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Story L, Shennan A. Cervical cerclage: An evolving evidence base. BJOG 2024. [PMID: 38962809 DOI: 10.1111/1471-0528.17905] [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: 10/23/2023] [Revised: 02/05/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
Cervical cerclage is an established intervention for the management of pregnancies at high risk of preterm birth. Although studies exist to support its use in certain situations, particularly in singleton pregnancies, many questions such as adjunct therapies and efficacy in specific subgroups of high-risk women have not been fully elucidated. This review will assess the current evidence as well as areas where there is currently a paucity of data and an urgent requirement for further research.
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Affiliation(s)
- Lisa Story
- Department of Women and Children's Health King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Hanke K, Fortmann MI, Auerswald GH, Härtel C, Olbertz D, Roll C, Grüttner B, Wieg C, Breunig S, Rody A, Felderhoff-Müser U, Herting E, Göpel W, Bossung V. Use and Impact of Pessary, Cerclage, and Progesterone for the Secondary Prevention of Preterm Birth: Data from the German Neonatal Network. Z Geburtshilfe Neonatol 2024; 228:246-254. [PMID: 38228167 DOI: 10.1055/a-2217-9463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND To evaluate the use and effect of cervical stitch cerclage, pessary, and progesterone on pregnancy outcome in mothers of very low birth weight infants (VLBWI) born<32 weeks of gestation in the German Neonatal Network (GNN). METHODS The GNN is a population-based cohort study enrolling VLBWI since 2009. We included 575 neonates from 424 mothers into our analysis, who were born between 2015 and 2019, after prenatal intervention with cerclage, pessary, progesterone or a combination between 20/0 to 25/0 weeks of gestation to prevent preterm birth. Median intervention-to-birth interval was the primary endpoint. RESULTS 231 of 424 pregnant women had a cerclage only (54.5%), 76 women a pessary only (17.9%), and 27 were prescribed progesterone only (15.3%). The most common combination treatment (>1 intervention group) was cerclage plus progesterone (n=27), followed by cerclage plus pessary (n=13). The median intervention-to-birth interval for the whole cohort was 24 days (IQR 19.0 days). The earlier the intervention was started, the longer the intervention-to-birth interval lasted: When started at 20 weeks, the interval was 34 days in contrast to 11.5 days, when started at 25 weeks. The >1 group was born at a significantly higher median GA with 27.0 weeks (IQR 2.9 weeks) and a higher median birth weight of 980 g (IQR 394 g) accordingly. CONCLUSION We propose that the earliest possible start of intervention leads to the most efficient pregnancy prolongation.
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Affiliation(s)
- Kathrin Hanke
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Mats Ingmar Fortmann
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Gesa Henrike Auerswald
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Christoph Härtel
- Department of Pediatrics, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Dirk Olbertz
- Department of Neonatology, University of Rostock, Rostock, Germany
| | - Claudia Roll
- Neonatology and Paediatric Intensive Care, Vestische Kinder- und Jugendklinik Datteln, Datteln, Germany
| | | | - Christian Wieg
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau gGmbH, Aschaffenburg, Germany
| | - Stephanie Breunig
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau gGmbH, Aschaffenburg, Germany
| | - Achim Rody
- Department of Obstetrics and Gynaecology, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | | | - Egbert Herting
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
| | - Verena Bossung
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland and 15 -University of Zurich, Zurich, Switzerland
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Roero S, Benedetto G, Charrier L, Ingala A, Ronco A, Fea T, Borgarello V, Bossotti C, Arduino S, Revelli A. Is the Early Screening of Lower Genital Tract Infections Useful in Preventing Adverse Obstetrical Outcomes in Twin Pregnancy? J Clin Med 2024; 13:2673. [PMID: 38731202 PMCID: PMC11084808 DOI: 10.3390/jcm13092673] [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: 04/11/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Objectives: Twin pregnancy implies a higher risk of preterm birth and, consequently, higher neonatal morbidity and mortality. In singleton pregnancies, infections of the lower genital tract (LGTIs) and bacterial vaginosis are associated with preterm labor, and their early detection has been proven effective in reducing complications like the preterm premature rupture of membranes (pPROM) and preterm delivery. The same evidence, however, is lacking for twin pregnancies. This study aimed to evaluate whether the early identification and treatment of LGTIs or bacterial vaginosis in asymptomatic women with twin pregnancy could reduce the rate of miscarriages, pPROM, and preterm birth. Methods: This study performed a retrospective comparison of 285 women with a multiple pregnancy submitted for a cervico-vaginal swab only at 20-22 weeks (Single Test Group, STG), and 199 women who underwent the swab at 12-14 and again at 20-22 weeks (Double Test Group, DTG). All women included in the study had a twin pregnancy and were followed up at Sant'Anna Hospital, Turin (Italy), between September 2012 and February 2021. Results: In STG, 21.7% of patients had a positive swab; in DTG, 19.9% had an early positive swab that was immediately treated by targeted antibiotics; and 16.7% had a mid-pregnancy positive swab. The DTG showed a significantly lower incidence of pPROM in univariate analysis (14.4% vs. 23.1%, p = 0.021), which was confirmed by multivariate analysis (OR 0.55, CI 0.33-0.93, p = 0.025). Conclusions: Our study suggests that, in asymptomatic women with twin pregnancy, the early screening of LGTIs and bacterial vaginosis by a cervico-vaginal swab at 12-14 weeks of gestational age is effective in reducing the risk of pPROM.
