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Nguyen TTH, Vu TV, Nguyen HVQ. Uterocervical angle and cervical length measurements for spontaneous preterm birth prediction in low-risk singleton pregnant women: a prospective cohort study. Arch Gynecol Obstet 2024; 310:1611-1619. [PMID: 39017927 DOI: 10.1007/s00404-024-07646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/09/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE Preterm birth is the leading cause of early neonatal morbidity and mortality. Strategies to predict preterm birth risk can help improve pregnancy outcomes. Even pregnant women without known risk factors for preterm birth can also experience it. This study aimed to evaluate the ability of the uterocervical angle and cervical length to predict spontaneous preterm birth in low-risk singleton pregnant women. METHODS A prospective study on 1107 singleton pregnant women between 16+0 and 23+6 weeks gestation at low risk for spontaneous preterm birth who were treated at the Haiphong Hospital of Obstetrics and Gynecology, Vietnam, between September 2020 and September 2021 was conducted. A single sonographer assessed the cervical length and the uterocervical angle using transvaginal ultrasonography. The patients were followed up until delivery to determine the main pregnancy outcome (spontaneous preterm birth before 37 weeks gestation). The cut-off points for the uterocervical angle and cervical length were established by analyzing the receiver operating characteristic curve. The sensitivity, specificity, likelihood ratio, positive and negative predictive values, and accuracy of the uterocervical angle and cervical length for predicting spontaneous preterm birth were determined. RESULTS A uterocervical angle ≥ 99° predicted spontaneous preterm birth at < 37 weeks, with a sensitivity and specificity of 91% and 76%, respectively. A cervical length ≤ 33.8 mm predicted preterm birth at < 37 weeks with a sensitivity and specificity of 25% and 66%, respectively. A uterocervical angle ≥ 99° combined with a cervical length ≤ 33.8 mm yielded the sensitivity, specificity, positive predictive value, likelihood ratio, and accuracy of spontaneous preterm birth prediction of 66%, 93%, 36%, 9, and 91%, respectively; thus provided a significant increase of specificity with an acceptable reduction of sensitivity as compared to cervical length alone. CONCLUSION Besides the cervical length, the uterocervical angle can be considered a valuable ultrasound parameter for predicting spontaneous preterm birth in low-risk singleton pregnant women. Combining the uterocervical angle and cervical length yielded stronger spontaneous preterm birth prediction values.
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Affiliation(s)
- Trang Thi Hoang Nguyen
- Department of Obstetrics and Gynecology, Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem St., Haiphong, Vietnam
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Hue University, 6 Ngo Quyen St., Hue, 491200, Vietnam
| | - Tam Van Vu
- Department of Obstetrics and Gynecology, Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem St., Haiphong, Vietnam
| | - Huy Vu Quoc Nguyen
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Hue University, 6 Ngo Quyen St., Hue, 491200, Vietnam.
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Biggio J. SMFM Consult Series #70: Management of short cervix in individuals without a history of spontaneous preterm birth. Am J Obstet Gynecol 2024; 231:B2-B13. [PMID: 38754603 DOI: 10.1016/j.ajog.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Most deliveries before 34 weeks of gestation occur in individuals with no previous history of preterm birth. Midtrimester cervical length assessment using transvaginal ultrasound is one of the best clinical predictors of spontaneous preterm birth. This Consult provides guidance for the diagnosis and management of a short cervix in an individual without a history of preterm birth. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that all cervical length measurements used to guide therapeutic recommendations be performed using a transvaginal approach and in accordance with standardized procedures as described by organizations such as the Perinatal Quality Foundation or the Fetal Medicine Foundation (GRADE 1C); (2) we recommend using a midtrimester cervical length of ≤25 mm to diagnose a short cervix in individuals with a singleton gestation and no previous history of spontaneous preterm birth (GRADE 1C); (3) we recommend that asymptomatic individuals with a singleton gestation and a transvaginal cervical length of ≤20 mm diagnosed before 24 weeks of gestation be prescribed vaginal progesterone to reduce the risk of preterm birth (GRADE 1A); (4) we recommend that treatment with vaginal progesterone be considered at a cervical length of 21 to 25 mm based on shared decision-making (GRADE 1B); (5) we recommend that 17-alpha hydroxyprogesterone caproate, including compounded formulations, not be prescribed for the treatment of a short cervix (GRADE 1B); (6) in individuals without a history of preterm birth who have a sonographic short cervix (10-25 mm), we recommend against cerclage placement in the absence of cervical dilation (GRADE 1B); (7) we recommend that cervical pessary not be placed for the prevention of preterm birth in individuals with a singleton gestation and a short cervix (GRADE 1B); and (8) we recommend against routine use of progesterone, pessary, or cerclage for the treatment of cervical shortening in twin gestations outside the context of a clinical trial (GRADE 1B).
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Kyvernitakis I, Baschat AA, Malan M, Rath W, Berger R, Henrich W, Schleussner E, Yousefi B, Timmesfeld N, Maul H. Cervical pessary to prevent preterm birth and poor neonatal outcome: An integrity meta-analysis of randomized controlled trials focusing on adherence to the European Medical Device Regulation. Int J Gynaecol Obstet 2024; 165:607-620. [PMID: 37830250 DOI: 10.1002/ijgo.15169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/28/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Findings from randomized trials (RCTs) on cervical pessary treatment to prevent spontaneous preterm birth are inconsistent. OBJECTIVES Our hypothesis suggests that adhering to the European Medical Device Regulation (MDR) and following the instructions for use are essential prerequisites for successful therapy. Conversely, the non-adherence to these guidelines will probably contribute to its failure. SEARCH STRATEGY AND SELECTION CRITERIA Based on validated criteria from integrity assessments we performed a systematic review identifying 14 RCTs evaluating the effect of cervical pessaries. DATA COLLECTION AND ANALYSIS We analyzed the implications of 14 criteria each accounting for 0-2 points of a score reflecting the clinical evaluation plan (CEP) as proposed by the MDR to evaluate the risk-benefit ratio of medical devices. MAIN RESULTS Seven RCTs in each singleton and twin pregnancies (5193 "cases") were included, detecting a high heterogeneity within control groups (I2 = 85% and 87%, respectively, P < 0.01). The CEP score varied from 11 to 26 points for all studies. The most common reasons for low scores and potential data compromise were poor recruitment rates, no (completed) power analysis, and no pre-registration, but mainly non-adherence to technical, biological, and clinical equivalence to the instructions for use as required by the MDR. All trials with score values greater than 20 had applied audit procedures. Within this group we found significantly reduced rates of spontaneous preterm birth at less than 34 weeks within the pessary group in singleton (odds ratio 0.28; 95% confidence interval 0.12-0.65) and twin pregnancies (odds ratio 0.30; 95% confidence interval 0.13-0.67). Similarly, there was a significant reduction in the composite poor neonatal outcome in singleton (odds ratio 0.25; 95% confidence interval 0.10-0.61) and twin pregnancies (odds ratio 0.54; 95% confidence interval 0.35-0.82) after a pessary as compared with controls. CONCLUSION Non-audited RCTs and meta-analyses mixing studies of different clinical quality as pre-defined by a CEP and the MDR pose the risk for erroneous conclusions.
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Affiliation(s)
- Ioannis Kyvernitakis
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Ahmet A Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcel Malan
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Werner Rath
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Richard Berger
- Department of Obstetrics and Gynecology, Marienhaus Klinikum St. Elisabeth, Neuwied, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ekkehard Schleussner
- Department of Obstetrics and Prenatal Medicine, University of Jena, Jena, Germany
| | - Bahareh Yousefi
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Holger Maul
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
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Kyvernitakis I, von Gehren F, Malan M, Baschat A, Maul H, Osinski M. Prediction of Preterm Birth with the Uterocervical Angle in Singleton Pregnancies Treated with a Cervical Pessary. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024; 45:190-198. [PMID: 37168018 DOI: 10.1055/a-2091-7179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Cervical pessaries are an established therapy option for patients at risk for spontaneous preterm birth (sPTB). The uterocervical angle (UCA) remains a promising sPTB predictor. However, its clinical significance has yet to be described in patients treated with a pessary. METHODS This study analyzed data of patients treated with a pessary because of cervical shortening in singleton pregnancies. The patients were divided into 2 groups according to transvaginal ultrasound findings: the funneling group (n = 68) and the no-funneling group (n = 42). Moreover, we analyzed patients within these prespecified groups according to the UCA < 95° and ≥ 95°. RESULTS Delivery occurred significantly earlier in patients treated with a pessary and with a high UCA ≥ 95°(p = 0.006). The median gestational age at delivery in patients treated with a pessary and with no funneling and a UCA < 95° vs. ≥ 95° were 39.00 and 36.14 weeks, respectively (p = 0.005). In cases with funneling and a UCA < 95° vs. ≥ 95° the mean gestational age at delivery was 38.14 and 38.07 weeks respectively (p=1,00). There was a significant negative linear correlation between UCA and the gestational age at delivery in all patients (p = 0.04), which was even profound in the group without funneling (p = 0.0002). However, we found no significant correlation between cervical length and gestational age at delivery in all patients (p = 0.42) as well as in the group without funneling (p = 0.28). CONCLUSION In spite of pessary treatment, patients with UCA ≥ 95° presented with a higher risk of sPTB compared to patients with UCA < 95°. This suggests that the UCA seems to be a better predictor of sPTB than the cervical length in patients receiving pessary treatment.
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Affiliation(s)
- Ioannis Kyvernitakis
- Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
| | - Friederike von Gehren
- Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
| | - Marcel Malan
- Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
| | - Ahmet Baschat
- Gynecology & Obstetrics, Johns Hopkins University, Baltimore, United States
| | - Holger Maul
- Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
| | - Maciej Osinski
- Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
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Goodell M, Leechalad L, Soti V. Are Cervical Pessaries Effective in Preventing Preterm Birth? Cureus 2024; 16:e51775. [PMID: 38187016 PMCID: PMC10771609 DOI: 10.7759/cureus.51775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/06/2024] [Indexed: 01/09/2024] Open
Abstract
Preterm births are a significant concern, as they can have serious consequences for both infants and mothers. It is crucial to identify risk factors associated with preterm birth and to implement effective interventions, such as progesterone, cervical pessary, and cervical cerclage, to prevent it. This systematic review aims to evaluate the efficacy of cervical pessary in reducing spontaneous preterm delivery. However, cervical pessaries have limited research and conflicting findings when compared to other interventions for preventing preterm labor. Therefore, this review seeks to analyze various studies to evaluate their overall effectiveness and better understand their role in treating this vulnerable population. The literature search was conducted using PubMed between January and September 2023, and the systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results of this review highlight the importance of continued research into mitigation strategies for preterm birth. There is some evidence that indicates that using cervical pessaries before 34 weeks can be effective. While some studies have reported positive outcomes when cervical pessaries are combined with other treatments like progesterone, there is no solid statistical evidence to support this claim. Furthermore, additional research is needed to comprehend the impact of singleton pregnancies and long-term outcomes for both mothers and infants.
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Affiliation(s)
- Morgan Goodell
- Obstetrics and Gynecology, Lake Erie College of Osteopathic Medicine, Elmira, USA
| | - Leilani Leechalad
- Internal Medicine, Lake Erie College of Osteopathic Medicine, Elmira, USA
| | - Varun Soti
- Pharmacology and Therapeutics, Lake Erie College of Osteopathic Medicine, Elmira, USA
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Nguyen THT, Vu VT, Nguyen VQH. Distribution of uterocervical angles of pregnant women at 16 + 0 to 23 + 6 weeks gestation with low risk for preterm birth: first vietnamese cohort of women with singleton pregnancies. BMC Pregnancy Childbirth 2023; 23:301. [PMID: 37118695 PMCID: PMC10148387 DOI: 10.1186/s12884-023-05597-3] [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: 12/22/2022] [Accepted: 04/11/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Cervical length (CL) measured by ultrasound in the second trimester is a predictor of spontaneous preterm birth (sPTB). The uterocervical angle (UCA) has recently been suggested as a predictor to identify women at risk of sPTB. The aim of this study was to investigate the UCAs' distribution in singleton pregnant women at 16+ 0 - 23+ 6 weeks of gestation with low risk for sPTB. METHODS This was a prospective cohort study of 1,051 pregnant women with singleton pregnancies at low risk for preterm delivery. Pregnant women with a viable singleton fetus at 16+ 0 - 23+ 6 weeks of gestation were enrolled in the study conducted at the Haiphong Hospital of Obstetrics and Gynecology, Vietnam, from 09/2019 to 09/2020. CL and the UCA were assessed using transvaginal ultrasonography (TVS) by a single sonographer. Subjects were followed-up until the end of pregnancy, and maternal and neonatal outcomes were recorded. The UCAs' range and their relationship with gestational age were evaluated using regression analysis. P < 0.05 was considered statistically significant. RESULTS The normal range of the UCA (5th - 95th percentiles) was 46.47° (95% CI, 40.27°-51.81°) to 127.06° (95% CI, 123.02° - 130.71°). The UCAs in the preterm birth (< 37 weeks) and full-term groups were 117.86° ± 20.25° and 83.80° ± 24.18°, respectively (p < 0.001). Linear regression analysis showed a significant change in the UCA range from 16+ 0 to 23+ 6 weeks of gestation (2.51 degrees per week, p < 0.001). The linear function yielded the highest correlation coefficient in the variation rule of the UCA values (r = 0.22). A total of 42/63 (66.7%) patients with preterm birth < 37 weeks had a UCA above the 75th percentile. The majority of women with preterm birth had a UCA ≥ 95° compared with those with full-term delivery (88.9% vs. 31.3%, p < 0.001). CONCLUSIONS The results of this study present background information about the normal range of UCA values in singleton pregnant women at 16+ 0 to 23+ 6 weeks at low risk for sPTB in this Vietnamese cohort. In this study population at low risk for sPTB, pregnant women with a UCA value ≥ 95o were also considered at risk for preterm birth.
