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Lamont RF, Richardson LS, Boniface JJ, Cobo T, Exner MM, Christensen IB, Forslund SK, Gaba A, Helmer H, Jørgensen JS, Khan RN, McElrath TF, Petro K, Rasmussen M, Singh R, Tribe RM, Vink JS, Vinter CA, Zhong N, Menon R. Commentary on a combined approach to the problem of developing biomarkers for the prediction of spontaneous preterm labor that leads to preterm birth. Placenta 2020; 98:13-23. [PMID: 33039027 DOI: 10.1016/j.placenta.2020.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Globally, preterm birth has replaced congenital malformation as the major cause of perinatal mortality and morbidity. The reduced rate of congenital malformation was not achieved through a single biophysical or biochemical marker at a specific gestational age, but rather through a combination of clinical, biophysical and biochemical markers at different gestational ages. Since the aetiology of spontaneous preterm birth is also multifactorial, it is unlikely that a single biomarker test, at a specific gestational age will emerge as the definitive predictive test. METHODS The Biomarkers Group of PREBIC, comprising clinicians, basic scientists and other experts in the field, with a particular interest in preterm birth have produced this commentary with short, medium and long-term aims: i) to alert clinicians to the advances that are being made in the prediction of spontaneous preterm birth; ii) to encourage clinicians and scientists to continue their efforts in this field, and not to be disheartened or nihilistic because of a perceived lack of progress and iii) to enable development of novel interventions that can reduce the mortality and morbidity associated with preterm birth. RESULTS Using language that we hope is clear to practising clinicians, we have identified 11 Sections in which there exists the potential, feasibility and capability of technologies for candidate biomarkers in the prediction of spontaneous preterm birth and how current limitations to this research might be circumvented. DISCUSSION The combination of biophysical, biochemical, immunological, microbiological, fetal cell, exosomal, or cell free RNA at different gestational ages, integrated as part of a multivariable predictor model may be necessary to advance our attempts to predict sPTL and PTB. This will require systems biological data using "omics" data and artificial intelligence/machine learning to manage the data appropriately. The ultimate goal is to reduce the mortality and morbidity associated with preterm birth.
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Affiliation(s)
- R F Lamont
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Division of Surgery, Northwick Park Institute for Medical Research Campus, University College London, London, UK.
| | - L S Richardson
- Dept of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Dept. Electrical and Computer Engineering Texas A&M University, College Station, TX, USA
| | - J J Boniface
- Sera Prognostics, Inc., 2749 East Parleys Way, Suite 200, Salt Lake City, UT, 84109, USA
| | - T Cobo
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecología, Obstetrícia I Neonatología, Fetal i+D Fetal Medicine Research Center, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona. Barcelona. Spain, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - M M Exner
- Hologic, Inc., 10210 Genetic Center Dr, San Diego, CA, 92121, USA
| | | | - S K Forslund
- Experimental and Clinical Research Center, A Cooperation of Charité-Universitätsmedizin and the Max-Delbrück Center, Berlin, Germany
| | - A Gaba
- Department of Obstetrics and Maternal-fetal Medicine, Vienna Medical University, Austria
| | - H Helmer
- Department of Obstetrics and Maternal-fetal Medicine, Vienna Medical University, Austria
| | - J S Jørgensen
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Centre for Innovative Medical Technologies (CIMT), Odense University Hospital, Kløvervænget 8, 5000, Odense C, Denmark; Odense Patient Data Explorative Network (OPEN), Odense University Hospital/University of Southern Denmark, J. B. Winsløws Vej 9 a, 3. Floor, 5000, Odense C, Denmark
| | - R N Khan
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Room 4115, Medical School, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | | | - K Petro
- Hologic, Inc., 10210 Genetic Center Dr, San Diego, CA, 92121, USA
| | - M Rasmussen
- MIRVIE Inc., 820 Dubuque Ave., South San Francisco, CA, 94080, USA
| | - R Singh
- ARCEDI Biotech ApS, Aarhus, Denmark
| | - R M Tribe
- Dept. of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital Campus, London, SE1 7EH, UK
| | - J S Vink
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - C A Vinter
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - N Zhong
- New York State Institute for Basic Research in Developmental Disabilities, 105 Forest Hill Road, Staten Island, NY, 10314, USA
| | - R Menon
- Dept of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Dept. Electrical and Computer Engineering Texas A&M University, College Station, TX, USA.
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Risk Assessment and Prevention of Spontaneous Preterm Birth. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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53
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Outcomes of ultrasound and physical-exam based cerclage: assessment of risk factors and the role of adjunctive progesterone in preventing preterm birth-a retrospective cohort study. Arch Gynecol Obstet 2020; 301:981-986. [PMID: 32170408 DOI: 10.1007/s00404-020-05482-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess outcomes of ultrasound and physical examination-based cerclage performed at mid to late second trimester and to assess the potential added value of progesterone treatment combined with cerclage for preventing preterm birth. STUDY DESIGN A retrospective cohort study of women who underwent cerclage in a university-affiliated tertiary medical center (2012-2018). Inclusion criteria included only ultrasound-based cerclage and physical examination-based cerclage. Women who underwent history-based cerclage or multiple gestations were excluded. Study groups were stratified by previous PTB < 37 weeks and other risk factors for PTB. Primary outcome was the incidence of preterm birth < 35 weeks of gestation. Secondary outcomes included the potential added value of progesterone treatment and neonatal outcome. RESULTS Sixty-nine women underwent cervical cerclage placement between 16-23 weeks of gestation. All women had short cervix (cervical length of < 25 mm) at presentation. Indications for cerclage placement included: 29% previous PTB, 32% prior cervical interventions (history of at least one D&C, hysteroscopy or cold-knife conization in the past), 22% had cervical dilatation > 1 cm at presentation, 12% due to failure of progesterone treatment defined as continued cervical shortening after 14 days of progesterone treatment, and 5% had other indications. Overall, 42 women (61%) gave birth at term. 27 women (39%) delivered prior to 37 weeks of gestation, of them, 20 women (29%) gave birth prior to 35 weeks. Overall median gestational age at delivery was 35 + 5 ± 4.7 weeks. Cervical dilatation at presentation of > 1 cm was associated with an increased risk for PTB < 35 weeks (OR 3.57, CI 1.43-30.81, p = 0.036). Previous PTB, prior cervical interventions and extent of cervical shortening at presentation did not increase the risk of PTB. Progesterone treatment in addition to cerclage did not result in a decreased risk for PTB < 35 weeks of gestation (OR 2.83, CI 0.58-13.89, p = 0.199). CONCLUSION Late second trimester cerclage is a practical measure for preventing PTB in cases of asymptomatic cervical shortening. Our study did not find adjunctive benefit for progesterone treatment with physical or ultrasound-based cerclage in reducing the rate PTB.
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Watson HA, Seed PT, Carter J, Hezelgrave NL, Kuhrt K, Tribe RM, Shennan AH. Development and validation of predictive models for QUiPP App v.2: tool for predicting preterm birth in asymptomatic high-risk women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:348-356. [PMID: 31325332 DOI: 10.1002/uog.20401] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/20/2019] [Accepted: 07/05/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Accurate mid-pregnancy prediction of spontaneous preterm birth (sPTB) is essential to ensure appropriate surveillance of high-risk women. Advancing the QUiPP App prototype, QUiPP App v.2 aimed to provide individualized risk of delivery based on cervical length (CL), quantitative fetal fibronectin (qfFN) or both tests combined, taking into account further risk factors, such as multiple pregnancy. Here we report development of the QUiPP App v.2 predictive models for use in asymptomatic high-risk women, and validation using a distinct dataset in order to confirm the accuracy and transportability of the QUiPP App, overall and within specific clinically relevant time frames. METHODS This was a prospective secondary analysis of data of asymptomatic women at high risk of sPTB recruited in 13 UK preterm birth clinics. Women were offered longitudinal qfFN testing every 2-4 weeks and/or transvaginal ultrasound CL measurement between 18 + 0 and 36 + 6 weeks' gestation. A total of 1803 women (3878 visits) were included in the training set and 904 women (1400 visits) in the validation set. Prediction models were created based on the training set for use in three groups: patients with risk factors for sPTB and CL measurement alone, with risk factors for sPTB and qfFN measurement alone, and those with risk factors for sPTB and both CL and qfFN measurements. Survival analysis was used to identify the significant predictors of sPTB, and parametric structures for survival models were compared and the best selected. The estimated overall probability of delivery before six clinically important time points (< 30, < 34 and < 37 weeks' gestation and within 1, 2 and 4 weeks after testing) was calculated for each woman and analyzed as a predictive test for the actual occurrence of each event. This allowed receiver-operating-characteristics curves to be plotted, and areas under the curve (AUC) to be calculated. Calibration was performed to measure the agreement between expected and observed outcomes. RESULTS All three algorithms demonstrated high accuracy for the prediction of sPTB at < 30, < 34 and < 37 weeks' gestation and within 1, 2 and 4 weeks of testing, with AUCs between 0.75 and 0.90 for the use of qfFN and CL combined, between 0.68 and 0.90 for qfFN alone, and between 0.71 and 0.87 for CL alone. The differences between the three algorithms were not statistically significant. Calibration confirmed no significant differences between expected and observed rates of sPTB within 4 weeks and a slight overestimation of risk with the use of CL measurement between 22 + 0 and 25 + 6 weeks' gestation. CONCLUSIONS The QUiPP App v.2 is a highly accurate prediction tool for sPTB that is based on a unique combination of biomarkers, symptoms and statistical algorithms. It can be used reliably in the context of communicating to patients the risk of sPTB. Whilst further work is required to determine its role in identifying women requiring prophylactic interventions, it is a reliable and convenient screening tool for planning follow-up or hospitalization for high-risk women. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H A Watson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - P T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - J Carter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - N L Hezelgrave
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - K Kuhrt
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - R M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - A H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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The placement of a cerclage in patients with twin pregnancies and a short cervix is associated with increased risk of preterm birth and adverse perinatal outcome. Am J Obstet Gynecol 2020; 222:194-196. [PMID: 31586601 DOI: 10.1016/j.ajog.2019.09.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/25/2019] [Indexed: 11/21/2022]
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Qureshey EJ, Quiñones JN, Rochon M, Sarno A, Rust O. Comparison of management options for twin pregnancies with cervical shortening. J Matern Fetal Neonatal Med 2019; 35:39-45. [PMID: 31878811 DOI: 10.1080/14767058.2019.1706477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To compare the effectiveness of expectant management (EM), cervical cerclage (CC) and vaginal progesterone (VP) in decreasing the rate of spontaneous preterm birth in twin gestations with midtrimester cervical shortening.Study design: This is a retrospective cohort study comparing pregnancy outcomes of twin gestations with midtrimester cervical shortening, defined as a cervical length (CL) on routine transvaginal ultrasound between 15 weeks 0 days and 24 weeks 6 days gestation of <2.5 cm, managed with either EM, CC or VP. Women were categorized by final management strategy. Primary outcome was gestational age at delivery. Secondary outcomes included latency period (defined as number of weeks between a diagnosis of cervical shortening and delivery), gestational age at delivery <32 weeks, mode of delivery, perinatal death, neonatal birthweight and rate of chorioamnionitis. Subanalysis of women with a CL < 1.5 cm was also performed. Logistic regression was used to identify predictors of delivery <32 weeks, controlling for potential confounders.Results: Between January 2006 and July 2016, 64 pairs of twins with midtrimester cervical shortening were identified, 18 managed with EM (28.1%), 29 CC (45.3%), and 17 VP (26.6%), 52 of which had information regarding delivery outcomes. 90.4% of women delivered prematurely (<37 weeks). Women in the CC group were diagnosed with cervical shortening at a significantly earlier mean gestational age (CC 20.6 ± 1.7 weeks versus EM 22.2 ± 2.9 weeks and VP 22.2 ± 2.0 weeks, p = .02) and had a shorter mean cervical length at the time of diagnosis (CC 1.18 ± 0.7 cm vs. EM 1.56 ± 0.7 and VP 1.95 ± 0.6, p = .002), as compared to those in the EM and VP groups. There was no difference in gestational age at delivery (EM 30.9 ± 5.2 weeks, CC 30.4 ± 4.9 weeks and VP 32.4 ± 4.1 weeks, respectively) or any of the secondary outcomes listed above. Women with a CL <1.5 cm delivered significantly earlier than those with a cervical length ≥1.5 cm (28.4 ± 4.7 weeks vs. 33.2 ± 3.6 weeks, p = .0001). After adjusting for potential confounders, cervical length <1.5 cm, not the management strategy, was the predictor of PTB before 32 weeks in this twin population [AOR 6.56 (95% CI 1.78, 24.20), p = .005].Conclusion: Twin pregnancies with midtrimester cervical shortening are at high risk for preterm delivery, and outcomes were similar regardless of management strategy. Large prospective trials are needed to evaluate the effect of different management strategies for cervical shortening in twins.
