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In the name of God. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with a history of preterm birth and a sonographic short cervix. Published online 17 J anuary 2013 in Wiley online library

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In the name of God

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In the name of God


Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with a history of preterm birth and a sonographic short cervix

Published online 17 January 2013 in Wiley online library

Ultrasound ObstetGynecol 2013;41


Preterm birth remains the leading cause of perinatal morbidity & mortality worldwide

so

Preventive strategies required to minimize burden of prematurity


Shortened Cx length in TVS is powerful predictor of spontaneous preterm birth


Vaginal progesterone for asymptomatic pregnant women with short Cx ≤ 25mm In comparison with placebo reduces:

  • Preterm birth rates before 33 weeks GA

  • Neonatal mortality/morbidity


In a Cochrane review :

cerclage in comparison with no treatment for preterm birth prevention in singleton pregnancy reported a less marked, but statistically significant


In meta-analysis Benefit of cerclage for women with singleton pregnancy is highlighted in:

  • Short Cx

  • Previous preterm birth


Cxpessaryversous expectant management in a recent multicenter study in spain:

380 pregnant women with Hx of preterm birth &Cx length ≤25mm

Significant reduction in:

Preterm birth <34 w GA (6.3% vs 26.8%)

Neonatal morbidity (4.2% vs 22.1%)


Aim of this study

Compare outcom of pregnancy in singleton pregnancy with Hx of preterm bith & Cx length ≤25mm in cerclage, vaginal progesterone or cervical pessary


Method:

3 different cohort of singleton pregnant women with a Hx of at least one spontaneous preterm birth< 34 & short cx on sono:

142 treated with cerclage in USA

59 vaginal progesterone UK

42 cervical pessarySpain


cerclage

15 clinical center in the USA 2003-2007:

Singleton pregnant women with previous histoty of preterm birth at 17W <GA<33+6

if Cx length <25mm cerclage done

if Cx length 25-29mm serial transvaginal scan at 16<GA<21+6 fortnightly or weekly screen for Neisseria gonorrhoeae & chlamydia trachomatis that treat with positive culture


Post cerclage management

  • Recommendation for pelvic rest

  • Abstinence from sexual activity

  • No douching

  • No tampons

  • Physical activity restrictions, no prolonged standing for >4 h

  • No heavy physical work involving lifting >20 pounds or straining

  • No valsalva


Cerclage removing

  • 37 W GA in NL pregnancy

  • Early removing in :

  • chorioamnion rupture

  • labor

  • hemorrhage


Vaginal progesterone

59 high risk Singleton pregnant women with:

  • Spontaneous preterm birth

  • Preterm ROM

  • Significant cervical surgery

    referred to the weekly outpatient clinic


Short cervix

Cervical length < 3rd centile

  • 30.5mm at 16 W

  • 24.5mm at 23W


  • Serial transvaginal scan from 16W every 1-4 W (depended on initial cervical length & GA of prior preterm birth )

  • 200mg vaginal progesteron at night (restriction in activity & prolonged standing but no advise for sexual activity)

  • If significant Cx shortening do cerclage (<15mm in women that was > 15mm or further shortening >50% in <15mm cervical length in initial treatment)

  • Vaginal swab were taken only for symptomatic pt


Cervical pessary

42 singleton pregnant women with pior preterm birth <34 in Spain 2007-2010

Serial TVS from 16W continued 1-4 W

Cervical & vaginal swab if infection proved appropriate treatment then with 1 week delay pessary inserted but not removing for infection after insertion


Removing pessary

In NL pregnancy 37W GA

Before 37W in:

  • Active vaginal bleeding

  • Threat of preterm labor with persistant contractions, despite tocolysis, or sever pt discomfort


results


Clinical outcom


Clinical outcom in cervical lenght<25 irrespective of GA


Discussion

Similar effectiveness of currently available treatment strategies for women with singleton pregnancy who has one prior preterm birth and shortened cervical length on TVS


Smoking & ethnicity are confounders known to be associated with preterm birth however in short Cx it is low


Infection screening

  • USA study: N.gonorrhoeae & C.trachomatis

  • Spanish: vaginal bacteriosis

  • Uk: screen symptomatic women

    Number of women who received AB is low so effectiveness of AB to prevent preterm birth remains unproven…


Progressive cervical shortening & CX length< 15mm increased benefit with cerclage despite treatment with progesteron


recommendation

  • Trials should be less invasine and cheaper treatment and need to be even larger studies

  • Choose cerclage, vaginal progesterone or cervical pessary for women with short cervix on sono or prior preterm birth is reasnable


Thanks for your attention

Thanks for your attention


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