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Affiliation(s)
- Thi Hoang Trang Nguyen
- Department of Obstetrics and Gynecology, Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem St, Haiphong, Vietnam
- Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy, Hue University, 6 Ngo Quyen St., Hue 491200, Hue, Vietnam
| | - Van Tam Vu
- Department of Obstetrics and Gynecology, Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem St, Haiphong, Vietnam
| | - Vu Quoc Huy Nguyen
- Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy, Hue University, 6 Ngo Quyen St., Hue 491200, Hue, Vietnam.
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Wennerholm UB, Bergman L, Kuusela P, Ljungström E, Möller AC, Hongslo Vala C, Ekelund AC, Liljegren A, Petzold M, Sjögren P, Svensson M, Strandell A, Jacobsson B. Progesterone, cerclage, pessary, or acetylsalicylic acid for prevention of preterm birth in singleton and multifetal pregnancies - A systematic review and meta-analyses. Front Med (Lausanne) 2023; 10:1111315. [PMID: 36936217 PMCID: PMC10015499 DOI: 10.3389/fmed.2023.1111315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
Background Preterm birth is the leading cause of childhood mortality and morbidity. We aimed to provide a comprehensive systematic review on randomized controlled trials (RCTs) on progesterone, cerclage, pessary, and acetylsalicylic acid (ASA) to prevent preterm birth in asymptomatic women with singleton pregnancies defined as risk of preterm birth and multifetal pregnancies. Methods Six databases (including PubMed, Embase, Medline, the Cochrane Library) were searched up to February 2022. RCTs published in English or Scandinavian languages were included through a consensus process. Abstracts and duplicates were excluded. The trials were critically appraised by pairs of reviewers. The Cochrane risk-of-bias tool was used for risk of bias assessment. Predefined outcomes including preterm birth, perinatal/neonatal/maternal mortality and morbidity, were pooled in meta-analyses using RevMan 5.4, stratified for high and low risk of bias trials. The certainty of evidence was assessed using the GRADE approach. The systematic review followed the PRISMA guideline. Results The search identified 2,309 articles, of which 87 were included in the assessment: 71 original RCTs and 16 secondary publications with 23,886 women and 32,893 offspring. Conclusions were based solely on trials with low risk of bias (n = 50).Singleton pregnancies: Progesterone compared with placebo, reduced the risk of preterm birth <37 gestational weeks: 26.8% vs. 30.2% (Risk Ratio [RR] 0.82 [95% Confidence Interval [CI] 0.71 to 0.95]) (high certainty of evidence, 14 trials) thereby reducing neonatal mortality and respiratory distress syndrome. Cerclage probably reduced the risk of preterm birth <37 gestational weeks: 29.0% vs. 37.6% (RR 0.78 [95% CI 0.69 to 0.88]) (moderate certainty of evidence, four open trials). In addition, perinatal mortality may be reduced by cerclage. Pessary did not demonstrate any overall effect. ASA did not affect any outcome, but evidence was based on one underpowered study.Multifetal pregnancies: The effect of progesterone, cerclage, or pessary was minimal, if any. No study supported improved long-term outcome of the children. Conclusion Progesterone and probably also cerclage have a protective effect against preterm birth in asymptomatic women with a singleton pregnancy at risk of preterm birth. Further trials of ASA are needed. Prevention of preterm birth requires screening programs to identify women at risk of preterm birth. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234946].
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Affiliation(s)
- Ulla-Britt Wennerholm
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lina Bergman
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Pihla Kuusela
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Södra Älvsborg Hospital, Department of Obstetrics and Gynecology, Borås, Sweden
| | - Elin Ljungström
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | - Anna C. Möller
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | | | - Ann-Catrin Ekelund
- Region Västra Götaland, Skaraborg Hospital, Medical Library, Skövde, Sweden
| | - Ann Liljegren
- Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, Gothenburg, Sweden
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Annika Strandell
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, HTA-centrum, Gothenburg, Sweden
| | - Bo Jacobsson
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Division of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
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Kumagai K, Murotsuki J, Dohi S, Nishikawa N, Kimura N, Nomiyama M, Osaga S, Hashimoto H, Nakai A, Sugiura-Ogasawara M, Ozaki Y. Does a cervical pessary reduce the rate of preterm birth in women with a short cervix? J Perinat Med 2022; 50:1107-1114. [PMID: 35589684 DOI: 10.1515/jpm-2021-0688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate neonatal outcomes after the use of a cervical pessary in Japanese women with short cervical length (CL) less than 25 mm. METHODS This multicenter study involved women with singleton pregnancies between 20 and 29+6 gestational weeks and a CL of less than 25 mm. The primary outcome was preterm birth (PTB) before 34 weeks of gestation. This study was registered in the Japan Registry of Clinical Trials (JRCT: jRCTs042180102). RESULTS Two hundred pregnant women were enrolled; 114 in the pessary group and 86 in the expectant management group as controls. In the pessary group, all 114 neonates were investigated for perinatal outcomes, and 112 pregnant women were investigated for primary, and secondary outcomes. In the control group, 86 pregnant women were investigated for primary and secondary outcomes and 86 neonates were investigated for neonatal outcomes. There were no significant differences in PTB in ≤34, ≤37, and ≤28 weeks of gestation or in preterm rupture of membranes (PROM) ≤34 weeks between the groups. The gestational weeks at birth and birth weight were significantly higher in the pessary group. Regression analysis demonstrated that the CL decreased without a pessary, whereas the shortening rate was suppressed during the intervention. No significant differences were observed in adverse neonatal outcomes, chorioamnionitis, or preterm PROM. CONCLUSIONS The cervical pessary effectively reduced CL shortening during pregnancy resulting in an average increased gestational age, however, did not reduced the rates of preterm birth.
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Affiliation(s)
- Kyoko Kumagai
- Department of Obstetrics and Gynecology, Nagoya City University, Aichi, Japan
| | - Jun Murotsuki
- Department of Maternal and Fetal Medicine, Tohoku University Graduate School of Medicine, Miyagi Children's Hospital, Miyagi, Japan
| | - Satoshi Dohi
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Naomi Nishikawa
- Department of Obstetrics and Gynecology, Nagoya City University West Medical Center, Aichi, Japan
| | - Naomi Kimura
- Department of Obstetrics and Gynecology, Konan Kosei Hospital, Aichi, Japan
| | - Makoto Nomiyama
- Department of Obstetrics and Gynecology, National Hospital Organization Saga Hospital, Saga, Japan
| | - Satoshi Osaga
- Clinical Research Management Center, Nagoya City University Hospital, Aichi, Japan
| | - Hiroya Hashimoto
- Clinical Research Management Center, Nagoya City University Hospital, Aichi, Japan
| | - Akihito Nakai
- Department of Obstetrics and Gynecology, Tama-Nagayama Hospital, Nippon Medical School, Tokyo, Japan
| | | | - Yasuhiko Ozaki
- Department of Obstetrics and Gynecology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
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Vidal MS, Lintao RCV, Severino MEL, Tantengco OAG, Menon R. Spontaneous preterm birth: Involvement of multiple feto-maternal tissues and organ systems, differing mechanisms, and pathways. Front Endocrinol (Lausanne) 2022; 13:1015622. [PMID: 36313741 PMCID: PMC9606232 DOI: 10.3389/fendo.2022.1015622] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Survivors of preterm birth struggle with multitudes of disabilities due to improper in utero programming of various tissues and organ systems contributing to adult-onset diseases at a very early stage of their lives. Therefore, the persistent rates of low birth weight (birth weight < 2,500 grams), as well as rates of neonatal and maternal morbidities and mortalities, need to be addressed. Active research throughout the years has provided us with multiple theories regarding the risk factors, initiators, biomarkers, and clinical manifestations of spontaneous preterm birth. Fetal organs, like the placenta and fetal membranes, and maternal tissues and organs, like the decidua, myometrium, and cervix, have all been shown to uniquely respond to specific exogenous or endogenous risk factors. These uniquely contribute to dynamic changes at the molecular and cellular levels to effect preterm labor pathways leading to delivery. Multiple intervention targets in these different tissues and organs have been successfully tested in preclinical trials to reduce the individual impacts on promoting preterm birth. However, these preclinical trial data have not been effectively translated into developing biomarkers of high-risk individuals for an early diagnosis of the disease. This becomes more evident when examining the current global rate of preterm birth, which remains staggeringly high despite years of research. We postulate that studying each tissue and organ in silos, as how the majority of research has been conducted in the past years, is unlikely to address the network interaction between various systems leading to a synchronized activity during either term or preterm labor and delivery. To address current limitations, this review proposes an integrated approach to studying various tissues and organs involved in the maintenance of normal pregnancy, promotion of normal parturition, and more importantly, contributions towards preterm birth. We also stress the need for biological models that allows for concomitant observation and analysis of interactions, rather than focusing on these tissues and organ in silos.
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Affiliation(s)
- Manuel S. Vidal
- Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines, Manila, Philippines
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Ryan C. V. Lintao
- Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines, Manila, Philippines
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Mary Elise L. Severino
- Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines, Manila, Philippines
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Ourlad Alzeus G. Tantengco
- Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines, Manila, Philippines
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Ramkumar Menon
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
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Teoh J, Pather S, Narayan R. Use of an Arabin pessary to prevent preterm birth in pregnancy complicated by a short cervix after cervical conization for cervical adenocarcinoma with residual disease: A case report and literature review. Case Rep Womens Health 2022; 36:e00437. [PMID: 35991521 PMCID: PMC9385544 DOI: 10.1016/j.crwh.2022.e00437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022] Open
Abstract
Surgical conization of the cervix for cervical cancer increases the risk of preterm birth in subsequent pregnancies. The ideal intervention to prevent preterm births in women with cervical insufficiency resulting from conization is not known. When histological margins of the cone biopsy are suspected to have residual malignancy, surveillance and oncological management during a concurrent pregnancy can be challenging. This case outlines the management of a pregnancy complicated by a short cervix secondary to conization for adenocarcinoma of cervix, with margins suspected to be not clear of disease. The patient had progressive shortening of the cervix despite vaginal progesterone, but maintained a cervical length of 16 mm following Arabin pessary insertion. She delivered a healthy neonate at 34 + 3 weeks of gestation (105 days following pessary insertion). The cervical pessary in combination with vaginal progesterone may be safe and effective in preventing preterm birth in a pregnancy with possible residual cervical cancer and a short cervix.
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Affiliation(s)
- Jessica Teoh
- Women and Babies Department, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW 2050, Australia
| | - Selvan Pather
- Gynaecologic Oncology, Chris O'Brien Lifehouse, 119-143 Missenden Road, Camperdown, NSW 2050, Australia
| | - Rajit Narayan
- Women and Babies Department, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW 2050, Australia
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11
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Vargas M, Mendoza M, García I, Farràs A, Maiz N, Carreras E, Goya M. Implications of training for pessary placement and accuracy of cervical length measurements after pessary placement: a prospective, double-blind, randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2022; 279:12-18. [DOI: 10.1016/j.ejogrb.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 08/17/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
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12
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Martin A, Suff N, Seed PT, David AL, Girling J, Shennan A. The use of fetal fibronectin and cervical length measurements in the prediction of spontaneous preterm birth in women with an Arabin pessary in situ. Eur J Obstet Gynecol Reprod Biol 2022; 276:113-117. [PMID: 35853271 DOI: 10.1016/j.ejogrb.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/25/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The ability to predict spontaneous PTB (sPTB) has improved greatly, allowing women at risk to be managed with prophylactic interventions such as cervical cerclage and the Arabin pessary. Cervicovaginal fetal fibronectin (qfFN) concentration and ultrasound measurement of cervical length (CL) are the two most established tools to predict sPTB. There is however limited data regarding the predictive value of qfFN and CL tests following insertion of an Arabin pessary. Our aim was therefore to determine the clinical use of qfFN and CL measurements to predict sPTB in women fitted with an Arabin pessary. STUDY DESIGN This study is a secondary analysis on the SUPPORT trial data. Data were prospectively collected from women attending high-risk preterm surveillance clinics in 3 London centres between July 2015 and April 2020. The matched control group was pregnant women attending the same high-risk preterm surveillance clinics who had not received an Arabin pessary. Receiver operating characteristic (ROC) curves for prediction of birth by 34 and by 37 weeks' gestation were generated for qfFN and CL measurements combined for both study groups. A formal comparison of area under the curve before 34 weeks' gestation (AUC < 34 weeks) was made between the two study groups. RESULTS At our primary endpoint of sPTB < 34 weeks' gestation, qfFN was a good predictor of sPTB in cases with an Arabin pessary in situ (AUC, 0.79, 95% CI: 0.62-0.90) and no worse than the control group who did not have an Arabin pessary, (AUC 0.74, 95% CI: 0.48-0.96). CL had good prediction for sPTB < 34 weeks' gestation in the control group (AUC 0.76, 95% CI: 0.63-0.88) but was lower and non-significant in the Arabin pessary case group (AUC 0.60, 95% CI: 0.43-0.76). CONCLUSIONS This study showed that cervicovaginal qfFN concentration is equally reliable in the prediction of sPTB in pregnant women at increased risk of sPTB with and without an Arabin pessary in situ, and significantly better than CL measurement alone for predicting delivery before 34 weeks. This commonly used test therefore has utility in predicting sPTB in pregnant women fitted with an Arabin pessary.
