of the approach to prevention, timing the administration of corticosteroids and where necessary tocolysis and magnesium sulfate are associated with an improved outcome. The role of genetics, infections and probiotics and how these emerging dimensions help in the diagnosis of preterm birth and consequently prevention are exciting and hopefully may identify sub-populations for targeted strategies.
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12
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Lee KN, Yun S, Park SY, Kim K, Lee KY, Lee JJ, Son GH. Factors Associated with Spontaneous Preterm Birth after Ultrasound-Indicated Cerclage. J Pers Med 2023; 13:1678. [PMID: 38138905 PMCID: PMC10744759 DOI: 10.3390/jpm13121678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Ultrasound-indicated cerclage (UIC) is recommended to prevent spontaneous preterm birth (sPTB) in women with a short cervix at mid-trimester and a history of PTB. We assessed the factors related to sPTB after UIC and determined the corresponding risks. This retrospective cohort study was conducted at a university hospital. UIC was performed between 15 and 26 weeks of gestation in women with a cervical length of <2.5 cm. Univariate and multivariate analyses were used to examine factors associated with sPTB after UIC. An earlier gestational age and shorter cervical length at UIC were associated with sPTB after UIC. While PTB history was not associated with an increased risk of sPTB, it did increase the risk of repeat cerclage after UIC. Higher levels of preoperative serum inflammatory markers and obesity significantly increased the risk of sPTB after UIC. These findings provide helpful guidance for patient counseling and management in predicting the delivery timing after UIC in women with a short cervix in the mid-trimester.
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Affiliation(s)
- Kyong-No Lee
- Department of Obstetrics and Gynecology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea;
| | - Sangho Yun
- Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea; (S.Y.); (J.J.L.)
| | - So-Yoon Park
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea; (S.-Y.P.); (K.K.); (K.-Y.L.)
| | - Kyoungseon Kim
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea; (S.-Y.P.); (K.K.); (K.-Y.L.)
| | - Keun-Young Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea; (S.-Y.P.); (K.K.); (K.-Y.L.)
| | - Jae Jun Lee
- Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea; (S.Y.); (J.J.L.)
- Departments of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Ga-Hyun Son
- Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon 24252, Republic of Korea; (S.Y.); (J.J.L.)
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea; (S.-Y.P.); (K.K.); (K.-Y.L.)
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13
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Pergialiotis V, Psarris A, Antsaklis P, Theodora M, Papapanagiotou A, Rodolakis A, Daskalakis G. Cervical Cerclage vs. Pessary in Women with a Short Cervix on Ultrasound. Ultraschall Med 2023; 44:e257-e262. [PMID: 36070802 DOI: 10.1055/a-1938-6042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Vasilios Pergialiotis
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Psarris
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Antsaklis
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Theodora
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Aggeliki Papapanagiotou
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Daskalakis
- First department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
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14
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Yoshida K. Bioengineering and the cervix: The past, current, and future for addressing preterm birth. Curr Res Physiol 2023; 6:100107. [PMID: 38107784 PMCID: PMC10724223 DOI: 10.1016/j.crphys.2023.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/23/2023] [Accepted: 09/20/2023] [Indexed: 12/19/2023] Open
Abstract
The uterine cervix plays two important but opposing roles during pregnancy - as a mechanical barrier that maintains the fetus for nine months and as a compliant structure that dilates to allow for the delivery of a baby. In some pregnancies, however, the cervix softens and dilates prematurely, leading to preterm birth. Bioengineers have addressed and continue to address the lack of reduction in preterm birth rates by developing novel technologies to diagnose, prevent, and understand premature cervical remodeling. This article highlights these existing and emerging technologies and concludes with open areas of research related to the cervix and preterm birth that bioengineers are currently well-positioned to address.
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Affiliation(s)
- Kyoko Yoshida
- Department of Biomedical Engineering, University of Minnesota, 7-105 Nils Hasselmo Hall, 312 Church Street SE, Minneapolis, MN, 55455, USA
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15
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Heyborne K. Reassessing Preterm Birth Prevention After the Withdrawal of 17-α Hydroxyprogesterone Caproate. Obstet Gynecol 2023; 142:493-501. [PMID: 37441790 DOI: 10.1097/aog.0000000000005290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023]
Abstract
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.
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Affiliation(s)
- Kent Heyborne
- Denver Health Medical Center and the University of Colorado School of Medicine, Aurora, Colorado
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16
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Li J, Wu Q, Chen Y, Wang J, Yan Y, Deng D, Huang R. Addition of cervical elastosonography to cervical length to predict preterm birth in pregnancy women with prior preterm birth: A preliminary prospective study. J Gynecol Obstet Hum Reprod 2023; 52:102617. [PMID: 37308039 DOI: 10.1016/j.jogoh.2023.102617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To investigate the characteristics of cervical elastosonography in pregnancies and establish an ultrasound-based combing predictor for improving the prediction in pregnant women with prior-preterm birth who might ultimately undergo preterm birth (PTB). MATERIALS AND METHODS 169 singleton pregnancies with prior-preterm birth were examined by cervical elastography from January to November of 2021. According to the ultrasound image and result of the following-up, the patients were separated into preterm groups and full-term groups with or without cerclage. There were five elastographic parameters: Elasticity Contrast Index (ECI), Cervical hard tissue Elasticity Ratio (CHR), External Cervical os Strain rate (ES), Closed Internal Cervical os Strain rate (CIS), CIS/ES ratio and CLmin. Multivariable logistic regression was used to screen out the most significant predictors. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the ability of prediction. RESULTS The PTB group without cerclage showed significantly softer cervix stiffness, while those with cerclage showed significantly harder. CHRmin with P < 0.05 in the univariate logistic regression analysis was screened as a more valuable cervical elastosonography parameter than other ones. The combination of CLmin and CHRmin in un-cerclage and integrating CHRmin, maternal age and pre-pregnancy BMI in cerclage presented good predictive value. The results of AUC were higher than CLmin, respectively (0.775 vs 0.734, 0.729 vs 0.548). CONCLUSIONS The addition of cervical elastography parameters (such as CHRmin) might improve the ability to predict preterm birth in pregnant women with previous preterm delivery, which was better than using CL alone.
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Affiliation(s)
- Jinghua Li
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100026, China.
| | - Qingqing Wu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100026, China.
| | - Yi Chen
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Jingjing Wang
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Yan Yan
- Capital Medical University of Biomedical Engineering, Beijing 100069, China
| | - Di Deng
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Ruizhen Huang
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
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17
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Lee SU, Jung G, Kim HW, Ko HS. How to screen the cervix and reduce the risk of spontaneous preterm birth in asymptomatic women without a prior preterm birth. Obstet Gynecol Sci 2023; 66:337-346. [PMID: 37439085 PMCID: PMC10514583 DOI: 10.5468/ogs.23022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/16/2023] [Accepted: 06/13/2023] [Indexed: 07/14/2023] Open
Abstract
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.
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Affiliation(s)
- Seon Ui Lee
- Department of Obstetrics and Gynecology, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea
| | - Gyul Jung
- Department of Obstetrics and Gynecology, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea
| | - Han Wool Kim
- Department of Obstetrics and Gynecology, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea
| | - Hyun Sun Ko
- Department of Obstetrics and Gynecology, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea
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18
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Giouleka S, Boureka E, Tsakiridis I, Siargkas A, Mamopoulos A, Kalogiannidis I, Athanasiadis A, Dagklis T. Cervical Cerclage: A Comprehensive Review of Major Guidelines. Obstet Gynecol Surv 2023; 78:544-553. [PMID: 37976303 DOI: 10.1097/ogx.0000000000001182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Importance Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates. Objective The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC. Evidence Acquisition A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out. Results There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate. Conclusions Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies.
