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Almousained MM, Alshehri AA, Aodah AH, Alhindi YM, Alqahtani SH, Alfassam HA, Almomen A, Tawfik EA. Development of progesterone electrospun nanofibers to coat Arabin pessaries as a dual preventive and therapeutic approach for preterm labor. Saudi Pharm J 2024; 32:101929. [PMID: 38223205 PMCID: PMC10787286 DOI: 10.1016/j.jsps.2023.101929] [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: 11/10/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024] Open
Abstract
Preterm labor is a growing health problem that causes newborn death, and safe and effective therapy is significantly needed. Arabin pessaries and progesterone are preventive and therapeutic approaches that can be applied to managing the short cervix; hence, reducing the risk of preterm labor. The main goal of current work is to fabricate a novel nanofiber formulation based on polycaprolactone (PCL) and loaded with progesterone to coat for Arabin pessaries to be used as dual preventive and therapeutic approaches for local vaginal delivery. Several important criteria were considered in this study to assess the prepared nanofibers (i.e.; nanofiber diameter, progesterone loading efficiency, progesterone release profiles and in vitro cytotoxicity assessment). The results showed a dimeter of 397 ± 88 nm, drug loading of 142 ± 3 µg/mg and encapsulation efficiency of 99 ± 2 % for the progesterone-loaded nanofibers. Approximately, 17 % of progesterone was released from the nanofibers after 90 days. The in vitro assessment showed that the application of progesterone is safe upon 24 and 48-hours incubation on HFF-1 cell line at concentrations ≤ 32 µg/mL and within 72-hours at a dose of ≤ 8 µg/mL. To conclude, the data recommended that progesterone-loaded nanofibers can coat the Arabin pessaries with the potential of being a safe and effective dual preventive and therapeutic tool for preterm labor.
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Affiliation(s)
- Manal M. Almousained
- Microelectronics and Semiconductors Institute, Energy and Industrial Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Abdullah A. Alshehri
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Alhassan H. Aodah
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Yasser M. Alhindi
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Sarah H. Alqahtani
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Haya A. Alfassam
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Aliyah Almomen
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Essam A. Tawfik
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
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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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Pessary Plus Progesterone to Prevent Preterm Birth in Women With Short Cervixes: A Randomized Controlled Trial. Obstet Gynecol 2022; 139:41-51. [PMID: 34856583 DOI: 10.1097/aog.0000000000004634] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test the effectiveness of cervical pessary in addition to vaginal progesterone for the prevention of preterm birth in women with midpregnancy short cervixes. METHODS We performed a multicenter, open-label, randomized controlled trial in 17 perinatal centers. Asymptomatic women with singleton or twin pregnancies and cervical lengths of 30 mm or less, measured at 18 0/7-22 6/7 weeks of gestation, were randomized to cervical pessary plus vaginal progesterone (pessary plus progesterone group) or vaginal progesterone only (progesterone-only group) (200 mg/day). Treatments were used from randomization to 36 weeks of gestation or delivery. The primary outcome was a composite of neonatal mortality and morbidity. Secondary outcomes were delivery before 37 weeks and before 34 weeks of gestation. Analysis was performed according to intention to treat. RESULTS Between July 9, 2015, and March 29, 2019, 8,168 women were screened, of whom 475 were randomized to pessary and 461 to progesterone only. The composite perinatal outcome occurred in 19.2% (89/463) of the women in the pessary group compared with 20.9% (91/436) of the women in the progesterone-only group (adjusted risk ratio [aRR] 0.88, 95% CI 0.69-1.12). Delivery rates before 37 weeks of gestation were 29.1% compared with 31.4% (aRR 0.86, 95% CI 0.72-1.04); delivery rates before 34 weeks were 9.9% compared with 13.9% (aRR 0.66, 95% CI 0.47-0.93). Women in the pessary group had more vaginal discharge (51.6% [245/476] vs 25.4% [117/479] [P<.001]), pain (33.1% [157/476] vs 24.1% [111/479] [P=.002]), and vaginal bleeding (9.7% [46/476] vs 4.8% [22/479] [P=.004]). CONCLUSION In asymptomatic women with short cervixes, the combination of pessary and progesterone did not decrease rates of neonatal morbidity or mortality when compared with progesterone only. CLINICAL TRIAL REGISTRATION Brazilian Clinical Trial Registry (ReBec), UTN:U1111-1164-2636.
