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Kyvernitakis I, Baschat AA, Malan M, Rath W, Berger R, Henrich W, Schleussner E, Yousefi B, Timmesfeld N, Maul H. Cervical pessary to prevent preterm birth and poor neonatal outcome: An integrity meta-analysis of randomized controlled trials focusing on adherence to the European Medical Device Regulation. Int J Gynaecol Obstet 2024; 165:607-620. [PMID: 37830250 DOI: 10.1002/ijgo.15169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/28/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Findings from randomized trials (RCTs) on cervical pessary treatment to prevent spontaneous preterm birth are inconsistent. OBJECTIVES Our hypothesis suggests that adhering to the European Medical Device Regulation (MDR) and following the instructions for use are essential prerequisites for successful therapy. Conversely, the non-adherence to these guidelines will probably contribute to its failure. SEARCH STRATEGY AND SELECTION CRITERIA Based on validated criteria from integrity assessments we performed a systematic review identifying 14 RCTs evaluating the effect of cervical pessaries. DATA COLLECTION AND ANALYSIS We analyzed the implications of 14 criteria each accounting for 0-2 points of a score reflecting the clinical evaluation plan (CEP) as proposed by the MDR to evaluate the risk-benefit ratio of medical devices. MAIN RESULTS Seven RCTs in each singleton and twin pregnancies (5193 "cases") were included, detecting a high heterogeneity within control groups (I2 = 85% and 87%, respectively, P < 0.01). The CEP score varied from 11 to 26 points for all studies. The most common reasons for low scores and potential data compromise were poor recruitment rates, no (completed) power analysis, and no pre-registration, but mainly non-adherence to technical, biological, and clinical equivalence to the instructions for use as required by the MDR. All trials with score values greater than 20 had applied audit procedures. Within this group we found significantly reduced rates of spontaneous preterm birth at less than 34 weeks within the pessary group in singleton (odds ratio 0.28; 95% confidence interval 0.12-0.65) and twin pregnancies (odds ratio 0.30; 95% confidence interval 0.13-0.67). Similarly, there was a significant reduction in the composite poor neonatal outcome in singleton (odds ratio 0.25; 95% confidence interval 0.10-0.61) and twin pregnancies (odds ratio 0.54; 95% confidence interval 0.35-0.82) after a pessary as compared with controls. CONCLUSION Non-audited RCTs and meta-analyses mixing studies of different clinical quality as pre-defined by a CEP and the MDR pose the risk for erroneous conclusions.
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Affiliation(s)
- Ioannis Kyvernitakis
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Ahmet A Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcel Malan
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Werner Rath
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Richard Berger
- Department of Obstetrics and Gynecology, Marienhaus Klinikum St. Elisabeth, Neuwied, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ekkehard Schleussner
- Department of Obstetrics and Prenatal Medicine, University of Jena, Jena, Germany
| | - Bahareh Yousefi
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Holger Maul
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
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van Dijk CE, van Gils AL, van Zijl MD, Koullali B, van der Weide MC, van den Akker ES, Hermsen BJ, van Baal WM, Visser H, van Drongelen J, Vollebregt KC, Muller M, van der Made FW, Gordijn SJ, de Mooij YM, Oudijk MA, de Boer MA, Mol BW, Kazemier BM, Pajkrt E. Cervical pessary versus vaginal progesterone in women with a singleton pregnancy, a short cervix, and no history of spontaneous preterm birth at less than 34 weeks' gestation: open label, multicentre, randomised, controlled trial. BMJ 2024; 384:e077033. [PMID: 38471724 DOI: 10.1136/bmj-2023-077033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To compare the effectiveness of cervical pessary and vaginal progesterone in the prevention of adverse perinatal outcomes and preterm birth in pregnant women of singletons with no prior spontaneous preterm birth at less than 34 weeks' gestation and who have a short cervix of 35 mm or less. DESIGN Open label, multicentre, randomised, controlled trial. SETTING 20 hospitals and five obstetric ultrasound practices in the Netherlands. PARTICIPANTS Women with a healthy singleton pregnancy and an asymptomatic short cervix of 35 mm or less between 18 and 22 weeks' gestation were eligible. Exclusion criteria were prior spontaneous preterm birth at less than 34 weeks, a cerclage in situ, maternal age of younger than 18 years, major congenital abnormalities, prior participation in this trial, vaginal blood loss, contractions, cervical length of less than 2 mm or cervical dilatation of 3 cm or more. Sample size was set at 628 participants. INTERVENTIONS 1:1 randomisation to an Arabin cervical pessary or vaginal progesterone 200 mg daily up to 36 weeks' of gestation or earlier in case of ruptured membranes, signs of infection, or preterm labour besides routine obstetric care. MAIN OUTCOME MEASURES Primary outcome was a composite adverse perinatal outcome. Secondary outcomes were rates of (spontaneous) preterm birth at less than 28, 32, 34, and 37 weeks. A predefined subgroup analysis was planned for cervical length of 25 mm or less. RESULTS From 1 July 2014 to 31 March 2022, 635 participants were randomly assigned to pessary (n=315) or to progesterone (n=320). 