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Affiliation(s)
- Sofia Roero
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Giulia Benedetto
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Lorena Charrier
- Departement of Public Health and Pediatrics, A.O.U. Città della Salute e della Scienza, University of Turin, Via Santena 5, 10126 Turin, Italy
| | - Agata Ingala
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Alice Ronco
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Teresa Fea
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Valentina Borgarello
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Carlotta Bossotti
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Silvana Arduino
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
| | - Alberto Revelli
- Twin Pregnancy Care Unit, Gynecology and Obstetrics 2U, A.O.U. Città della Salute e della Scienza, Sant’Anna Hospital, University of Turin (Department of Surgical Sciences), Via Ventimiglia 1, 10126 Turin, Italy
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Peng L, Gao Y, Yuan C, Kuang H. Effects of vaginal progesterone and placebo on preterm birth and antenatal outcomes in women with singleton pregnancies and short cervix on ultrasound: a meta-analysis. Front Med (Lausanne) 2024; 11:1328014. [PMID: 38646553 PMCID: PMC11026645 DOI: 10.3389/fmed.2024.1328014] [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: 10/25/2023] [Accepted: 02/28/2024] [Indexed: 04/23/2024] Open
Abstract
Background Vaginal progesterone in preterm birth and adverse outcomes caused by cervical insufficiency remains controversial. To address it, the effect of vaginal progesterone on preterm delivery and perinatal outcome of single pregnancy women with short cervix (less than 25 mm) was systematically evaluated by meta-analysis. Methods "Vaginal progesterone," "placebo," "ultrasound," "cervix," "singleton pregnancy," "preterm birth," and "antenatal outcomes" were entered to screen clinical studies PubMed, Embase, and the Chinese Biomedical Literature Database (CBM). The study population consisted of women with singleton pregnancies and a short cervix on ultrasound, and were assigned into the progesterone group (n = 1,368) and the placebo group (n = 1,373). Treatment began after the patient was diagnosed with short cervix until delivery. Neonatal survival rate, Neonatal Intensive Care Unit (NICU) admission rate, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), neonatal mortality, and birth weight <1,500 g were analyzed. Results A total of 8 articles, totaling 2,741 study subjects, were enrolled. The progesterone group exhibited an obvious reduced rate of preterm birth at <34 weeks (OR = 0.67, 95% CI: 0.53∼0.84; Z = 3.53, P = 0.004), preterm birth at <32 weeks (OR = 0.46, 95% CI: 0.28∼0.77; Z = 2.99, P = 0.003), NICU admission rate (OR = 0.45, 95% CI: 0.30∼0.66; Z = 0.15, P < 0.0001), RDS rate (OR = 0.42, 95% CI: 0.28∼0.63; Z = 4.25, P < 0.0001), IVH incidence rate (OR = 0.40, 95% CI: 0.17∼0.95; Z = 2.08, P = 0.04), neonatal mortality (OR = 0.25, 95% CI: 0.13∼0.46; Z = 4.39, P < 0.0001), and proportion of neonates with birth weight < 1,500 g (OR = 0.45, 95% CI: 0.32∼0.64; Z = 4.50, P < 0.0001). Conclusion Vaginal progesterone lowered the incidences of preterm birth and adverse pregnancy outcomes in women with singleton pregnancies and a short cervix.
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Affiliation(s)
- Limin Peng
- Department of Obstetrics, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
- Medical Department of First Clinical Medical College, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Yan Gao
- Department of Obstetrics, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Chengkun Yuan
- Department of Obstetrics, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Hongying Kuang
- Medical Department of First Clinical Medical College, Heilongjiang University of Chinese Medicine, Harbin, China
- Department of Gynecology, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
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De Vito M, Cetraro J, Capannolo G, Alameddine S, Patelli C, D'Antonio F, Rizzo G. Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines. J Perinat Med 2024; 52:262-269. [PMID: 38105222 DOI: 10.1515/jpm-2023-0262] [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: 06/26/2023] [Accepted: 10/23/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES Twin pregnancies are at increased risk of preterm birth (PTB) compared to singletons. Evaluation of cervical length (CL) represents the optimal tool to screen PTB in singleton. Conversely, there is less evidence on the use of CL in twins. Our aim was to evaluate the methodological quality and clinical heterogeneity of clinical practice guidelines (CPGs) on the CL application in twins using AGREE II methodology. METHODS MEDLINE, Scopus, and websites of the main scientific societies were examined. The following aspects were evaluated: diagnostic accuracy of CL, optimal gestational age at assessment and interventions in twin pregnancies with reduced CL. The quality of the published CPGs was carried out using "The Appraisal of Guidelines for REsearch and Evaluation (AGREE II)" tool. The quality of guideline was rated using a scoring system. Each considered item was evaluated by the reviewers on a seven-point scale that ranges from 1 (strongly disagree) to 7 (strongly agree). A cut-off >60 % identifies a CPGs as recommended. RESULTS The AGREE II standardized domain scores for the first overall assessment had a mean of 74 %. The score was more than 60 % in the 66.6 % of CPGs analyzed indicating an agreement between the reviewers on recommending the use of these CPGs. A significant heterogeneity was found; there was no specific recommendation on CL assessment in about half of the published CPGs. There was also significant heterogeneity on the CL cut-off to prompt intervention. CONCLUSIONS Despite the fact that the AGREE II analysis showed that the majority of the included guidelines are of good quality, there was a significant heterogeneity among CPGs as regard as the indication, timing, and cut-off of CL in twins as well as in the indication of interventions.
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Affiliation(s)
- Marika De Vito
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
| | - Jessica Cetraro
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
| | - Giulia Capannolo
- Department of Obstetrics and Gynecology, Università di Chieti, Chieti, Italy
| | - Sara Alameddine
- Department of Obstetrics and Gynecology, Università di Chieti, Chieti, Italy
| | - Chiara Patelli
- Department of Obstetrics and Gynecology, Università di Verona, Verona, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Università di Chieti, Chieti, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
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Calandra D, Mercaldi M, De Vito M, Buca D, Liberati M, Lucidi A, Rizzo G, D'Antonio F. Comparison between trans-vaginal and trans-abdominal ultrasound examination of the cervix in the second trimester of pregnancy: a prospective study. J Perinat Med 2024; 52:76-80. [PMID: 37942777 DOI: 10.1515/jpm-2023-0103] [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: 03/12/2023] [Accepted: 07/10/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To compare transvaginal (TV) and trans-abdominal (TA) ultrasound assessment of cervical length (CL) at the time of the second-trimester scan for fetal anomalies. METHODS This was a prospective study including consecutive pregnant women attending the low-risk ultrasound clinic of two fetal medicine centres in Italy. The inclusion criteria were women between 19 + 0 and 22 + 0 weeks of gestation, attending the prenatal ultrasound clinic for the routine second trimester screening for fetal anomalies. The primary outcome was to compare the CL measurement obtained at TV compared to TA ultrasound; the secondary outcome was to report the inter and intra-observer variability of CL measured with the two different approaches. All women underwent TV and TA assessment of the cervix performed by two experienced certified operators, blinded to each other. Intra-class correlation coefficients (ICC) and Bland-Altman analyses were used to analyse the data. RESULTS Two hundred and fifty women were included in the analysis. All women had anteverted uterus. The mean gestational age at ultrasound was 20.7 ± 0.7 weeks; 1.2 % (3/250) scans were performed at 19 weeks, 49.2 % (123/250) at 20 weeks, 44.8 % (112/250) at 21 weeks and 4.8 % (12/250) at 22 weeks of gestations. Identification of the major landmarks of CL at TA ultrasound was achieved in all the included cases. There was good reliability between CL measured at TA (ICC 0.95, 95 % CI 0.93-0.97 for observer 1 and 0.92 %, 95 % CI 0.89-0.94 for observer 2) and TV ultrasound 0.97, 95 % CI 0.96-0.98 for observer 1 and 0.96, 95 % CI 0.95-0.97 for observer 2). There was also good reliability between the two observers for both the TA and TV assessment of the CL. Mean TA CL was 41.4 ± 5.5 for observer 1 and 40.5 ± 4.8 for observer 2 with no significant differences between the two measurements (mean difference 0.92 mm, 95 % CI -9.7 to 11.2). Likewise, there was no difference between the CL measured at TV ultrasound between the two observers (mean difference -0.83 mm, 95 % CI -5.97 to 4.30). Finally, there was no difference in the mean CL measured at TA compared to TV, either considering the overall population of women (mean difference: -0.43, 955 CI -8.65 to 7.79), or when stratifying the analysis according to the parity status and the operator. CONCLUSIONS Among experienced operators, there was no difference between TV and TA ultrasound assessment of the CL at the time of the routine anomaly scan for fetal anomaly.