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Affiliation(s)
- Emma J Qureshey
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Joanne N Quiñones
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine and Lehigh Valley Health Network, Allentown, PA, USA
| | - Meredith Rochon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine and Lehigh Valley Health Network, Allentown, PA, USA
| | - Albert Sarno
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine and Lehigh Valley Health Network, Allentown, PA, USA
| | - Orion Rust
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine and Lehigh Valley Health Network, Allentown, PA, USA
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Berger R, Abele H, Bahlmann F, Bedei I, Doubek K, Felderhoff-Müser U, Fluhr H, Garnier Y, Grylka-Baeschlin S, Helmer H, Herting E, Hoopmann M, Hösli I, Hoyme U, Jendreizeck A, Krentel H, Kuon R, Lütje W, Mader S, Maul H, Mendling W, Mitschdörfer B, Nicin T, Nothacker M, Olbertz D, Rath W, Roll C, Schlembach D, Schleußner E, Schütz F, Seifert-Klauss V, Steppat S, Surbek D. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 1 with Recommendations on the Epidemiology, Etiology, Prediction, Primary and Secondary Prevention of Preterm Birth. Geburtshilfe Frauenheilkd 2019; 79:800-812. [PMID: 31423016 DOI: 10.1055/a-0903-2671] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 12/13/2022] Open
Abstract
Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recent scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods Based on the international literature, the members of the participating medical societies and organizations developed Recommendations and Statements. These were adopted following a formal process (structured consensus conference with neutral moderation, voting was done in writing using the Delphi method to achieve consensus). Recommendations Part I of this short version of the guideline lists Statements and Recommendations on the epidemiology, etiology, prediction and primary and secondary prevention of preterm birth.
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Affiliation(s)
- Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Harald Abele
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Franz Bahlmann
- Frauenklinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - Ivonne Bedei
- Frauenklinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany
| | | | - Ursula Felderhoff-Müser
- Klinik für Kinderheilkunde I/Perinatalzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Herbert Fluhr
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Yves Garnier
- Frauenklinik, Klinikum Osnabrück, Osnabrück, Germany
| | | | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Hoopmann
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Udo Hoyme
- Frauenklinik, Ilm-Kreis-Kliniken, Arnstadt, Germany
| | | | - Harald Krentel
- Frauenklinik, Annahospital Herne, Elisabethgruppe Katholische Kliniken Rhein Ruhr, Herne, Germany
| | - Ruben Kuon
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Wolf Lütje
- Frauenklinik, Evangelisches Amalie Sieveking-Krankenhaus Hamburg, Hamburg, Germany
| | - Silke Mader
- European Foundation for the Care of the Newborn Infant
| | - Holger Maul
- Frauenklinik, Asklepios Kliniken Hamburg, Hamburg, Germany
| | - Werner Mendling
- Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe an der Frauenklinik, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | | | | | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Berlin, Germany
| | - Dirk Olbertz
- Abteilung Neonatologie und neonatologische Intensivmedizin, Klinikum Südstadt Rostock, Rostock, Germany
| | - Werner Rath
- Emeritus, Universitätsklinikum Aachen, Aachen, Germany
| | - Claudia Roll
- Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln/Berlin Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | | | - Florian Schütz
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Daniel Surbek
- Universitäts-Frauenklinik, Inselspital, Universität Bern, Bern, Switzerland
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Liu CZ, Ho N, Nguyen AD, Lehner C, Sekar R, Amoako AA. The risk of preterm delivery and pregnancy outcomes in women with asymptomatic short cervix: a retrospective cohort study. J Matern Fetal Neonatal Med 2019; 34:1747-1753. [PMID: 31327275 DOI: 10.1080/14767058.2019.1647163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Routine cervical length measurement in asymptomatic pregnant women to prevent preterm birth has not been universally adopted due to poor predictive accuracy. The purpose of our study was to evaluate the risk of preterm delivery and pregnancy outcomes in women with asymptomatic short cervix and examine the implications of gestational age at presentation on these outcomes. STUDY DESIGN This was a retrospective cohort study of women with singleton pregnancies who presented prior to or at 32 + 0 weeks with an asymptomatic short cervix (≤25 mm) between April 2014 to March 2018 at a single tertiary maternity center. Women with cervical length ≤25 mm were grouped into four cohorts according to gestational age at presentation: Obstetric outcomes were compared between the cohorts and the general cohort of women delivering during the same period. Outcomes were compared using Mann-Whitney U, chi-square tests, and logistic regression. Survival analysis was carried out to compare the probability of delivery for each subgroup. RESULTS The rate of spontaneous preterm birth <37 weeks was highest in the cohort presenting at 25 + 0-27 + 6 weeks, and lowest in the first cohort presenting at <22 + 0 (60.0 versus 22.2%, p < .05). When compared with the general cohort, the rate of spontaneous preterm birth at <37-week gestation was significantly higher in the asymptomatic short cervix cohort (40.4 versus 8.7%, p < .001), with a 7.1-fold increase in the relative risk of spontaneous PTB. CONCLUSIONS In asymptomatic women, cervical shortening showed significant increase in the risk of preterm birth. Our study findings suggest that routine cervical screening may be helpful in predicting risk of preterm birth even in women who are considered low-risk for preterm birth.
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Affiliation(s)
- Cathy Z Liu
- Discipline of Obstetrics and Gynaecology, Faculty of Medicine, University of Queensland, Herston, Australia.,Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Nicole Ho
- Discipline of Obstetrics and Gynaecology, Faculty of Medicine, University of Queensland, Herston, Australia.,Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Anh D Nguyen
- Discipline of Obstetrics and Gynaecology, Faculty of Medicine, University of Queensland, Herston, Australia
| | - Christoph Lehner
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Herston, Australia.,Centre for Advanced Prenatal Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Renuka Sekar
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Herston, Australia.,Centre for Advanced Prenatal Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Akwasi A Amoako
- Discipline of Obstetrics and Gynaecology, Faculty of Medicine, University of Queensland, Herston, Australia.,Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Herston, Australia
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Berger R, Abele H, Bahlmann F, Bedei I, Doubek K, Felderhoff-Müser U, Fluhr H, Garnier Y, Grylka-Baeschlin S, Helmer H, Herting E, Hoopmann M, Hösli I, Hoyme U, Jendreizeck A, Krentel H, Kuon R, Lütje W, Mader S, Maul H, Mendling W, Mitschdörfer B, Nicin T, Nothacker M, Olbertz D, Rath W, Roll C, Schlembach D, Schleußner E, Schütz F, Seifert-Klauss V, Steppat S, Surbek D. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes. Geburtshilfe Frauenheilkd 2019; 79:813-833. [PMID: 31423017 PMCID: PMC6690742 DOI: 10.1055/a-0903-2735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023] Open
Abstract
Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.