612 were included in the intention to treat analysis. The composite adverse perinatal outcome occurred in 19 (6%) of 303 participants with a pessary versus 17 (6%) of 309 in the progesterone group (crude relative risk 1.1 (95% confidence interval (CI) 0.60 to 2.2)). The rates of spontaneous preterm birth were not significantly different between groups. In the subgroup of cervical length of 25 mm or less, spontaneous preterm birth at less than 28 weeks occurred more often after pessary than after progesterone (10/62 (16%) v 3/69 (4%), relative risk 3.7 (95% CI 1.1 to 12.9)) and adverse perinatal outcomes seemed more frequent in the pessary group (15/62 (24%) v 8/69 (12%), relative risk 2.1 (0.95 to 4.6)). CONCLUSIONS In women with a singleton pregnancy with no prior spontaneous preterm birth at less than 34 weeks' gestation and with a midtrimester short cervix of 35 mm or less, pessary is not better than vaginal progesterone. In the subgroup of a cervical length of 25 mm or less, a pessary seemed less effective in preventing adverse outcomes. Overall, for women with single baby pregnancies, a short cervix, and no prior spontaneous preterm birth less than 34 weeks' gestation, superiority of a cervical pessary compared with vaginal progesterone to prevent preterm birth and consecutive adverse outcomes could not be proven. TRIAL REGISTRATION International Clinical Trial Registry Platform (ICTRP, EUCTR2013-002884-24-NL).
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Affiliation(s)
- Charlotte E van Dijk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Annabelle L van Gils
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Maud D van Zijl
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Bouchra Koullali
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Marijke C van der Weide
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Eline S van den Akker
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Brenda J Hermsen
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | | | - Henricus Visser
- Department of Obstetrics and Gynaecology, Ter Gooi Medical Center, Blaricum, Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Karlijn C Vollebregt
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Haarlem, Netherlands
| | - Moira Muller
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Haarlem, Netherlands
| | - Flip W van der Made
- Department of Obstetrics and Gynaecology, Sint Fransiscus Gasthuis, Rotterdam, Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Yolanda M de Mooij
- Department of Obstetrics and Gynaecology, Zaans Medisch Centrum, Zaandam, Netherlands
| | - Martijn A Oudijk
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marjon A de Boer
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ben Wj Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Brenda M Kazemier
- Department of Obstetrics, Wilhelmina's Children Hospital, UMC Utrecht, Utrecht, Netherlands
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
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3
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Luca AM, Bernad E, Nemescu D, Vaduva C, Harabor A, Adam AM, Harabor V, Nechita A, Strobescu C, Mogos R, Carauleanu A, Vasilache IA, Socolov D. Unraveling the Efficacy of Therapeutic Interventions for Short Cervix: Insights from a Retrospective Study for Improved Clinical Management. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1018. [PMID: 37374221 DOI: 10.3390/medicina59061018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Preterm birth (PTB) is associated with important neonatal mortality and morbidity. The aim of this study was to retrospectively evaluate the average treatment effects on the treated and the efficacity of various therapeutic interventions for PTB in a cohort of patients with singleton pregnancies and short cervical lengths. Materials and Methods: This observational retrospective study included 1146 singleton pregnancies at risk of PTB that were segregated into the following groups: intravaginal progesterone (group 1), Arabin pessary (group 2), McDonald cerclage (group 3), intravaginal progesterone and Arabin pessary (group 4), and intravaginal progesterone and cerclage (group 5). Their treatment effects were evaluated and compared. Results: All evaluated therapeutic interventions significantly reduced the occurrence of late and early preterm births. The risk of late and early PTB was lowered for those pregnant patients who received progesterone and pessaries or progesterone and cerclage in comparison with those who received only progesterone. The extremely PTB risk of occurrence was significantly lowered only by the administration of progesterone in association with cervical cerclage in comparison with progesterone monotherapy. Conclusions: The combined therapeutic interventions had the highest efficacy in preventing preterm birth. An individualized evaluation is needed to establish the best therapeutic approach in particular cases.