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Affiliation(s)
- Davide Calandra
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Martina Mercaldi
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Marika De Vito
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Danilo Buca
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Alessandra Lucidi
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
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Creswell L, Rolnik DL, Lindow SW, O’Gorman N. Preterm Birth: Screening and Prediction. Int J Womens Health 2023; 15:1981-1997. [PMID: 38146587 PMCID: PMC10749552 DOI: 10.2147/ijwh.s436624] [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: 08/24/2023] [Accepted: 12/13/2023] [Indexed: 12/27/2023] Open
Abstract
Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.
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Affiliation(s)
- Lyndsay Creswell
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
| | - Daniel Lorber Rolnik
- Department of Obstetrics and Gynecology, Monash University, Melbourne, VIC, Australia
| | - Stephen W Lindow
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
| | - Neil O’Gorman
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
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Conde-Agudelo A, Romero R, Rehal A, Brizot ML, Serra V, Da Fonseca E, Cetingoz E, Syngelaki A, Perales A, Hassan SS, Nicolaides KH. Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in twin gestations: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 229:599-616.e3. [PMID: 37196896 PMCID: PMC10646154 DOI: 10.1016/j.ajog.2023.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To evaluate the efficacy of vaginal progesterone for the prevention of preterm birth and adverse perinatal outcomes in twin gestations. DATA SOURCES MEDLINE, Embase, LILACS, and CINAHL (from their inception to January 31, 2023), Cochrane databases, Google Scholar, bibliographies, and conference proceedings. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared vaginal progesterone to placebo or no treatment in asymptomatic women with a twin gestation. METHODS The systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was preterm birth <34 weeks of gestation. Secondary outcomes included adverse perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. We assessed the risk of bias in each included study, heterogeneity, publication bias, and quality of evidence, and performed subgroup and sensitivity analyses. RESULTS Eleven studies (3401 women and 6802 fetuses/infants) fulfilled the inclusion criteria. Among all twin gestations, there were no significant differences between the vaginal progesterone and placebo or no treatment groups in the risk of preterm birth <34 weeks (relative risk, 0.99; 95% confidence interval, 0.84-1.17; high-quality evidence), <37 weeks (relative risk, 0.99; 95% confidence interval, 0.92-1.06; high-quality evidence), and <28 weeks (relative risk, 1.00; 95% confidence interval, 0.64-1.55; moderate-quality evidence), and spontaneous preterm birth <34 weeks of gestation (relative risk, 0.97; 95% confidence interval, 0.80-1.18; high-quality evidence). Vaginal progesterone had no significant effect on any of the perinatal outcomes evaluated. Subgroup analyses showed that there was no evidence of a different effect of vaginal progesterone on preterm birth <34 weeks of gestation related to chorionicity, type of conception, history of spontaneous preterm birth, daily dose of vaginal progesterone, and gestational age at initiation of treatment. The frequencies of preterm birth <37, <34, <32, <30, and <28 weeks of gestation and adverse perinatal outcomes did not significantly differ between the vaginal progesterone and placebo or no treatment groups in unselected twin gestations (8 studies; 3274 women and 6548 fetuses/infants). Among twin gestations with a transvaginal sonographic cervical length <30 mm (6 studies; 306 women and 612 fetuses/infants), vaginal progesterone was associated with a significant decrease in the risk of preterm birth occurring at <28 to <32 gestational weeks (relative risks, 0.48-0.65; moderate- to high-quality evidence), neonatal death (relative risk, 0.32; 95% confidence interval, 0.11-0.92; moderate-quality evidence), and birthweight <1500 g (relative risk, 0.60; 95% confidence interval, 0.39-0.88; high-quality evidence). Vaginal progesterone significantly reduced the risk of preterm birth occurring at <28 to <34 gestational weeks (relative risks, 0.41-0.68), composite neonatal morbidity and mortality (relative risk, 0.59; 95% confidence interval, 0.33-0.98), and birthweight <1500 g (relative risk, 0.55; 95% confidence interval, 0.33-0.94) in twin gestations with a transvaginal sonographic cervical length ≤25 mm (6 studies; 95 women and 190 fetuses/infants). The quality of evidence was moderate for all these outcomes. CONCLUSION Vaginal progesterone does not prevent preterm birth, nor does it improve perinatal outcomes in unselected twin gestations, but it appears to reduce the risk of preterm birth occurring at early gestational ages and of neonatal morbidity and mortality in twin gestations with a sonographic short cervix. However, more evidence is needed before recommending this intervention to this subset of patients.