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Affiliation(s)
- Sonia Giouleka
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eirini Boureka
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Siargkas
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- Associate Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Mayer-Pickel K, Nanda M, Gajic M, Cervar-Zivkovic M. Preeclampsia and the Antiphospholipid Syndrome. Biomedicines 2023; 11:2298. [PMID: 37626793 PMCID: PMC10452741 DOI: 10.3390/biomedicines11082298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/06/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by venous or arterial thrombosis and/or adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies (aPLs). Preeclampsia complicates about 10-17% of pregnancies with APS. However, only early onset preeclampsia (<34 weeks of gestation) belongs to the clinical criteria of APS. The similarities in the pathophysiology of early onset preeclampsia and APS emphasize an association of these two syndromes. Overall, both are the result of a defective trophoblast invasion and decidual transformation at early gestation. Women with APS are at increased risk for prematurity; the reasons are mostly iatrogenic due to placental dysfunction, such as preeclampsia or FGR. Interestingly, women with APS have also an increased risk for preterm delivery, even in the absence of FGR and preeclampsia, and therefore it is not indicated but spontaneous. The basic treatment of APS in pregnancy is low-dose aspirin and low-molecular-weight heparin. Nevertheless, up to 20-30% of women develop complications at early and late gestation, despite basic treatment. Several additional treatment options have been proposed, with hydroxychloroquine (HCQ) being one of the most efficient. Additionally, nutritional interventions, such as intake of vitamin D, have shown promising beneficial effects. Curcumin, due to its antioxidant and anti-inflammatory properties, might be considered as an additional intervention as well.
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Affiliation(s)
- Karoline Mayer-Pickel
- Department of Obstetrics, Medical University Graz, 8036 Graz, Austria; (M.N.); (M.G.); (M.C.-Z.)
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D’Antonio F, Eltaweel N, Prasad S, Flacco ME, Manzoli L, Khalil A. Cervical cerclage for prevention of preterm birth and adverse perinatal outcome in twin pregnancies with short cervical length or cervical dilatation: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004266. [PMID: 37535682 PMCID: PMC10456178 DOI: 10.1371/journal.pmed.1004266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 08/25/2023] [Accepted: 06/23/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND The optimal approach to prevent preterm birth (PTB) in twins has not been fully established yet. Recent evidence suggests that placement of cervical cerclage in twin pregnancies with short cervical length at ultrasound or cervical dilatation at physical examination might be associated with a reduced risk of PTB. However, such evidence is based mainly on small studies thus questioning the robustness of these findings. The aim of this systematic review was to determine the role of cervical cerclage in preventing PTB and adverse maternal or perinatal outcomes in twin pregnancies. METHODS AND FINDINGS Key databases searched and date of last search: MEDLINE, Embase, and CINAHL were searched electronically on 20 April 2023. Eligibility criteria: Inclusion criteria were observational studies assessing the risk of PTB among twin pregnancies undergoing cerclage versus no cerclage and randomized trials in which twin pregnancies were allocated to cerclage for the prevention of PTB or to a control group (e.g., placebo or treatment as usual). The primary outcome was PTB <34 weeks of gestation. The secondary outcomes were PTB <37, 32, 28, 24 weeks of gestation, gestational age at birth, the interval between diagnosis and birth, preterm prelabor rupture of the membranes (pPROM), chorioamnionitis, perinatal loss, and perinatal morbidity. Subgroup analyses according to the indication for cerclage (short cervical length or cervical dilatation) were also performed. Risk of bias assessment: The risk of bias of the included randomized controlled trials (RCTs) was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, while that of the observational studies using the Newcastle-Ottawa scale (NOS). Statistical analysis: Summary risk ratios (RRs) of the likelihood of detecting each categorical outcome in exposed versus unexposed women, and (b) summary mean differences (MDs) between exposed and unexposed women (for each continuous outcome), with their 95% confidence intervals (CIs) were computed using head-to-head meta-analyses. Synthesis of the results: Eighteen studies (1,465 twin pregnancies) were included. Placement of cervical cerclage in women with a twin pregnancy with a short cervix at ultrasound or cervical dilatation at physical examination was associated with a reduced risk of PTB <34 weeks of gestation (RR: 0.73, 95% CI [0.59, 0.91], p = 0.005 corresponding to a 16% difference in the absolute risk, AR), <32 (RR: 0.69, 95% CI [0.57, 0.84], p < 0.001; AR: 16.92%), <28 (RR: 0.54, 95% [CI 0.43, 0.67], 0.001; AR: 18.29%), and <24 (RR: 0.48, 95% CI [0.23, 0.97], p = 0.04; AR: 15.57%) weeks of gestation and a prolonged gestational age at birth (MD: 2.32 weeks, 95% [CI 0.99, 3.66], p < 0.001). Cerclage in twin pregnancy with short cervical length or cervical dilatation was also associated with a reduced risk of perinatal loss (RR: 0.38, 95% CI [0.25, 0.60], p < 0.001; AR: 19.62%) and composite adverse outcome (RR: 0.69, 95% CI [0.53, 0.90], p = 0.007; AR: 11.75%). Cervical cerclage was associated with a reduced risk of PTB <34 weeks both in women with cervical length <15 mm (RR: 0.74, 95% CI [0.58, 0.95], p = 0.02; AR: 29.17%) and in those with cervical dilatation (RR: 0.68, 95% CI [0.57, 0.80], p < 0.001; AR: 35.02%). The association between cerclage and prevention of PTB and adverse perinatal outcomes was exclusively due to the inclusion of observational studies. The quality of retrieved evidence at GRADE assessment was low. CONCLUSIONS Emergency cerclage for cervical dilation or short cervical length <15 mm may be potentially associated with a reduction in PTB and improved perinatal outcomes. However, these findings are mainly based upon observational studies and require confirmation in large and adequately powered RCTs.
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Affiliation(s)
- Francesco D’Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Nashwa Eltaweel
- Division of Biomedical Science, Warwick Medical School University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
| | - Maria Elena Flacco
- Department of Environmental and Preventive Sciences, University of Ferrara, Ferrara, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
- Twins Trust Centre for Research and Clinical Excellence, St George’s Hospital, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women’s Hospital, University of Liverpool, Liverpool, United Kingdom
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Li Y, Chu R, Li Y, Zhang M, Ma Y. Delayed interval delivery in a quadruplet pregnancy: a case report and literature review. BMC Pregnancy Childbirth 2023; 23:353. [PMID: 37189021 DOI: 10.1186/s12884-023-05647-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/25/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND As the rate of multiple pregnancies increases, delayed interval delivery (DID) is increasingly being implemented to improve perinatal outcomes. But there are no international guidelines for DID in multiple pregnancies. We report a case of DID in a quadruplet pregnancy and review the relevant literature to summarize the management of DID in multiple pregnancies. CASE PRESENTATION A 22-year-old woman, 22 2/7 weeks' gestation, with quadruplets, was admitted to the hospital for a first cervical cerclage due to cervical dilation. Twenty-five days later, it was found that the cervix was dilated again, so after removing the cervical cerclage, the first quadruplet was delivered vaginally (25 6/7 weeks), and a second cervical cerclage was performed. Four days later, due to re-dilation of the cervix, after removal of the cervical cerclage, the second quadruplet was delivered vaginally (26 3/7 weeks), followed by a third cervical cerclage. Six days later, the pregnancy was terminated by cesarean section due to fetal distress, and the third and fourth quadruplets were delivered (27 2/7 weeks). The patient had no postoperative complications, and all four infants were treated in the neonatal intensive care unit and discharged successfully. CONCLUSION This case emphasizes that comprehensive management of delayed interval delivery can improve perinatal outcomes in multiple pregnancies, including anti-infection, tocolytic therapy, practice to promote fetal lung, and cervical cerclage.
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Affiliation(s)
- Yanan Li
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, China
| | - Yarong Li
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, China
| | - Meiling Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, China.