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Affiliation(s)
- Anastasia Martin
- University Hospital Sussex NHS Trust, Brighton BN2 5BE, United Kingdom.
| | - Natalie Suff
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, United Kingdom
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, United Kingdom
| | - Anna L David
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, United Kingdom; Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, United Kingdom
| | - Joanna Girling
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, 149 Tottenham Court Road, London W1T 7DN, United Kingdom
| | - Andrew Shennan
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, United Kingdom; West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom
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13
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van Limburg Stirum EVJ, Zegveld SJ, Simons NE, de Boer MA, Pajkrt E, Mol BWJ, Oudijk MA, van 't Hooft J. Consequences of cervical pessary for subsequent pregnancy: follow-up of randomized clinical trial (ProTWIN). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:771-777. [PMID: 34826166 PMCID: PMC9328140 DOI: 10.1002/uog.24821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/20/2021] [Accepted: 11/17/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the effect of cervical pessary, as a strategy to prevent preterm birth (PTB), on the outcome of subsequent pregnancy and maternal quality of life 4 years after the index twin pregnancy. METHODS Between 2009 and 2012, the ProTWIN trial randomized women with a multiple pregnancy to pessary use vs standard care for the prevention of PTB. The trial showed no benefit in unselected women with a twin pregnancy, but showed a 60% reduction in poor perinatal outcomes in favor of the pessary group in the subgroup of women with a mid-trimester short cervix (cervical length < 38 mm). All women were invited to participate in a follow-up study 4 years after their participation in the ProTWIN trial. In this follow-up study, maternal quality of life was assessed using the EQ-5D-3L questionnaire and women were asked separate questions about subsequent pregnancies. Results were compared between women who were randomized to the pessary vs the control group in the ProTWIN trial by calculating relative risk (RR) and 95% CI. Subgroup analysis was performed for women with a mid-trimester short cervix (cervical length < 38 mm). RESULTS Of the 813 women included in the ProTWIN trial, 408 (50.2%) participated in this follow-up study, comprising 228 randomized to the pessary group and 180 to the control group in the original trial. The median interval between participation in the ProTWIN trial and participation in this follow-up study was 4.1 (interquartile range (IQR), 3.9-7.1) years. Ninety-eight (24.0%) participants tried to conceive after their participation in the ProTWIN trial. Of those, 22 (22.4%) women did not have a subsequent pregnancy (no difference between pessary and control groups), seven (7.1%) women had at least one miscarriage but no live birth, and 67 (68.4%) women had at least one live birth (35 in the pessary vs 32 in the control group; RR, 0.93 (95% CI, 0.8-1.07)). In two women, the pregnancy outcome was unknown. Preterm delivery (< 37 weeks of gestation) of the first live birth occurred in three women in the pessary vs one woman in the control group (all singleton; RR, 2.57 (95% CI, 0.28-23.44)). No differences were found between the pessary and control groups in the subgroup of women with mid-trimester short cervix, but the numbers analyzed were small. The median health state index score was 0.95 (IQR, 0.82-0.95), with no difference between the pessary and control groups. CONCLUSION Our findings suggest that there are no long-term effects of pessary use on the outcome of subsequent pregnancies and maternal quality of life. Data on obstetric outcome were limited due to the small numbers. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E. V. J. van Limburg Stirum
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - S. J. Zegveld
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - N. E. Simons
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - M. A. de Boer
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC locationVrije UniversiteitAmsterdamThe Netherlands
| | - E. Pajkrt
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - B. W. J. Mol
- Department of Obstetrics and GynecologyMonash UniversityMelbourneVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of MedicineUniversity of AberdeenAberdeenUK
| | - M. A. Oudijk
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC locationVrije UniversiteitAmsterdamThe Netherlands
| | - J. van 't Hooft
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
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14
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Zhuang Y, Li H, Na Q, Yin S, Li N. Prevention of Preterm Birth by Cervical Pessary Combined with Vaginal Progesterone: a Systematic Review and Meta-analysis with Trial Sequential Analysis. Reprod Sci 2022; 30:93-110. [PMID: 35352330 PMCID: PMC9810688 DOI: 10.1007/s43032-022-00926-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/16/2022] [Indexed: 01/07/2023]
Abstract
This study was to assess the effectiveness of cervical pessary combined with vaginal progesterone for the prevention of preterm birth (PTB). Ten studies about singleton [five randomized controlled trials (RCTs), vs vaginal progesterone; four cohorts, vs vaginal progesterone; two cohorts, vs cervical cerclage + vaginal progesterone] and two cohort studies about multiple pregnancies (vs vaginal progesterone) were included after searching electronic databases. For singleton pregnancies, the meta-analysis of three non-RCTs [relative risk (RR) = 0.41, p = 0.001] or total trials in non-Asian country (RR = 0.56, p = 0.03) revealed that compared with vaginal progesterone alone, cervical pessary + vaginal progesterone treatment had significant effectiveness on preventing PTB < 34 weeks, but not for five RCTs; meta-analysis of two trials showed that cervical pessary + vaginal progesterone had no significant prevention effects of PTB compared with cervical cerclage + vaginal progesterone. For multiple pregnancies, meta-analysis of two trials showed that compared with vaginal progesterone, cervical pessary + vaginal progesterone treatment increased neonatal birth weight (standardized mean difference = 0.50, p = 0.01). Trial sequential analysis implied additional studies were required. Four studies vs other controls (pessary, three-combined, tocolysis, conservative or no treatment; one study, each) were selected for systematic review. In conclusion, cervical pessary combined with vaginal progesterone may be safe and effective to prevent PTB in singleton pregnancies and increase neonatal birth weight in the multiple pregnancies compared with vaginal progesterone alone.
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Affiliation(s)
- Yanyan Zhuang
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Huan Li
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Quan Na
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Shaowei Yin
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Na Li
- Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004, China.
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Seravalli V, Strambi N, D’Arienzo A, Magni F, Bernardi L, Morucchio A, Di Tommaso M. Patient’s experience with the Arabin cervical pessary during pregnancy: A questionnaire survey. PLoS One 2022; 17:e0261830. [PMID: 35020768 PMCID: PMC8754293 DOI: 10.1371/journal.pone.0261830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 12/11/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction
The cervical pessary is used in women with precocious cervical ripening to prevent preterm birth. Up to now however, there have been no systematic studies on compliance and tolerance, which vary among different study cohorts.
Material and methods
A questionnaire was administered to 166 women treated with the Arabin cervical pessary in one center. Data were analysed about the patient’s experience before insertion (adequacy of information received), during treatment (follow-up, impact on daily life, perceived discomfort, side effects) and at the time of removal (pain, if the patient’s expectations had been met regarding the treatment).
Results
Information received before the insertion of the Arabin cervical pessary was considered adequate in 163/166 (98.2%) women. An increase in vaginal discharge was experienced by 70/166 (42.2%) women. Discomfort or other side effects were reported in 13.8% and 16.3% of cases, respectively. Overall, 77% of women reported an improved quality of life and 94% considered the follow-up during pregnancy adequate. Removal was moderately painful for 58/166 (35%) of women. Patient’s expectations regarding the treatment were exceeded in the majority of cases (75.3%). In a final step, we compared our results to previous studies regarding the use of the pessary in singleton and twin pregnancies.
Conclusion
Although some trials report high rates of non-compliant patients, this could not be confirmed by our study. In contrast, most women reported having a positive experience and that they were motivated to continue the treatment when they were continuously followed by experienced clinicians.
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Affiliation(s)
- Viola Seravalli
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Noemi Strambi
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Francesco Magni
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Ludovico Bernardi
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Anna Morucchio
- Department of Health Sciences, University of Florence, Florence, Italy
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16
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Seravalli V, Campana D, Strambi N, Vialetto D, Di Tommaso M. Effectiveness of cervical pessary in women with arrested preterm labor compared to those with asymptomatic cervical shortening. J Matern Fetal Neonatal Med 2021; 35:8141-8146. [PMID: 34856856 DOI: 10.1080/14767058.2021.1962844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether the effectiveness of cervical pessary is different in women who experienced cervical shortening after a threatened preterm labor episode compared to those with asymptomatic short cervix. METHODS Retrospective study on singleton pregnancies at risk for preterm delivery (PTD) due to cervical length <25 mm before 28 weeks, who were treated with Arabin cervical pessary. Two groups of patients were compared: those who had contractions causing shortening of the cervix, prior to pessary placement, and those who had asymptomatic cervical shortening. Patients carrying a multiple pregnancy and those who underwent iatrogenic PTD were excluded. The primary outcome was the incidence of PTD at different gestational ages. Secondary outcome was the rate of preterm premature rupture of membrane (pPROM). The groups were compared using univariate and multivariate analyses. RESULTS 115 patients that met the inclusion criteria were identified. Of these, 91 (79%) had asymptomatic cervical shortening, while 24 (21%) had an episode of threatened preterm labor that resolved, and the pessary was placed after the contractions had stopped. The two groups were similar for maternal characteristics, obstetric history, mean gestational age and length of the cervix at the time of pessary insertion. The median gestational age at delivery was significantly lower (36.4 vs 38.0 weeks, p = .02), and the incidence of PTD significantly higher (58.3% vs 30.8%, OR 4.69, 95% CI 1.68-13.1, p < .01) among women who had arrested preterm labor before the pessary was placed compared to the asymptomatic group, after controlling for confounders. The incidence of PTD before 34 and before 32 weeks was also significantly higher in the symptomatic group (p = .02 and p = .005, respectively). Women with asymptomatic cervical shortening had a longer interval between the placement of the pessary and delivery (median 15 weeks). pPROM occurred with a similar incidence in both groups. CONCLUSIONS Arabin cervical pessary to prevent preterm delivery seems be less effective in women with a short cervix following an episode of threatened preterm labor than in those with asymptomatic cervical shortening in the second trimester. This finding may help physicians to select patients in which cervical pessary is more likely to be effective, and to improve patient's counseling about this intervention.
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Affiliation(s)
- Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Dante Campana
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Noemi Strambi
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Debora Vialetto
- Department of Clinical and Experimental Biomedical Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Mariarosaria Di Tommaso
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
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Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol 2021; 138:e65-e90. [PMID: 34293771 DOI: 10.1097/aog.0000000000004479] [Citation(s) in RCA: 163] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Preterm birth is among the most complex and important challenges in obstetrics. Despite decades of research and clinical advancement, approximately 1 in 10 newborns in the United States is born prematurely. These newborns account for approximately three-quarters of perinatal mortality and more than one half of long-term neonatal morbidity, at significant social and economic cost (1-3). Because preterm birth is the common endpoint for multiple pathophysiologic processes, detailed classification schemes for preterm birth phenotype and etiology have been proposed (4, 5). In general, approximately one half of preterm births follow spontaneous preterm labor, about a quarter follow preterm prelabor rupture of membranes (PPROM), and the remaining quarter of preterm births are intentional, medically indicated by maternal or fetal complications. There are pronounced racial disparities in the preterm birth rate in the United States. The purpose of this document is to describe the risk factors, screening methods, and treatments for preventing spontaneous preterm birth, and to review the evidence supporting their roles in clinical practice. This Practice Bulletin has been updated to include information on increasing rates of preterm birth in the United States, disparities in preterm birth rates, and approaches to screening and prevention strategies for patients at risk for spontaneous preterm birth.
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Koutsamanis I, Paudel A, Alva Zúñiga CP, Wiltschko L, Spoerk M. Novel polyester-based thermoplastic elastomers for 3D-printed long-acting drug delivery applications. J Control Release 2021; 335:290-305. [PMID: 34044092 DOI: 10.1016/j.jconrel.2021.05.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/08/2021] [Accepted: 05/21/2021] [Indexed: 12/31/2022]
Abstract
To improve patient compliance and personalised drug delivery, long-acting drug delivery devices (LADDDs), such as implants and inserts, greatly benefit from a customisation in their shape through the emerging 3D-printing technology, since their production usually follows a one-size-fits-most approach. The use of 3D-printing for LADDDs, however, is mainly limited by the shortage of flawlessly 3D-printable, yet biocompatible materials. The present study tackles this issue by introducing a novel, non-biodegradable material, namely a polyester-based thermoplastic elastomer (TPC) - a multi-block copolymer containing alternating semi-crystalline polybutylene terephthalate hard segments and poly-ether-terephthalate amorphous soft segments. Next to a detailed description of the material's 3D-printability by mechanical, rheological and thermal analyses, which was found to be superior to that of conventional polymers (ethylene-vinyl acetates (EVA)), this study establishes the fundamental understandings of the interactions between progesterone (P4) and TPC and drug-releasing properties of TPC for the first time. P4-loaded LADDDs based on TPC, prepared via an elaborated solvent-immersion technique, enable the release of P4 at pharmacologically relevant rates, similar to those of marketed formulations based on EVA and silicones. Additionally, TPC demonstrated an exceptional 3D-printability for a wide selection of implant sizes and complex geometries.
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Affiliation(s)
- Ioannis Koutsamanis
- Research Center Pharmaceutical Engineering GmbH, Inffeldgasse 13, 8010 Graz, Austria
| | - Amrit Paudel
- Research Center Pharmaceutical Engineering GmbH, Inffeldgasse 13, 8010 Graz, Austria; Institute of Process and Particle Engineering, Graz University of Technology, Inffeldgasse 13, 8010 Graz, Austria.
| | | | - Laura Wiltschko
- Research Center Pharmaceutical Engineering GmbH, Inffeldgasse 13, 8010 Graz, Austria
| | - Martin Spoerk
- Research Center Pharmaceutical Engineering GmbH, Inffeldgasse 13, 8010 Graz, Austria.