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Affiliation(s)
- Agustin Conde-Agudelo
- Pregnancy 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, United States 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
- Pregnancy 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, United States 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.
| | - Anoop Rehal
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Maria L Brizot
- Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vicente Serra
- Maternal-Fetal Medicine Unit, Instituto Valenciano de Infertilidad, University of Valencia, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain
| | - Eduardo Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Público Estadual Francisco Morato de Oliveira and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Elcin Cetingoz
- Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Argyro Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Alfredo Perales
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain; Department of Obstetrics, University Hospital La Fe, Valencia, Spain
| | - Sonia S Hassan
- Office of Women's Health, Integrative Biosciences Center, Wayne State University, Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Kypros H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
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Rodo C, Maiz N, Arevalo S, Lewi L, Couck I, Hollwitz B, Kyvernitakis I, Carreras E, Hecher K. The Arabin cervical pessary for the prevention of preterm birth in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation: a multicenter randomized controlled trial. Am J Obstet Gynecol 2023:S0002-9378(23)02059-8. [PMID: 38036166 DOI: 10.1016/j.ajog.2023.11.1245] [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: 07/10/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Miscarriage and preterm birth are leading causes of loss and disability in monochorionic twins after laser treatment of twin-twin transfusion syndrome. OBJECTIVE This study aimed to investigate the use of cervical pessary to reduce preterm birth before 32 weeks of gestation in monochorionic diamniotic twin pregnancies after fetal surgery for twin-twin transfusion syndrome. STUDY DESIGN In this open-label multicenter randomized trial, pregnant women carrying monochorionic diamniotic twins requiring fetoscopic laser coagulation for twin-twin transfusion syndrome were randomly assigned in a 1:1 ratio to pessary placement or conservative management. The primary outcome was birth before 32 weeks of gestation. The secondary outcomes were birth before 28, 30, 34, or 37 weeks of gestation; preterm premature rupture of membranes; fetal and neonatal survival; and a composite of maternal and neonatal complications. The estimated sample size was 364 patients, with 182 cases in each arm of the study. The analysis was performed according to the intention-to-treat principle. Moreover, 2 interim analyses were planned. RESULTS The trial was stopped prematurely after the first planned interim analysis for futility. Overall, 137 women were included in the analysis, 67 in the pessary group and 70 in the conservative management group. Preterm birth before 32 weeks of gestation occurred in 27 of 67 women (40.3%) in the pessary group and in 25 of 70 women (35.7%) in the conservative management group (adjusted odds ratio, 1.19; 95% confidence interval, 0.58-2.47; P=.63). No differences between groups was observed in the rate of deliveries before 28, 30, 34, and 37 weeks of gestation. Overall survival to delivery was 91.2% (125/137) for at least 1 twin, and 70.8% (97/137) for both twins, with no difference between groups. Neonatal survival at 30 days was 76.5% (208/272). There was no difference between the groups in maternal or neonatal morbidity. CONCLUSION In monochorionic diamniotic twin pregnancies requiring fetal therapy for twin-twin transfusion syndrome, routine use of cervical pessary did not reduce the rate of preterm birth before 32 weeks of gestation.
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Affiliation(s)
- Carlota Rodo
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain.
| | - Nerea Maiz
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain.
| | - Silvia Arevalo
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Isabel Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Bettina Hollwitz
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ioannis Kyvernitakis
- Department of Obstetrics and Prenatal Medicine, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Elena Carreras
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Shynlova O, Nadeem L, Lye S. Progesterone control of myometrial contractility. J Steroid Biochem Mol Biol 2023; 234:106397. [PMID: 37683774 DOI: 10.1016/j.jsbmb.2023.106397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/01/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023]
Abstract
During pregnancy, the primary function of the uterus is to be quiescent and not contract, which allows the growing fetus to develop and mature. A uterine muscle layer, myometrium, is composed of smooth muscle cells (SMCs). Before the onset of labor contractions, the uterine SMCs experience a complex biochemical and molecular transformation involving the expression of contraction-associated proteins. Labor is initiated when genes in SMCs are activated in response to a combination of hormonal, inflammatory and mechanical signals. In this review, we provide an overview of molecular mechanisms regulating the process of parturition in humans, focusing on the hormonal control of the myometrium, particularly the steroid hormone progesterone. The primary reason for discussing the regulation of myometrial contractility by progesterone is the importance of the clinical problem of preterm birth. It is thought that the hormonal mechanisms regulating premature uterine contractions represent an untimely triggering of the normal events occurring during term parturition. Yet, our knowledge of the complex and redundant hormonal pathways controlling uterine contractile activity leading to delivery of the neonate remains incomplete. Finally, we introduce recent animal studies using a novel class of drugs, Selective Progesterone Receptor Modulators, targeting progesterone signaling to prevent premature myometrial contractions.
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Affiliation(s)
- Oksana Shynlova
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto M5G 1X5, Canada; Department of Physiology, University of Toronto, M5S 1A1, Canada; Department of Obstetrics & Gynecology, University of Toronto, M5S 1A1, Canada.
| | - Lubna Nadeem
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto M5G 1X5, Canada
| | - Stephen Lye
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto M5G 1X5, Canada; Department of Physiology, University of Toronto, M5S 1A1, Canada; Department of Obstetrics & Gynecology, University of Toronto, M5S 1A1, Canada
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11
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Creswell L, Burke B, O'Sullivan L, Lindow SW, O'Gorman N. A cross-sectional survey of women's views and preferences for preterm birth screening and treatment. Eur J Obstet Gynecol Reprod Biol 2023; 290:14-21. [PMID: 37713943 DOI: 10.1016/j.ejogrb.2023.09.005] [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: 08/15/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVES Primary outcomes were to determine; 1) the desire for more patient information from healthcare professionals on preterm birth (PTB) prevention 2) the desire for PTB screening surveillance or participation in research or 3) the acceptability of transvaginal ultrasound (TVUS) or vaginal examinations to predict spontaneous PTB. METHODS A 19-question, piloted, self-administered survey was completed by unselected pregnant women in a tertiary maternity hospital in Dublin, Ireland. Data was collected to include maternal socio-demographics, past obstetric history, and current pregnancy details, in addition to views and preferences on PTB screening and preventative treatments. Statistical analysis to include binary and multinomial regression was performed by IBM SPSS Statistics for Windows (Version 29.0). RESULTS 277 women completed the study survey. 9.4% of women had attended the preterm birth surveillance clinic (PSC). 75.1% of respondents indicated a preference for more information from healthcare professionals about PTB. 65% reported that TVUS and vaginal examinations were acceptable in pregnancy. The acceptability of antenatal examinations was significantly influenced by ethnicity; white European (OR 2.58, CI 1.12-5.95, p = 0.003) and Asian (OR 3.39, CI 1.18-9.67, p = 0.02). Discomfort (25.3%) and vaginal bleeding (11.9%) were the most frequently reported concerns about TVUS. 95.7% of unselected women indicated that they would accept treatment to prevent PTB. Vaginal progesterone (53.8%) was preferred treatment compared to cervical cerclage (15.9%) or cervical pessary (16.6%). 55.6% of respondents stated they attend or wish to attend for additional appointments or research opportunities for PTB screening. Women with a previous PTB or second trimester miscarriage were more likely to attend or wish to attend for PTB screening (OR 3.23, CI 1.34-7.79, p = 0.009). CONCLUSION PTB is an important healthcare priority for pregnant women in Ireland. However, women require more information, counselling and reassurance about the utility and safety of TVUS in PSCs.