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Hussain FN, Al-Ibraheemi Z, Kaplowitz E, Parikh B, Feldman KM, Lam MC, Brustman L, Lewis D. Incidentally Found Midtrimester Shortened Cervical Length: Practice Patterns among American Maternal-Fetal Medicine Specialists. Am J Perinatol 2023; 40:341-347. [PMID: 35714654 DOI: 10.1055/a-1877-6491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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..
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Affiliation(s)
- Farrah N Hussain
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zainab Al-Ibraheemi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elianna Kaplowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, New York
| | - Bijal Parikh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kristina Martimucci Feldman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa Chu Lam
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lois Brustman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dawnette Lewis
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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23
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Phung J, Wang C, Reeders J, Zakar T, Paul JW, Tyagi S, Pennell CE, Smith R. Preterm labor with and without chorioamnionitis is associated with activation of myometrial inflammatory networks: a comprehensive transcriptomic analysis. Am J Obstet Gynecol 2023; 228:330.e1-330.e18. [PMID: 36002050 DOI: 10.1016/j.ajog.2022.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The onset of preterm labor is associated with inflammation. Previous studies suggested that this is distinct from the inflammation observed during term labor. Our previous work on 44 genes differentially expressed in myometria in term labor demonstrated a different pattern of gene expression from that observed in preterm laboring and nonlaboring myometria. We found increased expression of inflammatory genes in preterm labor associated with chorioamnionitis, but in the absence of chorioamnionitis observed no difference in gene expression in preterm myometria regardless of laboring status, suggesting that preterm labor is associated with different myometrial genes or signals originating from outside the myometrium. Given that a small subset of genes were assessed, this study aimed to use RNA sequencing and bioinformatics to assess the myometrial transcriptome during preterm labor in the presence and absence of chorioamnionitis. OBJECTIVE This study aimed to comprehensively determine protein-coding transcriptomic differences between preterm nonlaboring and preterm laboring myometria with and without chorioamnionitis. STUDY DESIGN Myometria were collected at cesarean delivery from preterm patients not in labor (n=16) and preterm patients in labor with chorioamnionitis (n=8) or without chorioamnionitis (n=6). Extracted RNA from myometrial tissue was prepared and sequenced using Illumina NovaSeq. Gene expression was quantified by mapping the sequence reads to the human reference genome (hg38). Differential gene expression analysis, gene set enrichment analysis, and weighted gene coexpression network analysis were used to comprehensively interrogate transcriptomic differences and their associated biology. RESULTS Differential gene expression analysis comparing preterm patients in labor with chorioamnionitis with preterm patients not in labor identified 931 differentially expressed genes, whereas comparing preterm patients in labor without chorioamnionitis with preterm patients not in labor identified no statistically significant gene expression changes. In contrast, gene set enrichment analysis and weighted gene coexpression network analysis demonstrated that preterm labor with and without chorioamnionitis was associated with enrichment of pathways involved in activation of the innate immune system and inflammation, and activation of G protein-coupled receptors. Key genes identified included chemotactic CYP4F3, CXCL8, DOCK2, and IRF1 in preterm labor with chorioamnionitis and CYP4F3, FCAR, CHUK, and IL13RA2 in preterm labor without chorioamnionitis. There was marked overlap in the pathways enriched in both preterm labor subtypes. CONCLUSION Differential gene expression analysis demonstrated that myometria from preterm patients in labor without chorioamnionitis and preterm patients not in labor were transcriptionally similar, whereas the presence of chorioamnionitis was associated with marked gene changes. In contrast, comprehensive bioinformatic analysis indicated that preterm labor with or without chorioamnionitis was associated with innate immune activation. All causes of preterm labor were associated with activation of the innate immune system, but this was more marked in the presence of chorioamnionitis. These data suggest that anti-inflammatory therapy may be relevant in managing preterm labor of all etiologies.
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Affiliation(s)
- Jason Phung
- Department of Maternity and Gynaecology, John Hunter Hospital, Newcastle, Australia; Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia.
| | - Carol Wang
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia
| | - Jocelyn Reeders
- Department of Anatomical Pathology, John Hunter Hospital, Newcastle, Australia
| | - Tamas Zakar
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia
| | - Jonathan W Paul
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia
| | - Sonika Tyagi
- Central Clinical School, Monash University, Clayton, Australia
| | - Craig E Pennell
- Department of Maternity and Gynaecology, John Hunter Hospital, Newcastle, Australia; Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia
| | - Roger Smith
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia
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24
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Wennerholm UB, Bergman L, Kuusela P, Ljungström E, Möller AC, Hongslo Vala C, Ekelund AC, Liljegren A, Petzold M, Sjögren P, Svensson M, Strandell A, Jacobsson B. Progesterone, cerclage, pessary, or acetylsalicylic acid for prevention of preterm birth in singleton and multifetal pregnancies - A systematic review and meta-analyses. Front Med (Lausanne) 2023; 10:1111315. [PMID: 36936217 PMCID: PMC10015499 DOI: 10.3389/fmed.2023.1111315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
Background Preterm birth is the leading cause of childhood mortality and morbidity. We aimed to provide a comprehensive systematic review on randomized controlled trials (RCTs) on progesterone, cerclage, pessary, and acetylsalicylic acid (ASA) to prevent preterm birth in asymptomatic women with singleton pregnancies defined as risk of preterm birth and multifetal pregnancies. Methods Six databases (including PubMed, Embase, Medline, the Cochrane Library) were searched up to February 2022. RCTs published in English or Scandinavian languages were included through a consensus process. Abstracts and duplicates were excluded. The trials were critically appraised by pairs of reviewers. The Cochrane risk-of-bias tool was used for risk of bias assessment. Predefined outcomes including preterm birth, perinatal/neonatal/maternal mortality and morbidity, were pooled in meta-analyses using RevMan 5.4, stratified for high and low risk of bias trials. The certainty of evidence was assessed using the GRADE approach. The systematic review followed the PRISMA guideline. Results The search identified 2,309 articles, of which 87 were included in the assessment: 71 original RCTs and 16 secondary publications with 23,886 women and 32,893 offspring. Conclusions were based solely on trials with low risk of bias (n = 50).Singleton pregnancies: Progesterone compared with placebo, reduced the risk of preterm birth <37 gestational weeks: 26.8% vs. 30.2% (Risk Ratio [RR] 0.82 [95% Confidence Interval [CI] 0.71 to 0.95]) (high certainty of evidence, 14 trials) thereby reducing neonatal mortality and respiratory distress syndrome. Cerclage probably reduced the risk of preterm birth <37 gestational weeks: 29.0% vs. 37.6% (RR 0.78 [95% CI 0.69 to 0.88]) (moderate certainty of evidence, four open trials). In addition, perinatal mortality may be reduced by cerclage. Pessary did not demonstrate any overall effect. ASA did not affect any outcome, but evidence was based on one underpowered study.Multifetal pregnancies: The effect of progesterone, cerclage, or pessary was minimal, if any. No study supported improved long-term outcome of the children. Conclusion Progesterone and probably also cerclage have a protective effect against preterm birth in asymptomatic women with a singleton pregnancy at risk of preterm birth. Further trials of ASA are needed. Prevention of preterm birth requires screening programs to identify women at risk of preterm birth. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234946].
