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Merced C, Pratcorona L, Higueras T, Vargas M, Del Barco E, Solà J, Carreras E, Goya M. Risk factors of early spontaneous preterm birth despite carrying a cervical pessary in singleton pregnancies with a short cervix: Development of a risk prediction model. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100305. [PMID: 38595705 PMCID: PMC11001768 DOI: 10.1016/j.eurox.2024.100305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024] Open
Abstract
Introduction We aimed to identify the incidence and risk factors of spontaneous preterm birth in pessary carriers with singleton pregnancies and a short cervix in the mid-trimester of pregnancy. Material and Methods Patient data were obtained from the PECEP Trial. We analyzed singleton pregnancies in pessary carriers with a short cervix (≤25 mm) between 18 and 22 gestational weeks. Demographics and obstetric history were compared to identify risk factors for spontaneous preterm birth < 34 gestational weeks. Each demographic and obstetric variable was compared between spontaneous preterm birth < 34 and ≥ 34 weeks of gestation.Regression analysis was used to identify risk factors. A risk score model was generated using the odds ratio for significant factors. The risk score model and spontaneous preterm birth risk were assessed using the receiver operating characteristic curve. Perinatal outcomes were compared by risk score. Results Among 190 pregnant individuals, 12 (6.3%) had spontaneous preterm birth < 34 gestational weeks. In the bivariate analysis, statistically significant differences between those with and without spontaneous preterm birth were only observed for mean cervical length at diagnosis and mean cervical length after pessary placement. By multiple logistic regression analysis, maternal age (OR 0.818; 95% CI 0.69-0.97; P 0.020), cervical length at diagnosis (OR 0.560; 95% CI 0.43-0.73; P < 0.001) and smoking status (OR 7.276; 95% CI 1.02-51.80; P 0.048) remained significantly associated with spontaneous preterm birth.The ROC curve from the multiple logistic regression analysis, including cervical length, maternal age and smoking status, had an area under the curve (AUC) of 0.952 (P < 0.001). The ROC curve for the risk score model incorporating all three variables had an AUC of 0.864 (95% CI 0.77-0.96; P < 0.001). A high-risk score was predictive of spontaneous preterm birth with a sensitivity of 75%, specificity of 84%, positive predictive value of 24%, and negative predictive value of 98%.Women with a high-risk score had a significantly reduced latency to delivery and poorer neonatal outcomes than those with a low-risk score. Conclusions Patients at a high risk for spontaneous preterm birth despite pessary therapy may be identified using cervical length at diagnosis added to maternal age and smoking status.
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Affiliation(s)
- Carme Merced
- Department of Obstetrics, Hospital Universitari de Vic, Consorci Hospitalari de Vic. Barcelona, Spain
| | - Laia Pratcorona
- Department of Obstetrics, Hospital Germans Trias I Pujol. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Higueras
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Vargas
- Department of Obstetrics, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain
| | - Esther Del Barco
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Judit Solà
- Data Analysis and Modeling Research Group, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, Spain
| | - Elena Carreras
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Goya
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
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Pena-Burgos EM, Sintes Álvarez-Arenas M, Quirós-González V, Bartha JL, De La Calle M. Utility of cervical pessary in the prevention of preterm birth in triplet pregnancies: A single-center observational retrospective study of 165 triplet pregnancies. Eur J Obstet Gynecol Reprod Biol 2024; 295:48-52. [PMID: 38335584 DOI: 10.1016/j.ejogrb.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Premature births are a health problem arising in triplet pregnancies, resulting in high levels of morbidity and mortality. The objective of this study is to evaluate the utility of cervical pessaries in reducing prematurity (<34 weeks) in triplet pregnancies. METHODS This is a single-center, retrospective case-control study regarding triplet pregnancies with follow-up at the La Paz University Hospital between 2000 and 2023. Maternal characteristics, obstetric and perinatal outcomes, and the use of cervical pessaries were examined. RESULTS 165 triplet pregnancies were analyzed: 87 (52.7 %) in the case group (premature triplet pregnancies) and 78 in the control group (non-premature triplet pregnancies). A cervical pessary was inserted in 15 (17.2 %) triplet pregnancies in the case group and in 12 (16.7 %) triplet pregnancies in the control group (p = 0.92; OR = 1.04 (0.46-2.35)). A pessary was later inserted in the non-premature group (p = 0.01). The risk of preterm labor and the use of tocolytics ± glucocorticoids were found to be significantly more frequent in the premature group, with p = 0.01; OR = 2.30 (1.21-4.36) and p < 0.01; OR = 2.36 (1.23-4.44), respectively. Protocol-based cesarean sections were more frequent in the non-premature group (p < 0.01), while cesarean sections due to maternal complications (p < 0.01) and premature membrane rupture (p < 0.01) were more frequent in the premature group. CONCLUSION The cervical pessary is not useful in preventing preterm births (< 34 weeks) in triplet pregnancies. It is likely that being pregnant with triplets is a powerful independent factor associated with prematurity, despite other pregnancy conditions. Women who are pregnant with triplets and at risk of preterm labor and those taking tocolytics ± glucocorticoids may benefit from pessary insertion.