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França MS, Hatanaka AR, Cruz JDJ, Andrade Júnior VLD, Kawanami Hamamoto TE, Sarmento SGP, Elito Júnior J, Pares DBDS, Mattar R, Araujo Júnior E, Moron AF. Cervical pessary plus vaginal progesterone in a singleton pregnancy with a short cervix: an experience-based analysis of cervical pessary's efficacy. J Matern Fetal Neonatal Med 2021; 35:6670-6680. [PMID: 33938351 DOI: 10.1080/14767058.2021.1919076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Several studies were published about cervical pessary, with controversial results. These studies demonstrated that the patient follow-up after pessary insertion is very different between the study centers and the number of pessary insertions per center was often <30 cases. This study aims to determine cervical pessary performance in singleton pregnancies with a short cervix based on a single center learning curve. METHODS Between 2011 and 2018, 128 singleton pregnancies between 18 and 24 gestational weeks with a short cervix (<25 mm) were referred to our clinic. All cases were treated with progesterone, and when available in our supplies (due to low resources) cervical pessary was also offered. Three groups were created for statistical analysis: Group 1 (n = 33), treated with progesterone-only; Groups 2 and 3, treated with cervical pessary plus progesterone. Group 2 included the first cases (n = 30) of pessary, defined by a learning curve and cumulative sum analysis, while Group 3 included the subsequent 65 cases. The primary outcome was preterm birth (PTB) < 34 gestational weeks. RESULTS The learning curve was performed with all cases of pessary plus progesterone, and 30 patients were obtained as the number needed for learning, in our study with two operators. The PTB rate < 34 weeks was 27.3, 20, and 4.6% in groups 1, 2, and 3, respectively. There was no significant difference between Group 1 and 2 (OR 1.1; 95% CI 0.066 - 18.45; p = .945). When comparing Groups 1 and 3 there was a significant difference in PTB rates (OR 0.08; CI95% 0.01-0.42; p = .003). Considering Kaplan-Meyer Survival analysis, we can observe that the performance of progesterone alone (Group 1) was similar to Group 2 (progesterone + first 30 cases of pessary) (p = .432), but the performance of Group 3 (progesterone + subsequent 65 cases of pessary) and Group 1 shows a statistically significant difference (p = .011). CONCLUSION Learning curve and cumulative sum analysis determined that the application and surveillance of at least 30 patients is required to see significant improvements in the primary outcome of PTB < 34 weeks.
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Affiliation(s)
- Marcelo Santucci França
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Alan Roberto Hatanaka
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | | | | | - Tatiana Emy Kawanami Hamamoto
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | | | - Júlio Elito Júnior
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - David Baptista da Silva Pares
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Rosiane Mattar
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Edward Araujo Júnior
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Antonio Fernandes Moron
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
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20
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Monari F, Salerno C, Torcetta F, Po' G, Facchinetti F. Intrapartum stillbirth for sepsis complicating Arabin cervical pessary placement in a twin pregnancy. Minerva Obstet Gynecol 2021; 73:384-387. [PMID: 34008394 DOI: 10.23736/s2724-606x.20.04721-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There is little evidence regarding the best treatment in case of dilated cervix and exposed membranes in twins. Current options for its management include vaginal progesterone, cervical cerclage and cervical pessary, but none of them had shown effectiveness compared to expectant management. We presented a case of twin pregnancy at 22 6/7 weeks' gestation admitted to the hospital because of cervical insufficiency with bulging of membranes. An Arabin pessary was positioned after a failed attempt of cervical cerclage and no antibiotic was given in absence of signs of infection. Cesarean delivery was performed at 24 weeks' gestation because of spontaneous preterm labor and spontaneous rupture of membranes with the first baby in a transverse lie position. At the uterus section, the first baby was stillborn, with Arabin pessary strictly adherent to his ecchymotic head, while the second baby was born alive. After diagnostic histopathological and microbiological investigations, we hypothesized that the first twin died for funisitis/sepsis and mechanical insult due to the strict adhesion of the pessary to the fetal head. We concluded that in case of bulging membranes and dilated cervix, antibiotic treatment should be evaluated, also in absence of signs/symptoms of infection or suspicion of rupture of the membranes, and pessary insertion should be avoided, namely at second trimester, because of the risk of its dislocation inside the uterus when contractions start and potential hurt to extremely preterm fetus.
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Affiliation(s)
- Francesca Monari
- Unit of Obstetrics and Gynecology, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy -
| | - Cristina Salerno
- Unit of Obstetrics and Gynecology, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Torcetta
- Unit of Neonatal, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gaia Po'
- Unit of Obstetrics and Gynecology, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Unit of Obstetrics and Gynecology, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
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21
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Norman JE, Norrie J, MacLennan G, Cooper D, Whyte S, Chowdhry S, Cunningham-Burley S, Mei XW, Smith JBE, Shennan A, Robson SC, Thornton S, Kilby MD, Marlow N, Stock SJ, Bennett PR, Denton J. Evaluation of the Arabin cervical pessary for prevention of preterm birth in women with a twin pregnancy and short cervix (STOPPIT-2): An open-label randomised trial and updated meta-analysis. PLoS Med 2021; 18:e1003506. [PMID: 33780463 PMCID: PMC8041194 DOI: 10.1371/journal.pmed.1003506] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 04/12/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Preterm-labour-associated preterm birth is a common cause of perinatal mortality and morbidity in twin pregnancy. We aimed to test the hypothesis that the Arabin pessary would reduce preterm-labour-associated preterm birth by 40% or greater in women with a twin pregnancy and a short cervix. METHODS AND FINDINGS We conducted an open-label randomised controlled trial in 57 hospital antenatal clinics in the UK and Europe. From 1 April 2015 to 14 February 2019, 2,228 women with a twin pregnancy underwent cervical length screening between 18 weeks 0 days and 20 weeks 6 days of gestation. In total, 503 women with cervical length ≤ 35 mm were randomly assigned to pessary in addition to standard care (n = 250, mean age 32.4 years, mean cervical length 29 mm, with pessary inserted in 230 women [92.0%]) or standard care alone (n = 253, mean age 32.7 years, mean cervical length 30 mm). The pessary was inserted before 21 completed weeks of gestation and removed at between 35 and 36 weeks or before birth if earlier. The primary obstetric outcome, spontaneous onset of labour and birth before 34 weeks 0 days of gestation, was present in 46/250 (18.4%) in the pessary group compared to 52/253 (20.6%) following standard care alone (adjusted odds ratio [aOR] 0.87 [95% CI 0.55-1.38], p = 0.54). The primary neonatal outcome-a composite of any of stillbirth, neonatal death, periventricular leukomalacia, early respiratory morbidity, intraventricular haemorrhage, necrotising enterocolitis, or proven sepsis, from birth to 28 days after the expected date of delivery-was present in 67/500 infants (13.4%) in the pessary group compared to 76/506 (15.0%) following standard care alone (aOR 0.86 [95% CI 0.54-1.36], p = 0.50). The positive and negative likelihood ratios of a short cervix (≤35 mm) to predict preterm birth before 34 weeks were 2.14 and 0.83, respectively. A meta-analysis of data from existing publications (4 studies, 313 women) and from STOPPIT-2 indicated that a cervical pessary does not reduce preterm birth before 34 weeks in women with a short cervix (risk ratio 0.74 [95% CI 0.50-1.11], p = 0.15). No women died in either arm of the study; 4.4% of babies in the Arabin pessary group and 5.5% of babies in the standard treatment group died in utero or in the neonatal period (p = 0.53). Study limitations include lack of power to exclude a smaller than 40% reduction in preterm labour associated preterm birth, and to be conclusive about subgroup analyses. CONCLUSIONS These results led us to reject our hypothesis that the Arabin pessary would reduce the risk of the primary outcome by 40%. Smaller treatment effects cannot be ruled out. TRIAL REGISTRATION ISRCTN Registry ISRCTN 02235181. ClinicalTrials.gov NCT02235181.
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Affiliation(s)
- Jane E. Norman
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
- * E-mail:
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - David Cooper
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - Sonia Whyte
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Sue Chowdhry
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Xue W. Mei
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Joel B. E. Smith
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Andrew Shennan
- Department of Women’s and Children’s Health, King’s College London, London, United Kingdom
| | - Stephen C. Robson
- Institute of Cellular Medicine, University of Newcastle, Newcastle, United Kingdom
| | - Steven Thornton
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mark D. Kilby
- Fetal Medicine Centre, Birmingham Women’s and Children’s NHS Foundation Trust and College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Neil Marlow
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Sarah J. Stock
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Phillip R. Bennett
- Institute for Reproductive and Developmental Biology, Imperial College London, London, United Kingdom
| | - Jane Denton
- Multiple Births Foundation, London, United Kingdom
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Hessami K, Kasraeian M, Sepúlveda-Martínez Á, Parra-Cordero MC, Vafaei H, Asadi N, Benito Vielba M. The Novel Ultrasonographic Marker of Uterocervical Angle for Prediction of Spontaneous Preterm Birth in Singleton and Twin Pregnancies: A Systematic Review and Meta-Analysis. Fetal Diagn Ther 2021; 48:1-7. [PMID: 33556952 DOI: 10.1159/000510648] [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: 06/22/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
The alteration of the uterocervical angle (UCA) has been proposed to play an important role in spontaneous preterm birth (sPTB). The aim of this systematic review and meta-analysis was to evaluate the evidence on the UCA predictive role in sPTB. In this study, PubMed, Web of Science, Scopus, and Google scholar were systematically searched from inception up to June 2020. Inter-study heterogeneity was also assessed using Cochrane's Q test and the I2 statistic. Afterward, the random-effects model was used to pool the weighted mean differences (WMDs) and the corresponding 95% confidence intervals (CIs). Eleven articles that reported second-trimester UCA of 5,061 pregnancies were included in this study. Our meta-analysis results indicate that a wider UCA significantly increases the risk of sPTB in following cases: all pregnancies (WMD = 15.25, 95% CI: 11.78-18.72, p < 0.001; I2 = 75.9%, p < 0.001), singleton (WMD = 14.43, 95% CI: 8.79-20.06, p < 0.001; I2 = 82.4%, p < 0.001), and twin pregnancies (WMD = 15.14, 95% CI: 13.42-16.87, p < 0.001; I2 = 0.0%, p = 0.464). A wider ultrasound-measured UCA in the second trimester seems to be associated with the increased risk of sPTB in both singleton and twin pregnancies, which reinforces the clinical evidence that UCA has the potential to be used as a predictive marker of sPTB.
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Affiliation(s)
- Kamran Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Maryam Kasraeian
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Álvaro Sepúlveda-Martínez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology Hospital Clínico de la Universidad de Chile, Santiago de Chile, Chile
| | - Mauro Cristian Parra-Cordero
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology Hospital Clínico de la Universidad de Chile, Santiago de Chile, Chile
| | - Homeira Vafaei
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Asadi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marta Benito Vielba
- Department of Obstetrics and Gynecology, Miguel Servet University Hospital, Zaragoza, Spain
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23
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Barinov SV, Tirskaya YI, Lazareva OV, Kadcyna TV, Shamina IV, Medyannikova IV, Borisova AV, Frikel EA, Beznoshchenko GB. Pregnancy outcomes in women with large uterine fibroids. J Matern Fetal Neonatal Med 2021; 35:5369-5374. [PMID: 33522331 DOI: 10.1080/14767058.2021.1879044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
STUDY AIM To evaluate the effects of the combination of Arabin pessary or cervical cerclage with vaginal micronised progesterone versus micronised progesterone or no medical management on the outcomes of pregnancies in women with large uterine fibroids. MATERIALS AND METHODS This was a retrospective, observational, controlled study in 120 women aged 18-45 years with large uterine (≥8 cm) fibroids diagnosed in the first trimester, who underwent treatment in the regional perinatal center of the Omsk Regional Clinical Hospital between 2015 and 2019. Women in Group A (n = 90) were divided into two subgroups. In Subgroup А1 (n = 35), participants received the combination of a cervical procedure (Arabin pessary or cerclage) and micronised progesterone, and in Subgroup А2 (n = 55) all participants additionally underwent myomectomy. In Group B (n = 18), only micronised progesterone was used. In Group C (n = 12), no medical therapy was administered during pregnancy. RESULTS Large uterine fibroids in pregnancy were associated with a threatened pregnancy loss in 46.4% of women and pain in almost 40% of women. Myomectomy in pregnancy was performed in 55 women. The combination of Arabin pessary or cervical cerclage with micronized progesterone reduced the rates of preterm delivery by 2.2-fold versus the progesterone-only group and by 11.2-fold versus no medical management group (χ2 = 19.4; p = .0001). CONCLUSION The combination of Arabin pessary or cervical cerclage with micronized progesterone in our study helped achieve term deliveries in >90% of pregnant women with large fibroids.
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Affiliation(s)
- Sergey V Barinov
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
| | - Yuliya I Tirskaya
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
| | - Oksana V Lazareva
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
| | - Tatyana V Kadcyna
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
| | - Inna V Shamina
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
| | - Irina V Medyannikova
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
| | - Anna V Borisova
- Department of Obstetrics and Gynecology with the Course of Perinatology, Peoples' Friendship University of Russia (RUDN University), Moscow, Russia
| | - Ekaterina A Frikel
- Perinatal Centre, Budget Healthcare Institution of the Omsk Region "Regional Clinical Hospital", Omsk, Russia
| | - Galina B Beznoshchenko
- Department of Obstetrics and Gynecology No. 2, Omsk State Medical University, Omsk, Russia
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24
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Khamees RE, Khattab BM, Elshahat AM, Taha OT, Aboelroose AA. Uterocervical angle versus cervical length in the prediction of spontaneous preterm birth in singleton pregnancy. Int J Gynaecol Obstet 2021; 156:304-308. [PMID: 33507541 DOI: 10.1002/ijgo.13629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/02/2020] [Accepted: 01/25/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the predictive role of the uterocervical angle and the cervical length in preterm birth. METHODS This was cross-sectional analytical study, recruiting 167 women at high-risk for preterm birth (delivery before 37 weeks of pregnancy). They had transvaginal ultrasound for evaluation of the uterocervical angle and the cervical length between at 30 and 32, 32+1 and 34, and 34+1 and 36+1 weeks of pregnancy. The primary outcome was to determine the predictive role of the uterocervical angle and the cervical length in preterm birth. RESULTS The mean uterocervical angle was significantly greater in those who delivered preterm (115.4° ± 9.1° versus 101.1° ± 8.3°, p < 0.001). The cervical length was insignificantly shorter in the same group (27.9 ± 4.0 and 29.1 ± 4.1 mm, respectively, p = 0.067). A uterocervical angle of 105° or more predicted preterm birth with sensitivity and specificity of 86.1% and 60.4%, respectively. A cervical length of 25 mm or less had sensitivity and specificity of 27.8% and 85.8%, respectively. CONCLUSION A uterocervical angle greater than 105° poses a high risk for preterm deliveries. It provides a higher diagnostic performance in high-risk patients than cervical canal length measurement.