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Booker WA, Reed EG, Power ML, Schulkin J, Gyamfi-Bannerman C, Manuck T, Berghella V, Vink J. OBGYN practice patterns regarding combination therapy for prevention of preterm birth: A national survey. Eur J Obstet Gynecol Reprod Biol 2021; 266:23-30. [PMID: 34560330 PMCID: PMC9812028 DOI: 10.1016/j.ejogrb.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Our objective was to examine if US obstetrician-gynecologists (OBGYNs) practice outside of evidenced-based guidelines and use a combination of interventions to prevent spontaneous preterm birth (sPTB). STUDY DESIGN An electronic survey was distributed to members of the Pregnancy-Related Care Research Network (PRCRN), and also to members of the Society of Maternal-Fetal Medicine (SMFM). The survey consisted of questions regarding physician demographics, and the use of interventions to prevent sPTB in women with 1) a prior sPTB, 2) an incidental short cervix (no prior sPTB), and 3) a history of cervical insufficiency. RESULTS The PRCRN response rate was 58.6% (283/483) with an additional 143 responses from SMFM members. Among PRCRN responders, 82.7% were general OBGYNs and 17.3% were Maternal-Fetal Medicine subspecialists. Respondents were from all geographic regions of the country; most practiced in a group private practice (42.6%) or academic institution (31.4%). In women with prior sPTB, 45.2% of respondents would consider combination therapy, most commonly weekly intramuscular progesterone (IM-P) and serial cervical length (CL) measurements. If the patient then develops a short cervix, 33.7% would consider adding an ultrasound-indicated cerclage. In women with an incidental short cervix, 66.8% of respondents were likely to recommend single therapy with daily vaginal progesterone (VP). If a patient developed an incidentally dilated cervix, 40.8% of PRCRN respondents would recommend dual therapy, most commonly cerclage + VP, whereas 64.3% of SMFM respondents were likely to continue with VP only. In women with a history of cervical insufficiency, 47% of PRCRN respondents indicated they would consider a combination of IM-P, history-indicated cerclage and serial CL measurements. CONCLUSION Although not currently supported by evidence-based medicine, combination therapy is commonly being used by U.S. OBGYNs to prevent sPTB in women with risk factors such as prior sPTB, short or dilated cervix or more than one of these risks.
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Affiliation(s)
- Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA; The Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA.
| | - Eda G Reed
- Smithsonian National Zoological Park and Conservation Biology Institute, Washington, DC, USA; Bloomberg School of Public Health and Carey Business School, Johns Hopkins University, Baltimore, MD, USA
| | - Michael L Power
- Smithsonian National Zoological Park and Conservation Biology Institute, Washington, DC, USA; American College of Obstetricians and Gynecologists, Washington, DC, USA
| | - Jay Schulkin
- American College of Obstetricians and Gynecologists, Washington, DC, USA; University of Washington School of Medicine, Seattle, WA, USA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA; The Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Tracy Manuck
- Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joy Vink
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA; The Preterm Birth Prevention Center, Columbia University Irving Medical Center, New York, NY, USA
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The impact of cervical conization size with subsequent cervical length changes on preterm birth rates in asymptomatic singleton pregnancies. Sci Rep 2021; 11:19703. [PMID: 34611206 PMCID: PMC8492699 DOI: 10.1038/s41598-021-99185-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023] Open
Abstract
The study aimed to explore the impact of cervical conization size (CCS) with subsequent cervical length (USCL) changes on preterm birth (PTB) rates in asymptomatic singleton pregnancies as compared to pregnancy outcomes in healthy women with an intact cervix (ICG), and to estimate PTB prevention efficiency in patients with a short cervix. Pregnancy outcomes in populations of similar age, ethnicity, residency, education and harmful habits having undergone cervical conization (CCG) were retrospectively analyzed and compared to ICG and cervical conization sub-populations adjusted by USCL during pregnancy (adequate cervical length vs. a short cervix) and a progesterone-only group (POG) vs. a progesterone-pessary group (PPG). Cervical conization was not associated with an increased PTB risk (CCG vs. ICG) when parameters of CCS and USCL were not adjusted (p = NS). A significantly higher proportion of parous women was observed in the CCG population than in the ICG (p = 0.0019). CCS turned out to be a key PTB risk during pregnancy, the larger CCS being associated with a short cervix (p = 0.0001) and higher PTB risks (p = 0.0001) with a notably increased PTB rate (p = 0.0001) in nulliparous women (p = 0.0022), whereas smaller CCS with adequate cervical length and a lower PTB rate was predominantly observed in women with prior parity. An initial equal USCL size was to be considerably elongated in women with adequate cervical length (p < 0.0001), and shortened in those with a short cervix (p < 0.0001). USCL assessment during pregnancy proved to be the PTB risk-predicting tool, with CCS supplementation apt to increase its diagnostic value. No substantial impact on pregnancy outcomes could be linked to any particular PTB prevention mode (POG or PPV). However, during pregnancy, the USCL changes relating to CCS proved to be more critical in pregnancy outcomes.