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Affiliation(s)
- Alina-Madalina Luca
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Elena Bernad
- Department of Obstetrics and Gynecology, Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Dragos Nemescu
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristian Vaduva
- Department of Mother and Child Medicine, Faculty of Medicine, University of Medicine and Pharmacy, 200349 Craiova, Romania
| | - Anamaria Harabor
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Ana-Maria Adam
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Valeriu Harabor
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Aurel Nechita
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Cristina Strobescu
- Department of Vascular Surgery, University of Medicine and Pharmacy "Grigore T. Popa", 700111 Iasi, Romania
| | - Raluca Mogos
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandru Carauleanu
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ingrid-Andrada Vasilache
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Demetra Socolov
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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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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Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA, Aboelfadle Mohamed A. Cervical pessary for preventing preterm birth in singleton pregnancies. Cochrane Database Syst Rev 2022; 12:CD014508. [PMID: 36453699 PMCID: PMC9713761 DOI: 10.1002/14651858.cd014508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND Preterm birth (PTB), defined as birth prior to 37 weeks of gestation, occurs in ten percent of all pregnancies. PTB is responsible for more than half of neonatal and infant mortalities and morbidities. Because cervical insufficiency is a common cause of PTB, one possible preventive strategy involves insertion of a cervical pessary to support the cervix. Several published studies have compared the use of pessary with different management options and obtained questionable results. This highlights the need for an up-to-date systematic review of the evidence. OBJECTIVES To evaluate the benefits and harms of cervical pessary for preventing preterm birth in women with singleton pregnancies and risk factors for cervical insufficiency compared to no treatment, vaginal progesterone, cervical cerclage or bedrest. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform to 22 September 2021. We also searched the reference lists of included studies for additional records. SELECTION CRITERIA We included published and unpublished randomised controlled trials (RCTs) comparing cervical pessary with no treatment, vaginal progesterone, cervical cerclage or bedrest for preventing PTB. We excluded quasi-randomised trials. Our primary outcome was delivery before 34 weeks' gestation. Our secondary outcomes were 1. delivery before 37 weeks' gestation, 2. maternal mortality, 3. maternal infection or inflammation, 4. preterm prelabour rupture of membranes, 5. harm to woman from the intervention, 6. maternal medications, 7. discontinuation of the intervention, 8. maternal satisfaction, 9. neonatal/paediatric care unit admission, 10. fetal/infant mortality, 11. neonatal sepsis, 12. gestational age at birth, 13. harm to offspring from the intervention 14. birthweight, 15. early neurodevelopmental morbidity, 15. late neurodevelopmental morbidity, 16. gastrointestinal morbidity and 17. respiratory morbidity. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and risk of bias, evaluated trustworthiness based on criteria developed by the Cochrane Pregnancy and Childbirth Review Group, extracted data, checked for accuracy and assessed certainty of evidence using the GRADE approach. MAIN RESULTS We included eight RCTs (2983 participants). We included five RCTs (1830 women) in the comparison cervical pessary versus no treatment, three RCTs (1126 pregnant women) in the comparison cervical pessary versus vaginal progesterone, and one study (13 participants) in the comparison cervical pessary versus cervical cerclage. Overall, the certainty of evidence was low to moderate due to inconsistency (statistical heterogeneity), imprecision (few events and wide 95% confidence intervals (CIs) consistent with possible benefit and harm), and risk of performance and detection bias. Cervical pessary versus no treatment Cervical pessary compared with no treatment may reduce the risk of delivery before 34 weeks (risk ratio (RR) 0.72, 95% CI 0.33 to 1.55; 5 studies, 1830 women; low-certainty evidence) or before 37 weeks (RR 0.68, 95% CI 0.44 to 1.05; 5 studies, 1830 women; low-certainty evidence). However, these results should be viewed with caution because the 95% CIs cross the line of no effect. Cervical pessary compared with no treatment probably has little or no effect on the risk of maternal infection or inflammation (RR 1.04, 95% CI 0.87 to 1.26; 2 studies, 1032 women; moderate-certainty evidence). It is unclear if cervical pessary compared with no treatment has an effect on neonatal/paediatric care unit admission (RR 0.96, 95% CI 0.58 to 1.59; 3 studies, 1332 infants; low-certainty evidence) or fetal/neonatal mortality (RR 0.93, 95% CI 0.58 to 1.48; 5 studies, 1830 infants; low-certainty evidence) because the 95% CIs are compatible with a wide range of effects that encompass both appreciable benefit and harm. Cervical pessary versus vaginal progesterone Cervical pessary may reduce the risk of delivery before 34 weeks (RR 0.72, 95% CI 0.52 to 1.02; 3 studies, 1126 women; moderate-certainty evidence) or before 37 weeks (RR 0.89, 95% CI 0.73 to 1.09; 3 studies, 1126 women; moderate-certainty evidence), but we are uncertain of the results because the 95% CI crosses the line of no effect. The intervention probably has little or no effect on maternal infection or inflammation (RR 0.95, 95% CI 0.81 to 1.12; 2 studies, 265 women; moderate-certainty evidence). It is unclear if cervical pessary compared with vaginal progesterone has an effect on the risk of neonatal/paediatric care unit admission (RR 0.98, 95% CI 0.49 to 1.98; low-certainty evidence) or fetal/neonatal mortality (RR 1.97, 95% CI 0.50 to 7.70; 2 studies; 265 infants; low-certainty evidence) because the 95% CIs are compatible with a wide range of effects that encompass both appreciable benefit and harm. Cervical pessary versus cervical cerclage Only one very small study of 13 pregnant women contributed data to this comparison; the results were unclear. AUTHORS' CONCLUSIONS In women with a singleton pregnancy, cervical pessary compared with no treatment or vaginal progesterone may reduce the risk of delivery before 34 weeks or 37 weeks, although these results should be viewed with caution due to uncertainty around the effect estimates. There is insufficient evidence with regard to the effect of cervical pessary compared with cervical cerclage on PTB. Due to low certainty-evidence in many of the prespecified outcomes and non-reporting of several other outcomes of interest for this review, there is a need for further robust RCTs that use standardised terminology for maternal and offspring outcomes. Future trials should take place in a range of settings to improve generalisability of the evidence. Further research should concentrate on comparisons of cervical pessary versus cervical cerclage and bed rest. Investigation of different phenotypes of PTB may be relevant.
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Affiliation(s)
- Hany Abdel-Aleem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
| | - Omar M Shaaban
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
| | - Mahmoud A Abdel-Aleem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
| | - Ahmed Aboelfadle Mohamed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assuit University Hospital, Assuit, Egypt
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Vargas M, Mendoza M, García I, Farràs A, Maiz N, Carreras E, Goya M. Implications of training for pessary placement and accuracy of cervical length measurements after pessary placement: a prospective, double-blind, randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2022; 279:12-18. [DOI: 10.1016/j.ejogrb.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 08/17/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
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8
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Doulaveris G, Vani K, Saccone G, Chauhan SP, Berghella V. Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals. Am J Obstet Gynecol MFM 2021; 4:100509. [PMID: 34656731 DOI: 10.1016/j.ajogmf.2021.100509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/26/2021] [Accepted: 10/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes. OBJECTIVE This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals. STUDY DESIGN The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria. RESULTS Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals. CONCLUSION Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.
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Affiliation(s)
- Georgios Doulaveris
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Drs Doulaveris and Vani).