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Affiliation(s)
- Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Harald Abele
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Franz Bahlmann
- Frauenklinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - Ivonne Bedei
- Frauenklinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany
| | | | - Ursula Felderhoff-Müser
- Klinik für Kinderheilkunde I/Perinatalzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Herbert Fluhr
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Yves Garnier
- Frauenklinik, Klinikum Osnabrück, Osnabrück, Germany
| | | | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Hoopmann
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Udo Hoyme
- Frauenklinik, Ilm-Kreis-Kliniken, Arnstadt, Germany
| | | | - Harald Krentel
- Frauenklinik, Annahospital Herne, Elisabethgruppe Katholische Kliniken Rhein Ruhr, Herne, Germany
| | - Ruben Kuon
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Wolf Lütje
- Frauenklinik, Evangelisches Amalie Sieveking-Krankenhaus Hamburg, Hamburg, Germany
| | - Silke Mader
- European Foundation for the Care of the Newborn Infants
| | - Holger Maul
- Frauenklinik, Asklepios Kliniken Hamburg, Hamburg, Germany
| | - Werner Mendling
- Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe an der Frauenklinik, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | | | | | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Berlin, Germany
| | - Dirk Olbertz
- Abteilung Neonatologie und neonatologische Intensivmedizin, Klinikum Südstadt Rostock, Rostock, Germany
| | - Werner Rath
- Emeritus, Universitätsklinikum Aachen, Aachen, Germany
| | - Claudia Roll
- Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln/Berlin Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | | | - Florian Schütz
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Daniel Surbek
- Universitäts-Frauenklinik, Inselspital, Universität Bern, Bern, Switzerland
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Grantz KL, Kawakita T, Lu YL, Newman R, Berghella V, Caughey A, Caughey A. SMFM Special Statement: State of the science on multifetal gestations: unique considerations and importance. Am J Obstet Gynecol 2019; 221:B2-B12. [PMID: 31002766 DOI: 10.1016/j.ajog.2019.04.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We sought to review the state of the science for research on multiple gestations. A literature search was performed with the use of PubMed for studies to quantify the representation of multiple gestations for a sample period (2012-2016) that were limited to phase III and IV randomized controlled trials, that were written in English, and that addressed at least 1 of 4 major pregnancy complications: fetal growth restriction or small-for-gestational-age fetus, gestational diabetes mellitus, preeclampsia, and preterm delivery. Of the 226 studies that are included in the analysis, multiple pregnancies were most represented in studies of preterm delivery: 17% of trials recruited both singleton and multiple pregnancies; another 18% of trials recruited only multiple pregnancies. For trials that studied preeclampsia, fetal growth restriction, and gestational diabetes mellitus, 17%, 8%, and 2%, respectively, recruited both singleton and multiple gestations. None of the trials on these 3 topics were limited to women with a multiple pregnancy. Women with a multiple pregnancy are at risk for complications similar to those of women with singleton pregnancies, but their risk is usually higher. Also, the pathophysiologic condition for some complications differs in multiple gestations from those that occur in singleton gestations. Conditions that are unique to multiple pregnancies include excess placenta, placental crowding or inability of the uteroplacental unit to support the normal growth of multiple fetuses, or suboptimal placental implantation sites with an increased risk of abnormal placental location. Other adverse outcomes in multiple gestations are also influenced by twin-specific risk factors, most notably chorionicity. Although twins have been well represented in many studies of preterm birth, these studies have failed to identify adequate predictive tests (short cervical length established over 2 decades ago remains the single best predictor), to establish effective interventions, and to differentiate the underlying pathophysiologic condition of twin preterm birth. Questions about fetal growth also remain. Twin growth deviates from that of singleton gestations starting at approximately 32 weeks of gestation; however, research with long-term follow-up is needed to better distinguish pathologic and physiologic growth deviations, which include growth discordance among pairs (or more). There are virtually no clinical trials that are specific to twins for gestational diabetes mellitus or preeclampsia, and subgroups for multiple pregnancies in existing trials are not large enough to allow definite conclusions. Another important area is the determination of appropriate maternal nutrition or micronutrient supplementation to optimize pregnancy and child health. There are also unique aspects to consider for research design in multiple gestations, such as designation and tracking of the correct fetus prenatally and through delivery. The correct statistical methods must be used to account for correlated data because multiple fetuses share the same mother and intrauterine environment. In summary, multiple gestations often are excluded from research studies, despite a disproportionate contribution to national rates of perinatal morbidity, mortality, and health-care costs. It is important to consider the enrollment of multifetal pregnancies in studies that target mainly women with singleton gestations, even when sample size is inadequate, so that insights that are specific to multiple gestations can be obtained when results of smaller studies are pooled together. The care of pregnant women with multiple gestations presents unique challenges; unfortunately, evidence-based clinical management that includes the diagnosis and treatment of common obstetrics problems are not well-defined for this population.
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Affiliation(s)
| | | | | | | | | | | | - Aaron Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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Mönckeberg M, Valdés R, Kusanovic JP, Schepeler M, Nien JK, Pertossi E, Silva P, Silva K, Venegas P, Guajardo U, Romero R, Illanes SE. Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis. J Perinat Med 2019; 47:500-509. [PMID: 30849048 PMCID: PMC6606339 DOI: 10.1515/jpm-2018-0388] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 12/16/2018] [Indexed: 01/30/2023]
Abstract
Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.
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Affiliation(s)
- Max Mönckeberg
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile,Department of Public Health and Epidemiology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | - Rafael Valdés
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile
| | - Juan P. Kusanovic
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile,Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile,Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD and Detroit, MI, USA
| | - Manuel Schepeler
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago, Chile
| | - Jyh K. Nien
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago, Chile
| | - Emiliano Pertossi
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Silva
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile,Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Karla Silva
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile
| | - Pía Venegas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | - Ulises Guajardo
- Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Sebastián E. Illanes
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile,Department of Obstetrics and Gynecology, Clínica Dávila, Santiago, Chile
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Han MN, O'Donnell BE, Maykin MM, Gonzalez JM, Tabsh K, Gaw SL. The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks. J Matern Fetal Neonatal Med 2019; 32:2143-2151. [PMID: 29363371 PMCID: PMC6251764 DOI: 10.1080/14767058.2018.1427719] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/03/2018] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management. METHODS This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5 cm, and cervical dilation ≥1.0 cm. The "cerclage" cohort received a cerclage from a single provider at a single institution from 2003-2016. The "no cerclage" group included all patients with similar indications that were expectantly managed from 2010-2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at <32 weeks, < 34 weeks, and <36 weeks, chorioamnionitis, birth weight, and neonatal mortality within 30 days of life. We also performed a planned subgroup analysis stratified by cerclage indication. RESULTS In all, 135 women were included in two cohorts: cerclage (n = 96) or no cerclage (n = 39). The rates of spontaneous preterm birth <32 weeks were 10.4% (n = 10) with cerclage versus 28.2% (n = 11) without cerclage (OR 0.23, CI 0.08-0.70, p = .017). After adjusting for cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth <32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06-0.90, p = .035), spontaneous preterm birth <36 weeks (aOR 0.34, CI 0.04-0.81, p = .013) as well as in overall preterm birth <32 weeks (aOR 0.31, CI 0.1-0.86, p = .018), and overall preterm birth <36 weeks (aOR 0.37, CI 0.10-0.84, p = .030). When stratified by short cervix or cervical dilation in the cerclage versus no cerclage groups, there was a significant decrease in spontaneous preterm birth <32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p = .01) but not in the cerclage group with short cervix only, even for cervical length <1.5 cm. Pregnancy latency was 91 days in the cerclage group versus 57 days in the no cerclage group (p = .001), with a median gestational age at delivery of 35 versus 32 weeks (p = .002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665 g, p < .001) and decrease in perinatal death <30 days (1.6 versus 12.9%, p = .001). CONCLUSIONS Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth <32 weeks compared to expectant management. However, when stratified by cerclage indication, this decrease in primary outcome only remained significant in the group with cervical dilation.
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Affiliation(s)
- Michelle N Han
- a Department of Obstetrics & Gynecology , University of California , Los Angeles , CA , USA
| | - Betsy E O'Donnell
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
| | - Melanie M Maykin
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
| | - Juan M Gonzalez
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
| | - Khalil Tabsh
- a Department of Obstetrics & Gynecology , University of California , Los Angeles , CA , USA
| | - Stephanie L Gaw
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
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Cerclage for women with twin pregnancies: a systematic review and metaanalysis. Am J Obstet Gynecol 2019; 220:543-557.e1. [PMID: 30527942 DOI: 10.1016/j.ajog.2018.11.1105] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/21/2018] [Accepted: 11/24/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE DATA This study was conducted to estimate whether cerclage could extend the prolongation of pregnancy, reduce the risk of preterm birth, and improve perinatal outcomes in women with twin pregnancies. STUDY ELIGIBILITY CRITERIA We included randomized controlled trials and cohort studies comparing the efficacy of cerclage with no cerclage for women with twin pregnancies. STUDY APPRAISAL AND SYNTHESIS METHODS The following databases were searched for all published studies that compared cerclage placement with expectant management in twin pregnancies from inception to July 2018: Medline, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and Cochrane Library. Each report was reviewed for inclusion or exclusion standard, and data extraction was performed by 2 authors independently. RESULTS A total of 16 studies with 1211 women that met the inclusion criteria were included in the final analysis. Our outcomes indicated that cerclage placement for twin pregnancies with a cervical length of <15 mm was associated with significant prolongation of pregnancy by a mean difference of 3.89 weeks of gestation (95% confidence interval, 2.19-5.59; P=.000; I2=0%) and a reduction of preterm birth at <37 weeks of gestation (risk ratio, 0.86; 95% confidence interval, 0.74-0.99; P=.040; I2=0%), <34 weeks of gestation (risk ratio, 0.57; 95% confidence interval, 0.43-0.75; P=.000; I2=0%) and <32 weeks of gestation (risk ratio, 0.61; 95% confidence interval, 0.41-0.90; P=.010; I2=0%), compared with those pregnancies in the control group. For women with a dilated cervix of >10 mm, cerclage placement was associated with significant prolongation of pregnancy by a mean difference of 6.78 weeks of gestation (95% confidence interval, 5.32-8.24; P=.000; I2=0%); a reduction of preterm birth at <34 weeks of gestation (risk ratio, 0.56; 95% confidence interval, 0.45-0.69; P=.000; I2=28%), <32 weeks of gestation (risk ratio, 0.50; 95% confidence interval, 0.38-0.65; P=.000; I2=14%), <28 weeks of gestation (risk ratio, 0.41; 95% confidence interval, 0.20-0.85; P=.030; I2=80%), and <24 weeks of gestation (risk ratio, 0.35; 95% confidence interval, 0.18-0.67; P=.001; I2=24%), and improvement of perinatal outcomes compared with those in the control group. However, for twin pregnancies with a normal cervical length (eg, cerclage for an indication for women with a history of preterm birth or twin alone), the efficacy of cerclage placement was less certain because of the limited data. CONCLUSION Our metaanalysis indicates that cerclage placement is beneficial for the reduction of preterm birth and the prolongation of pregnancy in twin pregnancies with a cervical length of <15 mm or dilated cervix of >10 mm. However, the benefit of history-indicated or twin alone-indicated cerclage is less certain in twin pregnancies with normal cervical length according to current literature. Further high-quality studies were needed to confirm the findings.