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Affiliation(s)
- E M Pena-Burgos
- La Paz University Hospital, Pathology Department, Madrid, Spain.
| | | | - V Quirós-González
- 12 Octubre University Hospital, Strategic Planning Directorate, Madrid, Spain
| | - J L Bartha
- La Paz University Hospital, Obstetrics and Gynaecology Department, Madrid, Spain
| | - M De La Calle
- La Paz University Hospital, Obstetrics and Gynaecology Department, Madrid, Spain
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/16/2022] [Indexed: 01/07/2023]
Abstract
This study was to assess the effectiveness of cervical pessary combined with vaginal progesterone for the prevention of preterm birth (PTB). Ten studies about singleton [five randomized controlled trials (RCTs), vs vaginal progesterone; four cohorts, vs vaginal progesterone; two cohorts, vs cervical cerclage + vaginal progesterone] and two cohort studies about multiple pregnancies (vs vaginal progesterone) were included after searching electronic databases. For singleton pregnancies, the meta-analysis of three non-RCTs [relative risk (RR) = 0.41, p = 0.001] or total trials in non-Asian country (RR = 0.56, p = 0.03) revealed that compared with vaginal progesterone alone, cervical pessary + vaginal progesterone treatment had significant effectiveness on preventing PTB < 34 weeks, but not for five RCTs; meta-analysis of two trials showed that cervical pessary + vaginal progesterone had no significant prevention effects of PTB compared with cervical cerclage + vaginal progesterone. For multiple pregnancies, meta-analysis of two trials showed that compared with vaginal progesterone, cervical pessary + vaginal progesterone treatment increased neonatal birth weight (standardized mean difference = 0.50, p = 0.01). Trial sequential analysis implied additional studies were required. Four studies vs other controls (pessary, three-combined, tocolysis, conservative or no treatment; one study, each) were selected for systematic review. In conclusion, cervical pessary combined with vaginal progesterone may be safe and effective to prevent PTB in singleton pregnancies and increase neonatal birth weight in the multiple pregnancies compared with vaginal progesterone alone.
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Affiliation(s)
- Yanyan Zhuang
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Huan Li
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Quan Na
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Shaowei Yin
- grid.412467.20000 0004 1806 3501Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004 China
| | - Na Li
- Department of Gynaecology and Obstetrics, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Shenyang, 110004, China.