| | - Kavita Vani
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Drs Doulaveris and Vani)
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Dr Saccone)
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Dr Chauhan)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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9
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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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França MS, Hatanaka AR, Cruz JDJ, Andrade Júnior VLD, Kawanami Hamamoto TE, Sarmento SGP, Elito Júnior J, Pares DBDS, Mattar R, Araujo Júnior E, Moron AF. Cervical pessary plus vaginal progesterone in a singleton pregnancy with a short cervix: an experience-based analysis of cervical pessary's efficacy. J Matern Fetal Neonatal Med 2021; 35:6670-6680. [PMID: 33938351 DOI: 10.1080/14767058.2021.1919076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Several studies were published about cervical pessary, with controversial results. These studies demonstrated that the patient follow-up after pessary insertion is very different between the study centers and the number of pessary insertions per center was often <30 cases. This study aims to determine cervical pessary performance in singleton pregnancies with a short cervix based on a single center learning curve. METHODS Between 2011 and 2018, 128 singleton pregnancies between 18 and 24 gestational weeks with a short cervix (<25 mm) were referred to our clinic. All cases were treated with progesterone, and when available in our supplies (due to low resources) cervical pessary was also offered. Three groups were created for statistical analysis: Group 1 (n = 33), treated with progesterone-only; Groups 2 and 3, treated with cervical pessary plus progesterone. Group 2 included the first cases (n = 30) of pessary, defined by a learning curve and cumulative sum analysis, while Group 3 included the subsequent 65 cases. The primary outcome was preterm birth (PTB) < 34 gestational weeks. RESULTS The learning curve was performed with all cases of pessary plus progesterone, and 30 patients were obtained as the number needed for learning, in our study with two operators. The PTB rate < 34 weeks was 27.3, 20, and 4.6% in groups 1, 2, and 3, respectively. There was no significant difference between Group 1 and 2 (OR 1.1; 95% CI 0.066 - 18.45; p = .945). When comparing Groups 1 and 3 there was a significant difference in PTB rates (OR 0.08; CI95% 0.01-0.42; p = .003). Considering Kaplan-Meyer Survival analysis, we can observe that the performance of progesterone alone (Group 1) was similar to Group 2 (progesterone + first 30 cases of pessary) (p = .432), but the performance of Group 3 (progesterone + subsequent 65 cases of pessary) and Group 1 shows a statistically significant difference (p = .011). CONCLUSION Learning curve and cumulative sum analysis determined that the application and surveillance of at least 30 patients is required to see significant improvements in the primary outcome of PTB < 34 weeks.
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Affiliation(s)
- Marcelo Santucci França
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Alan Roberto Hatanaka
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | | | | | - Tatiana Emy Kawanami Hamamoto
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | | | - Júlio Elito Júnior
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - David Baptista da Silva Pares
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Rosiane Mattar
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Edward Araujo Júnior
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
| | - Antonio Fernandes Moron
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo-SP, Brazil
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11
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França MS, Hatanaka AR, Andrade Junior VLD, Elito Junior J, Pares DBS, Hamamoto TENK, Sarmento SGP, Mattar R, Moron AF. Cervical Pessary Plus Progesterone for Twin Pregnancy with Short Cervix Compared to Unselected and Non-Treated Twin Pregnancy: A Historical Equivalence Cohort Study (EPM Twin Pessary Study). REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2020; 42:621-629. [PMID: 33129217 DOI: 10.1055/s-0040-1713806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE The present study aims to determine if the use of cervical pessary plus progesterone in short-cervix (≤ 25 mm) dichorionic-diamniotic (DC-DA) twin pregnancies is equivalent to the rate of preterm births (PBs) with no intervention in unselected DC-DA twin pregnancies. METHODS A historical cohort study was performed between 2010 and 2018, including a total of 57 pregnant women with DC-DA twin pregnancies. The women admitted from 2010 to 2012 (n = 32) received no treatment, and were not selected by cervical length (Non-Treated group, NTG), whereas those admitted from 2013 to 2018 (n = 25), were routinely submitted to cervical pessary plus progesterone after the diagnosis of short cervix from the 18th to the 27th weeks of gestation (Pessary-Progesterone group, PPG). The primary outcome analyzed was the rate of PBs before 34 weeks. RESULTS There were no statistical differences between the NTG and the PPG regarding PB < 34 weeks (18.8% versus 40.0% respectively; p = 0.07) and the mean birthweight of the smallest twin (2,037 ± 425 g versus 2,195 ± 665 g; p = 0.327). The Kaplan-Meyer Survival analysis was performed, and there were no differences between the groups before 31.5 weeks. Logistic regression showed that a previous PB (< 37 weeks) presented an odds ratio (OR) of 15.951 (95% confidence interval [95%CI]: 1.294-196.557; p = 0.031*) for PB < 34 weeks in the PPG. CONCLUSION In DC-DA twin pregnancies with a short cervix, (which means a higher risk of PB), the treatment with cervical pessary plus progesterone could be considered equivalent in several aspects related to PB in the NTG, despite the big difference between these groups.