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Stafford IA, Garite TJ, Maurel K, Combs CA, Heyborne K, Porreco R, Nageotte M, Baker S, Gopalani S, Dola C, How H, Das AF. Cervical Pessary versus Expectant Management for the Prevention of Delivery Prior to 36 Weeks in Women with Placenta Previa: A Randomized Controlled Trial. AJP Rep 2019; 9:e160-e166. [PMID: 31044098 PMCID: PMC6491366 DOI: 10.1055/s-0039-1687871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023] Open
Abstract
Objective This multicenter randomized controlled trial compared cervical pessary (CP) versus expectant management (EM) in women with placenta previa between 22.0 and 32.0 in prolonging gestation until ≥ 36.0 weeks' gestation. Study Design This study took place from November 2016 to June 2018. Women were randomized to receive either the Bioteque CP or EM. The pessary was removed at ≥ 36.0 weeks unless indicated. The primary outcome was gestational age (GA) at delivery, with secondary outcomes including need for transfusion, number and duration of antepartum admissions, type of delivery, and neonatal outcomes. A total of 140 patients were needed to show a 3-week prolongation of pregnancy in the pessary group; however, the trial was stopped early due to budgetary issues. Results Of the 33 eligible women, 17 were enrolled. Although not statistically significant, the mean GA at delivery in the CP group was greater than women in the EM group (36.5 ± 1.23 vs. 36.0 ± 2.0; p = 0.1673). The number and duration of antepartum admissions was greater in the EM group (2.7 ± 0.58 vs. 16.0 ± 22.76 days; p = 0.1264) as well. Conclusion Although the study was underpowered to determine the primary outcome, safety and feasibility of CP in pregnancies complicated with previa were demonstrated.
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Affiliation(s)
- Irene A Stafford
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.,Touro Infirmary, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Thomas J Garite
- University of California, Irvine, Orange, California.,The Center for Research, Education, Quality and Safety, Mednax, Inc., Sunrise, Florida
| | - Kimberly Maurel
- The Center for Research, Education, Quality and Safety, Mednax, Inc., Sunrise, Florida
| | - C Andrew Combs
- The Center for Research, Education, Quality and Safety, Mednax, Inc., Sunrise, Florida.,Obstetrix Medical Group, San Jose, California
| | - Kent Heyborne
- Denver Health and Hospital Authority, Denver, Colorado
| | | | | | - Susan Baker
- University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | | | - Chi Dola
- Tulane Lakeside Hospital for Women and Children, New Orleans, Louisiana
| | - Helen How
- Norton Hospital, Louisville, Kentucky
| | - Anita F Das
- Das Consulting Group, San Francisco, California
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Métairie M, Korb D, Morin C, Schmitz T, Sibony O. [Effectiveness of preventive cervical cerclage to prevent preterm birth in women with twin gestation with obstetrical history of late pregnancy loss or preterm birth]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2019; 47:286-290. [PMID: 30686725 DOI: 10.1016/j.gofs.2018.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Evaluate the effectiveness of preventive cervical cerclage for twin pregnancy with obstetrical history. METHODS Through this retrospective cohort study, subjects exposed between 2002 and 2017 were compared with unexposed ones. All patients who had twin pregnancy with at least one previous late pregnancy loss or prematurity before 34SA were included. Two groups were compared: "preventive cerclage" versus "no preventive cerclage". The outcome was the prematurity before 34 gestation weeks (GW) rate. RESULTS Among 1972 twin pregnancies registered between 2002 and 2017, 69 (3.5%) patients with at least one previous late pregnancy loss or prematurity before 34 GW, were part of the study. There were 20 (29.0%) women in the group "preventive cerclage" and 49 (71.0%) women in the group "no preventive cerclage". Women in the "preventive cerclage" group had poorer obstetrical history. The rate of prematurity before 34GW was not significantly different between these both groups (45.0% versus 44.9%; P=0.99, crude OR: 1.00 (0.35-2.83), adjusted OR: 1.06 (0.33-3.44)). CONCLUSIONS The prematurity rate before 34GW, in twin pregnancies with a previous late pregnancy loss or preterm birth, is not different with or without preventive cervical cerclage.
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Affiliation(s)
- M Métairie
- Maternité, hopital Robert-Debré, AP-HP, 48, boulevard Sérurier 75019 Paris, France.
| | - D Korb
- Maternité, hopital Robert-Debré, AP-HP, 48, boulevard Sérurier 75019 Paris, France; Inserm U1153, équipe EPOPé, CRESS, DHU risques et grossesse, université Paris Descartes, 75014 Paris, France
| | - C Morin
- Maternité, hopital Robert-Debré, AP-HP, 48, boulevard Sérurier 75019 Paris, France
| | - T Schmitz
- Maternité, hopital Robert-Debré, AP-HP, 48, boulevard Sérurier 75019 Paris, France; Inserm U1153, équipe EPOPé, CRESS, DHU risques et grossesse, université Paris Descartes, 75014 Paris, France
| | - O Sibony
- Maternité, hopital Robert-Debré, AP-HP, 48, boulevard Sérurier 75019 Paris, France
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Gyamfi-Bannerman C, Pandita A, Miller EC, Boehme AK, Wright JD, Siddiq Z, D'Alton ME, Friedman AM. Preeclampsia outcomes at delivery and race. J Matern Fetal Neonatal Med 2019; 33:3619-3626. [PMID: 30786794 DOI: 10.1080/14767058.2019.1581522] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of preeclampsia.Study design: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Health care Research and Quality for the years 2012-2014. Women aged 15-54 with a diagnosis of preeclampsia were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. The overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with the risk for specific outcomes such as stroke, acute heart failure or pulmonary edema, eclampsia, and acute renal failure. The risk for severe morbidity was stratified by comorbid risk and compared by race. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect.Results: A total of 101,741 women with preeclampsia from 2012 to 2014 were included in this analysis. The risk for severe morbidity was significantly higher among non-Hispanic black women (9.8%) than non-Hispanic white, Hispanic, and all other women, respectively (6.1, 7.7, and 7.5%, respectively, p < .01). For non-Hispanic black compared to non-Hispanic white, Hispanic, and all other women, risk was higher for stroke (17.1 versus 6.5, 12.7, and 9.3 per 10,000 deliveries, respectively, p < .01) and pulmonary edema or heart failure (56.2 versus 32.7, 30.2, and 38.4 per 10,000 deliveries, respectively, p < .01). Non-Hispanic black women were also more likely than non-Hispanic white women to experience renal failure (136.4 versus 60.4 per 10,000 deliveries, p < .01). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (p < .01). The risk for death was higher for black compared to non-black women (121.8 per 100,000 deliveries, 95% CI 69.7-212.9 versus 24.1 per 100,000 deliveries, 95% CI 14.6-39.8, respectively, p < .01)Conclusion: Black women were at higher risk for severe morbidity and mortality associated with preeclampsia.
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Affiliation(s)
- Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ambika Pandita
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Amelia K Boehme
- Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Zainab Siddiq
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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No 373 - Insuffisance cervicale et cerclage cervical. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:248-263. [DOI: 10.1016/j.jogc.2018.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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No. 373-Cervical Insufficiency and Cervical Cerclage. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:233-247. [DOI: 10.1016/j.jogc.2018.08.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Barbosa M, Bek Helmig R, Hvidman L. Twin pregnancies treated with emergency or ultrasound-indicated cerclage to prevent preterm births. J Matern Fetal Neonatal Med 2019; 33:3227-3232. [PMID: 30688138 DOI: 10.1080/14767058.2019.1570119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Introduction: Multiple gestations are high-risk pregnancies associated with an increased risk of neonatal morbidity and mortality, mainly due to preterm births. Numerous interventions have been attempted in order to delay the time of delivery and subsequently, prevent preterm births in twin gestations. To date, no really effective intervention has been found. Use of cerclage in twin pregnancies has been controversial. Recently, however, small retrospective cohort studies have shown a potentially positive effect with the use of cerclage in twin pregnancies. The aim of this study was to evaluate pregnancies and neonatal outcomes in twin gestations with a short cervix treated with cervical cerclage at a single University Hospital.Methods: This retrospective cohort study included all women - with twin gestation and a short cervix - who had an ultrasound indicated or emergency cervical cerclage at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark between January 1999 and May 2017. Cervical cerclage was offered to women before 26 weeks of gestation if: (1) the cervix at ultrasound was ≤20 mm without cervical dilatation (ultrasound-indicated cerclage), or (2) the cervix at ultrasound was ≤20 mm with cervical dilatation (emergency cerclage). Women with history-indicated cerclage placement or multifetal embryo reduction were excluded. A total of 65 women participated in the study.Results: The median gestational age at cerclage placement was 22.6 weeks with a median cervical length of 10 mm (range 0-20 mm). The frequency of preterm delivery before 32 weeks of gestation was 41.5% and 27.7% before 28 weeks. Median pregnancy latency was 77 days (range 4-148) and the median gestational age at delivery was 33.0 weeks. Gestational age at delivery was significantly lower among women with cervical dilatation and visible membranes than among women with a short cervix only (27.7 versus 33.6 weeks, p < .01) and so was the median pregnancy latency (48 versus 81 days, p < .05). Overall, neonatal survival was 91.5%.Conclusion: Cervical cerclage in twin pregnancies may prolong pregnancy even when placed on a very short or dilated cervix. In our study, the procedure was safe and without any serious complications. The overall neonatal survival rate was high.