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Affiliation(s)
- Ulla-Britt Wennerholm
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lina Bergman
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Pihla Kuusela
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Södra Älvsborg Hospital, Department of Obstetrics and Gynecology, Borås, Sweden
| | - Elin Ljungström
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | - Anna C. Möller
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | | | - Ann-Catrin Ekelund
- Region Västra Götaland, Skaraborg Hospital, Medical Library, Skövde, Sweden
| | - Ann Liljegren
- Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, Gothenburg, Sweden
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Annika Strandell
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, HTA-centrum, Gothenburg, Sweden
| | - Bo Jacobsson
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Division of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
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Yang HJ, Zhang DY, Hao YY, Xu HL, Li YZ, Zhang S, Li XY, Gong TT, Wu QJ. GRADE Use in Evidence Syntheses Published in High-Impact-Factor Gynecology and Obstetrics Journals: A Methodological Survey. J Clin Med 2023; 12. [PMID: 36675377 DOI: 10.3390/jcm12020446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/24/2022] [Accepted: 12/27/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: To identify and describe the certainty of evidence of gynecology and obstetrics systematic reviews (SRs) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Method: Database searches of SRs using GRADE, published between 1 January 2016 to 31 December 2020, in the 10 "gynecology and obstetrics" journals with the highest impact factor, according to the Journal Citation Report 2019. Selected studies included those SRs using the GRADE approach, used to determine the certainty of evidence. Results: Out of 952 SRs, ninety-six SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Sixty-seven SRs (7.04%) rated the certainty of evidence for specific outcomes. In total, we identified 946 certainty of evidence outcome ratings (n = 614 RCT ratings), ranging from very-low (42.28%) to low (28.44%), moderate (17.65%), and high (11.63%). High and very low certainty of evidence ratings accounted for 2.16% and 71.60% in the SRs of NRSs, respectively, compared with 16.78% and 26.55% in the SRs of RCTs. In the SRs of RCTs and NRSs, certainty of evidence was mainly downgraded due to imprecision and bias risks. Conclusions: More attention needs to be paid to strengthening GRADE acceptance and building knowledge of GRADE methods in gynecology and obstetrics evidence synthesis.
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Roman A, Gulersen M, Boelig RC, Berghella V. Proposed staging criteria for sonographic and physical exam for cervical changes at <24 weeks gestation to predict preterm birth. Am J Obstet Gynecol MFM 2023; 5:100753. [PMID: 36130675 DOI: 10.1016/j.ajogmf.2022.100753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Amanda Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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27
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Huang Y, Liang X, Liao J, Li Y, Chen Z. Relationship of Amniotic Fluid Sludge and Short Cervix With a High Rate of Preterm Birth in Women After Cervical Cerclage. J Ultrasound Med 2022; 41:2687-2693. [PMID: 35106799 PMCID: PMC9790537 DOI: 10.1002/jum.15952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE We aims to determine the relationship of amniotic fluid sludge (AFS) and/or short cervical length (CL, ≤25 mm) with a high rate of preterm birth in women after cervical cerclage. METHODS A retrospective cohort study was conducted among singleton pregnancies after cervical cerclage between January 2018 and December 2021. A total of 296 patients who underwent transvaginal ultrasound to evaluate CL and the presence of AFS within 2 weeks after cerclage were included. Pregnancy outcome after cerclage was analyzed in accordance with the presence of AFS and CL ≤25 mm. RESULTS In patients with cerclage, AFS was an independent risk factor for preterm birth at <28 and <36 weeks but not for preterm birth at <32 weeks, and CL ≤25 mm was an independent risk factor for preterm birth at <28, <32, and <36 weeks. The Kaplan-Meier analysis showed that the association between the presence of AFS and short gestational age at delivery was statistically significant in women with CL ≤25 mm (log rank test, P = .000). The Cox regression analysis showed that these results remained significant after adjusting for confounding factors (P = .000). The negative linear relationships between AFS and CL (R = -0.454, P < .001) also explained the outcome. CONCLUSIONS AFS and short cervix have a direct effect on pregnancies after cerclage. Mid-trimester AFS can become a supplementary ultrasound index for detecting preterm birth after cerclage in pregnant women with a short cervix.
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Affiliation(s)
- Yingmin Huang
- Department of Ultrasound MedicineThe Third Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Xiaowen Liang
- Department of Ultrasound MedicineThe Third Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Jianyi Liao
- Department of Ultrasound MedicineThe Third Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Yingtao Li
- Guangzhou Medical Centre for Critical Pregnant Women, Key Laboratory for Major Obstetric Disease of Guangdong ProvinceThe Third Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Zhiyi Chen
- Department of Ultrasound MedicineThe Third Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
- Medical Imaging Centre, The First Affiliated Hospital, Medical Imaging Centre, Hengyang Medical School, University of South ChinaHengyangChina
- Institute of Medical Imaging, University of South ChinaHengyangChina
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Meng L, Öberg S, Sandström A, Wang C, Reilly M. Identification of risk factors for incident cervical insufficiency in nulliparous and parous women: a population-based case-control study. BMC Med 2022; 20:348. [PMID: 36221132 PMCID: PMC9555073 DOI: 10.1186/s12916-022-02542-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cervical insufficiency is one of the underlying causes of late miscarriage and preterm birth. Although many risk factors have been identified, the relative magnitude of their association with risk in nulliparous versus parous women has not been well demonstrated, especially for incident cervical insufficiency (ICI). The aim of this study was to investigate and compare the magnitude of the association of ICI with predictive factors in nulliparous and parous women, and to further investigate various aspects of obstetric history for parous women. METHODS Pregnant women with a first diagnosis of cervical insufficiency were compared to a random sample of control pregnancies from women with no diagnosis by using Swedish national health registers. Demographic, reproductive, and pregnancy-specific factors were compared in case and control pregnancies, and relative risks presented as odds ratios (OR), stratified by nulliparous/parous. Independent associations with ICI were estimated from multivariable logistic regression. Associations with obstetric history were further estimated for multiparous women. RESULTS A total of 759 nulliparous ICI cases and 1498 parous cases were identified during the study period. Multifetal gestation had a strong positive association with ICI in both groups, but of much larger magnitude for nulliparous women. The number of previous miscarriages was also a much stronger predictor of risk in nulliparous women, especially for multifetal pregnancies. History of preterm delivery (<37 weeks' gestation) was an independent predictor for parous women, and for those whose most recent delivery was preterm, the association with ICI increased with each additional week of prematurity. A previous delivery with prolonged second stage of labor or delivery of a very large infant were both inversely associated with risk of ICI in the current pregnancy. CONCLUSIONS The differences in importance of predictive risk factors for incident cervical insufficiency in nulliparous and parous women can help resolve some of the inconsistencies in the literature to date regarding factors that are useful for risk prediction. Stratifying on parity can inform more targeted surveillance of at-risk pregnancies, enable the two groups of women to be better informed of their risks, and eventually inform screening and intervention efforts.
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Affiliation(s)
- Lili Meng
- Department of Gynecology and Obstetrics, the Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, Guangdong, China.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels vag 12A, 171 77, Stockholm, Sweden
| | - Sara Öberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels vag 12A, 171 77, Stockholm, Sweden.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Chen Wang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels vag 12A, 171 77, Stockholm, Sweden
| | - Marie Reilly
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels vag 12A, 171 77, Stockholm, Sweden.