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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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Yan Y, Basij M, Garg A, Varrey A, Alhousseini A, Hsu R, Hernandez-Andrade E, Romero R, Hassan SS, Mehrmohammadi M. Spectroscopic photoacoustic imaging of cervical tissue composition in excised human samples. PLoS One 2021; 16:e0247385. [PMID: 33657136 PMCID: PMC7928441 DOI: 10.1371/journal.pone.0247385] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/06/2021] [Indexed: 02/04/2023] Open
Abstract
Objective Cervical remodeling is an important component in determining the pathway of parturition; therefore, assessing changes in cervical tissue composition may provide information about the cervix’s status beyond the measurement of cervical length. Photoacoustic imaging is a non-invasive ultrasound-based technology that captures acoustic signals emitted by tissue components in response to laser pulses. This optical information allows for the determination of the collagen-to-water ratio (CWR). The purpose of this study was to compare the CWR evaluated by using spectroscopic photoacoustic (sPA) imaging in cervical samples obtained from pregnant and non-pregnant women. Methods This cross-sectional study comprised cervical biopsies obtained at the time of hysterectomy (n = 8) and at the scheduled cesarean delivery in pregnant women at term who were not in labor (n = 8). The cervical CWR was analyzed using a fiber-optic light-delivery system integrated to an ultrasound probe. The photoacoustic signals were acquired within the range of wavelengths that cover the peak absorption of collagen and water. Differences in the CWR between cervical samples from pregnant and non-pregnant women were analyzed. Hematoxylin and eosin and Sirius Red stains were used to compare the collagen content of cervical samples in these two groups. Results Eight cervix samples were obtained after hysterectomy, four from women ≤41 years of age and four from women ≥43 years of age; all cervical samples (n = 8) from pregnant women were obtained after 37 weeks of gestation at the time of cesarean section. The average CWR in cervical tissue samples from pregnant women was 18.7% (SD 7.5%), while in samples from non-pregnant women, it was 55.0% (SD 20.3%). There was a significantly higher CWR in the non-pregnant group compared to the pregnant group with a p-value <0.001. A subgroup analysis that compared the CWR in cervical samples from pregnant women and non-pregnant women ≤41 years of age (mean 46.3%, SD 23.1%) also showed a significantly higher CWR (p <0.01). Lower collagen content in the pregnancy group was confirmed by histological analysis, which revealed the loss of tissue composition, increased water content, and collagen degradation. Conclusion The proposed bimodal ultrasound and sPA imaging system can provide information on the biochemical composition of cervical tissue in pregnant and non-pregnant women. Photoacoustic imaging showed a higher collagen content in cervical samples from non-pregnant women as compared to those from pregnant women, which matched with the histological analysis. This novel imaging method envisions a new potential for a sensitive diagnostic tool in the evaluation of cervical tissue composition.
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Affiliation(s)
- Yan Yan
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, United States of America
| | - Maryam Basij
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, United States of America
| | - Alpana Garg
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Aneesha Varrey
- Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, Michigan, United States of America
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Ali Alhousseini
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan, United States of America
| | - Richard Hsu
- Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, Michigan, United States of America
| | - Edgar Hernandez-Andrade
- Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, Michigan, United States of America
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, Texas, United States of America
| | - Roberto Romero
- Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland and Detroit, Michigan, United States of America
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, United States of America
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, United States of America
- Detroit Medical Center, Detroit, Michigan, United States of America
- Department of Obstetrics and Gynecology, Florida International University, Miami, Florida, United States of America
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- Office of Women’s Health, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Mohammad Mehrmohammadi
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, United States of America
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- Department of Electrical and Computer Engineering, Wayne State University, Detroit, Michigan, United States of America
- Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, United States of America
- * E-mail:
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Goodfellow L, Care A, Alfirevic Z. Controversies in the prevention of spontaneous preterm birth in asymptomatic women: an evidence summary and expert opinion. BJOG 2020; 128:177-194. [PMID: 32981206 DOI: 10.1111/1471-0528.16544] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2020] [Indexed: 01/11/2023]
Abstract
Preterm birth prevention is multifaceted and produces many nuanced questions. This review addresses six important clinical questions about preterm birth prevention as voted for by members of the UK Preterm Clinical Network. The questions cover the following areas: preterm birth prevention in 'low-risk' populations; screening for asymptomatic genital tract infection in women at high risk of preterm birth; cervical length screening with cerclage or vaginal pessary in situ; cervical shortening whilst using progesterone; use of vaginal progesterone in combination with cervical cerclage; and optimal advice about intercourse for women at high risk of preterm birth.
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Affiliation(s)
- Laura Goodfellow
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Angharad Care
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Zarko Alfirevic
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
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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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Dawes L, Groom K, Jordan V, Waugh J. The use of specialised preterm birth clinics for women at high risk of spontaneous preterm birth: a systematic review. BMC Pregnancy Childbirth 2020; 20:58. [PMID: 31996173 PMCID: PMC6990596 DOI: 10.1186/s12884-020-2731-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/09/2020] [Indexed: 02/03/2023] Open
Abstract
Background Specialised preterm birth clinics care for women at high risk of spontaneous preterm birth. This systematic review assesses current practice within preterm birth clinics globally. Methods A comprehensive search strategy was used to identify all studies on preterm birth clinics on the MEDLINE, Embase, PsycINFO, CENTRAL and CINAHL databases. There were no restrictions to study design. Studies were limited to the English language and publications from 1998 onwards. Two reviewers assessed studies for inclusion, performed data extraction and reviewed methodological quality. Primary outcomes were referral criteria, investigations and interventions offered in preterm birth clinics. Secondary outcomes were the timing of planned first and last appointments and frequency of review. Results Thirty-two records fulfilled eligibility criteria and 20 studies were included in the main analysis following grouping of records describing the same study or clinic. Studies were of mixed study design and methodological quality. A total of 39 clinics were described; outcome data was not available for all clinics. Referral criteria included previous spontaneous preterm birth (38/38, 100%), previous mid-trimester loss (34/38, 89%) and previous cervical surgery (33/38, 87%). All clinics offered transvaginal cervical length scans. Additional investigations varied, including urogenital swabs (16/28, 57%) and fetal fibronectin (8/28, 29%). The primary treatment of choice for a sonographic short cervix was cervical cerclage in 10/33 (30%) clinics and vaginal progesterone in 6/33 (18%), with 10/33 (30%) using multiple first-line options and 6/33 (18%) using a combination of treatments. The majority of clinics planned timing of first review for 12–16 weeks (30/35, 86%) and the frequency of review was usually determined by clinical findings (18/24, 75%). There was a wide variation in gestational age at clinic discharge between 24 and 37 weeks. Conclusions There is variation in the referral criteria, investigations and interventions offered in preterm birth clinics and in the timing and frequency of review. Consistency in practice may improve with the introduction of consensus guidelines and national preterm birth prevention programmes. Trial registration Systematic review registration number: CRD42019131470.