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Affiliation(s)
- Marcelo Santucci França
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Alan Roberto Hatanaka
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Julio Elito Junior
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - David Baptista Silva Pares
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Stephanno Gomes Pereira Sarmento
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Obstetrics and Gynecology Department, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brazil
| | - Rosiane Mattar
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Antonio Fernandes Moron
- Obstetrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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12
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Han Y, Li M, Ma H, Yang H. Cervical insufficiency: a noteworthy disease with controversies. J Perinat Med 2020; 48:648-655. [PMID: 32692707 DOI: 10.1515/jpm-2020-0255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/19/2020] [Indexed: 11/15/2022]
Abstract
Cervical insufficiency (CI) is a mainly disease leading to recurrent abortions and preterm birth which may present in about 1% of obstetric populations. Recurrent pregnancy losses caused by CI incur serious economic burdens on society as well as huge psychological burdens to family members. However, many patients even clinicians in some areas of the world still remain confused about this disease. At the same time, the etiology of CI is still uncertain and it is still a controversial disease in diagnosis and treatment. This article summarizes the potential risk factors associated with CI, which could be worthy of attention and helpful for future research. It also reviews the methods for diagnosis and treatment of CI to better understand this noteworthy disease, as well as presents the related consensus and controversies according to the newly updated guidelines, which has practical significance for conducting more in-depth investigations in the future.
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Affiliation(s)
- Yu Han
- Department of First Clinical Medical College, Shanxi Medical University, Taiyuan, P.R. China
| | - Mengnan Li
- Department of Obstetrics, First Hospital of Shanxi Medical University, Taiyuan, P.R. China
| | - Huijing Ma
- Department of Obstetrics, First Hospital of Shanxi Medical University, Taiyuan, P.R. China
| | - Hailan Yang
- Department of Obstetrics, First Hospital of Shanxi Medical University, Taiyuan, P.R. China
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13
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14
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Conde-Agudelo A, Romero R, Nicolaides KH. Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 223:42-65.e2. [PMID: 32027880 DOI: 10.1016/j.ajog.2019.12.266] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting results. OBJECTIVE To evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women. DATA SOURCES MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth. STUDY APPRAISAL AND SYNTHESIS METHODS The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth <34 weeks of gestation. Secondary outcomes included adverse pregnancy, maternal, and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology. RESULTS Twelve studies (4687 women and 7167 fetuses/infants) met the inclusion criteria: 8 evaluated pessary vs no pessary in women with a short cervix, 2 assessed pessary vs no pessary in unselected multiple gestations, and 2 compared pessary vs vaginal progesterone in women with a short cervix. There were no significant differences between the pessary and no pessary groups in the risk of spontaneous preterm birth <34 weeks of gestation among singleton gestations with a cervical length ≤25 mm (relative risk, 0.80; 95% confidence interval, 0.43-1.49; 6 trials, 1982 women; low-quality evidence), unselected twin gestations (relative risk, 1.05; 95% confidence interval, 0.79-1.41; 1 trial, 1177 women; moderate-quality evidence), twin gestations with a cervical length <38 mm (relative risk, 0.75; 95% confidence interval, 0.41-1.36; 3 trials, 1128 women; low-quality evidence), and twin gestations with a cervical length ≤25 mm (relative risk; 0.72, 95% confidence interval, 0.25-2.06; 2 trials, 348 women; low-quality evidence). Overall, no significant differences were observed between the pessary and no pessary groups in preterm birth <37, <32, and <28 weeks of gestation, and most adverse pregnancy, maternal, and perinatal outcomes (low- to moderate-quality evidence for most outcomes). There were no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone in singleton gestations with a cervical length ≤25 mm (relative risk, 0.99; 95% confidence interval, 0.54-1.83; 1 trial, 246 women; low-quality evidence) and twin gestations with a cervical length <38 mm (relative risk, 0.73; 95% confidence interval, 0.46-1.18; 1 trial, 297 women; very low-quality evidence). Vaginal discharge was significantly more frequent in the pessary group than in the no pessary and vaginal progesterone groups (relative risks, ∼2.20; high-quality evidence). CONCLUSION Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Florida International University, Miami, FL.