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Affiliation(s)
| | - B Burke
- The Coombe Hospital, Dublin, Ireland
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12
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Tugrul Ersak D, Oluklu D, Beser DM, Hendem DU, Tokalıoglu EO, Kara O, Ayhan SG, Sahin D. Cervical sliding sign at second trimester in the prediction of early preterm birth in twin pregnancy. Int J Gynaecol Obstet 2023; 163:315-320. [PMID: 37431593 DOI: 10.1002/ijgo.14993] [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: 04/12/2023] [Revised: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To examine the cervical sliding sign (CSS) alongside cervical length (CL) in twin pregnancies to predict preterm birth (PB). METHODS Twin pregnancies (n = 37) with no known risk factor for PB were included in this prospective study. CSS was defined as the ultrasonographic finding in which the anterior lip of the cervix slides over the posterior lip with gentle and continuous pressure application. The CSS and CL measurements were held in the second trimester. Early PB was defined as the birth of the fetus before 32 weeks of gestation. The patients were divided into two groups as CSS-positive and CSS-negative. RESULTS Whereas 11 (29.7%) of the twin pregnancies were CSS-positive, 26 (70.3%) were CSS-negative. CSS positivity had a sensitivity of 75.0%, a specificity of 82.2%, a positive predictive value of 54.5%, and a negative predictive value of 92.3% to predict early PB. Multivariate logistic regression analysis revealed that CSS positivity was the only significant independent factor related to early PB. CONCLUSION CSS was shown to be superior to CL in providing a better insight to predict early PB. CSS evaluation should be performed in twin pregnancies.
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Affiliation(s)
- Duygu Tugrul Ersak
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Deniz Oluklu
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Dilek Menekse Beser
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Derya Uyan Hendem
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Eda Ozden Tokalıoglu
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ozgur Kara
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Sule Goncu Ayhan
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Dilek Sahin
- Department of Obstetrics and Gynecology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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13
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Heyborne K. Reassessing Preterm Birth Prevention After the Withdrawal of 17-α Hydroxyprogesterone Caproate. Obstet Gynecol 2023; 142:493-501. [PMID: 37441790 DOI: 10.1097/aog.0000000000005290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023]
Abstract
The U.S. Food and Drug Administration has recently withdrawn approval for 17-α hydroxyprogesterone caproate for prevention of recurrent preterm birth, and recent studies have called into question benefits of the pessary in the setting of a short cervix. Obstetric health care professionals are once again left with limited remaining options for preterm birth prevention. This narrative review summarizes the best current evidence on the use of vaginal progesterone, low-dose aspirin, and cerclage for the prevention of preterm birth; attempts to distill possible lessons learned from studies of progesterone and pessary, as well as their implementation into practice; and highlights areas where inroads into preterm birth prevention may be possible outside of the progesterone-aspirin-cerclage paradigm.
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Affiliation(s)
- Kent Heyborne
- Denver Health Medical Center and the University of Colorado School of Medicine, Aurora, Colorado
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14
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D’Antonio F, Eltaweel N, Prasad S, Flacco ME, Manzoli L, Khalil A. Cervical cerclage for prevention of preterm birth and adverse perinatal outcome in twin pregnancies with short cervical length or cervical dilatation: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004266. [PMID: 37535682 PMCID: PMC10456178 DOI: 10.1371/journal.pmed.1004266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 08/25/2023] [Accepted: 06/23/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND The optimal approach to prevent preterm birth (PTB) in twins has not been fully established yet. Recent evidence suggests that placement of cervical cerclage in twin pregnancies with short cervical length at ultrasound or cervical dilatation at physical examination might be associated with a reduced risk of PTB. However, such evidence is based mainly on small studies thus questioning the robustness of these findings. The aim of this systematic review was to determine the role of cervical cerclage in preventing PTB and adverse maternal or perinatal outcomes in twin pregnancies. METHODS AND FINDINGS Key databases searched and date of last search: MEDLINE, Embase, and CINAHL were searched electronically on 20 April 2023. Eligibility criteria: Inclusion criteria were observational studies assessing the risk of PTB among twin pregnancies undergoing cerclage versus no cerclage and randomized trials in which twin pregnancies were allocated to cerclage for the prevention of PTB or to a control group (e.g., placebo or treatment as usual). The primary outcome was PTB <34 weeks of gestation. The secondary outcomes were PTB <37, 32, 28, 24 weeks of gestation, gestational age at birth, the interval between diagnosis and birth, preterm prelabor rupture of the membranes (pPROM), chorioamnionitis, perinatal loss, and perinatal morbidity. Subgroup analyses according to the indication for cerclage (short cervical length or cervical dilatation) were also performed. Risk of bias assessment: The risk of bias of the included randomized controlled trials (RCTs) was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, while that of the observational studies using the Newcastle-Ottawa scale (NOS). Statistical analysis: Summary risk ratios (RRs) of the likelihood of detecting each categorical outcome in exposed versus unexposed women, and (b) summary mean differences (MDs) between exposed and unexposed women (for each continuous outcome), with their 95% confidence intervals (CIs) were computed using head-to-head meta-analyses. Synthesis of the results: Eighteen studies (1,465 twin pregnancies) were included. Placement of cervical cerclage in women with a twin pregnancy with a short cervix at ultrasound or cervical dilatation at physical examination was associated with a reduced risk of PTB <34 weeks of gestation (RR: 0.73, 95% CI [0.59, 0.91], p = 0.005 corresponding to a 16% difference in the absolute risk, AR), <32 (RR: 0.69, 95% CI [0.57, 0.84], p < 0.001; AR: 16.92%), <28 (RR: 0.54, 95% [CI 0.43, 0.67], 0.001; AR: 18.29%), and <24 (RR: 0.48, 95% CI [0.23, 0.97], p = 0.04; AR: 15.57%) weeks of gestation and a prolonged gestational age at birth (MD: 2.32 weeks, 95% [CI 0.99, 3.66], p < 0.001). Cerclage in twin pregnancy with short cervical length or cervical dilatation was also associated with a reduced risk of perinatal loss (RR: 0.38, 95% CI [0.25, 0.60], p < 0.001; AR: 19.62%) and composite adverse outcome (RR: 0.69, 95% CI [0.53, 0.90], p = 0.007; AR: 11.75%). Cervical cerclage was associated with a reduced risk of PTB <34 weeks both in women with cervical length <15 mm (RR: 0.74, 95% CI [0.58, 0.95], p = 0.02; AR: 29.17%) and in those with cervical dilatation (RR: 0.68, 95% CI [0.57, 0.80], p < 0.001; AR: 35.02%). The association between cerclage and prevention of PTB and adverse perinatal outcomes was exclusively due to the inclusion of observational studies. The quality of retrieved evidence at GRADE assessment was low. CONCLUSIONS Emergency cerclage for cervical dilation or short cervical length <15 mm may be potentially associated with a reduction in PTB and improved perinatal outcomes. However, these findings are mainly based upon observational studies and require confirmation in large and adequately powered RCTs.