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Affiliation(s)
- Malou Barbosa
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Rikke Bek Helmig
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Lone Hvidman
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, Aarhus, Denmark
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Fichera A, Prefumo F, Mazzoni G, Molinaris V, Zanardini C, Fratelli N, Frusca T, Sartori E. The use of ultrasound-indicated cerclage or cervical pessary in asymptomatic twin pregnancies with a short cervix at midgestation. Acta Obstet Gynecol Scand 2019; 98:487-493. [DOI: 10.1111/aogs.13521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/15/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Anna Fichera
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
| | - Giorgia Mazzoni
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
| | - Valentina Molinaris
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
| | - Nicola Fratelli
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
| | - Tiziana Frusca
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
- Department of Obstetrics and Gynecology; University of Parma; Parma Italy
| | - Enrico Sartori
- Department of Obstetrics and Gynecology; Spedali Civili; University of Brescia; Brescia Italy
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72
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Robot-assisted transabdominal cerclage for the prevention of preterm birth: A multicenter experience. Eur J Obstet Gynecol Reprod Biol 2019; 232:70-74. [DOI: 10.1016/j.ejogrb.2018.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/08/2018] [Accepted: 11/11/2018] [Indexed: 11/19/2022]
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Di Renzo GC, Cabero Roura L, Facchinetti F, Helmer H, Hubinont C, Jacobsson B, Jørgensen JS, Lamont RF, Mikhailov A, Papantoniou N, Radzinsky V, Shennan A, Ville Y, Wielgos M, Visser GHA. Preterm Labor and Birth Management: Recommendations from the European Association of Perinatal Medicine. J Matern Fetal Neonatal Med 2018; 30:2011-2030. [PMID: 28482713 DOI: 10.1080/14767058.2017.1323860] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- G C Di Renzo
- a Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - L Cabero Roura
- b Department of Obstetrics and Gynecology , Hospital Vall D'Hebron , Barcelona , Spain
| | - F Facchinetti
- c Mother-Infant Department, School of Midwifery , University of Modena and Reggio Emilia , Italy
| | - H Helmer
- d Department of Obstetrics and Gynaecology , General Hospital, University of Vienna , Vienna , Austria
| | - C Hubinont
- e Department of Obstetrics , Saint Luc University Hospital, Université de Louvain , Brussels , Belgium
| | - B Jacobsson
- f Department of Obstetrics and Gynecology , Institute of Clinical Sciences, University of Gothenburg , Gothenburg , Sweden
| | - J S Jørgensen
- g Department of Obstetrics and Gynaecology , Odense University Hospital , Odense , Denmark
| | - R F Lamont
- h Department of Gynaecology and Obstetrics , University of Southern Denmark, Odense University Hospital , Odense , Denmark.,i Division of Surgery , University College London, Northwick Park Institute of Medical Research Campus , London , UK
| | - A Mikhailov
- j Department of Obstetrics and Gynecology , 1st Maternity Hospital, State University of St. Petersburg , Russia
| | - N Papantoniou
- k Department of Obstetrics and Gynaecology , Athens University School of Medicine , Athens , Greece
| | - V Radzinsky
- l Department of Medicine , Peoples' Friendship University of Russia , Moscow , Russia
| | - A Shennan
- m St. Thomas Hospital, Kings College London , UK
| | - Y Ville
- n Service d'Obstétrique et de Médecine Foetale , Hôpital Necker Enfants Malades , Paris , France
| | - M Wielgos
- p Department of Obstetrics and Gynecology , Medical University of Warsaw , Warsaw , Poland
| | - G H A Visser
- o Department of Obstetrics , University Medical Center , Utrecht , The Netherlands
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Norman JE, Norrie J, Maclennan G, Cooper D, Whyte S, Cunningham Burley S, Smith JBE, Shennan A, Robson SC, Thornton S, Kilby MD, Marlow N, Stock SJ, Bennett PR, Denton J. Open randomised trial of the (Arabin) pessary to prevent preterm birth in twin pregnancy with health economics and acceptability: STOPPIT-2-a study protocol. BMJ Open 2018; 8:e026430. [PMID: 30530477 PMCID: PMC6286620 DOI: 10.1136/bmjopen-2018-026430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The STOPPIT-2 study aims to determine the clinical utility of the Arabin cervical pessary in preventing preterm birth in women with a twin pregnancy and a short cervix, about which there is current uncertainty. STOPPIT-2 will resolve uncertainty around effectiveness for women with a twin pregnancy and a cervical length of 35 mm or less, define adverse effects, ascertain acceptability and estimate National Health Service costs and savings. METHODS STOPPIT-2 is a pragmatic multicentre open-label randomised controlled trial. Consenting women with twin pregnancy will have an transvaginal ultrasound scan of their cervical length performed between 18+0 and 20+6 weeks' gestation by an accredited practitioner: women with a cervical length of ≤35 mm will be eligible for inclusion in the treatment phase of the study. The intervention by the insertion of the Arabin cervical pessary will be compared with standard treatment (no pessary).The primary outcomes are (obstetric) spontaneous onset of labour for the mother leading to delivery before 34 weeks' gestation and (neonatal) a composite of specific adverse outcomes or death occurring up to the end of the first 4 weeks after the estimated date of delivery to either or both babies.We plan to recruit 500 women in the treatment phase of the study. Assuming a treatment effect of 0.6, and background rates of 35% and 18%, respectively, for each of the primary outcomes, our study has 85% power to detect a difference between the intervention and the control groups. ANALYSIS Data will be analysed on the intention-to-treat principle. ETHICS STOPPIT-2 was approved by the South East Scotland Ethics Committee 02 on 29 August 2014, reference number 14/SS/1031 IRAS ID 159610. DISSEMINATION Peer reviewed journals, presentations at national and international scientific meetings. TRIAL REGISTRATION NUMBER ISRCTN98835694 and NCT02235181.
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Affiliation(s)
- Jane E Norman
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Maternal and Fetal Health, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Graeme Maclennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Sonia Whyte
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Maternal and Fetal Health, University of Edinburgh, Edinburgh, UK
| | | | - Joel B E Smith
- Health Economics Research Centre (HERC), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Shennan
- Tommy's Centre for Maternal and Fetal Health, King's College London, London, UK
| | - Stephen C Robson
- Institute of Cellular Medicine, University of Newcastle, Newcastle, UK
| | - Steven Thornton
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark D Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust and College of Medical and Dental Science, University of Birmingham, Birmingham, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Sarah J Stock
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Philip R Bennett
- Department of Surgery and Cancer, Imperial College London, London, UK
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Efficacy of an Emergency Cervical Cerclage Using Absorbable Monofilament Sutures. J Pregnancy 2018; 2018:4049792. [PMID: 30598846 PMCID: PMC6287138 DOI: 10.1155/2018/4049792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/06/2018] [Accepted: 10/28/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Although nonabsorbable woven tape has been widely used for cervical cerclage, technical difficulties that can occur with an effaced cervix because of the thickness of the tape, and the risks of local infection are two major concerns. This study investigated perinatal outcomes of pregnancies involving an emergency cervical cerclage using absorbable monofilament polydioxanone sutures, which is a narrow thread and protects against bacterial infection. Materials and Methods We performed a chart review of patients who underwent emergency McDonald cerclage with polydioxanone sutures at our institution between 2007 and 2015. Gestational age at delivery, duration between cerclage and delivery, and neonatal prognosis were evaluated as primary outcomes. Results Among the 23 patients (18 singleton and five twin pregnancies) evaluated, ultrasound-indicated (progressive cervical length shortening) were eight (35%) and physical examination-indicated (fetal membranes that prolapsed into the vagina or dilated cervix) were 15 patients (65%). The median gestational age at cerclage was 22+3 weeks (range, 17+5 to 25+3 weeks). Postoperative spontaneous abortion occurred in only one patient. The median gestational age at delivery was 32+5 weeks (range, 20+5 to 40+6 weeks). Extremely preterm delivery before 28 weeks of gestation occurred in four (17%) cases. Full-term delivery was achieved in 10 (42%) cases. The duration between cerclage and delivery ranged from 5 to 136 days (median, 77 days). Except for one case of spontaneous abortion, all newborns survived till hospital discharge. Conclusions Although our series included some patients at high risk for spontaneous abortion and preterm delivery, satisfactory prolongation and favorable neonatal outcomes were achieved for most patients by using absorbable monofilament sutures, thus suggesting the efficacy of this type of suture for emergency cervical cerclage.
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76
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Effects of emergency cerclage on the neonatal outcomes of preterm twin pregnancies compared to preterm singleton pregnancies: A neonatal focus. PLoS One 2018; 13:e0208136. [PMID: 30475916 PMCID: PMC6258419 DOI: 10.1371/journal.pone.0208136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/12/2018] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the efficacy and safety of emergency cerclage (EC) in preterm twins by comparing neonatal outcomes of preterm twins with those of preterm singletons. Study design This is a single-institution retrospective study of preterm infants born to women who underwent EC from 2008 to 2014. We compared various maternal and neonatal factors. The primary and secondary goals were to compare the maternal and neonatal morbidities and neonatal mortality, respectively. Results One hundred fifty-three infants were included comprising 32(21%) twins and 121(79%) singletons. The mean gestational age (GA) at the time of EC and the number of days from EC to delivery were not significantly different (47.9±27.5 vs. 48.3±35.5). The rate of preterm delivery at ≤32 weeks GA (69% vs. 79%) and ≤28 weeks GA (50% vs. 55%), and other prematurity-associated morbidities were not significantly different. The survival rate during hospitalization was 75% (24/32) in twins and 88% (107/121) in singletons (P = 0.054). Death within 7 days after birth occurred in 8 twins (25%) and 7 singletons (6%) (P = 0.001). All of the infants were <1,000 g with a GA of ≤27 weeks. Conclusion Compared to EC in singleton pregnancies, EC in twin pregnancies resulted in a higher mortality rate for preterm babies. EC might be considered a salvage procedure for selective twin pregnancies with cervical insufficiency.
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77
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Poon LC, McIntyre HD, Hyett JA, da Fonseca EB, Hod M. The first-trimester of pregnancy - A window of opportunity for prediction and prevention of pregnancy complications and future life. Diabetes Res Clin Pract 2018; 145:20-30. [PMID: 29852233 DOI: 10.1016/j.diabres.2018.05.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/04/2018] [Indexed: 12/26/2022]
Abstract
The International Federation of Gynecology and Obstetrics (FIGO) has identified non communicable maternal diseases (NCDs) as a new focus area. NCDs and exposures as related to pregnancy complications and later impairment of maternal and offspring health will form the basis for action in the forthcoming years. This paper summarizes recent advances, centered on the use of first-trimester testing, as a window of opportunity to predict and prevent many pregnancy complications; and for potential future prevention of NCDs in mother and offspring. Recent results from a large-scale randomized control trial have provided definitive proof that effective screening for preterm preeclampsia (preterm-PE), requiring delivery before 37 weeks' gestation, can be achieved with a combined test of maternal factors and biomarkers at 11-13 weeks and that aspirin, given to high-risk women, is effective in reducing the risk of preterm-PE and the length of stay in neonatal intensive care unit. This is the first successful example to illustrate that pregnancy complications is predictable and preventable in early pregnancy. Similar prediction and prevention strategies are being developed for hyperglycemia in pregnancy and preterm birth, with the intention for longer lasting interventions leading to significant downstream impact in improving long-term health in both mothers and babies.
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Affiliation(s)
- Liona C Poon
- Chinese University of Hong Kong, Hong Kong Special Administrative Region; King's College, London, England, United Kingdom
| | | | | | | | - Moshe Hod
- Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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78
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Park JY, Cho SH, Jeon SJ, Kook SY, Park H, Oh KJ, Hong JS. Outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency compared to singleton pregnancies. J Perinat Med 2018; 46:845-852. [PMID: 29116935 DOI: 10.1515/jpm-2017-0218] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/02/2017] [Indexed: 11/15/2022]
Abstract
Objectives To compare pregnancy outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency with that of singletons. Methods This retrospective cohort study included 88 consecutive women (17 twins and 71 singletons) who had undergone physical examination-indicated cerclage because of acute cervical insufficiency (defined as painless cervical dilation with (1) prolapsed and/or visible membranes at the external cervical os on speculum examination and (2) a functional cervical length of zero on transvaginal ultrasound) between 160/7 and 236/7 weeks. The primary outcome measure was preterm delivery <34 weeks. Results (1) The frequency of preterm delivery <34 weeks was not significantly different between the two groups [twins, 56% (9/16) vs. singleton, 53% (37/70), P>0.999]. (2) The perinatal mortality was 21% (7/34) in twins and 32% (23/71) in singletons. (3) The median gestational age at delivery for twin pregnancies was 31.0 weeks (IQR, 22.6-36.5 weeks), which was similar to that of singleton pregnancies (median 32.4 weeks; IQR 22.3-38.3 weeks). (4) There were no significant differences in preterm delivery before 28 and 32 weeks, interval from cerclage to delivery within 1, 2, 4 and 8 weeks and neonatal morbidities between the two groups. Conclusion The obstetric and neonatal outcomes of physical examination-indicated cerclage in twin pregnancies were comparable to those in singleton pregnancies.