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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15
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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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16
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Kuusela P, Wennerholm UB, Fadl H, Wesström J, Lindgren P, Hagberg H, Jacobsson B, Valentin L. Second trimester cervical length measurements with transvaginal ultrasound: A prospective observational agreement and reliability study. Acta Obstet Gynecol Scand 2020; 99:1476-1485. [PMID: 32392356 DOI: 10.1111/aogs.13895] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/29/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Universal screening for preterm delivery by adding transvaginal ultrasound measurement of cervical length to routine second trimester ultrasound has been proposed. The aim is to estimate inter- and intraobserver agreement and reliability of second trimester transvaginal ultrasound measurements of cervical length performed by specially trained midwife sonographers. MATERIAL AND METHODS This is a prospective reliability and agreement study performed in seven Swedish ultrasound centers. In total, 18 midwife sonographers specially trained to perform ultrasound measurements of cervical length and 286 women in the second trimester were included. In each center, two midwife sonographers measured cervical length a few minutes apart in the same woman, the number of women examined per examiner pair varying between 24 and 30 (LIVE study). Sixteen midwife sonographers measured cervical length twice ≥2 months apart on 93 video clips (CLIPS study). The main outcome measures were mean difference, limits of agreement, intraclass correlation coefficient, intra-individual standard deviation, repeatability, Cohen's kappa and Fleiss kappa. RESULTS The limits of agreement and intraclass correlation coefficient of the best examiner pair in the LIVE study were -4.06 to 4.72 mm and 0.91, and those of the poorest were -11.11 to 11.39 mm and 0.31. In the CLIPS study, median (range) intra-individual standard deviation was 2.14 mm (1.40-3.46), repeatability 5.93 mm (3.88-9.58), intraclass correlation coefficient 0.84 (0.66-0.94). Median (range) interobserver agreement for cervical length ≤25 mm in the CLIPS study was 94.6% (84.9%-98.9%) and Cohen's kappa 0.56 (0.12-0.92), median (range) intraobserver agreement was 95.2% (87.1%-98.9%) and Cohen's kappa 0.68 (0.27-0.93). CONCLUSIONS Agreement and reliability of cervical length measurements differed substantially between examiner pairs and examiners. If cervical length measurements are used to guide management there is potential for both over- and under-treatment. Uniform training and rigorous supervision and quality control are advised.
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Affiliation(s)
- Pihla Kuusela
- Center of Perinatal Medicine and Health, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborg Hospital, Borås, Sweden
| | - Ulla-Britt Wennerholm
- Center of Perinatal Medicine and Health, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Region Vastra Gotaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helena Fadl
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jan Wesström
- Center for Clinical Research Dalarna, Falun Hospital, Falun, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Peter Lindgren
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Hagberg
- Center of Perinatal Medicine and Health, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Region Vastra Gotaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Region Vastra Gotaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - Lil Valentin
- Department of Medical Sciences Malmö, Lund University, Lund, Sweden.,Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
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17
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Hentrich A, Marek S, Jackisch C. [Using Cervical Pessary to Prevent Premature Birth - a Clinical Analysis]. Z Geburtshilfe Neonatol 2020; 225:51-54. [PMID: 32392588 DOI: 10.1055/a-1153-9355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In the event of a cervical shortening < 25 mm before the 34th week of gestation, a cervical pessary can be inserted in accordance with the German AMWF guidelines. However, data concerning the benefit of this intervention in order to avoid premature birth are controversial. METHODS Between the 20th and 32nd week of gestation, we inserted a cervical pessary in 83 patients and evaluated our data with regard to the extension of gestational age due to this intervention. We also reviewed the literature on this topic. We retrospectively analysed the data in a high-risk group (cervical length<15 mm) and a low-risk group (15-25 mm). RESULTS Our data show a preterm birth in just 20% of all cases in both subgroups. 79% of the patients gave birth after 34 weeks and 59% after 37 weeks. CONCLUSIONS Our approach using an cervical pessary supported by local application of progesterone seems to be a well-tolerated intervention with few side effects and acceptable adherence. In addition, our data demonstrate a reduction in hospitalization, even though the evidence is divergent in this respect.
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Affiliation(s)
- Anna Hentrich
- Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach GmbH, Offenbach
| | - Susanne Marek
- Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach GmbH, Offenbach
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The State of the Science of Preterm Birth: Assessing Contemporary Screening and Preventive Strategies. J Perinat Neonatal Nurs 2020; 34:113-124. [PMID: 32332440 DOI: 10.1097/jpn.0000000000000470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preterm birth remains a leading cause of morbidity and mortality during the perinatal and neonatal periods. Now affecting approximately 1 in 10 births in the United States, preterm birth often occurs spontaneously and without a clear etiology. Careful assessment of risk factors, however, identifies vulnerable women allowing targeted interventions such as progestogen therapy and cerclage. This article is intended to highlight preterm birth risk factors and current predictive and preventive strategies for midwives, nurse practitioners, clinical nurse specialists, and perinatal nurses.
