Transcript Vaginal progesterone, cerclage or cervical pessary for

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 library
Ultrasound Obstet Gynecol 2013;41
Preterm birth remains the leading cause of
perinatal morbidity & mortality worldwide
so
Preventive 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 GA
O 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 Cx
O 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 USA
59 vaginal progesterone UK
42 cervical pessary Spain
cerclage
15 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 management
O Recommendation for pelvic rest
O Abstinence from sexual activity
O No douching
O No tampons
O Physical activity restrictions, no prolonged standing for
>4 h
O No heavy physical work involving lifting >20 pounds or
straining
O No valsalva
Cerclage removing
O 37 W GA in NL pregnancy
O Early removing in :
 chorioamnion rupture
 labor
 hemorrhage
Vaginal progesterone
59 high risk Singleton pregnant women with:
O Spontaneous preterm birth
O Preterm ROM
O Significant cervical surgery
referred to the weekly outpatient clinic
Short cervix
Cervical length < 3rd centile
O 30.5mm at 16 W
O 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 2007-2010
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
Removing pessary
In NL pregnancy 37W GA
Before 37W in:
O Active vaginal bleeding
O Threat of preterm labor with persistant
contractions, despite tocolysis, or sever pt
discomfort
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
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
Pregnanc
y outcom
Neonatal
outcom
Cercla
ge(A)
Vagina
l
proges
terone(
B)
Cervical
pessary
(c)
A vs B
A vs c
B vs c
Birth< 37w
63(44)
27(46)
19(45)
0.97 (0.69-1.35)
0.98 (0.67-1.43)
1.01 (0.661.56)
Birth<34w
40(28)
19(32)
5(12)
0.87 (0.56-1.38)
2.37 (1.00-5.61)
2.70 (1.106.67)
Birth <28w
20(14)
8(14)
3(7)
1.04 (0.48-2.22)
1.97(0.62-6.31)
1.90 (0.536.74)
C/s
43(30)
12(20)
10(24)
1.49 (0.85-2.61)
1.23 (0.70-2.31)
0.85 (0.411.79)
Perinatal loss
12(8)
5(8)
1(2)
0.99 (0.37-2.71)
3.55 (0.47-26.51)
3.56 (0.4329.37)
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 (0.4510.07)
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
progestero
ne (38)
Cx pessary
(42)
A vs B
A vs C
B vs c
Birth <34
40(28)
10(26)
5(12)
1.07 (0.591.94)
2.37 (0.995.61)
2.21 (0.83-5.98)
Perinatal
loss
12(8)
5(13)
1(2)
0.64 (0.241.71)
3.55
(0.47_26.51)
5.53 (0.6845.21)
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 screening
O USA study: N.gonorrhoeae & C.trachomatis
O Spanish: vaginal bacteriosis
O Uk: screen symptomatic women
Number 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
recommendation
O 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