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Affiliation(s)
- Lisa Dawes
- Liggins Institute, The University of Auckland, Private Bag 92019, Victoria Street West, Auckland, 1142, New Zealand. .,National Women's Health, Auckland City Hospital, Auckland, New Zealand.
| | - Katie Groom
- Liggins Institute, The University of Auckland, Private Bag 92019, Victoria Street West, Auckland, 1142, New Zealand.,National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics & Gynaecology, The University of Auckland, Auckland, New Zealand.,Cochrane New Zealand, Auckland, New Zealand
| | - Jason Waugh
- National Women's Health, Auckland City Hospital, Auckland, New Zealand.,Department of Obstetrics & Gynaecology, The University of Auckland, Auckland, New Zealand
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Berger R, Rath W, Abele H, Garnier Y, Kuon RJ, Maul H. Reducing the Risk of Preterm Birth by Ambulatory Risk Factor Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:858-864. [PMID: 31931955 PMCID: PMC6970314 DOI: 10.3238/arztebl.2019.0858] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 06/05/2019] [Accepted: 09/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The preterm birth rate in Germany has remained unchanged at 8-9% since 2009. Preterm birth is the most common cause of neonatal morbidity and mortality. In the absence of a causal treatment, it is important to lower the risk of preterm birth by preventive measures in prenatal outpatient care. METHODS This review is based on pertinent publications from the years 2000-2019 that were retrieved by a selective search in PubMed. RESULTS The clinical risk factors for preterm birth-known mainly from retrospective cohort studies-include previous preterm birth (adjusted odds ratio [aOR]: 3.6), multiple pregnancy (relative risk [RR]: 7.7), nicotine consumption (aOR: 1.7), and a short uterine cervix, i.e., <25 mm in the second trimester (aOR: 6.9). In women with a short cervix, vaginally administered progesterone significantly lowers the preterm birth rate (22.5% vs. 14.1% for birth before 33 weeks of gestation, RR: 0.62; 95% confidence interval [0.47; 0.81]). Nicotine abstinence is associated with a lower pre- term birth rate as well (aOR: 0.91; [0.88; 0,.94]), while working more than 40 hours per week (aOR: 1.25; [1,.01; 1,.54]) and heavy lifting during pregnancy (hazard ratio [HR]: 1.43; [1.13; 1.80]) are associated with a higher preterm birth rate. Avoidance of physical exertion, or bed rest, in the face of impending preterm birth does not lower the preterm birth rate, but it does increase the risk of complications, such as thromboembolism. CONCLUSION The meticulous assessment and elimination of treatable risk factors at the outset of ambulatory prenatal care can help lower the preterm birth rate. Further velopment of causally directed treat- ments (e.g., changes of relevant environmental and epigenetic factors).