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Frenken MWE, Goossens SMTA, Janssen MCR, Mulders LGM, Laar JOEHV. Cervical cerclage for prevention of preterm birth: the results from A 20-year cohort. J OBSTET GYNAECOL 2022; 42:2665-2671. [PMID: 35653798 DOI: 10.1080/01443615.2022.2081792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cerclages can be used to prevent preterm birth, although their effectiveness and safety is disputed. We aimed to describe obstetric outcomes after cerclage procedures. We included 156 singleton pregnancies and six multiple pregnancies. In singleton pregnancies with history-indicated, short cervix-indicated and emergency cerclages, respectively 84.6, 76.5 and 43.8% resulted in late preterm or term deliveries. In singletons, the following complications were reported: excessive bleeding in one emergency cerclage procedure and three re-cerclage procedures in the history-indicated cerclage group. No perioperative rupture of membranes occurred in singletons. When comparing results of experienced and less-experienced gynaecologists, a remarkably smaller take home child rate was observed for singletons treated by less-experienced gynaecologists: 90.7% and 94.4% for the two experienced gynaecologist as compared to 85.0% for the group of less-experienced gynaecologists. In conclusion, cerclages in singletons result in few cerclage-associated complications and a high take home child rate, when performed by experienced gynaecologists. Impact statementWhat is already known on this subject? Prematurity is the leading cause of perinatal and neonatal mortality and morbidity worldwide. Cervical cerclages can be used to prevent preterm birth, although their effectiveness and safety is disputed.What the results of this study add? In our cohort study, singleton pregnancies with cerclages seem to have satisfactory obstetric outcomes. We found a very low prevalence of cerclage-associated complications in singleton pregnancies, for both history-indicated, short cervix-indicated and emergency cerclages. Additionally, take home child rates in singleton pregnancies were remarkably higher when cerclage procedures were performed by experienced gynaecologists, compared to less experienced gynaecologists.What the implications are of these findings for clinical practice and/or further research? Based on the observed difference in take home child rates, we advise all cerclage procedures to be performed by experienced gynaecologists only. This may mean that women with an indication for cerclage will be referred to a more experienced colleague, either in the same, or in another hospital. To ensure treatment by an experienced gynaecologist, simulation-based training could also provide a solution.
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Affiliation(s)
- Maria W E Frenken
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Simone M T A Goossens
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Minke C R Janssen
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands
| | - Leon G M Mulders
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
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30
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Coutinho CM, Sotiriadis A, Odibo A, Khalil A, D'Antonio F, Feltovich H, Salomon LJ, Sheehan P, Napolitano R, Berghella V, da Silva Costa F. ISUOG Practice Guidelines: role of ultrasound in the prediction of spontaneous preterm birth. Ultrasound Obstet Gynecol 2022; 60:435-456. [PMID: 35904371 DOI: 10.1002/uog.26020] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 05/15/2023]
Affiliation(s)
- C M Coutinho
- Department of Gynecology and Obstetrics, Clinics Hospital, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - A Sotiriadis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Odibo
- Washington University School of Medicine, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St Louis, MO, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F D'Antonio
- Center for Fetal Care and High Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - H Feltovich
- Fetal Ultrasound, Intermountain Healthcare, Salt Lake City, UT, USA
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, France
| | - P Sheehan
- Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - R Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - F da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Adekola H, Addo J, Unal ER, James E, Prakash V, Abrams R, Ozgu-erdinc A. Outcomes following Placement and Removal of Transvaginal Cerclage in at Risk Pregnancies: A Single Center Experience. J Pregnancy 2022; 2022:1-6. [PMID: 35874435 PMCID: PMC9300365 DOI: 10.1155/2022/4277451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/30/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Gudicha DW, Romero R, Gomez-Lopez N, Galaz J, Bhatti G, Done B, Jung E, Gallo DM, Bosco M, Suksai M, Diaz-Primera R, Chaemsaithong P, Gotsch F, Berry SM, Chaiworapongsa T, Tarca AL. The amniotic fluid proteome predicts imminent preterm delivery in asymptomatic women with a short cervix. Sci Rep 2022; 12:11781. [PMID: 35821507 DOI: 10.1038/s41598-022-15392-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 06/23/2022] [Indexed: 11/09/2022] Open
Abstract
Preterm birth, the leading cause of perinatal morbidity and mortality, is associated with increased risk of short- and long-term adverse outcomes. For women identified as at risk for preterm birth attributable to a sonographic short cervix, the determination of imminent delivery is crucial for patient management. The current study aimed to identify amniotic fluid (AF) proteins that could predict imminent delivery in asymptomatic patients with a short cervix. This retrospective cohort study included women enrolled between May 2002 and September 2015 who were diagnosed with a sonographic short cervix (< 25 mm) at 16–32 weeks of gestation. Amniocenteses were performed to exclude intra-amniotic infection; none of the women included had clinical signs of infection or labor at the time of amniocentesis. An aptamer-based multiplex platform was used to profile 1310 AF proteins, and the differential protein abundance between women who delivered within two weeks from amniocentesis, and those who did not, was determined. The analysis included adjustment for quantitative cervical length and control of the false-positive rate at 10%. The area under the receiver operating characteristic curve was calculated to determine whether protein abundance in combination with cervical length improved the prediction of imminent preterm delivery as compared to cervical length alone. Of the 1,310 proteins profiled in AF, 17 were differentially abundant in women destined to deliver within two weeks of amniocentesis independently of the cervical length (adjusted p-value < 0.10). The decreased abundance of SNAP25 and the increased abundance of GPI, PTPN11, OLR1, ENO1, GAPDH, CHI3L1, RETN, CSF3, LCN2, CXCL1, CXCL8, PGLYRP1, LDHB, IL6, MMP8, and PRTN3 were associated with an increased risk of imminent delivery (odds ratio > 1.5 for each). The sensitivity at a 10% false-positive rate for the prediction of imminent delivery by a quantitative cervical length alone was 38%, yet it increased to 79% when combined with the abundance of four AF proteins (CXCL8, SNAP25, PTPN11, and MMP8). Neutrophil-mediated immunity, neutrophil activation, granulocyte activation, myeloid leukocyte activation, and myeloid leukocyte-mediated immunity were biological processes impacted by protein dysregulation in women destined to deliver within two weeks of diagnosis. The combination of AF protein abundance and quantitative cervical length improves prediction of the timing of delivery compared to cervical length alone, among women with a sonographic short cervix.
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Jin W, Hughes K, Sim S, Shemer S, Sheehan PM. Abnormal vaginal flora and spontaneous preterm birth in high-risk singleton pregnancies with cervical cerclage. J Matern Fetal Neonatal Med 2022; 35:9983-9990. [PMID: 35686697 DOI: 10.1080/14767058.2022.2081802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate abnormal vaginal and suture-based bacterial flora for associations with spontaneous preterm birth in high-risk singleton pregnancies with an ultrasound-indicated or emergency cervical cerclage. MATERIALS AND METHODS A retrospective study of 196 singleton pregnancies with an ultrasound-indicated or emergency cerclage at the Royal Women's Hospital, Australia, from 2004 to 2018. High vaginal swabs were collected regularly between 14 and 26 weeks' gestation, including pre- and post-cerclage insertion, and sent for microscopy and culture. Cervical suture was cultured upon removal. Primary outcomes were spontaneous preterm birth <37, <34 and <30 weeks. RESULTS 43.4% (85/196) of women delivered preterm. The acquisition and persistence of vaginal Escherichia coli following cerclage insertion were independently associated with spontaneous preterm birth <37 weeks (p = .0225, p = .0477). Escherichia coli growth from the cervical suture upon removal was associated with spontaneous preterm birth <34 weeks (p = .0458). The acquisition of vaginal mixed anaerobes post-cerclage was independently associated with spontaneous preterm birth <34 weeks (p = .0480). CONCLUSION For singleton pregnancies with an ultrasound-indicated or emergency cerclage, the presence of vaginal or suture-based Escherichia coli following cerclage insertion yields increased risk of cerclage failure and spontaneous preterm birth.
