in the name of god. vaginal progesterone, cerclage or cervical pessary for preventing preterm birth...
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In the name of God
Vaginal progesterone, cerclage or cervical pessary for
preventing preterm birth in asymptomatic singleton pregnant women with a
history of preterm birth and a sonographic short cervix
Published online 17 January 2013 in Wiley online libraryUltrasound Obstet Gynecol 2013;41
Preterm birth remains the leading cause of perinatal morbidity & mortality worldwide soPreventive strategies required to minimize burden of prematurity
Shortened Cx length in TVS is powerful predictor of spontaneous preterm birth
Vaginal progesterone for asymptomatic pregnant women with short Cx ≤ 25mm In comparison with placebo reduces:O Preterm birth rates before 33 weeks
GAO Neonatal mortality/morbidity
In a Cochrane review : cerclage in comparison with no treatment for preterm birth prevention in singleton pregnancy reported a less marked, but statistically significant
In meta-analysis Benefit of cerclage for women with singleton pregnancy is highlighted in:O Short CxO Previous preterm birth
Cx pessary versous expectant management in a recent multicenter study in spain:380 pregnant women with Hx of preterm birth &Cx length ≤25mm
Significant reduction in:Preterm birth <34 w GA (6.3% vs 26.8%)Neonatal morbidity (4.2% vs 22.1%)
Aim of this study
Compare outcom of pregnancy in singleton pregnancy with Hx of preterm bith & Cx length ≤25mm in cerclage, vaginal progesterone or cervical pessary
Method:
3 different cohort of singleton pregnant women with a Hx of at least one spontaneous preterm birth< 34 & short cx on sono:142 treated with cerclage in USA59 vaginal progesterone UK42 cervical pessary Spain
cerclage15 clinical center in the USA 2003-2007:Singleton pregnant women with previous histoty of preterm birth at 17W <GA<33+6 if Cx length <25mm cerclage done if Cx length 25-29mm serial transvaginal
scan at 16<GA<21+6 fortnightly or weekly screen for Neisseria gonorrhoeae & chlamydia trachomatis that treat with positive culture
Post cerclage managementO Recommendation for pelvic restO Abstinence from sexual activityO No douchingO No tamponsO Physical activity restrictions, no prolonged
standing for >4 hO No heavy physical work involving lifting >20
pounds or strainingO No valsalva
Cerclage removingO 37 W GA in NL pregnancyO Early removing in : chorioamnion rupture labor hemorrhage
Vaginal progesterone
59 high risk Singleton pregnant women with:O Spontaneous preterm birthO Preterm ROMO Significant cervical surgery
referred to the weekly outpatient clinic
Short cervix
Cervical length < 3rd centileO 30.5mm at 16 WO 24.5mm at 23W
O Serial transvaginal scan from 16W every 1-4 W (depended on initial cervical length & GA of prior preterm birth )
O 200mg vaginal progesteron at night (restriction in activity & prolonged standing but no advise for sexual activity)
O If significant Cx shortening do cerclage (<15mm in women that was > 15mm or further shortening >50% in <15mm cervical length in initial treatment)
O Vaginal swab were taken only for symptomatic pt
Cervical pessary
42 singleton pregnant women with pior preterm birth <34 in Spain 2007-2010Serial TVS from 16W continued 1-4 W Cervical & vaginal swab if infection proved appropriate treatment then with 1 week delay pessary inserted but not removing for infection after insertion
Removing pessary
In NL pregnancy 37W GABefore 37W in:O Active vaginal bleedingO Threat of preterm labor with
persistant contractions, despite tocolysis, or sever pt discomfort
resultsCerclage Vaginal
progesterone Cervical pessary
Maternal age 26 ± 5 30 ± 6 31± 7
Racial origineAfro-caribbean CaucasianOther
75(53)51(36)16(11)
3(5)53(89)3(5)
1(2)35(83)6(14)
Smoker 23(16) 21(36) 11(26)
BMI 30±8 25±6 27±6
Prior birth<34 2(1-3) 1(1-3) 1(1-3)
GA in initiation of treatment
19±2 21±3 21±2
Cx length in initiation of treatment
18.4±6.3 21.1±8.1 19.3±5.1
cerclage 142(100) 6(10) 0
Progesterone 54(38) 59(100) 0
Cx pessary 0 1(2) 42(100)
Clinical outcom
Cerclage(A)
Vaginal progesterone(B)
Cervical pessary (c)
A vs B A vs c B vs c
Pregnancy outcom
Birth< 37w 63(44)
27(46)
19(45) 0.97 (0.69-1.35)
0.98 (0.67-1.43) 1.01 (0.66-1.56)
Birth<34w 40(28)
19(32)
5(12) 0.87 (0.56-1.38)
2.37 (1.00-5.61) 2.70 (1.10-6.67)
Birth <28w 20(14)
8(14) 3(7) 1.04 (0.48-2.22)
1.97(0.62-6.31) 1.90 (0.53-6.74)
C/s 43(30)
12(20)
10(24) 1.49 (0.85-2.61)
1.23 (0.70-2.31) 0.85 (0.41-1.79)
Neonatal outcom
Perinatal loss 12(8) 5(8) 1(2) 0.99 (0.37-2.71)
3.55 (0.47-26.51) 3.56 (0.43-29.37)
Serious ICH 0 1(2) 0
Serious respiratory morbidity
12(8) 6(10) 2(4) 0.83(0.33-2.11) 1.77 (0.41-7.62) 2.14 (0.45-10.07)
Necrotizing entrocolitis
2(1) 0 1(2)
Retinopathy of prematurity
3(2) 0 0
Clinical outcom in cervical lenght<25 irrespective of GA
PRIMARY THERAPY FOR SHORT CERVIX
Relative risk(95 CI)
Cerclage (142)
Vaginal progesterone (38)
Cx pessary (42)
A vs B A vs C B vs c
Birth <34
40(28) 10(26) 5(12) 1.07 (0.59-1.94)
2.37 (0.99-5.61)
2.21 (0.83-5.98)
Perinatal loss
12(8) 5(13) 1(2) 0.64 (0.24-1.71)
3.55 (0.47_26.51)
5.53 (0.68-45.21)
Discussion
Similar effectiveness of currently available treatment strategies for women with singleton pregnancy who has one prior preterm birth and shortened cervical length on TVS
Smoking & ethnicity are confounders known to be associated with preterm birth however in short Cx it is low
Infection screeningO USA study: N.gonorrhoeae &
C.trachomatisO Spanish: vaginal bacteriosisO Uk: screen symptomatic womenNumber of women who received AB is low so effectiveness of AB to prevent preterm birth remains unproven…
Progressive cervical shortening & CX length< 15mm increased benefit with cerclage despite treatment with progesteron
recommendationO Trials should be less invasine and
cheaper treatment and need to be even larger studies
O Choose cerclage, vaginal progesterone or cervical pessary for women with short cervix on sono or prior preterm birth is reasnable
Thanks for your attention
Thanks for your
attention
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