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Affiliation(s)
- Francesco D’Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Nashwa Eltaweel
- Division of Biomedical Science, Warwick Medical School University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
| | - Maria Elena Flacco
- Department of Environmental and Preventive Sciences, University of Ferrara, Ferrara, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
- Twins Trust Centre for Research and Clinical Excellence, St George’s Hospital, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women’s Hospital, University of Liverpool, Liverpool, United Kingdom
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15
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Sorrenti S, Di Mascio D, Khalil A, Persico N, D'antonio F, Zullo F, D'ambrosio V, Greenberg G, Hasson J, Vena F, Muzii L, Brunelli R, Giancotti A. Pregnancy and perinatal outcomes of early vs late selective termination in dichorionic twin pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:552-558. [PMID: 36412550 DOI: 10.1002/uog.26126] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To evaluate outcomes of dichorionic twin pregnancies undergoing early vs late selective termination of pregnancy (ST). METHODS MEDLINE, EMBASE, CINAHL and the Web of Science databases were searched electronically up to March 2022. The primary outcome of this study was pregnancy loss prior to 24 weeks' gestation. The secondary outcomes included preterm birth (PTB) before 37, 34, and 32 weeks, preterm prelabor rupture of membranes (PPROM), gestational age (GA) at delivery, Cesarean delivery, mean birth weight, 5-min Apgar score < 7, overall neonatal morbidity and neonatal survival. Only prospective or retrospective studies reporting data on the outcome of early (before 18 weeks) vs late (at or after 18 weeks) ST in dichorionic twin pregnancies were considered suitable for inclusion. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale for cohort studies. Random-effects head-to-head meta-analysis was used to analyze the data. RESULTS Seven studies reporting on 649 dichorionic twin pregnancies were included in this systematic review. The risk of pregnancy loss prior to 24 weeks was significantly lower in dichorionic twin pregnancies undergoing early compared with late ST (1% vs 8%; odds ratio (OR), 0.25 (95% CI, 0.10-0.65); P = 0.004). The risk of PTB was significantly lower in dichorionic twin pregnancies undergoing early compared with late ST when considering PTB before 37 weeks (19% vs 45%; OR, 0.36 (95% CI, 0.23-0.57); P < 0.00001), before 34 weeks (4% vs 19%; OR, 0.24 (95% CI, 0.11-0.54); P = 0.0005) and before 32 weeks (4% vs 20%; OR, 0.21 (95% CI, 0.05-0.85); P = 0.03). The mean birth weight was significantly greater in the early-ST group (mean difference (MD), 392.2 g (95% CI, 59.1-726.7 g); P = 0.02), as was the mean GA at delivery (MD, 2.47 weeks (95% CI, 0.04-4.91 weeks); P = 0.049). There was no significant difference between dichorionic twin pregnancies undergoing early compared with late ST in terms of PPROM (P = 0.27), Cesarean delivery (P = 0.38), 5-min Apgar score < 7 (P = 0.35) and neonatal survival of the non-reduced twin (P = 0.54). CONCLUSIONS The risk of pregnancy loss prior to 24 weeks and the rate of PTB before 37, 34 and 32 weeks were significantly higher in dichorionic twin pregnancies undergoing late vs early ST, thus highlighting the importance of early diagnosis of fetal anomalies in twin pregnancies. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Sorrenti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - N Persico
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - F D'antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - F Zullo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - V D'ambrosio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - G Greenberg
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Hasson
- Faculty of Health Sciences, Assuta Medical Center, Ben-Gurion University, Be'er Sheva, Israel
| | - F Vena
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - L Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - R Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - A Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
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16
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Silva TV, Borovac-Pinheiro A, França MS, Marquat KF, Argenton JP, Mol BW, Pacagnella RC. The Use of Mid-Pregnancy Cervical Length to Predict Preterm Birth in Brazilian Asymptomatic Twin Gestations. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:171-178. [PMID: 37224838 PMCID: PMC10208731 DOI: 10.1055/s-0043-1769467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To describe a reference curve for cervical length (CL) in mid-trimester twin gestations using transvaginal ultrasound (TVU) and to investigate whether short CL increases spontaneous preterm birth (sPTB) in asymptomatic twin pregnancies. METHODS This was a prospective cohort study performed at 17 outpatient antenatal facilities of Brazil with women at 18 0/7 to 22 6/7 weeks of gestation who participated in a randomized clinical trial screening phase (P5 trial) between July 2015 and March 2019. TVU was performed to provide CL measurement in all screened women. Almost all women with CL ≤ 30 mm received vaginal progesterone 200mg/day and they were also randomized to receive cervical pessary or not. We considered data from the CL distribution among asymptomatic twin pregnancies and analyzed CL and its association with PTB generating receiver operating characteristics (ROC) curves and Kaplan-Meier curves. RESULTS A total of 253 pregnant women with twins were included in the distribution curve. The mean CL was 33.7 mm and median was 35.5mm. The 10th percentile was 17.8mm. We identified a PTB rate of 73.9% (187/253) with 33.6% of sPTB < 37 (85/253) and 15% (38/253) of sPTB < 34 weeks. The best cutoff point to predict sPTB < 37 was 24.15 mm. However, the ROC curve showed a poor performance (0.64). The Kaplan-Meier survival curves identified that only CL values ≤ 20mm were associated to sPTB < 34 weeks. CONCLUSION A cutoff point of CL ≤ 20 mm can be interesting point to identify short cervix in Brazilian twin pregnancies. However, in Brazilian asymptomatic twin pregnancies, CL does not show a good performance to predict PTB.
