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

1
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
  library
• Ultrasound Obstet Gynecol 201341

2

• Preterm birth remains the leading cause of
  perinatal morbidity mortality worldwide
• so
• Preventive strategies required to minimize burden
  of prematurity

3

• Shortened Cx length in TVS is powerful predictor
  of spontaneous preterm birth

4

• Vaginal progesterone for asymptomatic pregnant
  women with short Cx 25mm In comparison with
  placebo reduces
• Preterm birth rates before 33 weeks GA
• Neonatal mortality/morbidity

5

• In a Cochrane review
• cerclage in comparison with no treatment for
  preterm birth prevention in singleton pregnancy
  reported a less marked, but statistically
  significant

6

• In meta-analysis Benefit of cerclage for women
  with singleton pregnancy is highlighted in
• Short Cx
• Previous preterm birth

7

• 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 lt34 w GA (6.3 vs 26.8)
• Neonatal morbidity (4.2 vs 22.1)

8
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

9
Method

• 3 different cohort of singleton pregnant women
  with a Hx of at least one spontaneous preterm
  birthlt 34 short cx on sono
• 142 treated with cerclage in USA
• 59 vaginal progesterone UK
• 42 cervical pessary Spain

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cerclage

• 15 clinical center in the USA 2003-2007
• Singleton pregnant women with previous histoty of
  preterm birth at 17W ltGAlt336
• if Cx length lt25mm cerclage done
• if Cx length 25-29mm serial transvaginal scan at
  16ltGAlt216 fortnightly or weekly screen for
  Neisseria gonorrhoeae chlamydia trachomatis
  that treat with positive culture

11
Post cerclage management

• Recommendation for pelvic rest
• Abstinence from sexual activity
• No douching
• No tampons
• Physical activity restrictions, no prolonged
  standing for gt4 h
• No heavy physical work involving lifting gt20
  pounds or straining
• No valsalva

12
Cerclage removing

• 37 W GA in NL pregnancy
• Early removing in
• chorioamnion rupture
• labor
• hemorrhage

13
Vaginal progesterone

• 59 high risk Singleton pregnant women with
• Spontaneous preterm birth
• Preterm ROM
• Significant cervical surgery
• referred to the weekly outpatient clinic

14
Short cervix

• Cervical length lt 3rd centile
• 30.5mm at 16 W
• 24.5mm at 23W

15

• Serial transvaginal scan from 16W every 1-4 W
  (depended on initial cervical length GA of
  prior preterm birth )
• 200mg vaginal progesteron at night (restriction
  in activity prolonged standing but no advise
  for sexual activity)
• If significant Cx shortening do cerclage
  (lt15mm in women that was gt 15mm or further
  shortening gt50 in lt15mm cervical length in
  initial treatment)
• Vaginal swab were taken only for symptomatic pt

16
Cervical pessary

• 42 singleton pregnant women with pior preterm
  birth lt34 in Spain 2007-2010
• Serial 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

17
Removing pessary

• In NL pregnancy 37W GA
• Before 37W in
• Active vaginal bleeding
• Threat of preterm labor with persistant
  contractions, despite tocolysis, or sever pt
  discomfort

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results
Cerclage Vaginal progesterone Cervical pessary
Maternal age 26 5 30 6 31 7
Racial origine Afro-caribbean Caucasian Other 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 308 256 276
Prior birthlt34 2(1-3) 1(1-3) 1(1-3)
GA in initiation of treatment 192 213 212
Cx length in initiation of treatment 18.46.3 21.18.1 19.35.1
cerclage 142(100) 6(10) 0
Progesterone 54(38) 59(100) 0
Cx pessary 0 1(2) 42(100)
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Clinical outcom
Cerclage(A) Vaginal progesterone(B) Cervical pessary (c) A vs B A vs c B vs c
Pregnancy outcom Birthlt 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)
Pregnancy outcom Birthlt34w 40(28) 19(32) 5(12) 0.87 (0.56-1.38) 2.37 (1.00-5.61) 2.70 (1.10-6.67)
Pregnancy outcom Birth lt28w 20(14) 8(14) 3(7) 1.04 (0.48-2.22) 1.97(0.62-6.31) 1.90 (0.53-6.74)
Pregnancy outcom 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)
Neonatal outcom Serious ICH 0 1(2) 0
Neonatal outcom 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)
Neonatal outcom Necrotizing entrocolitis 2(1) 0 1(2)
Retinopathy of prematurity 3(2) 0 0
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Clinical outcom in cervical lenghtlt25
irrespective of GA
PRIMARY THERAPY FOR SHORT CERVIX PRIMARY THERAPY FOR SHORT CERVIX PRIMARY THERAPY FOR SHORT CERVIX Relative risk(95 CI) Relative risk(95 CI) Relative risk(95 CI)
Cerclage (142) Vaginal progesterone (38) Cx pessary (42) A vs B A vs C B vs c
Birth lt34 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)
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

22

• Smoking ethnicity are confounders known to
  be associated with preterm birth however in short
  Cx it is low

23
Infection screening

• USA study N.gonorrhoeae C.trachomatis
• Spanish vaginal bacteriosis
• Uk screen symptomatic women
• Number of women who received AB is low so
  effectiveness of AB to prevent preterm birth
  remains unproven

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• Progressive cervical shortening CX lengthlt 15mm
  increased benefit with cerclage despite treatment
  with progesteron

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recommendation

• Trials should be less invasine and cheaper
  treatment and need to be even larger studies
• Choose cerclage, vaginal progesterone or cervical
  pessary for women with short cervix on sono or
  prior preterm birth is reasnable