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Affiliation(s)
- Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Soo-Hyun Cho
- Health Promotion Center, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Se Jeong Jeon
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Song Yi Kook
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Hyunsoo Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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Enakpene CA, DiGiovanni L, Jones TN, Marshalla M, Mastrogiannis D, Della Torre M. Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening. Am J Obstet Gynecol 2018; 219:397.e1-397.e10. [PMID: 30017683 DOI: 10.1016/j.ajog.2018.06.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/11/2018] [Accepted: 06/26/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Premature cervical ripening plays a significant role in spontaneous preterm birth. Vaginal progesterone is the recommended treatment in singleton pregnancy with incidental short cervix. There is lack of evidence on whether it is beneficial to reinforce the cervix with cerclage when the cervical length becomes progressively shortened <10 mm while on vaginal progesterone. OBJECTIVE Our aims are to determine whether cerclage with vaginal progesterone will: (1) reduce the overall spontaneous preterm birth rate, (2) prolong pregnancy latency, and (3) improve neonatal outcomes compared to vaginal progesterone alone. STUDY DESIGN This was a retrospective cohort study at the University of Illinois at Chicago of all women with singleton pregnancy on vaginal progesterone for incidental short cervix, cervical length <20 mm. Only those with progressive cervical length shortening <10 mm who delivered at the University of Illinois at Chicago from January 2013 through December 2016 were included. The decision to perform cerclage was based on individual physician preference. Demographic data; information on serial cervical length status; medical, obstetric, and social history; cerclage vs no cerclage; and neonatal outcomes were compared. RESULTS A total of 310 women with incidental short cervix on vaginal progesterone were identified, and of these, 75 had progressive shortening cervical length <10 mm and met inclusion criteria. Among the women with extremely shortened cervical length <10 mm, 36 women (48%) had cervical cerclage plus vaginal progesterone, and 39 women (52%) continued on vaginal progesterone alone. The baseline characteristics, mean cervical length (5.06 vs 5.52 mm), and mean gestational age at diagnosis of extreme short cervix (21.5 vs 21.3 weeks) were similar between women who received cerclage vs those who did not, respectively. The mean gestational age at delivery was significantly greater for those with cerclage (34 weeks and 3 days vs 27 weeks and 2 days; P < .001). The rate of spontaneous preterm birth at <37, 35, 32, 28, and 24 weeks were significantly lower in the cerclage group: 44.1% vs 84.2%, 38.2% vs 81.6%, 23.5% vs 78.9%, 14.7% vs 63.2%, and 11.8% vs 39.5%, respectively. The rate of spontaneous preterm birth <37 weeks remained significant after controlling for confounders (relative risk, 0.11; 95% confidence interval, 0.03-0.41; P < .001). The average pregnancy latency was 14 weeks in the cerclage combined with vaginal progesterone group compared to vaginal progesterone alone group. Neonatal intensive care unit admission and development of respiratory distress syndrome were significantly lower in the cerclage group compared to vaginal progesterone alone group: 13 (36.1%) vs 23 (65.7%) (relative risk, 0.55; 95% confidence interval, 0.34-0.90; P = .018) and 8 (22.2%) vs 17 (43.6%) (relative risk, 0.59; 95% confidence interval, 0.29-0.90; P = .027), respectively. Neonates of women with cerclage were also significantly less likely to develop necrotizing enterocolitis or experience neonatal death. CONCLUSION Our study showed that cerclage plus vaginal progesterone in women with extremely shortened cervix significantly decreased overall spontaneous preterm birth rates, prolonged pregnancy latency by 2-fold, and decreased the overall neonatal morbidity and mortality.
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Kyvernitakis I, Maul H, Bahlmann F. Controversies about the Secondary Prevention of Spontaneous Preterm Birth. Geburtshilfe Frauenheilkd 2018; 78:585-595. [PMID: 29962517 PMCID: PMC6018068 DOI: 10.1055/a-0611-5337] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/28/2018] [Accepted: 04/17/2018] [Indexed: 02/07/2023] Open
Abstract
Preterm birth is one of the major global health problems and part of the Millennium Development goals because of the associated high number of perinatal or neonatal mortality and long-term risks of neurodevelopmental and metabolic diseases. Transvaginal sonography has meanwhile been established as a screening tool for spontaneous preterm birth despite its relatively low sensitivity when considering only the cervical length. Vaginal progesterone has been shown to reduce prematurity rates below 34 weeks in a screening population of singleton pregnancies. Up to now, no positive long-term effect could be demonstrated after 2 years. It seems to have no benefit to prolong pregnancies after a period of preterm contractions and in risk patients without cervical shortening. Meta-analyses still demonstrate conflicting results dependent on quality criteria used for selection. A cerclage is only indicated in singleton pregnancies with previous spontaneous preterm birth and a combined cervical shortening in the current pregnancy. Nevertheless, the short- and long-term outcome has never been evaluated, whereas maternal complications may be increased. There is no evidence for a prophylactic cervical cerclage in twin pregnancies even in cases with cervical shortening. Emergency cerclage remains an indication after individual counseling. The effect of a cervical pessary in singleton pregnancy seems to be more pronounced in studies where a few investigators with increasing experience have treated and followed the patients at risk for preterm birth. Mainly in twin pregnancies, pessary treatment seems to be promising compared to other treatment options of secondary prevention when the therapy is started at early stages of precocious cervical ripening. At present, several international trials with the goal to reduce global rates of prematurity are in progress which will hopefully allow to specify the indications and methods of intervention for certain subgroups. When trials are summarized, prospective meta-analyses carry a lower risk of bias than the meanwhile uncontrolled magnitude of retrospective meta-analyses with conflicting results.
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Affiliation(s)
- Ioannis Kyvernitakis
- Dpt. of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt a. M., Dr. Senckenberg Foundation and Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Holger Maul
- Dpt. of Obstetrics and Prenatal Medicine, Asklepios Kliniken Barmbek and Nord-Heidberg, Hamburg, Germany
| | - Franz Bahlmann
- Dpt. of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt a. M., Dr. Senckenberg Foundation and Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
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Vink J, Myers K. Cervical alterations in pregnancy. Best Pract Res Clin Obstet Gynaecol 2018; 52:88-102. [PMID: 30314740 DOI: 10.1016/j.bpobgyn.2018.03.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/28/2018] [Accepted: 03/29/2018] [Indexed: 12/15/2022]
Abstract
Spontaneous preterm birth (SPTB), defined as delivery before 37 weeks' gestation, remains a significant obstetric dilemma even after decades of research in this field. Although trends from 2007 to 2014 showed the rate of preterm birth slightly decreased, the CDC recently reported the rate of preterm birth has increased for two consecutive years since 2014. Currently, 1 in 10 pregnancies in the US still end prematurely. In this chapter, we focus on the "compartment" of the cervix. The goal is to outline the current knowledge of normal cervical structure and function in pregnancy and the current knowledge of how the cervix malfunctions lead to SPTB. We review the mechanisms by which our current interventions are hypothesized to work. Finally, we outline gaps in knowledge and future research directions that may lead to novel and effective interventions to prevent premature cervical failure and SPTB.
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Affiliation(s)
- Joy Vink
- Dept. of OB/GYN, Columbia University Medical Center, New York, NY, USA.
| | - Kristin Myers
- Dept. of Mechanical Engineering, Columbia University, New York, NY, USA
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Diamant H, Mastrolia SA, Weintraub AY, Sheizaf B, Zilberstein T, Yohay D. Effectiveness and safety of late midtrimester cervical cerclage. J Matern Fetal Neonatal Med 2018; 32:3007-3011. [PMID: 29631471 DOI: 10.1080/14767058.2018.1454426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications. Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as proportions. Results: The average gestational age at birth was 35 ± 5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17 ± 5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%). Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.
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Affiliation(s)
- Hagit Diamant
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel
| | - Salvatore Andrea Mastrolia
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel
| | - Adi Y Weintraub
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel
| | - Boaz Sheizaf
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel
| | - Tali Zilberstein
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel
| | - David Yohay
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel
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Abstract
In the decades since the introduction of ultrasound into routine obstetric practice, the advantages of ultrasound have moved beyond the simple ability to identify multiple pregnancies antenatally to the possibility of screening them for fetal anomalies, pre-eclampsia, preterm birth, and the complications specific to monochorionic pregnancies. Screening studies have often excluded twins because physiological differences impact on the validity and sensitivity of the screening tests in routine use in singletons, and therefore, the evidence of screening performance in multiple pregnancy lags behind the evidence from singleton pregnancies. In general, most pregnancy complications are more common in twin pregnancy, but screening tests are less accurate or well validated. In this review article we present the current state of the evidence and avenues for future research relating to the use of ultrasound and screening for complications in twin pregnancies, including the monochorionicity-related pathologies, such as twin-twin transfusion syndrome, selective growth restriction, twin anaemia-polycythaemia sequence and twin reversed arterial perfusion sequence.
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Affiliation(s)
| | - Asma Khalil
- Fetal Medicine Unit, St George's University of London, London, UK.