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Seravalli V, Campana D, Strambi N, Vialetto D, Di Tommaso M. Effectiveness of cervical pessary in women with arrested preterm labor compared to those with asymptomatic cervical shortening. J Matern Fetal Neonatal Med 2021; 35:8141-8146. [PMID: 34856856 DOI: 10.1080/14767058.2021.1962844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether the effectiveness of cervical pessary is different in women who experienced cervical shortening after a threatened preterm labor episode compared to those with asymptomatic short cervix. METHODS Retrospective study on singleton pregnancies at risk for preterm delivery (PTD) due to cervical length <25 mm before 28 weeks, who were treated with Arabin cervical pessary. Two groups of patients were compared: those who had contractions causing shortening of the cervix, prior to pessary placement, and those who had asymptomatic cervical shortening. Patients carrying a multiple pregnancy and those who underwent iatrogenic PTD were excluded. The primary outcome was the incidence of PTD at different gestational ages. Secondary outcome was the rate of preterm premature rupture of membrane (pPROM). The groups were compared using univariate and multivariate analyses. RESULTS 115 patients that met the inclusion criteria were identified. Of these, 91 (79%) had asymptomatic cervical shortening, while 24 (21%) had an episode of threatened preterm labor that resolved, and the pessary was placed after the contractions had stopped. The two groups were similar for maternal characteristics, obstetric history, mean gestational age and length of the cervix at the time of pessary insertion. The median gestational age at delivery was significantly lower (36.4 vs 38.0 weeks, p = .02), and the incidence of PTD significantly higher (58.3% vs 30.8%, OR 4.69, 95% CI 1.68-13.1, p < .01) among women who had arrested preterm labor before the pessary was placed compared to the asymptomatic group, after controlling for confounders. The incidence of PTD before 34 and before 32 weeks was also significantly higher in the symptomatic group (p = .02 and p = .005, respectively). Women with asymptomatic cervical shortening had a longer interval between the placement of the pessary and delivery (median 15 weeks). pPROM occurred with a similar incidence in both groups. CONCLUSIONS Arabin cervical pessary to prevent preterm delivery seems be less effective in women with a short cervix following an episode of threatened preterm labor than in those with asymptomatic cervical shortening in the second trimester. This finding may help physicians to select patients in which cervical pessary is more likely to be effective, and to improve patient's counseling about this intervention.
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Affiliation(s)
- Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Dante Campana
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Noemi Strambi
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Debora Vialetto
- Department of Clinical and Experimental Biomedical Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Mariarosaria Di Tommaso
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
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Tajima M, Yanazume S, Orita Y, Tazaki Y, Shinya M, Kobayashi H. Cervical pessary plus vaginal progesterone versus long-term tocolysis for the prevention of preterm birth: An observational retrospective study. Int J Gynaecol Obstet 2020; 150:206-212. [PMID: 32282943 DOI: 10.1002/ijgo.13164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/23/2020] [Accepted: 04/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare cervical pessaries plus vaginal progesterone versus long-term tocolysis for preventing preterm birth for women with a short cervix. METHODS Retrospective evaluation of women with singleton pregnancy who received cervical pessaries plus vaginal progesterone (combined group) or ritodrine hydrochloride (tocolysis group) for short cervix (≤25 mm at 20-24 weeks, or ≤20 mm at 25-34 weeks) at a general hospital in Kagoshima, Japan, 2015-2019. The primary outcome was rate of preterm birth (<36 weeks); secondary outcomes were maternal hospital admittance and treatment complications. RESULTS Data were evaluated from 95 women (combined group, n=43; tocolysis group, n=52). There was no significant difference in cervical length or gestational age at intervention between the groups. Overall, 3/43 (7.0%) women delivered before 36 weeks in the combined group versus 16/52 (30.8%) in the tocolysis group (relative risk, 0.56; 95% confidence interval, 0.41-0.76; P=0.004). Median maternal admittance was shorter in the combined group (6.6 vs 41.0 days, P<0.001). Although 36/43 (83.7%) women in the combined group reported increased vaginal discharge, no major complications occurred. CONCLUSION A combination of pessaries and vaginal progesterone reduced the rate of preterm birth (<36 weeks) for women with short cervix as compared with long-term tocolysis.
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Affiliation(s)
- Masaki Tajima
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Shintaro Yanazume
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuji Orita
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yukiko Tazaki
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Mitsuhisa Shinya
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hiroaki Kobayashi
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
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Xiong YQ, Tan J, Liu YM, Qi YN, He Q, Li L, Zou K, Sun X. Cervical pessary for preventing preterm birth in singletons and twin pregnancies: an update systematic review and meta-analysis. J Matern Fetal Neonatal Med 2020; 35:100-109. [PMID: 31948303 DOI: 10.1080/14767058.2020.1712705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objectives: To evaluate the effectiveness of cervical pessary in preventing preterm birth (PTB) and improving perinatal outcomes among singleton and twin pregnancies.Methods: Electronic databases were systematically searched from their inception until 14 March 2019. Randomized clinical trials comparing the effectiveness of cervical pessary placement with expectant management were included. The primary outcome was the incidence of PTB <34 weeks.Results: Thirteen studies were included, involving eight studies about singleton and six studies about twin pregnancies. For singleton pregnancies with short cervical length, cervical pessary, comparing with expectant treatment, seemed have no effectiveness in preventing PTB <34 weeks (relative risk, 95% confidence interval, 0.73, 0.42-1.28), <37 weeks (0.69, 0.43-1.09), and <28 weeks (0.79, 0.42-1.48); while for twin pregnancies with short cervical length, cervical pessary also did not reduce the risk of PTB <34 weeks (0.81, 0.49-1.35), <37 weeks (0.93, 0.83-1.05), and <28 weeks (0.72, 0.38-1.38). However, cervical pessary seemed have the effectiveness of reducing the risk of spontaneous PTB <28 weeks (0.50, 0.25-0.99) and low birth weight (<1500 g) (0.68, 0.50-0.94) among twin pregnancies with short cervical length. In addition, cervical pessary increased the rate of vaginal discharge and did not improve perinatal outcomes among both singleton and twin pregnancies.Conclusions: Comparing with the expectant treatment, the effectiveness of cervical pessary for reducing the risk of PTB remains uncertain. Additional trials are warranted to further evaluate the effectiveness of cervical pessary.