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Affiliation(s)
- Wallace Jin
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia.,Pregnancy Research Centre, The Royal Women's Hospital, Melbourne, Australia
| | - Kelly Hughes
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia.,Pregnancy Research Centre, The Royal Women's Hospital, Melbourne, Australia
| | - Shirlene Sim
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Scott Shemer
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia.,Pregnancy Research Centre, The Royal Women's Hospital, Melbourne, Australia
| | - Penelope M Sheehan
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia.,Pregnancy Research Centre, The Royal Women's Hospital, Melbourne, Australia
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Campbell F, Salam S, Sutton A, Jayasooriya SM, Mitchell C, Amabebe E, Balen J, Gillespie BM, Parris K, Soma-Pillay P, Chauke L, Narice B, Anumba DO. Interventions for the prevention of spontaneous preterm birth: a scoping review of systematic reviews. BMJ Open 2022; 12:e052576. [PMID: 35568487 PMCID: PMC9109033 DOI: 10.1136/bmjopen-2021-052576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/04/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Globally, 11% of babies are born preterm each year. Preterm birth (PTB) is a leading cause of neonatal death and under-five mortality and morbidity, with lifelong sequelae in those who survive. PTB disproportionately impacts low/middle-income countries (LMICs) where the burden is highest. OBJECTIVES This scoping review sought to the evidence for interventions that reduce the risk of PTB, focusing on the evidence from LMICs and describing how context is considered in evidence synthesis. DESIGN We conducted a scoping review, to describe this wide topic area. We searched five electronic databases (2009-2020) and contacted experts to identify relevant systematic reviews of interventions to reduce the risk of PTB. We included published systematic reviews that examined the effectiveness of interventions and their effect on reducing the risk of PTB. Data were extracted and is described narratively. RESULTS 139 published systematic reviews were included in the review. Interventions were categorised as primary or secondary. The interventions where the results showed a greater effect size and consistency across review findings included treatment of syphilis and vaginal candidiasis, vitamin D supplementation and cervical cerclage. Included in the 139 reviews were 1372 unique primary source studies. 28% primary studies were undertaken in LMIC contexts and only 4.5% undertaken in a low-income country (LIC) Only 10.8% of the reviews sought to explore the impact of context on findings, and 19.4% reviews did not report the settings or the primary studies. CONCLUSION This scoping review highlights the lack of research evidence derived from contexts where the burden of PTB globally is greatest. The lack of rigour in addressing contextual applicability within systematic review methods is also highlighted. This presents a risk of inappropriate and unsafe recommendations for practice within these contexts. It also highlights a need for primary research, developing and testing interventions in LIC settings.
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Affiliation(s)
| | - Shumona Salam
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | | | | | - Caroline Mitchell
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Emmanuel Amabebe
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Julie Balen
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Bronwen M Gillespie
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Kerry Parris
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Priya Soma-Pillay
- Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Lawrence Chauke
- Department of Obstetrics and Gynaecology, University of Witwatersrand, Johannesburg, South Africa
| | - Brenda Narice
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Dilichukwu O Anumba
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
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Giouleka S, Tsakiridis I, Kostakis N, Koutsouki G, Kalogiannidis I, Mamopoulos A, Athanasiadis A, Dagklis T. Preterm Labor: A Comprehensive Review of Guidelines on Diagnosis, Management, Prediction and Prevention. Obstet Gynecol Surv 2022; 77:302-17. [PMID: 35522432 DOI: 10.1097/OGX.0000000000001023] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Importance Preterm labor (PTL) is one of the most common and serious pregnancy complications associated with significant perinatal morbidity and mortality, as well as long-term neurologic impairment in the offspring. Objective The aim of this study was to review and compare the most recently published major guidelines on diagnosis, management, prediction, and prevention of this severe complication of pregnancy. Evidence Acquisition A descriptive review of guidelines from the National Institute for Health and Care Excellence (NICE), the World Health Organization, the American College of Obstetricians and Gynecologists, the New South Wales Government, and the European Association of Perinatal Medicine (EAPM) on PTL was carried out. Results There is a consensus among the reviewed guidelines that the diagnosis of PTL is based on clinical criteria, physical examination, measurement of cervical length (CL) with transvaginal ultrasound (TVUS) and use of biomarkers, although there is disagreement on the first-line diagnostic test. The NICE and the EAPM are in favor of TVUS CL measurement, whereas the New South Wales Government mentions that fetal fibronectin testing is the mainstay for PTL diagnosis. Moreover, there is consistency among the guidelines regarding the importance of treating PTL up to 34 weeks of gestation, to delay delivery for 48 hours, for the administration of antenatal corticosteroids, magnesium sulfate, and in utero transfer to higher care facility, although several discrepancies exist regarding the tocolytic drugs of choice and the administration of corticosteroids and magnesium sulfate after 34 and 30 gestational weeks, respectively. Routine cesarean delivery in case of PTL is unanimously not recommended. Finally, the NICE, the American College of Obstetricians and Gynecologists, and the EAPM highlight the significance of screening for PTL by TVUS CL measurement between 16 and 24 weeks of gestation and suggest the use of either vaginal progesterone or cervical cerclage for the prevention of PTL, based on specific indications. Cervical pessary is not recommended as a preventive measure. Conclusions Preterm labor is a significant contributor of perinatal morbidity and mortality with a substantial impact on health care systems. Thus, it seems of paramount importance to develop consistent international practice protocols for timely diagnosis and effective management of this major obstetric complication and subsequently improve pregnancy outcomes.
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Martinez O, Moran HK, Wolff SF, Gibbs C, Lee G, Gorman K, Martin A. Cerclage versus vaginal progesterone in low-risk pregnant women with a short cervix. J Matern Fetal Neonatal Med 2022; 35:9878-9883. [PMID: 35440280 DOI: 10.1080/14767058.2022.2065193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare vaginal progesterone to cerclage in preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, incidentally found sonographic cervical length of <15 mm, and no history of preterm birth. STUDY DESIGN A retrospective cohort study was conducted on 68 women who delivered at the University of Kansas Health System with a singleton gestation found to have a cervical length <15 mm on transvaginal ultrasound and no history of preterm birth. Women treated with vaginal progesterone (n = 29) were compared to women who underwent cerclage placement (n = 39). The primary outcome was preterm birth at <34 weeks of gestation. Secondary outcomes include preterm birth at <37 and <28 weeks of gestation and neonatal morbidities. RESULTS Of the 268 patients who had a cervical length of <15 mm on transvaginal ultrasound, 68 participants met inclusion criteria and were included in the final analysis. Twenty-nine participants received vaginal progesterone and 39 participants received cervical cerclage. The average cervical length at initiation of therapy was greater in the progesterone cohort versus cerclage cohort, respectively (10.5 vs. 8.0 mm, p < .01). All other baseline characteristics were similar between groups, including no difference in average gestational age at initiation of therapy (21.6 vs. 21.5 weeks, p = .87). Average latency after therapy did not differ between groups (100 vs. 92.7 days p = .43). The incidence of preterm birth at <37 weeks (OR = 1.49, 95% CI = 0.57-3.93), <34 weeks (OR = 1.47, 95% CI = 0.52-4.18), and <28 weeks (OR = 1.90, 95% CI = 0.45-8.07), did not differ significantly between groups. Additionally, no difference in neonatal morbidity was detected. CONCLUSION At our institution, we found no difference between vaginal progesterone and cerclage in the average latency period or risk of preterm birth among women with an incidental short cervix of <15 mm and no history of preterm birth, despite the significantly shorter initial cervical length in the cerclage group. These findings suggest either vaginal progesterone or cerclage could be used to reduce the risk of preterm birth among this high-risk population.
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Affiliation(s)
- Olivet Martinez
- University of Kansas School of Medicine, Kansas City, MO, USA
| | | | - Sharon Fitzgerald Wolff
- Department of Population Health, University of Kansas School of Medicine, Kansas City, MO, USA
| | - Charles Gibbs
- Division of Maternal-Fetal-Medicine, University of Kansas School of Medicine, Kansas City, MO, USA.,Department of Obstetrics and Gynecology, University of Kansas School of Medicine, Kansas City, MO, USA
| | - Gene Lee
- Division of Maternal-Fetal-Medicine, University of Kansas School of Medicine, Kansas City, MO, USA.,Department of Obstetrics and Gynecology, University of Kansas School of Medicine, Kansas City, MO, USA
| | - Kelly Gorman
- Division of Maternal-Fetal-Medicine, University of Kansas School of Medicine, Kansas City, MO, USA.,Department of Obstetrics and Gynecology, University of Kansas School of Medicine, Kansas City, MO, USA
| | - Angela Martin
- Division of Maternal-Fetal-Medicine, University of Kansas School of Medicine, Kansas City, MO, USA.,Department of Obstetrics and Gynecology, University of Kansas School of Medicine, Kansas City, MO, USA
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Abstract
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 (200/7-256/7 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.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
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Zhuang Y, Li H, Na Q, Yin S, Li N. Prevention of Preterm Birth by Cervical Pessary Combined with Vaginal Progesterone: a Systematic Review and Meta-analysis with Trial Sequential Analysis. Reprod Sci 2022; 30:93-110. [PMID: 35352330 PMCID: PMC9810688 DOI: 10.1007/s43032-022-00926-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/16/2022] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Yanyan Zhuang
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Huan Li
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Quan Na
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Shaowei Yin
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Na Li
- Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004, China.