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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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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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Berger R, Abele H, Bahlmann F, Bedei I, Doubek K, Felderhoff-Müser U, Fluhr H, Garnier Y, Grylka-Baeschlin S, Helmer H, Herting E, Hoopmann M, Hösli I, Hoyme U, Jendreizeck A, Krentel H, Kuon R, Lütje W, Mader S, Maul H, Mendling W, Mitschdörfer B, Nicin T, Nothacker M, Olbertz D, Rath W, Roll C, Schlembach D, Schleußner E, Schütz F, Seifert-Klauss V, Steppat S, Surbek D. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 1 with Recommendations on the Epidemiology, Etiology, Prediction, Primary and Secondary Prevention of Preterm Birth. Geburtshilfe Frauenheilkd 2019; 79:800-812. [PMID: 31423016 DOI: 10.1055/a-0903-2671] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 12/13/2022] Open
Abstract
Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recent scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods Based on the international literature, the members of the participating medical societies and organizations developed Recommendations and Statements. These were adopted following a formal process (structured consensus conference with neutral moderation, voting was done in writing using the Delphi method to achieve consensus). Recommendations Part I of this short version of the guideline lists Statements and Recommendations on the epidemiology, etiology, prediction and primary and secondary prevention of preterm birth.
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Affiliation(s)
- Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Harald Abele
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Franz Bahlmann
- Frauenklinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - Ivonne Bedei
- Frauenklinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany
| | | | - Ursula Felderhoff-Müser
- Klinik für Kinderheilkunde I/Perinatalzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Herbert Fluhr
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Yves Garnier
- Frauenklinik, Klinikum Osnabrück, Osnabrück, Germany
| | | | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Hoopmann
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Udo Hoyme
- Frauenklinik, Ilm-Kreis-Kliniken, Arnstadt, Germany
| | | | - Harald Krentel
- Frauenklinik, Annahospital Herne, Elisabethgruppe Katholische Kliniken Rhein Ruhr, Herne, Germany
| | - Ruben Kuon
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Wolf Lütje
- Frauenklinik, Evangelisches Amalie Sieveking-Krankenhaus Hamburg, Hamburg, Germany
| | - Silke Mader
- European Foundation for the Care of the Newborn Infant
| | - Holger Maul
- Frauenklinik, Asklepios Kliniken Hamburg, Hamburg, Germany
| | - Werner Mendling
- Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe an der Frauenklinik, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | | | | | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Berlin, Germany
| | - Dirk Olbertz
- Abteilung Neonatologie und neonatologische Intensivmedizin, Klinikum Südstadt Rostock, Rostock, Germany
| | - Werner Rath
- Emeritus, Universitätsklinikum Aachen, Aachen, Germany
| | - Claudia Roll
- Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln/Berlin Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | | | - Florian Schütz
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Daniel Surbek
- Universitäts-Frauenklinik, Inselspital, Universität Bern, Bern, Switzerland
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Prevention of spontaneous preterm birth. Arch Gynecol Obstet 2019; 299:1261-1273. [DOI: 10.1007/s00404-019-05095-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
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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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Corrêa TD, Amorim EG, Tomazelli JAG, Corrêa MD. Use of the Pessary in the Prevention of Preterm Delivery. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2019; 41:53-58. [PMID: 30716786 PMCID: PMC10418961 DOI: 10.1055/s-0038-1676511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The gestational complication most associated with perinatal mortality and morbidity is spontaneous preterm birth with gestational age < 37 weeks. Therefore, it is necessary to identify its risk factors and attempt its prevention. The benefits of the pessary in prematurity are under investigation. Our objective was to analyze the use of the pessary in the prevention of preterm births in published studies, and to compare its efficacy with other methods. METHODS Randomized clinical trials published between 2010 and 2018 were selected from electronic databases. Studies on multiple gestations were excluded. RESULTS Two studies were in favor of the pessary as a preventive method, one study was contrary to the method and another two showed no statistically significant difference. The meta-analysis showed no statistical difference with the use of a cervical pessary in the reduction of births < 37 (odds ratio [OR]: 0.63; confidence interval [95% CI]: 0.38-1.06) and < 34 weeks (OR: 0.74; 95% CI: 0.35-1.57) CONCLUSION: The pooled data available to date seems to show a lack of efficacy of the cervical pessary in the prevention of preterm birth, although the heterogeneity of the studies made comparisons more difficult.
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Affiliation(s)
- Thayane Delazari Corrêa
- Departament of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Ester Gomes Amorim
- Departament of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Mário Dias Corrêa
- Departament of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Cervical Pessary Compared With Vaginal Progesterone for Preventing Early Preterm Birth: A Randomized Controlled Trial: Correction. Obstet Gynecol 2018; 132:1507. [DOI: 10.1097/aog.0000000000002999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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