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Affiliation(s)
- Richard Berger
- Marienhaus Klinikum St. Elisabeth, Department of Gynecology and Obstetrics, Neuwied
| | - Werner Rath
- University Medical Center Schleswig-Holstein, Campus Kiel
| | - Harald Abele
- Tübingen University Hospital, Center for Women’s Health, Tübingen
| | - Yves Garnier
- Klinikum Osnabrück GmbH, Department of Gynecology and Obstetrics, Osnabrück
| | - Ruben-J. Kuon
- Heidelberg University Hospital, Department of Gynecology and Obstetrics, Heidelberg
| | - Holger Maul
- Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Department of Gynecology and Obstetrics, Hamburg
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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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13
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Mouzakiti N, Sierra F, Herzeg A, Al Naimi A, Reising C, Bahlmann F, Kyvernitakis I. The impact of a short cervix and funneling on the outcome in singleton pregnancies treated with an Arabin-pessary or a McDonald cerclage. J Matern Fetal Neonatal Med 2019; 34:2491-2497. [PMID: 31522584 DOI: 10.1080/14767058.2019.1668923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The presence of sonographic funneling is a co-predictor of spontaneous preterm birth (sPTB). The aim of this study was to assess the outcome in patients with a short cervix and funneling after a McDonald cerclage or an Arabin pessary. METHODS We retrospectively analyzed data of 238 singleton pregnancies with cervical shortening <25 mm subclassified by either isolated cervical shortening (n = 105) or cervical shortening and additional funneling (n = 133). In the group of isolated cervical shortening, a total of 93 patients had received a cervical pessary and 12 had McDonald cerclage. In the group of patients with additional funneling, 98 had received a cervical pessary and 35 had a cerclage. We evaluated PTB rates <28, <32, <34, and <37 weeks as well as prolongation of gestation, birth weight, and admission to NICU. RESULTS In the pessary groups (n = 191), funneling resulted in a significantly higher rate of PTB before 34 weeks as compared to patients with isolated cervical shortening (26.5 versus 8.6%, p=.0066). Similarly, in the cerclage groups (n = 47), funneling resulted in an absolute increase of PTB, albeit not significant (37.1 versus 0%, p=.1435) due to the smaller number. There were no significant differences in terms of prevention of PTB before 34 weeks in patients treated with pessary or cerclage, neither in the group of patients with isolated shortening nor in the group of patients with additional funneling (p=.9771 and p=.3916, respectively). However, in patients with funneling, we demonstrated a significantly lower neonatal admission rate in the pessary arm (n = 27, 27.6%) as compared to the cerclage arm (n = 31, 88.6%) (p = .0002). Similarly, the NICU admission time was shorter in both pessary groups -with and without funneling - as compared to patients treated with cerclage (p = .0000). CONCLUSION Pessary placement and cerclage should optimally be considered before the presence of funneling. Furthermore, there were lower rates of neonatal admission during pregnancy and a shorter admission time of babies after birth when mothers received a cervical pessary as compared to the group with cervical cerclage.
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Affiliation(s)
- Niki Mouzakiti
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany.,Faculty of Medicine, Philipps University of Marburg, Marburg, Germany
| | - Felix Sierra
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany
| | - Akos Herzeg
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany
| | - Ammar Al Naimi
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany
| | - Christoph Reising
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany.,Faculty of Medicine, Philipps University of Marburg, Marburg, Germany
| | - Franz Bahlmann
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany
| | - Ioannis Kyvernitakis
- Department of Obstetrics and Gynecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Children's Hospital Frankfurt/Main Frankfurt, Germany.,Faculty of Medicine, Philipps University of Marburg, Marburg, Germany
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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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15
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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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Effectiveness of the cervical pessary for the prevention of preterm birth in singleton pregnancies with a short cervix: a meta-analysis of randomized trials. Arch Gynecol Obstet 2019; 299:1215-1231. [DOI: 10.1007/s00404-019-05096-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
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17
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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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18
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Wolnicki BG, von Wedel F, Mouzakiti N, Al Naimi A, Herzeg A, Bahlmann F, Kyvernitakis I. Combined treatment of McDonald cerclage and Arabin-pessary: a chance in the prevention of spontaneous preterm birth? J Matern Fetal Neonatal Med 2019; 33:3249-3257. [PMID: 30700183 DOI: 10.1080/14767058.2019.1570123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Patients with cervical shortening obtained by transvaginal ultrasound and/or previous preterm delivery are at increased risk for preterm birth in the current pregnancy. The aim of the present cohort study was to compare the rate of preterm birth and early neonatal parameters in patients at risk and screening patients who received either a cerclage or a combined treatment of cerclage and cervical pessary.Methods: A retrospective cohort study was conducted from March 2005 to March 2017 including all patients in our department which received a McDonald cerclage or a combined treatment of McDonald cerclage and an Arabin pessary. A total of 81 women with singleton pregnancies were considered the final sample of this cohort study, of whom 34 patients received a cerclage and 47 patients received a cerclage combined with a pessary. Patients "at risk" with a history of preterm birth at <37 weeks of gestation, late-term abortion, conization, or cervical cerclage in a previous pregnancy because of a cervical shortening <10th percentile and women with no inherent historic risk factors but a current cervical length <3rd percentile (screening group) were analyzed separately. We defined delivery <34 weeks of gestation as the primary outcome. Secondary outcomes were preterm birth (PTB) <28, <32, and <37 weeks of gestation, admission to the neonatal intensive care unit (NICU), neonatal admission time, birthweight, and prolongation of the gestation.Results: There were no differences between the two study groups with regard to baseline characteristics. Delivery <34 weeks of gestation occurred in 32.4 and 27.7% of patients treated with cerclage versus combined treatment respectively (p = .48). Similarly, there was no difference in the rate of preterm birth at <28, <32, or <37 weeks of gestation. The mean neonatal admission time at the neonatal intensive care unit was shorter in the combined treatment group versus in the cerclage group (p = .02). There was a trend for higher birthweight (2368 g ± 962 vs. 2650 g ± 1063) in favor of the combined treatment arm (p = .077).Conclusion: The combined treatment of cerclage with an Arabin pessary seems to be a considerable alternative in the prevention of spontaneous PTB (sPTB), especially for patients with cervical length <3rd percentile, and in particular for patients with amnion prolapse in terms of birthweight and neonatal admission time.