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Pan JR, Li TY, Tucker D, Chen KY. Pregnancy outcomes in women with active anorexia nervosa: a systematic review. J Eat Disord 2022; 10:25. [PMID: 35172902 PMCID: PMC8848585 DOI: 10.1186/s40337-022-00551-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is a common misconception that women with active anorexia nervosa (AN) are less likely to conceive. Pregnancies in women with AN are considered high risk. The purpose of this systematic review was to explore pregnancy complications in women with active AN, including maternal, fetal, and neonatal complications. METHODS The authors conducted a systematic review in accordance with PRISMA statement guidelines with stringent selection criteria to include studies on patients with active AN during pregnancy. RESULTS There were 21 studies included in our review. Anaemia, caesarean section, concurrent recreational substance use, intrauterine growth restriction, preterm birth, small-for-gestation (SGA) birth, and low birth weight were the most reported pregnancy complications in women with active AN, while the rates of gestational diabetes and postpartum haemorrhage were lower. DISCUSSION Women with active AN have a different profile of pregnancy complications comparing to malnourished women and women in starvation. We recommend early discussion with women diagnosed with AN regarding their fertility and pregnancy complications. We recommend clinicians to aim to improve physical and psychological symptoms of AN as well as correction of any nutritional deficiency ideally prior to conception. Management of pregnancies in women with active AN requires regular monitoring, active involvement of obstetricians and psychiatrist. Paediatric follow-up postpartum is recommended to ensure adequate feeding, wellbeing and general health of the infants. Psychiatric follow-up is recommended for mothers due to risk of worsening symptoms of AN during perinatal period.
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Affiliation(s)
- Jeremy Ryan Pan
- Townsville Hospital and Health Service, Townsville, QLD, Australia. .,College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia.
| | - Tina Yutong Li
- Townsville Hospital and Health Service, Townsville, QLD, Australia
| | - Danny Tucker
- Townsville Hospital and Health Service, Townsville, QLD, Australia.,College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Kai Yang Chen
- Townsville Hospital and Health Service, Townsville, QLD, Australia.,College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Kobayashi A, Takahashi H, Matsubara S, Baba Y, Nagayama S, Ogoyama M, Horie K, Suzuki H, Usui R, Ohkuchi A, Fujiwara H. Prognosis and Prognostic Factors of Patients with Emergent Cerclage: A Japanese Single-Center Study. Obstet Gynecol Int 2021; 2021:4351783. [PMID: 34987587 DOI: 10.1155/2021/4351783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/11/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives The aims of this study were to clarify the following: (1) how often does prolonged pregnancy ≥34 weeks occur in patients with emergent cerclage without progesterone and (2) the risk factors preventing such pregnancy continuation. Materials and Methods This retrospective observational study was performed using medical records of patients for whom emergent cerclage had been performed between April 2006 and December 2018 in our institute. Results Emergent cerclage was performed in 123 patients (median age: 34, interquartile range: 31–36). Primiparous patients numbered 44 (36%). A history of spontaneous preterm birth (SPTB) was present in 30 (24%). The median presurgical cervical length (CL) was 16 (8–21) mm at surgery. Of the 123, 20 (16%) were delivered at 33 + 6 weeks or less (<34 weeks). We conducted logistic regression analysis of the risk factors of SPTBs <34 weeks after cerclage. Three risk factors were identified that increased the risk of SPTB <34 weeks: presurgical CL 0 mm (odds ratio (OR): 5.30; 95% confidence interval (CI): 1.58–17.7), a history of SPTB (OR: 4.65; 95% CI: 1.38–15.7), and the presence of sludge (OR: 4.14; 95% CI: 1.20–14.3). Conclusion Three risk factors predicted SPTB <34 weeks after emergency cerclage without progesterone administration: unmeasurable CL (CL 0 mm), a history of SPTB, and the presence of sludge on ultrasound. SPTB <34 weeks occurred after emergency cerclage in 16% of patients, being comparable with the recent data with progesterone.
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Pahlavan F, Niknejad F, Irani S, Niknejadi M. Does amniotic fluid sludge result in preterm labor in pregnancies after assisted reproduction technology? A nested Case - Control study. J Matern Fetal Neonatal Med 2021; 35:7153-7157. [PMID: 34470560 DOI: 10.1080/14767058.2021.1945575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE to investigate the relationship between the Amniotic fluid Sludge exposure during pregnancy and the Preterm Labor (PTL) in pregnant women who had undergone Assisted Reproductive Technology procedures (ART) in Royan institute. MATERIALS AND METHODS It was a nested case-control study that was conducted on 110 eligible pregnant women who had undergone IVF procedure in Royan institute, Tehran, Iran. The final sample size was 63 subjects with Amniotic fluid Sludge and 67 subjects with normal Amniotic fluid. Delivery before 37 of gestation was considered as PTL.The study was approved by the ethics committee of the Royan institute and the written consent form was filled by participants. Data was entered to the SPSS (version 21, SPSS, Inc.). The baseline characteristics of the participants were described as absolute (n) and relative (%) frequencies for the covariates. Man Whitney and T-Test were used to compare the mean of covariates and the P-value lower than 0.05 was considered significant. The prevalence of the PTL was compared between two groups. RESULTS The mean Gestational Age at delivery in case and control group were 36.46 ± 3.45 and 38.03 ± 1.61, respectively which was significant (p = .01). The prevalence of PTL in case and control group were 23.8% and 10.4% respectively which was significant (p = .04). The percentage of cases with cervical length less than 30 (mm) in case and control group were 28.6% and 10.4%, respectively (p = .008) and the percentage of cerclage in case and control group were 33.3% and 7.5% respectively, (p = .00) which were significant statistically. CONCLUSION The amniotic fluid sludge has a direct effect on the cervical length of pregnancies after ART. In such cases, PTB will be probable in the presence of sludge in spite of preventive treatments such as cerclage.
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Affiliation(s)
- Fattaneh Pahlavan
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Fatemeh Niknejad
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Shohreh Irani
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Maryam Niknejadi
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
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Boelig RC. Should singleton gestations without prior preterm birth receive an ultrasound-indicated cerclage? Tempting, but we must wait for more level 1 data. Am J Obstet Gynecol MFM 2021; 3:100431. [PMID: 34419385 DOI: 10.1016/j.ajogmf.2021.100431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
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American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol 2021; 138:e65-90. [PMID: 34293771 DOI: 10.1097/AOG.0000000000004479] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Preterm birth is among the most complex and important challenges in obstetrics. Despite decades of research and clinical advancement, approximately 1 in 10 newborns in the United States is born prematurely. These newborns account for approximately three-quarters of perinatal mortality and more than one half of long-term neonatal morbidity, at significant social and economic cost (1-3). Because preterm birth is the common endpoint for multiple pathophysiologic processes, detailed classification schemes for preterm birth phenotype and etiology have been proposed (4, 5). In general, approximately one half of preterm births follow spontaneous preterm labor, about a quarter follow preterm prelabor rupture of membranes (PPROM), and the remaining quarter of preterm births are intentional, medically indicated by maternal or fetal complications. There are pronounced racial disparities in the preterm birth rate in the United States. The purpose of this document is to describe the risk factors, screening methods, and treatments for preventing spontaneous preterm birth, and to review the evidence supporting their roles in clinical practice. This Practice Bulletin has been updated to include information on increasing rates of preterm birth in the United States, disparities in preterm birth rates, and approaches to screening and prevention strategies for patients at risk for spontaneous preterm birth.