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Affiliation(s)
- Rasha E Khamees
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Basma M Khattab
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Amal M Elshahat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Omima T Taha
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ahmed A Aboelroose
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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25
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Current Approaches to Risk Assessment and Prevention of Preterm Birth-A Continuing Public Health Crisis. Ochsner J 2020; 20:426-433. [PMID: 33408582 PMCID: PMC7755547 DOI: 10.31486/toj.20.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: Preterm birth remains a major cause of neonatal morbidity and mortality. Several potential pathways and pathophysiologic processes can lead to preterm birth, complicating efforts to screen for the risk of preterm birth and making implementation of prevention strategies difficult. Methods: Based on a review of the literature, this article addresses screening strategies for preterm birth risk stratification and interventions for preterm birth prevention. Results: In women with a history of a prior spontaneous preterm birth, cervical cerclage placement in the setting of short cervix reduces the rate of recurrent spontaneous preterm birth. Weekly injections of 17-hydroxyprogesterone caproate (17-P) have been used as standard treatment for the prevention of recurrent preterm birth since 2011. However, results of a replication study of 17-P published in 2020 have raised questions regarding the effectiveness of this drug, and it is under review by the US Food and Drug Administration. Among women with no history of preterm birth, cervical length appears to be the best predictor of risk for preterm birth in asymptomatic women. In women with a cervical length <25 mm, vaginal progesterone has been demonstrated to reduce the risk of preterm birth. Conclusion: Strategies including cervical length screening, vaginal progesterone administration, cervical cerclage placement, and, potentially, 17-P administration may help reduce rates of preterm birth when used in the appropriate patient populations. Development of protocols for patient evaluation and risk stratification will help identify patients at highest risk for preterm birth and allow use of the best available therapeutic interventions.
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26
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Gründler K, Gerber B, Stubert J. Uterocervical angle as a predictor of preterm birth on a high-risk collective between 20 and 31 weeks of gestation: A cohort analysis. Acta Obstet Gynecol Scand 2020; 99:1527-1533. [PMID: 32649774 DOI: 10.1111/aogs.13955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/14/2020] [Accepted: 07/06/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The cervical length (CL) measurement is a widely used method to estimate the risk of preterm birth. Due in particular to the high false-positive rate, the establishment of markers with improved test characteristics is a great challenge. A potential predictor of preterm birth is the uterocervical angle (UCA) and this additional measurement may improve the risk assessment. It was the aim of this study to compare the test properties of CL and UCA on patients at risk for preterm birth. MATERIAL AND METHODS 109 patients with at least one of the following signs of threatening preterm birth between 20+0/7 and 31+6/7 weeks were included in a prospective cohort analysis: regular (>3/30 min) or painful uterine contractions, CL below 25 mm or a history of preterm birth. Exclusion criteria were premature rupture of membranes, hypertensive disorders, vaginal bleeding, surgical cerclage, Arabin pessary or cervical dilation of more than 30 mm. The determination of the UCA was carried out in a standardized manner using the image documents captured by vaginal sonographic CL measurement. The primary endpoint was preterm birth <34 weeks, secondary endpoints were delivery <37 weeks and within 7 days. RESULTS The UCA was on average 103° and the mean UCA in preterm and term groups did not differ significantly (P = .924). The UCA was not predictive for threatened preterm birth, even if only singletons were considered. For CL the best predictive accuracy for preterm birth <34 weeks was observed at a cut-off value of 14 mm with sensitivity 0.50, specificity 0.80, positive predictive value 0.30, negative predictive value 0.90, positive likelihood ratio 2.4, negative likelihood ratio 0.6 and an odds ratio of 3.9 (95% confidence interval 1.3-11.7, P = .016). CONCLUSIONS The assessment of UCA in patients at risk for preterm birth was not suitable to predict the probability of a threatened preterm birth. Measurement of UCA cannot be recommended in this situation.
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Affiliation(s)
- Kathleen Gründler
- Department of Obstetrics and Gynecology, HELIOS Hospital Schwerin, Schwerin, Germany
| | - Bernd Gerber
- Department of Obstetrics and Gynecology, Rostock University Medical Center, Rostock, Germany
| | - Johannes Stubert
- Department of Obstetrics and Gynecology, Rostock University Medical Center, Rostock, Germany
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27
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Conde-Agudelo A, Romero R, Nicolaides KH. Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 223:42-65.e2. [PMID: 32027880 DOI: 10.1016/j.ajog.2019.12.266] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting results. OBJECTIVE To evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women. DATA SOURCES MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth. STUDY APPRAISAL AND SYNTHESIS METHODS The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth <34 weeks of gestation. Secondary outcomes included adverse pregnancy, maternal, and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology. RESULTS Twelve studies (4687 women and 7167 fetuses/infants) met the inclusion criteria: 8 evaluated pessary vs no pessary in women with a short cervix, 2 assessed pessary vs no pessary in unselected multiple gestations, and 2 compared pessary vs vaginal progesterone in women with a short cervix. There were no significant differences between the pessary and no pessary groups in the risk of spontaneous preterm birth <34 weeks of gestation among singleton gestations with a cervical length ≤25 mm (relative risk, 0.80; 95% confidence interval, 0.43-1.49; 6 trials, 1982 women; low-quality evidence), unselected twin gestations (relative risk, 1.05; 95% confidence interval, 0.79-1.41; 1 trial, 1177 women; moderate-quality evidence), twin gestations with a cervical length <38 mm (relative risk, 0.75; 95% confidence interval, 0.41-1.36; 3 trials, 1128 women; low-quality evidence), and twin gestations with a cervical length ≤25 mm (relative risk; 0.72, 95% confidence interval, 0.25-2.06; 2 trials, 348 women; low-quality evidence). Overall, no significant differences were observed between the pessary and no pessary groups in preterm birth <37, <32, and <28 weeks of gestation, and most adverse pregnancy, maternal, and perinatal outcomes (low- to moderate-quality evidence for most outcomes). There were no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone in singleton gestations with a cervical length ≤25 mm (relative risk, 0.99; 95% confidence interval, 0.54-1.83; 1 trial, 246 women; low-quality evidence) and twin gestations with a cervical length <38 mm (relative risk, 0.73; 95% confidence interval, 0.46-1.18; 1 trial, 297 women; very low-quality evidence). Vaginal discharge was significantly more frequent in the pessary group than in the no pessary and vaginal progesterone groups (relative risks, ∼2.20; high-quality evidence). CONCLUSION Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Florida International University, Miami, FL.
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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28
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Dang VQ, He YT, Pham HN, Trieu TT, Bui TQ, Vuong NT, Nguyen LM, Nguyen DT, Le TV, Li W, Le CH, Mol BW, Vuong LN. Effectiveness of cervical pessary compared to cervical cerclage with or without vaginal progesterone for the prevention of preterm birth in women with twin pregnancies and a short cervix: study protocol for a two-by-two factorial randomised clinical trial. BMJ Open 2020; 10:e036587. [PMID: 32554744 PMCID: PMC7304826 DOI: 10.1136/bmjopen-2019-036587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Women with twin pregnancies and a short cervix are at increased risk for preterm birth (PTB). Given the burden of prematurity and its attendant risks, the quest for effective interventions in twins has been an area of considerable research. Studies investigating the effectiveness of cervical cerclage, cervical pessary and vaginal progesterone in preventing PTB have yielded conflicting results. The aim of this study is to compare the effectiveness of cervical pessary and cervical cerclage with or without vaginal progesterone to prevent PTB in women with twin pregnancies and a cervical length (CL) ≤ 28 mm. METHODS AND ANALYSIS This multicentre, randomised clinical trial will be conducted at My Duc Hospital and My Duc Phu Nhuan Hospital, Vietnam. Asymptomatic women with twin pregnancies and a CL ≤28 mm, measured at 16-22 weeks' gestation, will be randomised in a 1:1:1:1 ratio to receive a cerclage, pessary, cerclage plus progesterone or pessary plus progesterone. Primary outcome will be PTB <34 weeks. Secondary outcomes will be maternal and neonatal complications. We preplanned a subgroup analysis according to CL from all women after randomisation and divided into four quartiles. Analysis will be conducted on an intention-to-treat basis. The rate of PTB <34 weeks' gestation in women with twin pregnancies and a cervix ≤28 mm and treated with pessary in our previous study at My Duc Hospital was 24.2%. A sample size of 340 women will be required to show or refute that cervical cerclage decreases the rate of PTB <34 weeks by 50% compared with pessary (from 24.2% to 12.1%, α level 0.05, power 80%, 5% lost to follow-up and protocol deviation). This study is not to be powered to assess interactions between interventions. ETHICS AND DISSEMINATION Ethical approval was obtained from the Institutional Ethics Committee of My Duc Hospital and informed patient consent was obtained before study enrolment. Results of the study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03863613 (date of registration: 4 March 2019).
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Affiliation(s)
- Vinh Q Dang
- Department of Obstetrics and Gynecology, My Duc Hospital, Ho Chi Minh City, Viet Nam
- HOPE Research Center, Ho Chi Minh City, Viet Nam
| | - Yen Tn He
- HOPE Research Center, Ho Chi Minh City, Viet Nam
- Department of Obstetrics and Gynecology, My Duc Phu Nhuan Hospital, Ho Chi Minh City, Viet Nam
| | - Ha Nh Pham
- Department of Obstetrics and Gynecology, My Duc Hospital, Ho Chi Minh City, Viet Nam
| | - Tuyen Tt Trieu
- Department of Obstetrics and Gynecology, My Duc Phu Nhuan Hospital, Ho Chi Minh City, Viet Nam
| | - Trung Q Bui
- Department of Obstetrics and Gynecology, My Duc Hospital, Ho Chi Minh City, Viet Nam
| | - Nhu T Vuong
- Department of Obstetrics and Gynecology, My Duc Hospital, Ho Chi Minh City, Viet Nam
| | | | | | - Thanh V Le
- Department of Obstetrics and Gynecology, My Duc Hospital, Ho Chi Minh City, Viet Nam
| | - Wentao Li
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Cam H Le
- Department of Obstetrics and Gynecology, My Duc Phu Nhuan Hospital, Ho Chi Minh City, Viet Nam
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Lan N Vuong
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at HCMC, Ho Chi Minh City, Viet Nam
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Sawaddisan R, Kor-Anantakul O, Pruksanusak N, Geater A. Uterocervical angle measurement for preterm birth prediction in singleton pregnant women with no history of preterm birth and normal cervical length: A prospective cohort study. Eur J Obstet Gynecol Reprod Biol 2020; 252:30-35. [PMID: 32562939 DOI: 10.1016/j.ejogrb.2020.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the ability of second trimester uterocervical angle (UCA) to predict spontaneous preterm birth (sPTB) in low-risk singleton pregnant women. STUDY DESIGN Transvaginal sonographies were performed in the second trimester of 450 singleton pregnant women with no history of sPTB and no history of second trimester miscarriage with normal cervical length (CL) who attended antenatal care at Songklanagarind Hospital, a tertiary teaching hospital in southern Thailand. Gestational ages at delivery were recorded then the UCA values were evaluated according to sPTB occurrence. The differences in mean values of UCA between sPTB and full-term groups were evaluated using t-test. A receiver operating characteristics (ROC) curve was used to assess the ability of UCA to predict sPTB. RESULTS After excluding women with unknown pregnancy outcomes or missing UCA images, the sPTB rate was 34/421 (8.1 %). In women with anteflexed uterus, the mean UCA value was wider in the sPTB group compared to those with term birth if the measurements were performed at GA 19.5-24 weeks (sPTB group, 123.4°vs controls, 104.3°; P = 0.017). The ROC curve showed an area under the curve (AUC) of 0.7045. The optimal UCA cut-off value was ≥110 degrees, which gave a sensitivity of 83.3 % and a specificity of 61.2 %. The positive predictive value (PPV) was 16.7 %, negative predictive value (NPV) 97.5 %, positive likelihood ratio (LR+) 2.2 and negative likelihood ratio (LR-) 0.3. CONCLUSION The UCA in the second trimester is not a good predictor of sPTB in low risk pregnant women.
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Affiliation(s)
- Rapphon Sawaddisan
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Ounjai Kor-Anantakul
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ninlapa Pruksanusak
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Alan Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Piccioni MG, Del Negro V, Bruno Vecchio RC, Faralli I, Savastano G, Galoppi P, Perrone G. Is the Arabin Pessary really useful in preventing preterm birth? A review of literature. J Gynecol Obstet Hum Reprod 2020; 50:101824. [PMID: 32485317 DOI: 10.1016/j.jogoh.2020.101824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 01/04/2023]
Abstract
The aim of this review is to describe the state of the art in the use of Arabin Pessary for the prevention of spontaneous preterm birth (SPTB). We conducted a review of the literature in order to collect relevant studies concerning the efficacy of Arabin Pessary in preventing preterm birth, also considering it in addition or in comparison with other methods such as cervical cerclage or vaginal progesterone and in both singleton and twin pregnancy. Despite the large number of studies available there is not a clear consensus about the superiority of one of this methods over the others. In addition to this, although Arabin Pessary is widely used in clinical practice, no guidelines for management and use of cervical pessary during pregnancy have been assessed.