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Affiliation(s)
- Bartosch Georg Wolnicki
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
| | - Friederike von Wedel
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
| | - Niki Mouzakiti
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
| | - Ammar Al Naimi
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
| | - Akos Herzeg
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
| | - Franz Bahlmann
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
| | - Ioannis Kyvernitakis
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Childern's Hospital Frankfurt/Main, Frankfurt/Main, Germany
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Grabovac M, Lewis-Mikhael AM, McDonald SD. Interventions to Try to Prevent Preterm Birth in Women With a History of Conization: A Systematic Review and Meta-analyses. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:76-88.e7. [DOI: 10.1016/j.jogc.2018.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
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20
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Roman AR, Da Silva Costa F, Araujo Júnior E, Sheehan PM. Rescue Adjuvant Vaginal Progesterone May Improve Outcomes in Cervical Cerclage Failure. Geburtshilfe Frauenheilkd 2018; 78:785-790. [PMID: 30140107 PMCID: PMC6102116 DOI: 10.1055/a-0637-9324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/04/2018] [Accepted: 06/03/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction
Aim of the study was to evaluate the effect of rescue adjuvant vaginal progesterone in women with ongoing, transvaginal ultrasound (TVUS)-confirmed cervical shortening despite cervical cerclage.
Materials and Methods
A retrospective case control study was performed of women undergoing cervical surveillance following either history- or ultrasound-indicated cervical cerclage. We compared women managed with cervical cerclage and vaginal progesterone to women managed with cervical cerclage alone. Women with a singleton pregnancy who underwent cervical cerclage were identified from a database. Data on the concurrent use of vaginal progesterone, cervical length measurements, interventions and birth outcomes were collected from patient notes and clinical pathology notes. Patients from each intervention group were matched, based on exact shortest cervical length measurements obtained during surveillance and age of gestation when the measurement was obtained.
Results
66 women were matched and included in the study, based on exact shortest cervical length measurements. Each group had an identical mean shortest cervical length of 12.09 mm. The outcomes of 33 women who received both cervical cerclage and vaginal progesterone were compared to the outcomes of 33 women who were treated with cervical cerclage alone. The administration of vaginal progesterone to women with ongoing cervical shortening despite cervical cerclage was found to significantly prolong the pregnancy (36.36 weeks vs. 32.63 weeks; p = 0.0036) compared to women treated with cerclage alone. This use of rescue adjuvant vaginal progesterone was also associated with higher birth weights (2829 g vs. 2134 g; p = 0.0065) compared to women who had cervical cerclage alone; however, there was no difference in Apgar scores, composite neonatal morbidity or neonatal intensive care admission.
Conclusion
Women with cervical shortening despite the presence of cervical cerclage may benefit from further TVUS cervical length surveillance and the administration of vaginal progesterone if further cervical shortening occurs. Despite both groups having clinically significant shortened cervical lengths and cervical cerclage in situ, adjunct vaginal progesterone treatment resulted in older gestational age at birth and higher birth weight. Further investigation and confirmation of this finding in a larger prospective trial is warranted to explore this potential benefit for the management of preterm birth in future.
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Affiliation(s)
- Alina R Roman
- Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Fabricio Da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University and Monash Ultrasound for Women, Clayton, Victoria, Australia
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil
| | - Penelope M Sheehan
- Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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21
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Jarde A, Lewis-Mikhael AM, Dodd JM, Barrett J, Saito S, Beyene J, McDonald SD. The More, the Better? Combining Interventions to Prevent Preterm Birth in Women at Risk: a Systematic Review and Meta-Analysis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 39:1192-1202. [PMID: 29197486 DOI: 10.1016/j.jogc.2017.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To systematically examine the evidence around the combination of interventions to prevent preterm birth. METHODS Without language restrictions, we searched clinicaltrials.gov and five electronic databases (Medline, EMBASE, CINAHL, Cochrane CENTRAL, and Web of Science) up to July 7, 2016. We included randomized and non-randomized studies where asymptomatic women at risk of preterm birth received any combination of progesterone, cerclage, or pessary compared with either one or no intervention. Primary outcomes were preterm birth <34 and <37 weeks and neonatal death. Two independent reviewers extracted data using a piloted form and assessed risk and direction of bias. We pooled data with unlikely or unclear bias using random-effects meta-analyses. Comparisons with likely bias (e.g., confounding by indication) were not pooled. RESULTS We screened 1335 results and assessed 154 full texts, including seven studies. In singletons, we found no differences in preterm birth <34 weeks when comparing pessary & progesterone with pessary alone (RR 1.30, 95% CI 0.70-2.42) or progesterone alone (RR 1.16, 95% CI 0.79-1.72). Similarly, we found no differences in preterm birth <37 weeks when comparing cerclage & progesterone with cerclage alone (RR 1.04, 95% CI 0.56-1.93) or with progesterone alone (RR 0.82, 95% CI 0.57-1.19) nor between pessary & progesterone and pessary alone (RR 1.04, 95% CI 0.62-1.74). No data were available for neonatal death in singletons. CONCLUSIONS Despite being a common clinical practice, evidence to support the combined use of multiple versus single interventions for preventing preterm birth is scarce.