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Gulersen M, Bornstein E, Domney A, Blitz MJ, Rafael TJ, Li X, Krantz D, Rochelson B. Cerclage in singleton gestations with an extremely short cervix (≤10 mm) and no history of spontaneous preterm birth. Am J Obstet Gynecol MFM 2021; 3:100430. [PMID: 34271252 DOI: 10.1016/j.ajogmf.2021.100430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/20/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson).
| | - Eran Bornstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY (Dr Bornstein)
| | - Alixandra Domney
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson)
| | - Matthew J Blitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Bay Shore, NY (Dr Blitz)
| | - Timothy J Rafael
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson)
| | - Xueying Li
- Eurofins NTD, Melville, NY (Ms Li and Mr Krantz)
| | - David Krantz
- Eurofins NTD, Melville, NY (Ms Li and Mr Krantz)
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY (Drs Gulersen, Domney, Rafael, and Rochelson)
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Park H, Kwon DY, Kim SY, Park J, Kim YM, Sung JH, Choi SJ, Oh SY, Kim JS, Roh CR. Association of adherence to guidelines for cervical cerclage with perinatal outcomes and placental inflammation in women with cervical length ≥2.0 cm. Taiwan J Obstet Gynecol 2021; 60:665-673. [PMID: 34247804 DOI: 10.1016/j.tjog.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines. MATERIAL AND METHODS This study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology. RESULTS Among 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033). CONCLUSION Cerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation.
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Affiliation(s)
- Hyea Park
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Do Youn Kwon
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seo-Yeon Kim
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Juyoung Park
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoo-Min Kim
- Department of Obstetrics and Gynecology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jung-Sun Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheong-Rae Roh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Lim KI, Butt K, Nevo O, Crane JM. Guideline No. 401: Sonographic Cervical Length in Singleton Pregnancies: Techniques and Clinical Applications. J Obstet Gynaecol Can 2021; 42:1394-1413.e1. [PMID: 33189242 DOI: 10.1016/j.jogc.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES • To assess the association between sonography-derived cervical length measurement and preterm birth. • To describe the various techniques to measure cervical length using sonography. • To review the natural history of the short cervix. • To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. OUTCOMES Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. INTENDED USERS Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. TARGET POPULATION Women at increased risk of a short cervix or at risk of preterm birth. EVIDENCE Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care (Online Appendix Table A1). BENEFITS, HARMS, COSTS Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SUMMARY STATEMENTS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES): RECOMMENDATIONS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES).
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Huang X, Chen R, Li B. Analysis of maternal and neonatal outcomes using cervical cerclage or conservative treatment in singleton gestations with a sonographic short cervix. Medicine (Baltimore) 2021; 100:e25767. [PMID: 33950964 PMCID: PMC8104303 DOI: 10.1097/md.0000000000025767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 04/10/2021] [Indexed: 01/04/2023] Open
Abstract
To investigate the effect of cervical cerclage or conservative treatment on maternal and neonatal outcomes in singleton gestations with a sonographic short cervix, and further compare the relative treatment value.A retrospective study was conducted among women with singleton gestations who had a short cervical length (<25 mm) determined by ultrasound during the period of 14 to 24 weeks' gestation in our institution. We collected clinical data and grouped the patients according to a previous spontaneous preterm birth (PTB) at <34 weeks of gestation or second trimester loss (STL) and sub-grouped according to treatment option, further comparing the maternal and neonatal outcomes between different groups.In the PTB or STL history cohort, the cerclage group had a later gestational age at delivery (35.3 ± 3.9 weeks vs 31.6 ± 6.7 weeks) and a lower rate of perinatal deaths (2% vs 29.3%) compared with the conservative treatment group. In the non-PTB-STL history cohort, the maternal and neonatal outcomes were not significantly different between the cerclage group and conservative treatment group. More importantly, for patients with a sonographic short cervix who received cervical cerclage, there was no significant difference in the maternal and neonatal outcomes between the non-PTB-STL group and PTB or STL group.For singleton pregnant with a history of spontaneous PTB or STL and a short cervical length (<25 mm), cervical cerclage can significantly improve maternal and neonatal outcomes; however, conservative treatment (less invasive and expensive than cervical cerclage) was more suitable for those pregnant women without a previous PTB and STL history.
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Fontán Atalaya IM, Caruso A, Perea Cruz A, Fernandez Torres B. Painless cervical dilation with "hourglass membranes". Conservative management: our experience. Minerva Obstet Gynecol 2021; 73:638-645. [PMID: 33876896 DOI: 10.23736/s2724-606x.21.04703-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
| | - Andrea Caruso
- Department of Obstetrics and Gynaecology, Virgen Macarena Hospital, Seville, Spain
| | - Almudena Perea Cruz
- Department of Obstetrics and Gynaecology, Virgen Macarena Hospital, Seville, Spain
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Bloomfield J, Pénager C, Mandelbrot L. Shirodkar cerclage: Obstetrical and neonatal outcomes in a single-center cohort of 55 cases. J Gynecol Obstet Hum Reprod 2021; 50:102152. [PMID: 33887533 DOI: 10.1016/j.jogoh.2021.102152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/09/2021] [Accepted: 04/15/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cervical insufficiency is thought to be responsible for 10% of preterm deliveries. Shirodkar cerclage is among the available techniques ranging from McDonald's to definitive procedures, however the indications for the prevention of preterm births and mid-trimester miscarriages are still poorly delineated. OBJECTIVE To describe the characteristics, obstetrical and neonatal outcomes of pregnancies with Shirodkar cerclage procedures. METHOD We performed a descriptive retrospective single-center study, including all patients who had a Shirodkar cerclage between January 1, 2008 and December 31, 2020. The main outcomes measured were delivery at or beyond 24 and 32 weeks of gestations (WG). RESULTS 55 Shirodkar cerclages were performed over the period studied. 7.3% of patients had a uterine malformation, 9% had a history of cervical conization. 74.5% had history of one or more mid-trimester miscarriages. 63.6% had a history of a failed emergency or prophylactic cerclage. The median gestational age (GA) at cerclage placement was 14 WG. There were 4 deliveries before 24 WG, 8 before 32 WG and 16 before 37 WG. Overall neonatal survival was 48/53 (90.6%). The median GA at delivery was 38 weeks (IQR 35-39), with 70.3% of vaginal deliveries. CONCLUSION Shirodkar cerclage was successful in more than 90% of patients, despite their obstetric history. Shirodkar cerclage may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes. Its advantage over definitive cerclage is to allow for vaginal delivery.
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Affiliation(s)
- Joy Bloomfield
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris, Paris, France; FHU PREMA, Paris and Colombes, France
| | - Cécile Pénager
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris, Paris, France; FHU PREMA, Paris and Colombes, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris, Paris, France; FHU PREMA, Paris and Colombes, France; Inserm UMR1137 IAME, Paris, France.
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Okuhara M, Tsuda H, Nishiko Y, Fuma K, Kuribayashi M, Tezuka A, Ando T, Mizuno K. The efficacy of therapeutic cervical cerclage in singleton pregnancies: a retrospective study. J Matern Fetal Neonatal Med 2021; 35:6267-6271. [PMID: 33843437 DOI: 10.1080/14767058.2021.1910663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Michika Okuhara
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hiroyuki Tsuda
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Yuki Nishiko
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Kazuya Fuma
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Momoko Kuribayashi
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Atsuko Tezuka
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Tomoko Ando
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Kimio Mizuno
- Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
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