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Affiliation(s)
- M G Piccioni
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - V Del Negro
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - R C Bruno Vecchio
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - I Faralli
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - G Savastano
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - P Galoppi
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - G Perrone
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Italy.
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Hentrich A, Marek S, Jackisch C. [Using Cervical Pessary to Prevent Premature Birth - a Clinical Analysis]. Z Geburtshilfe Neonatol 2020; 225:51-54. [PMID: 32392588 DOI: 10.1055/a-1153-9355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In the event of a cervical shortening < 25 mm before the 34th week of gestation, a cervical pessary can be inserted in accordance with the German AMWF guidelines. However, data concerning the benefit of this intervention in order to avoid premature birth are controversial. METHODS Between the 20th and 32nd week of gestation, we inserted a cervical pessary in 83 patients and evaluated our data with regard to the extension of gestational age due to this intervention. We also reviewed the literature on this topic. We retrospectively analysed the data in a high-risk group (cervical length<15 mm) and a low-risk group (15-25 mm). RESULTS Our data show a preterm birth in just 20% of all cases in both subgroups. 79% of the patients gave birth after 34 weeks and 59% after 37 weeks. CONCLUSIONS Our approach using an cervical pessary supported by local application of progesterone seems to be a well-tolerated intervention with few side effects and acceptable adherence. In addition, our data demonstrate a reduction in hospitalization, even though the evidence is divergent in this respect.
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Affiliation(s)
- Anna Hentrich
- Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach GmbH, Offenbach
| | - Susanne Marek
- Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach GmbH, Offenbach
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Barbone AS, Li X, Arabin B, Kira Y, Jani JC, Cannie MM. Preliminary modeling of effective positioning of Arabin cerclage pessary in women at high risk of preterm birth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:557-558. [PMID: 31237035 DOI: 10.1002/uog.20375] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 06/09/2023]
Affiliation(s)
- A S Barbone
- Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - X Li
- Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - B Arabin
- Clara Angela Foundation, Berlin, Germany
| | - Y Kira
- Clara Angela Foundation, Berlin, Germany
| | - J C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
- Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Cervical pessary for preterm twin pregnancy in women with a short cervix. Obstet Gynecol Sci 2020; 63:231-238. [PMID: 32489967 PMCID: PMC7231939 DOI: 10.5468/ogs.2020.63.3.231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 11/08/2022] Open
Abstract
Objective We aimed to evaluate the effectiveness of cervical pessary for extending twin pregnancy in women with a short cervix. Methods Between January 2014 and March 2019, the use of a cervical pessary for twin pregnancy in women with a cervical length of ≤15 mm was investigated between 16 and 28 weeks of gestation. We included women with a shortened cervix after a cerclage procedure and visible fetal membranes and cervical dilatation. Thirteen patients underwent pessary insertion and were matched with a control group of 15 patients. Pregnancy and neonatal outcomes were compared between the groups. We excluded women with major fetal anomalies discovered before or after birth and known placenta previa. Results Women who underwent pessary insertion were diagnosed with a short cervix (0.65±0.47 vs. 0.66±0.51 cm in the pessary and control groups, respectively; P=0.957) at a gestational age similar to that of the controls (23.29 vs. 25.14 weeks, P=0.294). There was no significant difference in gestational age at delivery between them (33.29 vs. 27.29 weeks in the pessary and control groups, respectively, P=0.058). The pessary group had a longer interval between the diagnosis and delivery than the control group (60.7±28.3 vs. 22.6±24.5 days, P=0.001). The number of adverse neonatal outcomes was significantly lower in the pessary group (n=7; 28.0%) than in the control group (n=14; 58.3%; P=0.032). Conclusion The use of a cervical pessary may prolong gestation in twin pregnancies in women with an extremely short cervix until viable gestational age.
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Sawaddisan R, Kor-Anantakul O, Pruksanusak N, Geater A. Distribution of uterocervical angles in the second trimester of pregnant women at low risk for preterm delivery. J OBSTET GYNAECOL 2020; 41:77-82. [PMID: 32148135 DOI: 10.1080/01443615.2020.1718622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The uterocervical angle (UCA) has recently been studied as a parameter to identify women at risk for spontaneous preterm birth (sPTB). This study aimed to investigate the distribution of UCA values by transvaginal sonography (TVS) in the second trimester of women at low risk for sPTB. TVS was performed in 450 low-risk pregnant women at gestational age (GA) 160/7-240/7 weeks. The UCA distribution by GA was visualised using a scatter plot. The range of UCA values and their relationship with GA were assessed using quantile regression analysis. p < .05 was considered statistically significant. A total of 242 participants with anteflexed uterus, no history of caesarean section and term delivery were analysed. The normal range of UCA (5th and 95th percentiles) was from 63.0 degrees (95% CI, 53.1-72.9) to 148.8 degrees (95% CI, 139.5-158.0) with no significant changes during this GA period (-0.3 degrees per week, p = .757).Impact statementWhat is already known on this subject? Spontaneous preterm birth (sPTB) is a major problem in obstetrics. A screening strategy using history of sPTB and cervical length (CL) measurement is the current standard to identify women at risk for sPTB and provide adequate prevention. However, a third of women who are identified as low risk go on to have sPTB, so a better means needs to be found to more reliably identify women at risk. Various studies have found that a wide uterocervical angle (UCA) was associated with sPTB, and thus the UCA has been proposed as a potential sPTB screening parameter. However, to date there is a lack of prospective studies evaluating this proposal, and no consensus about the proper gestational age to perform UCA measurements to identify women at risk of sPTB.What do the results of this study add? This study reports the distribution of UCA at the GA of 160/7-240/7 weeks of low-risk singleton pregnancy women who delivered at term. The mid-90% values ranged from 63.0 degrees to 148.8 degrees with no significant differences in this GA period.What are the implications of these findings for clinical practice and/or further research? Because of the wide range of UCA values at GA 160/7-240/7 weeks, more studies regarding UCA values in various gestational ages are required to fully understand the trend of UCA values along pregnancy and confirm whether or not the UCA would be a useful parameter for sPTB prediction and if so at what gestational age it would have to be assessed.
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Affiliation(s)
- Rapphon Sawaddisan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ounjai Kor-Anantakul
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ninlapa Pruksanusak
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Alan Geater
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Le KD, Nguyen LK, Nguyen LTM, Mol BWJ, Dang VQ. Cervical pessary vs vaginal progesterone for prevention of preterm birth in women with twin pregnancy and short cervix: economic analysis following randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:339-347. [PMID: 31432562 DOI: 10.1002/uog.20848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/01/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare the cost-effectiveness of cervical pessary vs vaginal progesterone to prevent preterm birth and neonatal morbidity in women with twin pregnancy and a short cervix. METHODS Between 4 March 2016 and 3 June 2017, we performed this economic analysis following a randomized controlled trial (RCT), performed at My Duc Hospital, Ho Chi Minh City, Vietnam, that compared cervical pessary to vaginal progesterone in women with twin pregnancy and cervical length < 38 mm between 16 and 22 weeks of gestation. We used morbidity-free neonatal survival as a measure of effectiveness. Data on pregnancy outcome, maternal morbidity and neonatal complications were collected prospectively from medical files; additional information was obtained via telephone interviews with the patients. The incremental cost-effectiveness ratio was calculated as the incremental cost required to achieve one extra surviving morbidity-free neonate in the pessary group compared with in the progesterone group. Probabilistic and one-way sensitivity analyses were also performed. RESULTS During the study period, we screened 1113 women with twin pregnancy, of whom 300 fulfilled the inclusion criteria of the RCT and gave informed consent to participate. These women were assigned randomly to receive cervical pessary (n = 150) or vaginal progesterone (n = 150), with two women and one woman, respectively, being lost to follow-up. The rate of morbidity-free neonatal survival was significantly higher in the pessary group compared with the progesterone group (n = 241/296 (81.4%) vs 219/298 (73.5%); relative risk, 1.11 (95% CI, 1.02-1.21), P = 0.02). The mean total cost per woman was 3146 € in the pessary group vs 3570 € in the progesterone group (absolute difference, -424 € (95% CI, -842 to -3 €), P = 0.048). The cost per morbidity-free neonate was significantly lower in the pessary group compared with that in the progesterone group (2492 vs 2639 €; absolute difference, -147 € (95% CI, -284 to 10 €), P = 0.035). CONCLUSION In women with twin pregnancy and a short cervix, cervical pessary improves significantly the rate of morbidity-free neonatal survival while reducing costs, as compared with vaginal progesterone. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- K D Le
- HOPE Research Center, Ho Chi Minh City, Vietnam
| | - L K Nguyen
- My Duc Hospital, Ho Chi Minh City, Vietnam
| | | | - B W J Mol
- Department of Obstetrics and Gynecology, Monash University, Melbourne, Australia
| | - V Q Dang
- HOPE Research Center, Ho Chi Minh City, Vietnam
- My Duc Hospital, Ho Chi Minh City, Vietnam
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Pessary Compared With Vaginal Progesterone for the Prevention of Preterm Birth in Women With Twin Pregnancies and Cervical Length Less Than 38 mm: A Randomized Controlled Trial. Obstet Gynecol 2019; 133:459-467. [PMID: 30741812 DOI: 10.1097/aog.0000000000003136] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effectiveness of cervical pessary to vaginal progesterone for the prevention of preterm birth in women with twin pregnancies and short cervix. METHODS This randomized controlled trial was conducted at My Duc Hospital, Vietnam. Asymptomatic women with twin pregnancies and cervical length less than 38 mm were randomized to Arabin pessary or vaginal progesterone (400 mg once a day) group. The primary outcome was preterm birth at less than 34 weeks of gestation. Secondary outcomes were adverse maternal and perinatal complications. We planned a subgroup analysis according to quartile of cervical length. Analysis was conducted on an intention-to-treat basis. We estimated that the primary outcome would occur in 28.4% of women treated with progesterone. Thus a total sample size of 290 women divided equally into two groups was required to detect a 14% absolute risk difference in the primary outcome between the two groups (power 80%, alpha-error 5%, 10% loss to follow-up). RESULTS Between March 2016 and June 2017, we randomized 300 women, 150 women in each group. Preterm birth at less than 34 weeks of gestation occurred in 24 (16%) women in the pessary group and 33 (22%) women in the progesterone group (relative risk [RR] 0.73, 95% CI 0.46-1.18). The use of pessary significantly reduced the composite of poor perinatal outcomes (19% vs 27%; RR 0.70, 95% CI 0.43-0.93). In women with cervical length of 28 mm or less (25th percentile), pessary significantly reduced the preterm birth rate at less than 34 weeks of gestation from 46% (16/35) to 21% (10/47) (RR 0.47, 95% CI 0.24-0.90) and significantly improved the composite of poor perinatal outcomes. CONCLUSION Cervical pessary and 400 mg vaginal progesterone resulted in similar rates of preterm birth at less than 34 weeks of gestation in women with twin pregnancies and cervical length less than 38 mm. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02623881.
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Pacagnella RC, Mol BW, Borovac-Pinheiro A, Passini R, Nomura ML, Andrade KC, Ellovitch N, Fernandes KG, Bortoletto TG, Pereira CM, Miele MJ, França MS, Cecatti JG. A randomized controlled trial on the use of pessary plus progesterone to prevent preterm birth in women with short cervical length (P5 trial). BMC Pregnancy Childbirth 2019; 19:442. [PMID: 31775669 PMCID: PMC6880495 DOI: 10.1186/s12884-019-2513-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 09/16/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Preterm birth is the leading cause of mortality and disability in newborn and infants. Having a short cervix increases the risk of preterm birth, which can be accessed by a transvaginal ultrasound scan during the second trimester. In women with a short cervix, vaginal progesterone and pessary can both reduce this risk, which progesterone more established than cervical pessary. The aim of this study is to compare the use of vaginal progesterone alone versus the association of progesterone plus pessary to prevent preterm birth in women with a short cervix. METHODS This is a pragmatic open-label randomized controlled trial that will take place in 17 health facilities in Brazil. Pregnant women will be screened for a short cervix with a transvaginal ultrasound between 18 0/7 until 22 6/7 weeks of gestational age. Women with a cervical length below or equal to 30 mm will be randomized to the combination of progesterone (200 mg) and pessary or progesterone (200 mg) alone until 36 + 0 weeks. The primary outcome will be a composite of neonatal adverse events, to be collected at 10 weeks after birth. The analysis will be by intention to treat. The sample size is 936 women, and a prespecified subgroup analysis is planned for cervical length (= < or > 25 mm). Categorical variables will be expressed as a percentage and continuous variables as mean with standard deviation. Time to delivery will be assessed with Kaplan-Meier analysis and Cox proportional hazard analysis. DISCUSSION In clinical practice, the combination of progesterone and pessary is common however, few studies have studied this association. The combination of treatment might act in both the biochemical and mechanical routes related to the onset of preterm birth. TRIAL REGISTRATION Brazilian Clinical Trial Registry (ReBec) RBR-3t8prz, UTN: U1111-1164-2636, 2014/11/18.
