Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta-analysis

BACKGROUND

Preterm birth (PTB) is the leading cause of infant death, but it is unclear which intervention is best to prevent it.

OBJECTIVES

To compare progesterone, cerclage and pessary, determine their relative effects and rank them.

SEARCH STRATEGY

We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL and Web of Science (to April 2016), without restrictions, and screened references of previous reviews.

SELECTION CRITERIA

We included randomised trials of progesterone, cerclage or pessary for preventing PTB in women with singleton pregnancies at risk as defined by each study.

DATA COLLECTION AND ANALYSIS

We extracted data by duplicate using a piloted form and performed Bayesian random-effects network meta-analyses and pairwise meta-analyses. We rated evidence quality using GRADE, ranked interventions using SUCRA and calculated numbers needed to treat (NNT).

MAIN RESULTS

We included 36 trials (9425 women; 25 low risk of bias trials). Progesterone ranked first or second for most outcomes, reducing PTB < 34 weeks [odds ratio (OR) 0.44; 95% credible interval (CrI) 0.22-0.79; NNT 9; low quality], <37 weeks (OR 0.58; 95% CrI 0.41-0.79; NNT 9; moderate quality), and neonatal death (OR 0.50; 95% CrI 0.28-0.85; NNT 35; high quality), compared with control, in women overall at risk. We found similar results in the subgroup with previous PTB, but only a reduction of PTB < 34 weeks in women with a short cervix. Pessary showed inconsistent benefit and cerclage did not reduce PTB < 37 or <34 weeks.

CONCLUSIONS

Progesterone was the best intervention for preventing PTB in singleton pregnancies at risk, reducing PTB < 34 weeks, <37 weeks, neonatal demise and other sequelae.

TWEETABLE ABSTRACT

Progesterone was better than cerclage and pessary to prevent preterm birth, neonatal death and more in network meta-analysis.

Does non-pharmacological therapy for antenatal depression reduce risks for the infant?

Depression during pregnancy has been associated with an increased risk of adverse outcomes for the infant such as preterm birth. These risks are not reduced with pharmacological treatment, but the effect of non-pharmacological therapies is unknown. We performed a systematic review to assess the risk of adverse perinatal outcomes in non-pharmacologically treated depressed women compared to non-depressed women. We found no studies that met our inclusion criteria, highlighting a critical need for research on this topic.

Can we safely recommend gestational weight gain below the 2009 guidelines in obese women? A systematic review and meta-analysis

A systematic review was conducted to determine the risk of adverse pregnancy outcomes with gestational weight gain (GWG) below the 2009 Institute of Medicine guidelines compared with within the guidelines in obese women. MEDLINE, Embase, Cochrane Register, CINHAL and Web of Science were searched from 1 January 2009 to 31 July 2014. Quality was assessed using a modified Newcastle-Ottawa scale. Three primary outcomes were included: preterm birth, small for gestational age (SGA) and large for gestational age (LGA). Eighteen cohort studies were included. GWG below the guidelines had higher odds of preterm birth (adjusted odds ratio [AOR] 1.46; 95% confidence interval [CI] 1.07-2.00) and SGA (AOR 1.24; 95% CI 1.13-1.36) and lower odds of LGA (AOR 0.77; 95% CI 0.73-0.81) than GWG within the guidelines. Across the three obesity classes, the odds of SGA and LGA did not show any notable gradient and remained unexplored for preterm birth. Decreased odds were noted for macrosomia (AOR 0.64; 95% CI 0.54-0.77), gestational hypertension (AOR, 0.70; 95% CI 0.53-0.93), pre-eclampsia (AOR 0.90; 95% CI 0.82-0.99) and caesarean (AOR 0.87; 95% CI 0.82-0.92). GWG below the guidelines cannot be routinely recommended but might occasionally be individualized for certain women, with caution, taking into account other known risk factors.

Long-term interferon-β treatment for multiple sclerosis

The aim of our study was to analyze the dropout rate in patients with relapsing-remitting multiple sclerosis (RRMS) under long-term treatment with the three commercially available interferon beta (IFNbeta) preparations. According to the drug taken, we divided 122 RRMS patients into 4 groups: Betaferon group, 56 patients taking INFbeta-1b (24 MIU weekly, subcutaneous injections); Avonex group, 38 patients taking IFNbeta-1a (6 MIU weekly, intramuscularly); Rebif group, 18 patients taking INFbeta-1b (18 MIU subcutaneously). Ten patients who shifted from Betaferon to Avonex were included in a fourth group. Dropouts were registered every trimester with the related cause. Data were evaluated using Kaplan-Meier survival analysis and log-rank test. During the observation period of five years, 48 patients (39.9%) dropped out: 48% of the patients in Betaferon group withdrew at a median of 758 days, 26% of the Avonex group at 356 days; 38% of the Rebif group at 421 days, and 40% of those who shifted from Betaferon to Avonex at 259 days. The differences between groups were not significant on survival analysis. Patients receiving higher dose treatment (Betaferon and Rebif groups) dropped out mainly for clinical adverse events; conversely, patients receiving lower dose therapy (Avonex group) dropped out most often for inefficacy. Patients who shifted to a lower dose treatment (fourth group) had a dropout rate similar to that of the initial treatment. Our data showed that one-third of the patients stopped the therapy, mostly for adverse events and then for inefficacy, while the remaining two-thirds were still on treatment without problems up to 5 years of follow-up. Compliance seems related to the dose of the drug, but further analysis is needed to confirm our data.

Chlamydia infection in street youth: Need for more aggressive screening programs

OBJECTIVES

To determine, first, the sexual practices among street youth in the Ottawa-Carleton, Ontario region; second, the percentage of street youth who report previous sexually transmitted disease (STD) screening; and third, the rate of previous infection with Chlamydia trachomatis in this population.

METHODS

This prospective street youth pilot study was cross-sectional in design. Street youth aged 15 to 20 years were recruited through a drop-in centre or shelter in Ottawa, Ontario between August and October 1993. Information on demographics, substance use, current sexual practices and STD screening and infection history were obtained through a structured face to face interview and a 75-item questionnaire. Past C trachomatis infection was determined by microimmunofluorescence assay with purified antigens of C trachomatis (serovars A to K), Chlamydia psittaci (avian strain 6BC) and Chlamydia pneumoniae (TW-183 strain).

RESULTS

Ninety-eight per cent of the youth approached participated. Of the 100 street youth (61 males, mean age 17.8 years; 39 females, mean age 17.1 years), 94% were sexually active, with 21% of males and 26% of females having had four or more different sexual partners in the previous year. Only 27% of males and 8% of females reported consistent condom use with all partners all of the time. Thirty per cent of males and 50% of females reported previous STD testing. Of the 100 street youth, 22 (16 males and six females) had had previous C trachomatis infection by serotesting, but only three of 16 (19%) of these males and three of six (50%) of these females reported previous STD testing. None of the 22 recalled previous diagnosis or treatment for any STD.

CONCLUSIONS

These street youth reported a high prevalence of risky sexual behaviour, and this supports the national STD guidelines for targeted screening in this population. The current screening guidelines for C trachomatis in this population do not reach the majority of street youth.