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