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Affiliation(s)
- Thaís Valéria Silva
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, SP, Brazil
- CISAM Maternity Hospital, University of Pernambuco, Recife, PE, Brazil
| | - Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, SP, Brazil
| | - Marcelo Santucci França
- Department of Obstetrics, Screening and Prevention of Preterm Birth Sector, Discipline of Fetal Medicine, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, SP, Brazil
| | - Kaline Fernandes Marquat
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, SP, Brazil
| | - Juliana Passos Argenton
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, SP, Brazil
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecologic, Monash University, Clayton, Victoria, Australia
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom
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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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The Controversies and Challenges in the Management of Twin Pregnancy: From the Perspective of International Federation of Gynecology and Obstetrics Guidelines. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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19
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Vaginal Nanoformulations for the Management of Preterm Birth. Pharmaceutics 2022; 14:pharmaceutics14102019. [PMID: 36297454 PMCID: PMC9611874 DOI: 10.3390/pharmaceutics14102019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 12/01/2022] Open
Abstract
Preterm birth (PTB) is a leading cause of infant morbidity and mortality in the world. In 2020, 1 in 10 infants were born prematurely in the United States. The World Health Organization estimates that a total of 15 million infants are born prematurely every year. Current therapeutic interventions for PTB have had limited replicable success. Recent advancements in the field of nanomedicine have made it possible to utilize the vaginal administration route to effectively and locally deliver drugs to the female reproductive tract. Additionally, studies using murine models have provided important insights about the cervix as a gatekeeper for pregnancy and parturition. With these recent developments, the field of reproductive biology is on the cusp of a paradigm shift in the context of treating PTB. The present review focuses on the complexities associated with treating the condition and novel therapeutics that have produced promising results in preclinical studies.
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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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Diagnostic Pitfall in Atypical Febrile Presentation in a Patient with a Pregnancy-Specific Dermatosis—Case Report and Literature Review. Medicina (B Aires) 2022; 58:medicina58070847. [PMID: 35888566 PMCID: PMC9315689 DOI: 10.3390/medicina58070847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 12/04/2022] Open
Abstract
Pruritic urticarial papules and plaques of pregnancy (PUPPP) usually occurs in the third trimester of pregnancy in primiparous women. It is a self-limiting inflammatory disorder with a still unknown pathogenic mechanism. The abdominal wall overdistension, with a subsequent inflammatory response due to damage to the connective tissue, represents a pathogenesis explanation. Clinical features involve intensely pruritic urticarial rash with edematous, erythematous papules and plaques. The clinical picture and dermal biopsy establish the diagnosis. Topical corticosteroids and oral antihistamines are usually sufficient, but sometimes systemic corticosteroids are necessary. Maternal and fetal prognosis is excellent, and the lesions resolve after birth with no scarring or pigmentary change. We present a case of a 36-year-old patient with a 32-week pregnancy who was admitted with a generalized pruritic rash accompanied by fever. The final diagnosis was decided after multiple pathology exclusions. Treatment consisted of systemic corticoid therapy. The patient gave birth by cesarean section to a healthy newborn without dermatological lesions or other conditions. Adding more PUPPP cases to the literature portfolio will bring more awareness to this under-recognized and under-reported skin disorder. We trust this case will encourage other physicians to publish more cases of pregnancy-specific dermatoses.
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22
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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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23
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Groussolles M, Winer N, Sentilhes L, Biquart F, Massoud M, Vivanti AJ, Bouchghoul H, Rozenberg P, Olivier P, Desbriere R, Chauleur C, Perrotin F, Coatleven F, Fuchs F, Bretelle F, Tsatsaris V, Salomon LJ, Sananes N, Kayem G, Houflin-Debarge V, Schmitz T, Benoist G, Arnaud C, Ehlinger V, Vayssière C. Arabin pessary to prevent adverse perinatal outcomes in twin pregnancies with a short cervix: a multicenter randomized controlled trial (PESSARONE). Am J Obstet Gynecol 2022; 227:271.e1-271.e13. [PMID: 35123930 DOI: 10.1016/j.ajog.2022.01.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/17/2022] [Accepted: 01/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The number of twin pregnancies continues to increase worldwide as both the number of pregnancies obtained by medically assisted reproduction and age at first pregnancy keep rising. Preterm delivery is the major complication associated with twin pregnancies. The effectiveness of preventive treatments such as progesterone or cervical cerclage for women with a short cervix is doubtful in twin pregnancies. The effectivity of cervical pessaries in preventing preterm birth and its associated morbidity and mortality is also controversial. OBJECTIVE We sought to investigate if the Arabin pessary reduces adverse neonatal outcomes in twin pregnancies with a short cervix. STUDY DESIGN This open-label, multicenter, randomized controlled trial on twin pregnancies with a cervical length of <35 mm compared pessary placement at 16+0 to 24+0 weeks' gestation with standard care alone. The primary endpoint was a composite of adverse neonatal outcomes, namely peripartum or neonatal death or significant neonatal morbidity before hospital discharge, defined as at least 1 of the following complications: bronchopulmonary dysplasia, intraventricular hemorrhage grade III to IV, periventricular leukomalacia, necrotizing enterocolitis grade II or higher, culture-proven sepsis, and retinopathy requiring treatment. A sample size of 308 pregnancies was planned to ensure 80% power to compare the proportions of women with at least 1 infant with an adverse neonatal outcome. The intention-to-treat analysis after multiple imputation of missing data, was supplemented with a secondary analysis that controlled for gestational age and cervical length, both at inclusion. The primary endpoint was also compared between randomization groups in the per-protocol population, which excluded patients with prespecified major protocol violations (mostly cervical cerclage and/or progesterone after inclusion). Secondary endpoints included preterm birth, spontaneous preterm birth, and pessary side effects. RESULTS In total, 315 women were randomized to either receive a pessary (n=157) or standard management (n=158). Overall, 10.8% (34 women) of participants had a missing value for the primary endpoint, mostly (79%) because of the lack of paternal consent for neonatal data collection. In the intention-to-treat analysis, the adverse neonatal outcome occurred in 16.8% of the pessary group vs in 22.5% of the control group (risk ratio, 0.69; 95% confidence interval, 0.39-1.23; P=.210). The per-protocol analysis did not show any significant difference between groups (risk ratio, 0.78; 95% confidence interval, 0.47-1.28; P=.320). The occurrence of preterm birth or spontaneous preterm birth did not differ significantly between groups. No serious side effects were associated with pessary use. CONCLUSION Pessary use in our study did not significantly reduce adverse neonatal outcomes in twin pregnancies with a short cervix.
