Cerclage for Short Cervix on Ultrasonography in Women With Singleton Gestations and Previous Preterm Birth: A Meta-Analysis

Prevention of preterm labour via the modulation of inflammatory pathways

Pregnancy is characterized by a complex interplay of inflammatory events regulated by both the innate and acquired immune systems. Similarly, parturition can be viewed as the activation of "pro-labour" inflammatory pathways, which drive cervical ripening and myometrial activation. Premature activation of these pathways, for example, by infection, can lead to preterm labour and birth. Nuclear factor κβ is a key modulator of these pathways and functions by regulating the expression of prostaglandins, chemokines and pro-inflammatory cytokines involved in both term and preterm labour. Future design of therapeutics that target key mediators of inflammation and immune activation would therefore be a rational approach for preventing preterm labour and immune-mediated neonatal brain damage.

Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data

OBJECTIVE

To determine whether the use of vaginal progesterone in asymptomatic women with a sonographic short cervix (≤ 25 mm) in the midtrimester reduces the risk of preterm birth and improves neonatal morbidity and mortality.

STUDY DESIGN

Individual patient data metaanalysis of randomized controlled trials.

RESULTS

Five trials of high quality were included with a total of 775 women and 827 infants. Treatment with vaginal progesterone was associated with a significant reduction in the rate of preterm birth <33 weeks (relative risk [RR], 0.58; 95% confidence interval [CI], 0.42-0.80), <35 weeks (RR, 0.69; 95% CI, 0.55-0.88), and <28 weeks (RR, 0.50; 95% CI, 0.30-0.81); respiratory distress syndrome (RR, 0.48; 95% CI, 0.30-0.76); composite neonatal morbidity and mortality (RR, 0.57; 95% CI, 0.40-0.81); birthweight <1500 g (RR, 0.55; 95% CI, 0.38-0.80); admission to neonatal intensive care unit (RR, 0.75; 95% CI, 0.59-0.94); and requirement for mechanical ventilation (RR, 0.66; 95% CI, 0.44-0.98). There were no significant differences between the vaginal progesterone and placebo groups in the rate of adverse maternal events or congenital anomalies.

CONCLUSION

Vaginal progesterone administration to asymptomatic women with a sonographic short cervix reduces the risk of preterm birth and neonatal morbidity and mortality.

Gestational age of previous twin preterm birth as a predictor for subsequent singleton preterm birth

OBJECTIVE

We sought to determine an optimal gestational-age cutoff of preterm twin deliveries for predicting subsequent singleton preterm birth (PTB).

STUDY DESIGN

We performed a retrospective study of women with a spontaneous twin delivery who subsequently had a singleton gestation. Univariate and multivariate analyses determined the risk of a spontaneous singleton PTB after a PTB of a twin gestation. Different gestational-age cutoffs of the previous twin PTB were evaluated.

RESULTS

Among 255 women, previous twin PTB at <34 weeks' gestation was associated with an increased risk of singleton PTB (odds ratio, 9.67; 95% confidence interval, 3.07-30.47). Every twin gestational age cutoff at <34 weeks' gestation had a significantly higher risk of subsequent singleton PTB, which was no longer significant at ≥ 34 weeks' gestation (odds ratio, 1.68; 95% confidence interval, 0.23-12.19).

CONCLUSION

In women with a previous spontaneous twin PTB at <34 weeks' gestation, there is an increased risk of subsequent singleton PTB. A twin birth at ≥ 34 weeks' gestation is not associated with an increased risk for a subsequent singleton PTB.

Successful tubal blastocyst transfer after laparoscopic cervical cerclage: cesarean delivery of a live very low-birth-weight infant and later hysterectomy for uterine rupture

OBJECTIVE

To report the management of a woman who presented with secondary infertility and amenorrhea after 2 Lletz procedures and a cone biopsy and who had cervical stenosis, a foreshortened cervix, and hematometra.

DESIGN

Case report.

SETTING

Fertility clinic and tertiary hospital.

PATIENT(S)

A 34-year-old woman who wanted further children but had had a previous cesarean delivery and then a cone biopsy for cervical intraepithelial neoplasia III that resulted in a foreshortened cervix and cervical obstruction.

INTERVENTION(S)

Laparoscopic cervical cerclage, IVF, blastocyst tubal transfer, cesarean delivery, hysterectomy.

MAIN OUTCOME MEASURE(S)

Pregnancy; morbidity for the woman and her infant.

RESULT(S)

An intrauterine pregnancy occurred after blastocyst intrafallopian transfer, but there was uterine herniation necessitating premature delivery of a very low-birth-weight infant that had lung problems but is now healthy. The mother later developed a hematometra that ruptured, requiring an emergency hysterectomy from which her recovery was protracted.

CONCLUSION(S)

This first report of a blastocyst intrafallopian transfer was associated with an intrauterine pregnancy; however, when the indication for blastocyst tubal transfer of an obstructed cervix is associated with a foreshortened cervix requiring cervical cerclage, there can be major health risks for infant and mother.