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84
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Mishra S, Bagga R, Kalra J, Jain V, Dutta S. Routine second trimester cervical length screening in low risk women identified women at risk of a 'very' preterm birth but did not reduce the preterm birth rate: a randomised study from India. J OBSTET GYNAECOL 2018. [PMID: 29537316 DOI: 10.1080/01443615.2017.1419461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Women (n = 300) at 'low risk' for a preterm birth (PTB), a singleton pregnancy and for a 16-24 week period of gestation (POG) were randomised to undergo cervical length (CL) measurement by transvaginal sonography (TVS) or not. The aim was to see if routine CL measurement and treatment of a short CL reduced the PTB rate. 'Low risk' was defined by an absence of a prior abortion or PTB of a singleton infant (>16 to <37 weeks) due to a spontaneous preterm labour (PTL) or a preterm pre-labour rupture of membranes (pPROM). The PTB rate was similar in the screened and unscreened group (10.3 and 8%, respectively, p = .433). In the screened group, women who delivered at 'term' or 'moderate to late' preterm (32 to <37 weeks) had a significantly higher mean CL (3.46 ± 0.41 and 3.48 ± 0.65 cm, respectively) than the women who delivered 'very' preterm (28 to 31 + 6 weeks; 2.05 ± 0.5 cm; p = .01). A short CL ≤2.5 cm was observed in two primigravidas (2/147 or 1.3%). They delivered at 28 + 3 and 30 + 6 weeks POG, respectively, despite treatment with vaginal progesterone and rescue cerclage in one. Their neonates were discharged in a good condition. In our low risk cohort, a routine second trimester CL measurement did not reduce the overall PTB rate. However, it identified two primigravidas at risk of having a 'very' PTB.Clinical Trials Registry (CTRI), India: Registration number CTRI/2016/01/010438 Impact statement What is already known on this subject? In women with a singleton pregnancy who are at a 'low risk' for preterm birth (PTB), a short cervical length (CL) at mid trimester measured by transvaginal sonography (TVS) identifies those at risk for a PTB. This risk may be reduced by the treatment with vaginal progesterone. At present, though evidence in favour of CL measurement in low-risk women exists, it is not established as a part of antenatal care. What do the results of this study add? A routine second trimester CL measurement in low risk women did not reduce the PTB rate. However, screening for a short CL helped to identify two primigravidas at risk for a 'very' PTB. It may be possible that detection and treatment of a short CL averted an 'extremely' PTB (<28 weeks) in these two women. What are the implications of these findings for clinical practice and/or further research? Future studies should assess the outcome of women with a short mid-trimester CL to see whether its treatment resulted in pregnancy prolongation and an improved neonatal outcome.
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Affiliation(s)
- Siddhidatri Mishra
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Rashmi Bagga
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Jasvinder Kalra
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Vanita Jain
- a Department of Obstetrics and Gynaecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Sourabh Dutta
- b Department of Paediatrics, Division of Neonatology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
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85
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Mitric C, Ponette V. Successful Rescue Cerclage in a Monochorionic Diamniotic Twin Pregnancy at 20 Weeks: Case Report and Overview of Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:473-475. [PMID: 29503249 DOI: 10.1016/j.jogc.2017.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND In twin pregnancies, elective cerclage placement based on obstetrical history or ultrasound findings has been shown to be ineffective and even harmful. There are currently no guidelines for the use of rescue cervical cerclage in twin pregnancies. CASE The current report presents the case of a 33-year-old patient with monochorionic diamniotic twins (MCDA) found to have dilated cervix at 3.5cm with exposed membranes upon physical examination at 19 weeks and 3 days. An emergency McDonald cerclage was placed at 20 weeks and the patient carried the current pregnancy until 35weeks 6 days. CONCLUSION Rescue cerclage represents an important option to consider in order to preserve twin pregnancies regardless of chorionicity.
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Affiliation(s)
- Cristina Mitric
- Department of Obstetrics and Gynecology, McGill University, Montreál, QC.
| | - Vincent Ponette
- Department of Obstetrics and Gynecology, McGill University, Montreál, QC
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86
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Samson FD, Merriman AL, Tate DL, Apostolakis-Kyrus K, Gomez LM. Adjuvant administration of 17-α-hydroxy-progesterone caproate in women with three or more second trimester pregnancy losses undergoing cervical cerclage is no more effective than cerclage alone. J Perinat Med 2018; 46:155-161. [PMID: 28753545 DOI: 10.1515/jpm-2017-0074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 06/12/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the role of adjuvant 17-α-hydroxy-progesterone caproate (17OHP-C) in reducing the risk of preterm delivery <34 weeks and adverse perinatal outcomes in women with ≥3 second trimester pregnancy losses attributed to cervical insufficiency undergoing prophylactic cerclage. MATERIAL AND METHODS Retrospective cohort study of women with prophylactic cerclage placed between 2006 and 2014 divided into a cohort of (i) those receiving adjuvant 17OHP-C (n=43), and (ii) controls with cerclage alone (n=59). RESULTS Demographic characteristics were comparable in both groups. There was no significant difference in gestational age at delivery between the cerclage-17OHP-C group (33.4±5.6 weeks) and the cerclage-alone group (34.4±4.6 weeks); P=0.33. We noted a non-significant increase for deliveries <34 weeks in the cerclage-17OHP-C group (44.2%) compared to controls (28.8%) which remained non-significant after adjusting for confounders; P=0.46. There was no statistically significant difference in the rate of delivery <37, 32, 28 and 24 weeks. Adverse neonatal outcomes were comparable in both groups (cerclage-17OHP-C 48.8% vs. cerclage-alone 39%); P=0.43. CONCLUSION Intramuscular 17OHP-C in combination with prophylactic cerclage in women with cervical insufficiency and ≥3 second trimester pregnancy losses had no synergistic effect in reducing the rate of recurrent preterm birth or improving perinatal outcomes.
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Affiliation(s)
- Fernand D Samson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Amanda L Merriman
- Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Danielle L Tate
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Katherine Apostolakis-Kyrus
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Luis M Gomez
- Perinatal Associates of Northern Virginia, Inova Health System, Maternal Fetal Medicine, 3300 Gallows Road, Falls Church, VA, 22042, USA, Tel.: +1 (703) 776-2745, Fax: +1 (703) 776-6443
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87
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Lim K, Butt K, Crane JM. No. 257-Ultrasonographic Cervical Length Assessment in Predicting Preterm Birth in Singleton Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e151-e164. [DOI: 10.1016/j.jogc.2017.11.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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88
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Lim K, Butt K, Crane JM. Archivée: No 257-Recours à l'évaluation échographique de la longueur cervicale pour prédire l'accouchement préterme dans le cadre de grossesses monofœtales. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e165-e180. [DOI: 10.1016/j.jogc.2017.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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89
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Aboudiab MS, Chon AH, Korst LM, Llanes A, Ouzounian JG, Chmait RH. Management of twin-twin transfusion syndrome with an extremely short cervix. J OBSTET GYNAECOL 2018; 38:359-362. [PMID: 29374983 DOI: 10.1080/01443615.2017.1330324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The objective of this study was to describe the management and perinatal outcomes of patients with twin-twin transfusion syndrome (TTTS) and an extremely short cervical length (CL). This retrospective study examined 17 patients with TTTS and a preoperative CL ≤1.0 cm who had undergone laser surgery and perioperative cervical cerclage placement successfully. In this subset of patients, the median interval between surgery and delivery was 9.6 (range 2.1-13.9) weeks and only one patient had PPROM within 3 weeks of surgery. The median gestational age at delivery was 30.9 (range 23.1-37.6) weeks, 30-day survival of at-least-one twin was 88.2% and dual survivorship was 82.4%. Overall, patients with TTTS and a preoperative CL ≤1.0 cm who were able to undergo successful laser surgery and emergent cerclage placement had favourable outcomes. Impact statement The management of patients with twin-twin transfusion syndrome (TTTS) and extremely short cervical length (CL) varies between foetal surgery centres. This study demonstrates that laser surgery and cerclage placement in such patients are not only technically feasible, but also can result in favourable perinatal outcomes. Patients with an extremely short CL should not be uniformly excluded from laser surgery for TTTS.
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Affiliation(s)
- Myrna S Aboudiab
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
| | - Andrew H Chon
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
| | - Lisa M Korst
- b Childbirth Research Associates, LLC , North Hollywood , CA , USA
| | - Arlyn Llanes
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
| | - Joseph G Ouzounian
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
| | - Ramen H Chmait
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
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90
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Murray SR, Stock SJ, Cowan S, Cooper ES, Norman JE. Spontaneous preterm birth prevention in multiple pregnancy. THE OBSTETRICIAN & GYNAECOLOGIST : THE JOURNAL FOR CONTINUING PROFESSIONAL DEVELOPMENT FROM THE ROYAL COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS 2018; 20:57-63. [PMID: 30008614 PMCID: PMC6034359 DOI: 10.1111/tog.12460] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/21/2023]
Abstract
KEY CONTENT Twin pregnancies are associated with a three-fold greater perinatal mortality than singleton pregnancies. Prematurity is a main contributor, with 50% of twin pregnancies delivering before 37 weeks and 10% delivering before 32 weeks of gestation.The aetiology of preterm delivery in twin pregnancies is likely multifactorial and different from that of singletons.Cervical cerclage reduces preterm birth rates in singletons but has mixed results in twins with some studies showing harm.The use of progesterone to prevent preterm birth in singletons has conflicting results and has not been proven to prevent preterm birth in twins. Studies continue to determine whether the cervical pessary is effective in preventing preterm birth in multiple pregnancies.There is a paucity of data available on the prevention of preterm birth in triplets/higher order multiples but similar principles to twin pregnancy apply. LEARNING OBJECTIVES To review the burden of preterm birth in multiple pregnancy.To understand the methods available for preventing preterm birth in multiple pregnancies and the evidence surrounding the use of each one.To be aware of the use of the Arabin pessary.