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Affiliation(s)
- Yi-Quan Xiong
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Mei Liu
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Ya-Na Qi
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Qiao He
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Li
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
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Abstract
OBJECTIVE Vaginal progesterone and cervical pessary are both shown to be effective in preventing preterm. We conducted a meta-analysis to evaluate whether the combination of these two interventions has any additional benefit in preventing preterm birth and improving perinatal outcomes in asymptomatic women with a singleton gestation who had a midtrimester sonographic short cervix compared with vaginal progesterone alone. METHODS Five databases were searched from their inception to 21 February 2019. We estimated relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. The primary outcome was preterm birth <34 weeks, and second outcomes included low birth weight (LBW) delivery, perinatal death, and neonatal intensive care unit (NICU) admission. RESULTS Three RCTs with a total of 820 participants were identified. Cervical pessary had no significant prevention effect of preterm birth when combined with vaginal progesterone compared to the control group with vaginal progesterone alone (RR = 0.91; 95% CI, 0.47-1.77). No significant difference has been revealed between groups in LBW delivery (RR = 1.13; 95% CI, 0.86-1.48), perinatal death (RR = 1.27; 95% CI, 0.58-2.78) and NICU admission (RR = 1.24; 95% CI, 0.84-1.85). CONCLUSIONS Comparing with vaginal progesterone alone, cervical pessary plus vaginal progesterone did not reduce the rates of preterm birth at <34 weeks of gestation. There was no difference in LBW delivery, perinatal death, and NICU admission. We need more evidence to balance the benefit and side effects on the combination of vaginal progesterone and cervical pessary for preventing preterm birth.
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Affiliation(s)
- Jing Liu
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tao Meng
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ge Zhao
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, China
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Shor S, Zimerman A, Maymon R, Kovo M, Wolf M, Wiener I, Bar J, Melcer Y. Combined therapy with vaginal progesterone, Arabin cervical pessary and cervical cerclage to prevent preterm delivery in high-risk women. J Matern Fetal Neonatal Med 2019; 34:2154-2158. [PMID: 31438741 DOI: 10.1080/14767058.2019.1659771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Preterm birth is the leading cause of perinatal morbidity and mortality. Vaginal progesterone cervical cerclage and Arabin cervical pessary are considered as preventive treatments in women at risk for preterm birth. However, there is less evidence as to which of these interventions is the preferred management. The current study aims was to compare the outcome of pregnancy in women with a short cervical length managed with 4 different treatment protocols: therapy with vaginal progesterone, cervical cerclage and an Arabin cervical pessary (group A), Arabin cervical pessary and vaginal progesterone (group B), cervical cerclage and vaginal progesterone (group C), or vaginal progesterone alone (group D). METHODS A retrospective cohort study of singleton pregnancies managed in three tertiary medical centers between September 2011 and December 2017. RESULTS In the study period, 286 pregnant women underwent vaginal ultrasonography between 15 and 29 weeks gestation. They all had a short cervical length (≤25 mm). Of these, 18 (6.3%), 120 (41.9%), 38 (13.3%) and 110 (38.5%) patients received treatment classifying them into groups A, B, C, and D, respectively. A significantly higher rate of patients in group A had either a history of cervical incompetence (44.4 versus 9.2 versus 7.9 and 0.9%, respectively, p = .0001) or a cervical procedure (61.1 versus 37.5 versus 28.9 and 27.3%, respectively, p = .027) compared to patients in group B, C, and D. Despite having a shorter cervical length at recruitment in group A (median (range); 14.5 (0-25) versus 15 (0-25) versus 15.5 (0-25) and 19 (2-25) mm, respectively, p = .002) the rate of spontaneous preterm delivery <37-week gestation was similar across groups (44.4 versus 32.5 versus 36.8 versus 32.7%, respectively, p = .665). CONCLUSION A combined rescue therapy involving vaginal progesterone, cervical cerclage, and Arabin cervical pessary emerges as a promising management strategy in pregnant women who have a short cervical length and a high background risk for preterm delivery. This combination may prolong their pregnancy and safely bring them near term. Additional studies are needed to confirm these preliminary findings.