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Affiliation(s)
- Rodolfo C. Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Ben W. Mol
- Obstetrics & Gynaecology Monash Health, Monash University, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168 Australia
| | - Anderson Borovac-Pinheiro
- Obstetric Unit, Woman´s Hospital, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Renato Passini
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Marcelo L. Nomura
- Obstetric Unit, Woman´s Hospital, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Kleber Cursino Andrade
- Ultrasound Department, Woman´s Hospital, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitaria Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Nathalia Ellovitch
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Karayna Gil Fernandes
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Thaísa Guedes Bortoletto
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Cynara Maria Pereira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Maria Julia Miele
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
| | - Marcelo Santucci França
- Federal University of São Paulo – UNIFESP, R. Napoleão de Barros, 715-Vila Clementino, São Paulo, SP 04024-002 Brasil
| | - Jose G. Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas – UNICAMP, Rua Alexander Fleming, 101 Cidade Universitária Zeferino Vaz, Campinas, 13087-460 Brasil
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Barinov SV, Tirskaya YI, Shamina IV, Ledovskikh IO, Atamanenko OJ. Placental blood flow and pregnancy outcomes in women with abnormal placental localization and absence of placental "migration". J Matern Fetal Neonatal Med 2019; 34:3496-3502. [PMID: 31736394 DOI: 10.1080/14767058.2019.1685973] [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: 10/25/2022]
Abstract
Aim: We investigated the arcuate artery blood flow in the region of the abnormally localized placenta in women who had undergone insertion of an obstetric pessary and were receiving micronized progesterone.Materials and methods: The study included 120 pregnant women with high perinatal risks and abnormal placental localization. The patients were randomized to receive the Arabin's pessary and vaginal micronized progesterone (Group A, n = 60) or vaginal micronized progesterone only (Group B, n = 60). Randomization was carried based on the order of hospital admission: odd patient numbers were allocated to Group A and even numbers to Group B. Patients underwent a series of ultrasound scans to evaluate the placental migration and presence of abnormal placental attachment. Depending on the results of the scan, study participants were divided into the following groups: (1) patients without placental migration: A1 (n = 23) and B1 (n = 42); and (2) patients with placental migration: A2 (n = 37) and B2 (n = 18). Women in subgroups A1 and B1 were further divided into the subgroups based on the presence of abnormal placental attachment: A1x (n = 5) and B1x (n = 12) with abnormal placental attachment; and A1O (n = 18) and B1O (n = 30) without the abnormal placental attachment.Conclusion: In patients with abnormal placental attachment, the resistance of blood flow in the arcuate arteries was significantly higher than in those with normal placental attachment. A significant increase in the blood flow resistance occurred between 24 and 28 weeks of gestation. The combined use of the obstetric pessary and vaginal micronized progesterone in women with abnormal placental localization helped maintain the resistivity index at low levels and reduce the rate of abnormal placental attachment by 1.3-fold (OR 0.694 (95% CI: 0.21-2.29)).
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Affiliation(s)
- S V Barinov
- Federal State Budget Institution of Higher Education, "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - Y I Tirskaya
- Federal State Budget Institution of Higher Education, "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - I V Shamina
- Federal State Budget Institution of Higher Education, "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - I O Ledovskikh
- Perinatal Centre, Budget Healthcare Omsk Region Institution, Regional Clinical Hospital, Omsk, Russia
| | - O J Atamanenko
- Perinatal Centre, Budget Healthcare Omsk Region Institution, Regional Clinical Hospital, Omsk, Russia
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Kyvernitakis I, Maul H, Rath W, Kraft K, Kuon R, Hamza A, Reuschel E, Filsinger B, Abele H, Garnier Y, Bahlmann F, Schleußner E, Berger R. Position Paper of the Task Force for Obstetrics and Prenatal Medicine (AGG - Section Preterm Birth) on the Placement, Removal and Surveillance of the Arabin Cervical Pessary in Patients at Risk for Spontaneous Preterm Birth. Geburtshilfe Frauenheilkd 2019; 79:1171-1175. [PMID: 31736505 PMCID: PMC6846727 DOI: 10.1055/a-1007-8613] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 02/06/2023] Open
Abstract
This position paper describes clinically important, practical aspects of cervical pessary treatment. Transvaginal ultrasound is standard for the assessment of cervical length and selection of patients who may benefit from pessary treatment. Similar to other treatment modalities, the clinical use and placement of pessaries requires regular training. This training is essential for proper pessary placement in patients in emergency situations to prevent preterm delivery and optimize neonatal outcomes. Consequently, pessaries should only be applied by healthcare professionals who are not only familiar with the clinical implications of preterm birth as a syndrome but are also trained in the practical application of the devices. The following statements on the clinical use of pessary application and its removal serve as an addendum to the recently published German S2-consensus guideline on the prevention and treatment of preterm birth.
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Affiliation(s)
- Ioannis Kyvernitakis
- Section of Prenatal Diagnostics and Therapy, Dept. of Obstetrics and Prenatal Medicine, Asklepios Center of Excellence Hamburg, Campus Barmbek, Heidberg-Nord and Wandbek, Hamburg, Germany
| | - Holger Maul
- Dept. of Obstetrics and Prenatal Medicine, Asklepios Center of Excellence Hamburg, Campus Barmbek, Heidberg-Nord and Wandbek, Hamburg, Germany
| | - Werner Rath
- Dept. of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Katrina Kraft
- Dept. of Obstetrics and Gynecology, Harlaching Hospital Munich, Munich, Germany
| | - Ruben Kuon
- Dept. of Gynecological Endocrinology and Fertility Disorders, University Hospital of Heidelberg, Heidelberg, Germany
| | - Amr Hamza
- Dept. of Obstetrics and Gynecology, University Hospital Saarland, Homburg, Germany
| | - Edith Reuschel
- Dept. of Obstetrics and Gynecology, University of Regensburg, Hospital of the Barmherzige Brueder, Clinic St Hedwig, Regensburg, Germany
| | - Barbara Filsinger
- Dept. of Obstetrics and Gynecology, Diakonissen Hospital Speyer, Speyer, Germany
| | - Harald Abele
- Center for Mother and Child, University-Hospital Tübingen, Tübingen, Germany
| | - Yves Garnier
- Dept. of Obstetrics and Gynecology, Osnabrück Hospital, Osnabrück, Germany
| | - Franz Bahlmann
- Dept. of Obstetrics and Gynecology, Buergerhospital and Clementine Children's Hospital Frankfurt a. M., Frankfurt a. M., Germany
| | - Ekkehard Schleußner
- Dept. Of Obstetrics and Prenatal Medicine, University of Jena, Jena, Germany
| | - Richard Berger
- Dept. of Obstetrics and Gynecology, Marienhospital Neuwied, Neuwied, Germany
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Liu J, Song G, Meng T, Zhao G. Vaginal progesterone combined with cervical pessary in preventing preterm birth: a meta-analysis. J Matern Fetal Neonatal Med 2019; 34:3050-3056. [PMID: 31619103 DOI: 10.1080/14767058.2019.1677596] [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: 10/25/2022]
Abstract
OBJECTIVE Vaginal progesterone and cervical pessary are both shown to be effective in preventing preterm. We conducted a meta-analysis to evaluate whether the combination of these two interventions has any additional benefit in preventing preterm birth and improving perinatal outcomes in asymptomatic women with a singleton gestation who had a midtrimester sonographic short cervix compared with vaginal progesterone alone. METHODS Five databases were searched from their inception to 21 February 2019. We estimated relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. The primary outcome was preterm birth <34 weeks, and second outcomes included low birth weight (LBW) delivery, perinatal death, and neonatal intensive care unit (NICU) admission. RESULTS Three RCTs with a total of 820 participants were identified. Cervical pessary had no significant prevention effect of preterm birth when combined with vaginal progesterone compared to the control group with vaginal progesterone alone (RR = 0.91; 95% CI, 0.47-1.77). No significant difference has been revealed between groups in LBW delivery (RR = 1.13; 95% CI, 0.86-1.48), perinatal death (RR = 1.27; 95% CI, 0.58-2.78) and NICU admission (RR = 1.24; 95% CI, 0.84-1.85). CONCLUSIONS Comparing with vaginal progesterone alone, cervical pessary plus vaginal progesterone did not reduce the rates of preterm birth at <34 weeks of gestation. There was no difference in LBW delivery, perinatal death, and NICU admission. We need more evidence to balance the benefit and side effects on the combination of vaginal progesterone and cervical pessary for preventing preterm birth.
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Affiliation(s)
- Jing Liu
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tao Meng
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ge Zhao
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, China
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Abstract
This review underlines the important role that obstetricians play in the prevention of retinopathy of prematurity. Efforts predominately focus on predicting which pregnant women are at highest risk of preterm birth, instigating treatments to prevent pre-eclampsia, fetal growth restriction and maternal infection which could lead to iatrogenic or spontaneous preterm birth, and optimizing care when preterm birth is inevitable. More broadly, optimizing maternal health pre-conception through stopping smoking, improving diet, reducing obesity with its associated gestational diabetes, and treating hypertension may reduce preterm birth and other pregnancy complications. This is a message that all healthcare professionals including obstetricians, neonatologists and GPs, nursing and midwifery staff need to communicate all women and men who are contemplating having a baby.
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Affiliation(s)
- Lindsay M Kindinger
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, WC1E 6HX, UK.
| | - Anna L David
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, WC1E 6HX, UK
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Barinov SV, Artymuk NV, Novikova ON, Shamina IV, Tirskaya YI, Belinina AA, Lazareva OV, Kadcyna TV, Borisova AV, Stepanov SS, Di Renzo GC. Analysis of risk factors and predictors of pregnancy loss and strategies for the management of cervical insufficiency in pregnant women at a high risk of preterm birth. J Matern Fetal Neonatal Med 2019; 34:2071-2079. [PMID: 31409178 DOI: 10.1080/14767058.2019.1656195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIM To identify risk factors and predictors of pregnancy loss and to compare the efficacy of Arabin's pessary with cervical cerclage in women at a high risk of pregnancy loss. MATERIALS AND METHODS This was a two-center retrospective case-control study that included 240 women at a high risk of preterm delivery. Group I (n = 161) included women who underwent insertion of the Arabin's pessary between 14 and 24 weeks of pregnancy. Group II (n = 79) included women who had undergone circular cervical cerclage during the current pregnancy. All women included in the study received micronized vaginal progesterone at the dose of 200 mg/day until and including 34 weeks of gestation. RESULTS Threatened pregnancy loss defined as spotting or vaginal bleeding in the first trimester was diagnosed in 29.8% (48/161) of patients in Group I versus 37.9% in Group II (p = .448). Postpartum bleeding occurred in 8.1% (13/161) in women in Group I versus 22.8% in Group II (χ2 = 6.500; p = .011). Our study showed that cervical cerclage was most suitable for patients with history of obstetric complications, cervical length <15 mm, and large isthmic uterine fibroids. The use of the Arabin's pessary reduced the rate of preterm births by 1.7-fold. A cluster analysis demonstrated that predictors of preterm birth in women with a high risk of pregnancy loss included: threatened pregnancy loss associated with chorionic/placental abruption, cervical incompetence, uterine fibroid growth to a large size, history of multiple spontaneous pregnancy losses, cervical tears during past labor, and gestational diabetes diagnosed for the first time during the current pregnancy. CONCLUSIONS Women with a high risk of pregnancy loss treated with Arabin's pessary or cerclage plus vaginal progesterone had a term delivery rate of 70.4% (169/240). The combined strategy of pregnancy management allowed to markedly reduce the number of preterm births.
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Affiliation(s)
- S V Barinov
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia
| | - N V Artymuk
- Department of Obstetrics and Gynecology named after Professor G.A. Ushakova, Kemerovo State Medical University, Kemerovo, Russia
| | - O N Novikova
- Department of Obstetrics and Gynecology named after Professor G.A. Ushakova, Kemerovo State Medical University, Kemerovo, Russia
| | - I V Shamina
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia
| | - Y I Tirskaya
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia
| | - A A Belinina
- Altai State Clinical Perinatal Centre, Barnaul, Russia
| | - O V Lazareva
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia
| | - T V Kadcyna
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia
| | - A V Borisova
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia.,Peoples Friendship University of Russia (RUDN) Moscow, Russian Federation
| | - S S Stepanov
- 2nd Department of Obstetrics and Gynaecology, Omsk State Medical University, Omsk, Russia
| | - G C Di Renzo
- Department of Obstetrics and Gynecology and Centre for Reproductive and Perinatal Medicine, The University of Perugia, Perugia, Italy
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Shor S, Zimerman A, Maymon R, Kovo M, Wolf M, Wiener I, Bar J, Melcer Y. Combined therapy with vaginal progesterone, Arabin cervical pessary and cervical cerclage to prevent preterm delivery in high-risk women. J Matern Fetal Neonatal Med 2019; 34:2154-2158. [PMID: 31438741 DOI: 10.1080/14767058.2019.1659771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Preterm birth is the leading cause of perinatal morbidity and mortality. Vaginal progesterone cervical cerclage and Arabin cervical pessary are considered as preventive treatments in women at risk for preterm birth. However, there is less evidence as to which of these interventions is the preferred management. The current study aims was to compare the outcome of pregnancy in women with a short cervical length managed with 4 different treatment protocols: therapy with vaginal progesterone, cervical cerclage and an Arabin cervical pessary (group A), Arabin cervical pessary and vaginal progesterone (group B), cervical cerclage and vaginal progesterone (group C), or vaginal progesterone alone (group D). METHODS A retrospective cohort study of singleton pregnancies managed in three tertiary medical centers between September 2011 and December 2017. RESULTS In the study period, 286 pregnant women underwent vaginal ultrasonography between 15 and 29 weeks gestation. They all had a short cervical length (≤25 mm). Of these, 18 (6.3%), 120 (41.9%), 38 (13.3%) and 110 (38.5%) patients received treatment classifying them into groups A, B, C, and D, respectively. A significantly higher rate of patients in group A had either a history of cervical incompetence (44.4 versus 9.2 versus 7.9 and 0.9%, respectively, p = .0001) or a cervical procedure (61.1 versus 37.5 versus 28.9 and 27.3%, respectively, p = .027) compared to patients in group B, C, and D. Despite having a shorter cervical length at recruitment in group A (median (range); 14.5 (0-25) versus 15 (0-25) versus 15.5 (0-25) and 19 (2-25) mm, respectively, p = .002) the rate of spontaneous preterm delivery <37-week gestation was similar across groups (44.4 versus 32.5 versus 36.8 versus 32.7%, respectively, p = .665). CONCLUSION A combined rescue therapy involving vaginal progesterone, cervical cerclage, and Arabin cervical pessary emerges as a promising management strategy in pregnant women who have a short cervical length and a high background risk for preterm delivery. This combination may prolong their pregnancy and safely bring them near term. Additional studies are needed to confirm these preliminary findings.