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Affiliation(s)
- Sarah R Murray
- MRC Centre for Reproductive HealthQueen's Medical Research InstituteUniversity of EdinburghEdinburghEH16 4TJUK
| | - Sarah J Stock
- MRC Centre for Reproductive HealthQueen's Medical Research InstituteUniversity of EdinburghEdinburghEH16 4TJUK
| | - Shona Cowan
- Royal Infirmary EdinburghEdinburghEH16 4SAUK
| | | | - Jane E Norman
- MRC Centre for Reproductive HealthQueen's Medical Research InstituteUniversity of EdinburghEdinburghEH16 4TJUK
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91
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Coffman JC, Herndon BH, Thakkar M, Fiorini K. Anesthesia for Non-delivery Obstetric Procedures. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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92
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Yoneda S, Yoneda N, Fukuta K, Shima T, Nakashima A, Shiozaki A, Yoshino O, Kigawa M, Yoshida T, Saito S. In which preterm labor-patients is intravenous maintenance tocolysis effective? J Obstet Gynaecol Res 2017; 44:397-407. [DOI: 10.1111/jog.13547] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 10/08/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Satoshi Yoneda
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Noriko Yoneda
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Kaori Fukuta
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Tomoko Shima
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Akitoshi Nakashima
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Arihiro Shiozaki
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Osamu Yoshino
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - Mika Kigawa
- Faculty of Health and Social Services; Kanagawa University of Human Services; Yokosuka Japan
| | - Taketoshi Yoshida
- Division of Neonatology Maternal and Perinatal Center; Toyama University Hospital; Toyama Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
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93
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Farghali M, Abdelazim I, Abdelrazek K. Delayed second twin delivery: benefits and risks. J Matern Fetal Neonatal Med 2017; 32:1626-1632. [PMID: 29198155 DOI: 10.1080/14767058.2017.1413547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND An increasing number of reports describe the delayed second twin delivery for days, or weeks with good results in the majority of the cases, and different survival rate between centers, without reported randomized controlled trials (RCTs). OBJECTIVES This study was designed to evaluate the suggested management of the delayed second twin delivery in the Sabah Maternity Hospital regarding its outcome, possible risks, and benefits. PATIENTS AND METHODS Forty-seven twin pregnancies with preterm labor (PTL) of the first fetus between 20-30 weeks, and delayed delivery of the second twin were included in this study. Studied women signed informed consent about the possible risks of keeping the live fetus in the hostile intrauterine environment, and benefits of the prolonged gestation for the second twin. Throughout the conservative treatment of the second twin, the studied women were hospitalized with regular follow up for infections, consumptive coagulopathy parameters, and wellbeing of the second twin. RESULTS There was significant difference in the gestational age at delivery between the first and second twin (22.6 ± 3.4 versus 34.3 ± 2.5 weeks; respectively, p = .01). There was significant difference in the birth weight between the first and second twin (435 ± 91.2 versus 1472 ± 61.5 g; respectively, p = .004). The rate of the cesarean delivery was significantly high during delivery of the second twin compared with the first twin (23.4% (11/47) versus 0% (0/47); respectively, p = .0001) with high survival rate for the second twin (85.1% (40/47)) after the delayed second twin delivery. CONCLUSIONS The birth weight, the gestational age, and the survival rate of the studied second twin significantly increased after the suggested management of the delayed second twin delivery.
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Affiliation(s)
- Mohamed Farghali
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Ain Shams University , Cairo , Egypt
| | - Ibrahim Abdelazim
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Ain Shams University , Cairo , Egypt
| | - Khaled Abdelrazek
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Ain Shams University , Cairo , Egypt
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94
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Abstract
Spontaneous preterm birth remains the leading cause of neonatal morbidity and mortality worldwide, and accounts for a significant global health burden. Several obstetric strategies to screen for spontaneous preterm delivery, such as cervical length and fetal fibronectin measurement, have emerged. However, the effectiveness of these strategies relies on their ability to accurately predict those pregnancies at increased risk for spontaneous preterm birth (SPTB). Transvaginal cervical shortening is predictive of preterm birth and when coupled with appropriate preterm birth prevention strategies, has been associated with reductions in SPTB in asymptomatic women with a singleton gestation. The use of qualitative fetal fibronectin may be useful in conjunction with cervical length assessment in women with acute preterm labor symptoms, but data supporting its clinical utility remain limited. As both cervical length and qualitative fetal fibronectin have limited capacity to predict preterm birth, further studies are needed to investigate other potential screening modalities.
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Affiliation(s)
- Moeun Son
- Feinberg School of Medicine, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, 250 E. Superior St, Suite 05-2175, Chicago, IL.
| | - Emily S Miller
- Feinberg School of Medicine, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, 250 E. Superior St, Suite 05-2175, Chicago, IL
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95
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Predictors of cerclage failure in patients with singleton pregnancy undergoing prophylactic cervical cerclage. Arch Gynecol Obstet 2017; 297:347-352. [DOI: 10.1007/s00404-017-4600-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 11/20/2017] [Indexed: 11/24/2022]
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96
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Berghella V, Ciardulli A, Rust OA, To M, Otsuki K, Althuisius S, Nicolaides KH, Roman A, Saccone G. Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:569-577. [PMID: 28295722 DOI: 10.1002/uog.17457] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/19/2017] [Accepted: 02/24/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to quantify the efficacy of cervical cerclage in preventing preterm birth (PTB) in asymptomatic singleton pregnancies with a short mid-trimester cervical length (CL) on transvaginal sonography (TVS) and without prior spontaneous PTB. METHODS Electronic databases were searched from inception of each database until February 2017. No language restrictions were applied. All randomized controlled trials (RCTs) of asymptomatic singleton pregnancies without prior spontaneous PTB, found to have short CL < 25 mm on mid-trimester TVS and then randomized to management with either cerclage or no cerclage, were included. Corresponding authors of all the included trials were contacted to obtain access to the data and perform a meta-analysis of individual patient-level data. Data provided by the investigators were merged into a master database constructed specifically for the review. Primary outcome was PTB < 35 weeks. Summary measures were reported as relative risk (RR) with 95% CI. The quality of the evidence was assessed using the GRADE approach. RESULTS Five RCTs, including 419 asymptomatic singleton gestations with TVS-CL < 25 mm and without prior spontaneous PTB, were analyzed. In women who were randomized to the cerclage group compared with those in the control group, no statistically significant differences were found in PTB < 35 (21.9% vs 27.7%; RR, 0.88 (95% CI 0.63-1.23); I2 = 0%; five studies, 419 participants), < 34, < 32, < 28 and < 24 weeks, gestational age at delivery, preterm prelabor rupture of membranes (PPROM) and neonatal outcomes. In women who received cerclage compared with those who did not, planned subgroup analyses revealed a significantly lower rate of PTB < 35 weeks in women with TVS-CL < 10 mm (39.5% vs 58.0%; RR, 0.68 (95% CI, 0.47-0.98); I2 = 0%; five studies; 126 participants) and in women who received tocolytics (17.5% vs 32.7%; RR, 0.54 (95% CI, 0.31-0.93); I2 = 0%; four studies; 169 participants) or antibiotics (18.3% vs 31.5%; RR, 0.58 (95% CI, 0.33-0.98); I2 = 0%; three studies; 163 participants) as additional therapy to cerclage. The quality of evidence was downgraded two levels because of serious imprecision and indirectness, and therefore was judged as low. CONCLUSIONS In singleton gestations without prior spontaneous PTB but with TVS-CL < 25 mm in the second trimester, cerclage does not seem to prevent preterm delivery or improve neonatal outcome. However, in these pregnancies, cerclage seems to be efficacious at lower CLs, such as < 10 mm, and when tocolytics or antibiotics are used as additional therapy, requiring further studies in these subgroups. Given the low quality of evidence, further well-designed RCTs are needed to confirm the findings of this study. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- V Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - A Ciardulli
- Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, Italy
| | - O A Rust
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA, USA
| | - M To
- Kings College Hospital, London, UK
| | - K Otsuki
- Department of Obstetrics and Gynecology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - S Althuisius
- Department of Obstetrics and Gynecology, Dr. Horacio E. Oduber Hospital, Oranjestad, Aruba
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London, UK
| | - A Roman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - G Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Benito Vielba M, De Bonrostro Torralba C, Pallares Arnal V, Herrero Serrano R, Tejero Cabrejas EL, Campillos Maza JM. Delayed-interval delivery in twin pregnancies: report of three cases and literature review. J Matern Fetal Neonatal Med 2017; 32:351-355. [DOI: 10.1080/14767058.2017.1378336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Marta Benito Vielba
- Departamento de Obstetricia y Ginecología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Victoria Pallares Arnal
- Departamento de Obstetricia y Ginecología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Rebeca Herrero Serrano
- Departamento de Obstetricia y Ginecología, Hospital Universitario Miguel Servet, Zaragoza, Spain
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The Role of PTB Clinics: A Review of the Screening Methods, Interventions and Evidence for Preterm Birth Surveillance Clinics for High-Risk Asymptomatic Women. WOMEN’S HEALTH BULLETIN 2017. [DOI: 10.5812/whb.12667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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99
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Saccone G, Ciardulli A, Xodo S, Dugoff L, Ludmir J, Pagani G, Visentin S, Gizzo S, Volpe N, Maruotti GM, Rizzo G, Martinelli P, Berghella V. Cervical Pessary for Preventing Preterm Birth in Singleton Pregnancies With Short Cervical Length: A Systematic Review and Meta-analysis. JOURNAL OF ULTRASOUND IN MEDICINE 2017; 36:1535-1543. [PMID: 28398701 DOI: 10.7863/ultra.16.08054] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/12/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with a second trimester short cervix. METHODS Electronic databases were searched from their inception until February 2016. We included randomized clinical trials (RCTs) comparing the use of the cervical pessary with expectant management in singletons pregnancies with transvaginal ultrasound cervical length (TVU CL) ≤25 mm. The primary outcome was incidence of SPTB <34 weeks. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI). RESULTS Three RCTs (n = 1,420) were included. The mean gestational age (GA) at randomization was approximately 22 weeks. The Arabin pessary was used as intervention in all three trials, and was removed by vaginal examination at approximately 37 weeks. Cervical pessary was not associated with prevention of SPTB <37 (20.2% vs 50.2%; RR 0.50, 95% CI 0.23 to 1.09), <34, <32, and <28 weeks, compared to no pessary. No differences were found in the mean of GA at, interval from randomization to delivery, incidence of preterm premature rupture of membranes and of cesarean delivery, and in neonatal outcomes. The Arabin pessary was associated with a significantly higher risk of vaginal discharge. CONCLUSIONS In singleton pregnancies with a TVU CL ≤25mm at 200 -246 weeks, the Arabin pessary does not reduce the rate of spontaneous preterm delivery or improve perinatal outcome. Individual patient data meta-analysis may clarify whether cervical pessary may be beneficial in subgroups, such as only singleton gestations without prior SPTB or by different CL cutoffs.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
| | - Andrea Ciardulli
- Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, Italy
| | - Serena Xodo
- Department of Gynaecology and Obstetrics, School of Medicine, University of Udine, Udine, Italy
| | - Lorraine Dugoff
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Reproductive Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jack Ludmir
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giorgio Pagani
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Maternal and Fetal Health, Fondazione Poliambulanza, Brescia, Italy
| | - Silvia Visentin
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Woman's and Child's Health, University of Padua, Padua, Italy
| | - Salvatore Gizzo
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Woman's and Child's Health, University of Padua, Padua, Italy
| | - Nicola Volpe
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Feto-Maternal Medicine Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
| | - Giuseppe Rizzo
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
- Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Rome, Italy
| | - Pasquale Martinelli
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
- Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG), Rome, Italy
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
Preterm birth is the leading cause of perinatal morbidity and mortality in developed nations. The heterogeneous causes of spontaneous preterm birth make prediction and prevention difficult. The primary importance of transvaginal cervical sonography and cervicovaginal fetal fibronectin lies in their high negative predictive values in assessing risk for preterm birth. Cervical length may be useful in identifying women who are candidates for cervical cerclage or progesterone therapy for preterm birth prevention. Together, cervical length and fibronectin can be used in the triaging of women symptomatic for preterm labor.
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