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Affiliation(s)
- Shimrit Shor
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Ariel Zimerman
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel, both affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Maya Wolf
- Department of Obstetrics and Gynecology, Galilee Medical Center, Faculty of Medicine in the Galilee, Nahariya, affiliated with the Bar Ilan University, Tel Aviv, Israel
| | - Ifat Wiener
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel, both affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center, formerly Assaf Harofeh Medical Center, Zerifin, Israel
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Melcer Y, Kovo M, Maymon R, Bar J, Wiener I, Neeman O, Pekar-Zlotin M, Zimerman A. Arabin cervical pessary with vaginal progesterone versus vaginal progesterone for preventing preterm delivery. J Matern Fetal Neonatal Med 2019; 33:3439-3444. [PMID: 30669913 DOI: 10.1080/14767058.2019.1573894] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To compare the rate of preterm delivery in pregnant women with a short cervical length managed with Arabin cervical pessary and vaginal progesterone versus vaginal progesterone alone.Methods: This was a retrospective cohort study of singletons pregnancies managed in two tertiary medical centers between September 2011 and May 2017. One center utilized the combined treatment of Arabin cervical pessary and vaginal progesterone (study group) and the second utilized vaginal progesterone approach (control group).Results: During the study period, a total of 202 pregnant women who underwent vaginal ultrasonography between 15 and 29 weeks gestation. They all had short cervical length (≤25 mm). Among them, 94 (46.5%) and 108 (53.5%) patients were in the study and control group, respectively. A significantly higher rate of patients in the study group had either a history of cervical incompetence (9.6 vs. 0.9%, respectively, p = 0.006) or cervical surgery (7.9 vs. 0%, respectively, p = .003). Despite having shorter cervical length at recruitment (14.3 ± 5.9 vs. 16.9 ± 5.7, respectively, p = .002) the rate of spontaneous delivery < 34-week gestation was lower in the study group (7.4 vs. 17.6%, respectively, p = .036) and they delivered 1-week later compared to the control group (37.2 ± 2.1 vs. 36.2 ± 3.7, respectively, p = 0.02).Conclusion: We found that for pregnant women with singletons and who had a short cervical length, the combined treatment of Arabin cervical pessary and vaginal progesterone had lower rate of preterm delivery < 34 weeks of gestation and prolonged gestation compared to those women who were treated with vaginal progesterone alone. Our preliminary findings warrant randomized control studies in order to further illuminate our results.
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Affiliation(s)
- Yaakov Melcer
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel (both affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel)
| | - Ron Maymon
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel (both affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel)
| | - Ifat Wiener
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Ortal Neeman
- Department of Obstetrics and Gynecology, Assuta Hospital, Ashdod, Israel (affiliated to University of the Negev, Beer-Sheva, Ben-Gurion, Israel)
| | - Marina Pekar-Zlotin
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
| | - Ariel Zimerman
- Department of Obstetrics and Gynecology, the Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel
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Kosinski P, Luterek K, Bomba-Opon D, Lipa M, Wielgos M. Cervical Measurement and Pessary Application in Relation to Gestational Age at Delivery in Patients Treated with Fetoscopic Endotracheal Occlusion. Fetal Diagn Ther 2018; 46:119-124. [PMID: 30404087 DOI: 10.1159/000493792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/14/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the impact of cervical length and cervical pessary application in congenital diaphragmatic hernia (CDH) treated by the fetoscopic endotracheal occlusion (FETO) procedure. METHODS The study group consisted of 80 patients with severe CDH treated by FETO. Cervical length measurement was performed by transvaginal ultrasound in all patients within the 24 h prior to the FETO procedure. The study group (n = 44) had cervical pessaries applied routinely within the 24 h following the FETO procedure, whereas the control group (n = 36) were not offered pessaries and only had cervical length measurement performed. RESULTS The median cervical length was 31 (range 22-45) mm. The median gestational age at delivery was 34.7 (range 27.8-39.2) weeks. Gestational age at delivery correlated significantly with gestational age at balloon removal (r = 0.768; p < 0.0001) and premature rupture of membranes (r = 0.501; p = 0.003). There was no significant correlation between gestational age at delivery and cervical length before the procedure (r = 0.141; p = 0.26) or pessary application (r = 0.081; p = 0.51). In the multivariate linear regression model, the only factor independently associated with gestational age at delivery was gestational age at fetoscopic balloon removal (β = 0.713; p < 0.0001). CONCLUSION In cases of severe CDH treated by the FETO procedure, neither cervical length before the procedure nor cervical pessary application was associated with gestational age at delivery.