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Affiliation(s)
- Alexander Jarde
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON.
| | | | - Jodie M Dodd
- The Robinson Research Institute, Discipline of Obstetrics & Gynaecology, University of Adelaide, Adelaide, Australia
| | - Jon Barrett
- Sunnybrook Health Sciences Centre, Toronto, ON
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Joseph Beyene
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON
| | - Sarah D McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON
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22
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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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23
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Kyvernitakis I, Maul H, Bahlmann F. Controversies about the Secondary Prevention of Spontaneous Preterm Birth. Geburtshilfe Frauenheilkd 2018; 78:585-595. [PMID: 29962517 PMCID: PMC6018068 DOI: 10.1055/a-0611-5337] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/28/2018] [Accepted: 04/17/2018] [Indexed: 02/07/2023] Open
Abstract
Preterm birth is one of the major global health problems and part of the Millennium Development goals because of the associated high number of perinatal or neonatal mortality and long-term risks of neurodevelopmental and metabolic diseases. Transvaginal sonography has meanwhile been established as a screening tool for spontaneous preterm birth despite its relatively low sensitivity when considering only the cervical length. Vaginal progesterone has been shown to reduce prematurity rates below 34 weeks in a screening population of singleton pregnancies. Up to now, no positive long-term effect could be demonstrated after 2 years. It seems to have no benefit to prolong pregnancies after a period of preterm contractions and in risk patients without cervical shortening. Meta-analyses still demonstrate conflicting results dependent on quality criteria used for selection. A cerclage is only indicated in singleton pregnancies with previous spontaneous preterm birth and a combined cervical shortening in the current pregnancy. Nevertheless, the short- and long-term outcome has never been evaluated, whereas maternal complications may be increased. There is no evidence for a prophylactic cervical cerclage in twin pregnancies even in cases with cervical shortening. Emergency cerclage remains an indication after individual counseling. The effect of a cervical pessary in singleton pregnancy seems to be more pronounced in studies where a few investigators with increasing experience have treated and followed the patients at risk for preterm birth. Mainly in twin pregnancies, pessary treatment seems to be promising compared to other treatment options of secondary prevention when the therapy is started at early stages of precocious cervical ripening. At present, several international trials with the goal to reduce global rates of prematurity are in progress which will hopefully allow to specify the indications and methods of intervention for certain subgroups. When trials are summarized, prospective meta-analyses carry a lower risk of bias than the meanwhile uncontrolled magnitude of retrospective meta-analyses with conflicting results.
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Affiliation(s)
- Ioannis Kyvernitakis
- Dpt. of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt a. M., Dr. Senckenberg Foundation and Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Holger Maul
- Dpt. of Obstetrics and Prenatal Medicine, Asklepios Kliniken Barmbek and Nord-Heidberg, Hamburg, Germany
| | - Franz Bahlmann
- Dpt. of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt a. M., Dr. Senckenberg Foundation and Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
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24
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Lee KN, Whang EJ, Chang KHJ, Song JE, Son GH, Lee KY. History-indicated cerclage: the association between previous preterm history and cerclage outcome. Obstet Gynecol Sci 2018; 61:23-29. [PMID: 29372146 PMCID: PMC5780317 DOI: 10.5468/ogs.2018.61.1.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Our hospital's policy is to perform history-indicated cerclage (HIC) for pregnant patients with 1 or more second-trimester pregnancy losses. Recently, the American College of Obstetricians and Gynecologists (ACOG) guideline regarding indications for HIC was changed from 3 or more previous second-trimester fetal losses to one or more. In this study, we aimed to evaluate the efficacy of the revised guideline and to investigate the association between previous preterm history and cerclage outcome. METHODS We conducted a retrospective observational study of cases of HIC in singleton pregnancies performed at our hospital between January 2007 and June 2016. We compared the perioperative complications and incidences of preterm delivery in patients with one previous second-trimester pregnancy loss against those in patients with ≥2 losses. RESULTS The incidence of preterm delivery (<32 weeks) was significantly lower in patients with one previous second-trimester pregnancy loss than in those with ≥2 losses (15/194 [8%] vs. 28/205 [14%]). In the 1 loss and ≥2 losses groups, the rates of preterm premature rupture of membranes (PPROM) were 7% and 8%, the rates of PPROM at <32 weeks 2.1% and 3.4%, and the ratios of neonatal intensive care unit admission 10% and 17%, respectively. CONCLUSION Comparison of HIC in one previous second-trimester pregnancy loss group with HIC in the 2 or more previous second-trimester pregnancy loss group found no difference in pregnancy outcome. This finding supports the amended ACOG guideline for HIC indications. Based on our results, we also propose development of a new protocol for HIC-related complications.