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Affiliation(s)
- Shimrit Shor
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Ariel Zimerman
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel, both affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Maya Wolf
- Department of Obstetrics and Gynecology, Galilee Medical Center, Faculty of Medicine in the Galilee, Nahariya, affiliated with the Bar Ilan University, Tel Aviv, Israel
| | - Ifat Wiener
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel, both affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
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Daskalakis G, Zacharakis D, Pergialiotis V, Kalmantis K, Theodora M, Siristatidis C, Antsaklis P, Antsaklis A, Loutradis D. Evaluation of the efficacy of cervical pessary combined with vaginal progesterone in women with a short cervix and additional risk factors for preterm delivery. J Matern Fetal Neonatal Med 2019; 34:1277-1283. [PMID: 31216905 DOI: 10.1080/14767058.2019.1634686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine the efficacy of a combined management with cervical pessary and vaginal progesterone of women with a singleton pregnancy and a short cervix in both low and high risk-cases based on their previous obstetrical history and maternal factors. STUDY DESIGN This was a prospective cohort study of women with a singleton pregnancy and a sonographically detected mid-trimester cervical length ≤ 25 mm. The high-risk group consisted of women with a history of a previous spontaneous preterm birth (PB), or a second-trimester miscarriage, or a loop electrosurgical excision procedure of the cervix (LEEP) while the low-risk group of women without such a history. All women were managed with cervical pessary and daily vaginal administration of 200 mg of progesterone. The primary outcome measure was spontaneous delivery before 34 weeks (238 days) of gestation. RESULTS One hundred ninety-six cases with a CL ≤ 25 mm were detected during the study period. Fifty-two women declined to participate in the study. The remaining 144 women were divided into two groups based on the presence (n = 44) or absence (n = 100) of specific risk factors for PB. The rate of PTB < 34 weeks was similar in both low and high-risk pregnancies while a significantly higher rate of sPTB < 37 weeks was found in women with high-risk pregnancies (p = .005). CONCLUSION The combined treatment of cervical pessary and vaginal progesterone has a similar influence on preterm delivery rate < 34 weeks, in both low and high-risk women, with a mid-trimester short cervix.
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Affiliation(s)
- George Daskalakis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Zacharakis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- 3rd Department of Obstetrics and Gynecology, "Attikon" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Kalmantis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Mariana Theodora
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalambos Siristatidis
- 3rd Department of Obstetrics and Gynecology, "Attikon" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Antsaklis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aris Antsaklis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Barinov SV, Shamina IV, Di Renzo GC, Lazareva OV, Tirskaya YI, Medjannikova IV, Ledovskikh IO, Klementyeva LL, Dudkova GV. The role of cervical pessary and progesterone therapy in the phenomenon of placenta previa migration. J Matern Fetal Neonatal Med 2019; 33:913-919. [PMID: 30081730 DOI: 10.1080/14767058.2018.1509068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: This study aimed to evaluate the effects of combined management of placenta previa with the Arabin cervical pessary and progesterone.Study design: In this randomized controlled study, we followed up 217 patients with placenta previa and high risk of preterm birth. The main group (n = 81) underwent combined management with the Arabin cervical pessary and progesterone; the control group (n = 136) received progesterone only. Placental migration was monitored using Doppler scanning from 24 weeks of pregnancy onwards.Results: Patients receiving the combination of the Arabin cervical pessary and progesterone had a three-fold reduced rate of bleeding during pregnancy compared with patients in the control group (11.3% versus 33.1%; p = .006). Placental migration occurred 1.8 times more often in the pessary group (48.1% versus 26.4%; p = .037), and preterm labor <34 weeks occurred 2.7 times less often compared with the control group (p = .031). The use of the Arabin cervical pessary caused a change in the anterior cervico-uterine angle by 7.4 degrees, and reduction in the arcuate artery RI at 32-33 weeks of pregnancy compared with the control group.Conclusions: The use of the Arabin cervical pessary combined with progesterone in patients with placenta previa significantly reduced the rate of preterm delivery <34 weeks and bleeding during pregnancy.
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Affiliation(s)
- Sergey V Barinov
- Federal State Budget Educational Institution of Higher Education "Omsk State Medical University", Russian Ministry of Healthcare, Omsk, Russia
| | - Inna V Shamina
- Federal State Budget Educational Institution of Higher Education "Omsk State Medical University", Russian Ministry of Healthcare, Omsk, Russia
| | - Gian Carlo Di Renzo
- Department of Obstetrics and Gynecology and Centre for Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Oksana V Lazareva
- Federal State Budget Educational Institution of Higher Education "Omsk State Medical University", Russian Ministry of Healthcare, Omsk, Russia
| | - Yuliya I Tirskaya
- Federal State Budget Educational Institution of Higher Education "Omsk State Medical University", Russian Ministry of Healthcare, Omsk, Russia
| | - Irina V Medjannikova
- Federal State Budget Educational Institution of Higher Education "Omsk State Medical University", Russian Ministry of Healthcare, Omsk, Russia
| | - Inna O Ledovskikh
- Perinatal center, Budget Healthcare Omsk Region Institution "Regional Clinical Hospital", Omsk, Russia
| | | | - Galina V Dudkova
- Perinatal center, Budget Healthcare Omsk Region Institution "Regional Clinical Hospital", Omsk, Russia
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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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Melcer Y, Kovo M, Maymon R, Bar J, Wiener I, Neeman O, Pekar-Zlotin M, Zimerman A. Arabin cervical pessary with vaginal progesterone versus vaginal progesterone for preventing preterm delivery. J Matern Fetal Neonatal Med 2019; 33:3439-3444. [PMID: 30669913 DOI: 10.1080/14767058.2019.1573894] [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] [Indexed: 10/27/2022]
Abstract
Purpose: To compare the rate of preterm delivery in pregnant women with a short cervical length managed with Arabin cervical pessary and vaginal progesterone versus vaginal progesterone alone.Methods: This was a retrospective cohort study of singletons pregnancies managed in two tertiary medical centers between September 2011 and May 2017. One center utilized the combined treatment of Arabin cervical pessary and vaginal progesterone (study group) and the second utilized vaginal progesterone approach (control group).Results: During the study period, a total of 202 pregnant women who underwent vaginal ultrasonography between 15 and 29 weeks gestation. They all had short cervical length (≤25 mm). Among them, 94 (46.5%) and 108 (53.5%) patients were in the study and control group, respectively. A significantly higher rate of patients in the study group had either a history of cervical incompetence (9.6 vs. 0.9%, respectively, p = 0.006) or cervical surgery (7.9 vs. 0%, respectively, p = .003). Despite having shorter cervical length at recruitment (14.3 ± 5.9 vs. 16.9 ± 5.7, respectively, p = .002) the rate of spontaneous delivery < 34-week gestation was lower in the study group (7.4 vs. 17.6%, respectively, p = .036) and they delivered 1-week later compared to the control group (37.2 ± 2.1 vs. 36.2 ± 3.7, respectively, p = 0.02).Conclusion: We found that for pregnant women with singletons and who had a short cervical length, the combined treatment of Arabin cervical pessary and vaginal progesterone had lower rate of preterm delivery < 34 weeks of gestation and prolonged gestation compared to those women who were treated with vaginal progesterone alone. Our preliminary findings warrant randomized control studies in order to further illuminate our results.
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Affiliation(s)
- Yaakov Melcer
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel (both affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel)
| | - Ron Maymon
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel (both affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel)
| | - Ifat Wiener
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Ortal Neeman
- Department of Obstetrics and Gynecology, Assuta Hospital, Ashdod, Israel (affiliated to University of the Negev, Beer-Sheva, Ben-Gurion, Israel)
| | - Marina Pekar-Zlotin
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Ariel Zimerman
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
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Ivandic J, Care A, Goodfellow L, Poljak B, Sharp A, Roberts D, Alfirevic Z. Cervical pessary for short cervix in high risk pregnant women: 5 years experience in a single centre. J Matern Fetal Neonatal Med 2018; 33:1370-1376. [PMID: 30173599 DOI: 10.1080/14767058.2018.1519018] [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: 10/28/2022]
Abstract
Purpose: To describe single center clinical experience with cervical pessary used for high-risk pregnant women who also had short cervix. We have focused on the techniques to optimize efficacy and minimize the risk of complications and side effects related to pessary insertion, removal, and pregnancy management.Methods: This is an audit from specialist preterm birth prevention clinic in Liverpool Women's Hospital, United Kingdom for the period between January 2013 and December 2017. We also conducted postal survey in November 2015 to evaluate women's experience with vaginal pessary.Results: Out of 235 women who were treated for short cervix, 129 (55%) had cervical pessary as a first line treatment. Overall, 50% of treated women reached term. 17 women (13%) needed additional treatment, 9 women had pessary reinserted (7%), and 53 (41%) had pessary removed before 36 weeks, mainly due to ruptured membranes. Significant vaginal discharge and pelvic discomfort were reported by 14 and 7% women, respectively. 89% of treated women would recommend the pessary treatment to others.Conclusions: Whilst the cervical pessary continues to be evaluated in clinical trials, our experience suggests that pessary is quite easy to insert and remove and is well tolerated by the women.
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Affiliation(s)
- Jelena Ivandic
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Angharad Care
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Laura Goodfellow
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Borna Poljak
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Andrew Sharp
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Devender Roberts
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Zarko Alfirevic
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
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Eser A, Ozkaya E. Uterocervical angle: an ultrasound screening tool to predict satisfactory response to labor induction. J Matern Fetal Neonatal Med 2018; 33:1295-1301. [PMID: 30249147 DOI: 10.1080/14767058.2018.1517324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: A wide uterocervical angle >95° detected during the second trimester was associated with an increased risk for spontaneous preterm birth.Objective: We aimed to determine whether an ultrasonographic marker, uterocervical angle, correlates with satisfactory response to labor induction.Study design: We conducted a prospective cohort study from May 2016 through December 2017 of singleton term gestations undergoing transvaginal ultrasound for cervical length screening and uterocervical angle measurement. Uterocervical angle was measured between the lower uterine segment and the cervical canal. Latent phase duration >720 min was accepted to be a prolonged latent phase. The primary outcome was a prediction of satisfactory response to labor induction (latent phase duration <720 min).Results: Both anterior uterocervical angle (AUC = 0.802, p < .001) and the cervical length (AUC = 0.679, p < .05) significantly predicted satisfactory response to labor induction. Optimal cutoff value was obtained at the value of 97° (64% sensitivity, 91% specificity) for anterior uterocervical angle and 27 mm (64% sensitivity, 64% specificity) for the cervical length. Kaplan-Meier survival analysis showed that duration from labor induction to delivery was significantly higher in a group with longer cervical length (p = .04), additionally labor induction to delivery time was significantly higher in a group with lower UCA (p = .04).Conclusions: Both the cervical length and anterior uterocervical length were predictors for the satisfactory response to labor induction, and both parameters were found to be significantly associated with time from induction to delivery in survival analysis.
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Affiliation(s)
- Ahmet Eser
- Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
| | - Enis Ozkaya
- Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
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Daskalakis G, Zacharakis D, Theodora M, Antsaklis P, Papantoniou N, Loutradis D, Antsaklis A. Safety and efficacy of the cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth. J Perinat Med 2018; 46:531-537. [PMID: 29055173 DOI: 10.1515/jpm-2017-0009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 09/18/2017] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the safety and efficacy of the combined treatment of cervical pessary and endovaginal progesterone for the prevention of spontaneous preterm birth (SPB) in women with a short cervical length (CL) between 20 and 24 weeks of gestation. MATERIALS AND METHODS This is a prospective study of women with a singleton pregnancy and a sonographically detected mid-trimester CL ≤25 mm. The primary outcome measure was spontaneous delivery before 34 weeks (238 days) of gestation. RESULTS The study sample consisted of 90 women with a mean CL of 14.2 mm (SD=6.5 mm). Of the women, 34.4% had at least one risk factor for SPB; 7.8% delivered preterm before 34 weeks of gestation, and 25.6%, before 37 weeks. Neonatal death occurred in two (2.2%) cases due to respiratory distress syndrome. Lower body mass index values, history of preterm delivery and number of second trimester miscarriages were independently associated with delivery before 34 weeks. CONCLUSION The combination of vaginal progesterone and cervical pessary for the prevention of SPB in women with a short cervix is safe and well tolerated. This therapy was associated with pregnancy prolongation, reduced prematurity rate and a low rate of perinatal complications.
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Affiliation(s)
- Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, 8 I. Metaxa Street, 15236-P. Penteli, Athens, Greece, Tel.: +30-6945-235757, Fax: +30210-5317224
| | - Dimitrios Zacharakis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Theodora
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Antsaklis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Papantoniou
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Loutradis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aris Antsaklis
- 1st Department of Obstetrics and Gynecology, "Alexandra" Maternity Hospital, National and Kapodistrian University of Athens, Athens, Greece
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