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Affiliation(s)
- Przemyslaw Kosinski
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland,
| | - Katarzyna Luterek
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Bomba-Opon
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Michal Lipa
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Miroslaw Wielgos
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
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11
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Ivandic J, Care A, Goodfellow L, Poljak B, Sharp A, Roberts D, Alfirevic Z. Cervical pessary for short cervix in high risk pregnant women: 5 years experience in a single centre. J Matern Fetal Neonatal Med 2018; 33:1370-1376. [PMID: 30173599 DOI: 10.1080/14767058.2018.1519018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: To describe single center clinical experience with cervical pessary used for high-risk pregnant women who also had short cervix. We have focused on the techniques to optimize efficacy and minimize the risk of complications and side effects related to pessary insertion, removal, and pregnancy management.Methods: This is an audit from specialist preterm birth prevention clinic in Liverpool Women's Hospital, United Kingdom for the period between January 2013 and December 2017. We also conducted postal survey in November 2015 to evaluate women's experience with vaginal pessary.Results: Out of 235 women who were treated for short cervix, 129 (55%) had cervical pessary as a first line treatment. Overall, 50% of treated women reached term. 17 women (13%) needed additional treatment, 9 women had pessary reinserted (7%), and 53 (41%) had pessary removed before 36 weeks, mainly due to ruptured membranes. Significant vaginal discharge and pelvic discomfort were reported by 14 and 7% women, respectively. 89% of treated women would recommend the pessary treatment to others.Conclusions: Whilst the cervical pessary continues to be evaluated in clinical trials, our experience suggests that pessary is quite easy to insert and remove and is well tolerated by the women.
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Affiliation(s)
- Jelena Ivandic
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Angharad Care
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Laura Goodfellow
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Borna Poljak
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Andrew Sharp
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Devender Roberts
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Zarko Alfirevic
- Liverpool Womens NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
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12
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Madar H, Mattuizzi A, Sentilhes L. Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is the evidence sufficient? J Perinat Med 2018; 46:691. [PMID: 29176014 DOI: 10.1515/jpm-2017-0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/02/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, 33036, Bordeaux, France
| | - Aurélien Mattuizzi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
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13
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Rodó C, Arévalo S, Lewi L, Couck I, Hollwitz B, Hecher K, Carreras E. Arabin cervical pessary for prevention of preterm birth in cases of twin-to-twin transfusion syndrome treated by fetoscopic LASER coagulation: the PECEP LASER randomised controlled trial. BMC Pregnancy Childbirth 2017; 17:256. [PMID: 28764674 PMCID: PMC5540345 DOI: 10.1186/s12884-017-1435-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 07/19/2017] [Indexed: 11/25/2022] Open
Abstract
Background Fetoscopic LASER coagulation of the placental anastomoses has changed the prognosis of twin-twin transfusion syndrome. However, the prematurity rate in this cohort remains very high. To date, strategies proposed to decrease the prematurity rate have shown inconclusive, if not unfavourable results. Methods This is a randomised controlled trial to investigate whether a prophylactic cervical pessary will lower the incidence of preterm delivery in cases of twin-twin transfusion syndrome requiring fetoscopic LASER coagulation. Women eligible for the study will be randomised after surgery and allocated to either pessary or expectant management. The pessary will be left in place until 37 completed weeks or earlier if delivery occurs. The primary outcome is delivery before 32 completed weeks. Secondary outcomes are a composite of adverse neonatal outcome, fetal and neonatal death, maternal complications, preterm rupture of membranes and hospitalisation for threatened preterm labour. 352 women will be included in order to decrease the rate of preterm delivery before 32 weeks’ gestation from 40% to 26% with an alpha-error of 0.05 and 80% power. Discussion The trial aims at clarifying whether the cervical pessary prolongs the pregnancy in cases of twin-twin transfusion syndrome regardless of cervical length at the time of fetoscopy. Trial registration ClinicalTrials.gov Identifier: NCT01334489. Registered 04 December 2011.