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Affiliation(s)
- Kyong-No Lee
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Eun-Jee Whang
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kylie Hae-Jin Chang
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Eun Song
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Ga-Hyun Son
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Keun-Young Lee
- Department of Obstetrics and Gynecology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
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25
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Herrera-Muñoz A, Fernández-Alonso AM, Fischer-Suárez N, Chedraui P, Pérez-López FR. Maternal serum cytokine levels in pregnancies complicated with threatened preterm labour. Gynecol Endocrinol 2017; 33:408-412. [PMID: 28277132 DOI: 10.1080/09513590.2017.1284786] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To investigate serum inflammatory markers in singleton gestations complicated with threatened preterm labour (TPL). METHODS Pregnant women complicated with TPL (n = 61) were recruited to measure maternal serum levels of a panel of cytokines and C-reactive protein and then compared to controls without TPL, matched for gestational age (n = 64) and term pregnancies in the prodromal phase of labour (PPL) (n = 31). In addition, baseline cytokine levels were compared among cases and controls according to the outcome. RESULTS Women with TPL displayed higher CRP and white blood counts levels together with lower granulocyte macrophage colony-stimulating factor (GMC-SF) compared to both controls without TPL and to term gestations in the PPL. Also, interleukin 10 (IL-10), IL-6, IL-7, IL-8 and tumour necrosis alpha (TNF-α) levels were found significantly higher in TPL cases as compared to controls without TPL and term women in the PLL. Baseline cytokine levels (except IL-10) were higher among TPL cases who later delivered preterm. TPL cases delivering preterm displayed lower GMC-SF levels as compared to those delivering at term. Multivariate analysis found that gestational age at birth positively correlated with cervical length and inversely with CRP, IL-6 and TNF-α levels (p < 0.0001). CONCLUSIONS TPL and preterm birth were related to inflammatory changes in the maternal side that correlate with cervical shortening and the initiation of uterine contractions.
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Affiliation(s)
| | | | | | - Peter Chedraui
- b Institute of Biomedicine, Research Area for Women's Health, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil , Guayaquil , Ecuador , and
| | - Faustino R Pérez-López
- c Department of Obstetrics and Gynecology , Facultad de Medicina, Universidad de Zaragoza, Hospital Clínico Lozano Blesa , Zaragoza , Spain
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26
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van Zijl MD, Koullali B, Mol BW, Pajkrt E, Oudijk MA. Prevention of preterm delivery: current challenges and future prospects. Int J Womens Health 2016; 8:633-645. [PMID: 27843353 PMCID: PMC5098751 DOI: 10.2147/ijwh.s89317] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Preterm birth (PTB), defined as delivery at <37 weeks of gestation, is the most important cause of neonatal morbidity and mortality. Therefore, preventing PTB is one of the main goals in obstetric care. In this review, we provide an overview of the current available literature on screening for risk factors for PTB and a summary of preventive strategies in both low-risk and high-risk women with singleton or multiple gestations. Furthermore, current challenges and future prospects on PTB are discussed. For an optimal prevention of PTB, risk stratification should be based on a combination of (maternal) risk factors, obstetric history, and screening tools. Cervical length measurements can help identify women at risk. Thereafter, preventive strategies such as progesterone, pessaries, and cerclage may help prevent PTB. Effective screening and prevention of PTB vary between the different pregnancy populations. In singleton or multiple pregnancies with a short cervix, without previous PTB, a pessary or progesterone might prevent PTB. In women with a (recurrent) PTB in the past, progesterone and a cerclage may prevent recurrence. The effect of a pessary in these high-risk women is currently being studied. A strong collaboration between doctors, patients' organizations, pharmaceutical companies, and (international) governments is needed to reduce the morbidity and mortality as a result of spontaneous PTB.
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Affiliation(s)
- Maud D van Zijl
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bouchra Koullali
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ben Wj Mol
- The Robinson Research Institute, School for Reproductive Health and Pediatrics, University of Adelaide, Adelaide, SA, Australia
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
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27
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Karbasian N, Sheikh M, Pirjani R, Hazrati S, Tara F, Hantoushzadeh S. Combined treatment with cervical pessary and vaginal progesterone for the prevention of preterm birth: A randomized clinical trial. J Obstet Gynaecol Res 2016; 42:1673-1679. [DOI: 10.1111/jog.13138] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/16/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Niloofar Karbasian
- Breastfeeding Research Center; Tehran University of Medical Sciences; Tehran Iran
| | - Mahdi Sheikh
- Maternal, Fetal and Neonatal Research Center; Tehran University of Medical Sciences; Tehran Iran
| | - Reihaneh Pirjani
- Arash Women's Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Shahla Hazrati
- Maternal, Fetal and Neonatal Research Center; Tehran University of Medical Sciences; Tehran Iran
| | - Fatemeh Tara
- Breastfeeding Research Center; Tehran University of Medical Sciences; Tehran Iran
| | - Sedigheh Hantoushzadeh
- Maternal, Fetal and Neonatal Research Center; Tehran University of Medical Sciences; Tehran Iran
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28
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Abstract
Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.
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Affiliation(s)
- Angie C. Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kirsten Salmeen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Dawn Gano
- Departments of Neurology & Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Irina Burd
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mari-Paule Thiet
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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