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Abstract
Along with the rise of assisted reproductive technology, multifetal gestations increased dramatically. Twin pregnancies account for 97% of multifetal pregnancies and 3% of all births in the United States. Twins and higher-order multiples carry increased risks of obstetric, perinatal, and maternal complications; these risks increase with increasing fetal number. Neonatal morbidity and mortality in multifetal gestations is driven primarily by prematurity. Both spontaneous and indicated preterm births are increased in multifetal gestations, and only a limited number of strategies are available to mitigate this risk. No single intervention has been shown to decrease the rate of spontaneous preterm birth in most twin pregnancies. Low-dose aspirin prophylaxis is recommended in all multifetal pregnancies to reduce the risk of preeclampsia and its associated complications. Antenatal management of multifetal gestations depends on chorionicity, which should be established using ultrasonography in the first trimester. Unlike dichorionic twin gestations, monochorionic pregnancies experience unique complications because of their shared vascular connections, and therefore, need frequent ultrasound surveillance. Even uncomplicated twin gestations have higher rates of unanticipated stillbirth compared with singletons. Delivery of twin pregnancies is generally indicated in the late preterm to early term period depending on chorionicity and other clinical factors. For most diamniotic twin pregnancies with a cephalic presenting fetus, vaginal delivery after 32 weeks' gestation is a safe and reasonable option with high rates of success and no increased risk of perinatal morbidity.
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
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Tsonis O, Balogun S, Adjei JO, Mogekwu O, Iliodromiti S. Management of recurrent miscarriages: an overview of current evidence. Curr Opin Obstet Gynecol 2021; 33:370-377. [PMID: 34419993 DOI: 10.1097/gco.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recurrent miscarriage (RM) or recurrent pregnancy loss (RPL) is defined as the consecutive loss of two or more pregnancies before the age of viability. The exact prevalence of RM is unknown, but it has been reported between 1% and 2%. The objective of this review is to provide a critical summary of the latest evidence for the investigation and management of women with RM. RECENT FINDINGS RMs are associated with multiple factors including increased female age and lifestyle habits, as well as genetic factors, hereditary and acquired thrombophilia and infections. Metabolic and endocrine factors, in addition to anatomical causes such as uterine malformations have also been suggested as a causative factors of RM. SUMMARY The management of RM would be expected to cause specific, however, in the majority of the cases no cause is identified, and the factors associated with RM may not be causally related with the condition.
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Affiliation(s)
| | | | | | | | - Stamatina Iliodromiti
- Bart's Health NHS Trust
- Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University
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Di Renzo GC, Tosto V, Tsibizova V, Fonseca E. Prevention of Preterm Birth with Progesterone. J Clin Med 2021; 10:4511. [PMID: 34640528 PMCID: PMC8509841 DOI: 10.3390/jcm10194511] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/29/2022] Open
Abstract
Gestational age at birth is a critical factor for perinatal and adulthood outcomes, and even for transgenerational conditions' effects. Preterm birth (PTB) (prematurity) is still the main determinant for infant mortality and morbidity leading cause of infant morbidity and mortality. Unfortunately, preterm birth (PTB) is a relevant public health issue worldwide and the global PTB rate is around 11%. The premature activation of labor is underlined by complex mechanisms, with a multifactorial origin influenced by numerous known and probably unknown triggers. The possible mechanisms involved in a too early labor activation have been partially explained, and involve chemokines, receptors, and imbalanced inflammatory paths. Strategies for the early detection and prevention of this obstetric condition were proposed in clinical settings with interesting results. Progesterone has been demonstrated to have a key role in PTB prevention, showing several positive effects, such as lower prostaglandin synthesis, the inhibition of cervical stromal degradation, modulating the inflammatory response, reducing gap junction formation, and decreasing myometrial activation. The available scientific knowledge, data and recommendations address multiple current areas of debate regarding the use of progesterone in multifetal gestation, including different formulations, doses and routes of administration and its safety profile in pregnancy.
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Affiliation(s)
- Gian Carlo Di Renzo
- Centre of Perinatal and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Perugia, 06132 Perugia, Italy;
- Department of Obstetrics and Gynecology, Faculty of General Medicine, I.M. Sechenov First State University of Moscow, 119991 Moscow, Russia
| | - Valentina Tosto
- Centre of Perinatal and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Perugia, 06132 Perugia, Italy;
| | - Valentina Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, 197341 Saint Petersburg, Russia;
| | - Eduardo Fonseca
- Department of Obstetrics and Gynecology, Federal University of Paraiba, Joao Pessoa 58051-900, PB, Brazil;
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Bovbjerg ML. Current Resources for Evidence-Based Practice, September 2021. J Obstet Gynecol Neonatal Nurs 2021; 50:642-654. [PMID: 34437841 DOI: 10.1016/j.jogn.2021.08.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes an assessment of safety of birth centers in the United States and commentaries on reviews focused on aspirin prophylaxis in pregnancy and the new gestational weight gain evidence summary from the United States Preventive Services Task Force.
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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: 160] [Impact Index Per Article: 53.3] [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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