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Affiliation(s)
- Carlota Rodó
- Maternal - Fetal Medicine Unit. Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain.
| | - Sílvia Arévalo
- Maternal - Fetal Medicine Unit. Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Isabel Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Bettina Hollwitz
- Department of Obstetrics and Prenatal Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Prenatal Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Elena Carreras
- Maternal - Fetal Medicine Unit. Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain
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14
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Martinez de Tejada B. Maternal sepsis complicating arabin cervical pessary placement for the prevention of preterm birth: a case report. BMC Pregnancy Childbirth 2017; 17:34. [PMID: 28095812 PMCID: PMC5240248 DOI: 10.1186/s12884-016-1209-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 12/28/2016] [Indexed: 11/10/2022] Open
Abstract
Background Preterm delivery is a major health problem and contributes to more than 50% of all neonatal and infant deaths. Recently, there has been a renewed interest in the use of cervical pessaries as a safe and effective intervention with few maternal side-effects for the prevention of preterm birth in both single and twin pregnancies. Case presentation A 43-year-old gravida 5, para 1 (previous preterm birth at 24 weeks) patient with an in vitro fertilization twin pregnancy had an Arabin cervical pessary placed at 19 weeks of pregnancy due to the presence of cervical funneling identified by ultrasound screening. She developed chorioamnionitis and sepsis and delivered at 21 3/7 weeks after extraction of the pessary. Conclusion Severe maternal infection may complicate pessary treatment for the prevention of preterm birth. Careful follow-up is necessary in women with a cervical pessary during pregnancy, particularly when important funneling is present.
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Affiliation(s)
- Begoña Martinez de Tejada
- Obstetrics Unit, Department of Obstetrics and Gynecology, Geneva University Hospitals and Faculty of Medicine, 30 Boulevard de la Cluse, 1205, Geneva, Switzerland.
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15
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Sentilhes L, Sénat MV, Ancel PY, Azria E, Benoist G, Blanc J, Brabant G, Bretelle F, Brun S, Doret M, Ducroux-Schouwey C, Evrard A, Kayem G, Maisonneuve E, Marcellin L, Marret S, Mottet N, Paysant S, Riethmuller D, Rozenberg P, Schmitz T, Torchin H, Langer B. Prevention of spontaneous preterm birth: Guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2017; 210:217-24. [PMID: 28068594 DOI: 10.1016/j.ejogrb.2016.12.035] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 12/29/2016] [Indexed: 01/22/2023]
Abstract
In France, 60,000 neonates are born preterm every year (7.4%), half of them after the spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated with decreased prematurity (level of evidence [LE]1). It is therefore recommended (Grade A). Routine screening and treatment of vaginal bacteriosis is not recommended in the general population (Grade A). The only population for which vaginal progesterone is recommended is that comprising asymptomatic women with singleton pregnancies, no history of preterm delivery, and a short cervix at 16-24 weeks of gestation (Grade B). A history-indicated cerclage is not recommended for women with only a history of conization (Grade C), uterine malformation (professional consensus), isolated history of preterm delivery (Grade B), or twin pregnancies for primary (Grade B) or secondary (Grade C) prevention of preterm birth. A history-indicated cerclage is recommended for a singleton pregnancy with a history of at least 3 late miscarriages or preterm deliveries (Grade A). Ultrasound cervical length screening is recommended between 16 and 22 weeks for women with a singleton previously delivered before 34 weeks gestation, so that cerclage can be offered if cervical length <25mm before 24 weeks (Grade C). A cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with twin pregnancies (Grade A) or in populations of asymptomatic women with a short cervix (professional consensus). Although the implementation of universal screening by transvaginal ultrasound for cervical length at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In cases of preterm labor, (i) it is not possible to recommend any one of the several methods (ultrasound of the cervical length, vaginal examination, or fetal fibronectin assay) over any other to predict preterm birth (Grade B); (ii) routine antibiotic therapy is not recommended (Grade A); (iii) prolonged hospitalization (Grade B) and bed rest (Grade C) are not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (Grade B), unlike beta-agonists (Grade C), can be used for tocolysis in spontaneous preterm labor without preterm premature rupture of membranes. Maintenance tocolysis is not recommended (Grade B). Antenatal corticosteroid administration is recommended for all women at risk of preterm delivery before 34 weeks of gestation (Grade A). After 34 weeks, the evidence is insufficiently consistent to justify recommending systematic antenatal corticosteroid treatment (Grade B), but a course of this treatment might be indicated in clinical situations associated with high risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (Grade C). Repeated courses of antenatal corticosteroids are not recommended (Grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 weeks (Grade A). Cesareans are not recommended for fetuses in vertex presentation (professional consensus). Both planned vaginal and elective cesarean delivery are possible for breech presentations (professional consensus). Delayed cord clamping may be considered if the neonatal or maternal state allows (professional consensus).
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Di Tommaso M, Seravalli V, Arduino S, Bossotti C, Sisti G, Todros T. Arabin cervical pessary to prevent preterm birth in twin pregnancies with short cervix. J OBSTET GYNAECOL 2016; 36:715-718. [PMID: 27013088 DOI: 10.3109/01443615.2016.1148127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A retrospective study was conducted to evaluate the effect of Arabin cervical pessary in twin pregnancies with cervical length (CL) <25 mm between 21 and 31 weeks. Forty patients receiving pessary were matched with 40 controls without pessary. They were matched for gestational age (GA) at admission and CL. GA at delivery, delivery before 36, 34 and 32 weeks, latency between detection of short cervix and delivery, and duration of hospital admission were compared between groups. Women with the pessary delivered at higher GA compared to controls (35 vs. 33 weeks, p = 0.02). Cervical pessary significantly reduced the incidence of delivery <36 and < 34 weeks (p < 0.05), but not before 32 weeks. Interval between detection of short cervix and delivery was longer in the pessary group and duration of hospital admission was shorter (p = 0.03) compared to women without pessary.
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Affiliation(s)
- Mariarosaria Di Tommaso
- a Department of Health Sciences , University of Florence. AOU Careggi , Florence , Italy , and
| | - Viola Seravalli
- a Department of Health Sciences , University of Florence. AOU Careggi , Florence , Italy , and
| | - Silvana Arduino
- b Department of Obstetrics and Gynecology , 2nd U. University of Turin, AO Town of Health and Science , Turin , Italy
| | - Carlotta Bossotti
- b Department of Obstetrics and Gynecology , 2nd U. University of Turin, AO Town of Health and Science , Turin , Italy
| | - Giovanni Sisti
- a Department of Health Sciences , University of Florence. AOU Careggi , Florence , Italy , and
| | - Tullia Todros
- b Department of Obstetrics and Gynecology , 2nd U. University of Turin, AO Town of Health and Science , Turin , Italy
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Yüce T, Konuralp B, Kalafat E, Söylemez F. Pessary use in pregnant women with short cervix. J Turk Ger Gynecol Assoc 2016; 17:120-2. [PMID: 27403080 DOI: 10.5152/jtgga.2015.15098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 12/28/2015] [Indexed: 11/22/2022] Open
Abstract
The purpose of this case series is to provide preliminary evidence on the efficacy of pessary application in women with short cervix and at risk for preterm labor. Between May 2015 and July 2015, four pregnant women were followed-up with Arabin pessaries. The gestational age at the time of diagnosis was between the 23(th) and 29(th) weeks. Pessary application was associated with a prolongation of pregnancy lasting between 28 and 98 days. The gestational age at the time of delivery was between the 33rd and 39th weeks. Pessary use is non-invasive for the prolongation of pregnancy in pregnant women with shortened cervix. The major advantage of pessary use is its easy application without requiring anesthesia.
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Affiliation(s)
- Tuncay Yüce
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Bahar Konuralp
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Feride Söylemez
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
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