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) / Pessário cervical associado a progesterona em gestações gemelares com colo curto comparado a gestações gemelares não selecionadas e não tratadas: estudo de coorte histórica de equivalência (Estudo de Pessário em Gêmeos EPM)

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.

Resumo Objetivo Este estudo tem como objetivo determinar se o uso de pessário cervical associado a progesterona em gestações de gêmeos dicoriônicos-diamnióticos (DC-DAs) com colo do útero curto (≤ 25 mm) apresenta taxa de parto prematuro (PP) equivalente à de gestações gemelares DC-DA sem nenhuma intervenção/não selecionadas. Métodos Um estudo de coorte histórica foi realizado entre 2010 e 2018, incluindo um total de 57 mulheres grávidas com gestações gemelares DC-DA. As mulheres admitidas de 2010 a 2012 (n = 32) não receberam tratamento, e não foram selecionadas pelo comprimento cervical (grupo Não Tratado, GNT), enquanto as admitidas de 2013 a 2018 (n = 25) receberam pessário cervical rotineiramente associado a progesterona após o diagnóstico de colo curto entre a 18a e a 27ª semanas de gestação (grupo Pessário-Progesterona, GPP). O desfecho primário analisado foi a taxa de PP antes de 34 semanas. Resultados Não houve diferenças estatísticas entre o GNT e o GPP em relação ao PP < 34 semanas (respectivamente, 18,8%; versus 40,0%;; p = 0,07) e ao peso médio ao nascer do gêmeo menor (2.037 ± 425 g versus 2.195 ± 665 g; p = 0,327). A análise de Kaplan-Meyer foi realizada, e não houve diferenças entre os grupos antes de 31,5 semanas. A regressão logística demonstrou que o nascimento prematuro anterior (< 37 semanas) apresentou razão de probabilidades (odds ratio, OR) de 15,951 (intervalo de confiança de 95%; [IC95%;]: 1,294-196,557; p = 0,031*) para o nascimento prematuro < 34 semanas no GPP. Conclusão Em gêmeos DC-DA com colo uterino curto (o que significa maior risco de nascimento prematuro), o tratamento com pessário cervical associado a progesterona pode ser considerado equivalente em diversos aspectos relacionados à prematuridade no GNT, apesar da grande diferença entre os grupos.

Uso de pesario cervical y prevención de parto pretérmino / Cervical pessary use and preterm labor prevention

Introducción: El parto pretérmino constituye una causa importante de morbimortalidad perinatal con repercusiones sociales y económicas a nivel mundial. La intervención oportuna ante la identificación de factores de riesgo y un adecuado manejo consiguen reducir su incidencia y evitar las consecuencias de la prematurez. Objetivo: El presente trabajo se realiza con el objetivo de destacar al pesario cervical como una herramienta mecánica en la prevención del parto pretérmino, y una opción de tratamiento en embarazos mayores de 25 semanas con insuficiencia cervical. Presentación del caso: Se trata de una paciente de 38 años de edad con antecedente de parto pretérmino espontaneo (de 33 semanas), que ingresa a las 21 semanas de embarazo con dilatación cervical de 3cm y acortamiento de la longitud cervical de 14mm, signos ecográficos: sludge y funneling. Se optó por manejo expectante con medidas complementarias: administración de antibiótico, progesterona y uso de pesario cervical. Tras el control clínico de la infección y mayor acortamiento cervical a 7mm a pesar del uso de progesterona, se colocó un pesario cervical a las 25,5 semanas, a las 27,5 semanas fue dada de alta, a las 36,6 semanas se retiró el pesario tras inicio de actividad uterina. Discusión: La progesterona y el cerclaje son medidas de elección en casos de insuficiencia cervical, sin embargo, ante las dificultades técnicas de colocación; el pesario representó una alternativa. El uso de pesario permitió que el embarazo progrese al término con resultados beneficiosos y sin evidencia de efectos adversos.

Introduction: Preterm delivery is an important cause of perinatal morbidity and mortality with global social and economic repercussions. Timely intervention in the identification of risk factors and proper management reduce their incidence and avoid the consequences of prematurity. Objective:This work is carried out with the aim of highlight the cervical pessary as a mechanical tool in the prevention of preterm birth and a treatment option in pregnancies over 25 weeks with cervical insufficiency. Case presentation: This is a 38-year-old patient with a history of spontaneous preterm delivery (33 weeks), who was admitted at 21 weeks of pregnancy with cervical dilation of 3cm and shortening of the cervical length of 14mm, ultrasound signs: sludge and funneling. Expectant management was opted, with complementary measures: administration of antibiotics, progesterone and use of a cervical pessary. After clinical control of the infection and greater cervical shortening to 7mm despite the use of progesterone, a cervical pessary was placed at 25.5 weeks, at 27.5 weeks she was discharged, at 36.6 weeks she was discharged. The pessary was removed after the start of uterine activity. Discussion: Progesterone and cerclage are the measures of choice in cases of cervical insufficiency, however, given the technical difficulties of placement; the pessary represented an alternative. Conclusion: The use of the pessary allowed the pregnancy to progress to term with beneficial results and without evidence of adverse effects.

The comparison of USG measured cervical length in pregnant women with previous induced abortion versus those who have not had an induced abortion

Background: The majority of women who undergo induced abortion are young and of low parity. Hence, it is desirable to look for any association effects of induced abortion with future reproductive outcomes. In this study, we aim to compare ultrasound measured cervical length in pregnant women with previous induced abortion versus those who have not had an induced abortion.Methods: This was a prospective observational study performed at tertiary care hospital. Total of 400 patients were recruited, divided into two groups. Patients with an induced abortion in previous pregnancy were included as cases and those with no history were taken as controls. Cervical length was measured by transvaginal ultrasound in all participants at 11-14, 18-22 and 28-32 weeks. Pregnancies were followed up to note incidence of spontaneous preterm delivery, preterm pre labour rupture of membranes (PPROM), threatened preterm, and second trimester miscarriage.Results: Authors have found that there was no significant difference in the cervical length of pregnant patients with or without a history of prior induced abortions.  In our study authors found that mean cervical length at 11-14weeks, 18-22 weeks, and 28-32 weeks was 3.47±0.126cm and 3.48±0.195cm; 3.44±0.296cm and 3.49±0.182cm; 3.36±0.477cm and 3.42±0.310cm respectively among cases and controls. However, there was a demonstrably increased risk of spontaneous preterm delivery, PPROM and threatened preterm in patients with a history of prior induced abortion.Conclusions: Authors conclude that previous induced abortion increases the risk of threatened preterm, PPROM, spontaneous preterm delivery in the subsequent pregnancy. But, this risk is not predictable by measuring cervical length as the mean cervical length remained the same in both the groups.

Vaginal progesterone in risk reduction of preterm birth in women with short cervix

Background: Preterm birth is a global health problem affecting the neonate, family and country in general. It is the leading cause of perinatal mortality and morbidity. Short cervical length detected on transvaginal ultrasound is the most practical risk factor for prediction of preterm birth. The aim of this study was to determine the efficacy and safety of vaginal progesterone in reducing the rate of preterm birth in women with a short cervix and to determine its effect on neonatal mortality and morbidity.Methods: The study was carried out in the Department of Obstetrics and Gynaecology at Assam Medical College, Dibrugarh for a period of one year. It included 128 asymptomatic women with a singleton pregnancy and a sonographic short cervix. Women were randomly divided into two groups, one of which was given placebo and the other was given vaginal progesterone and a comparative study was conducted.Results: It was observed that delivery before 37 weeks of gestation was less frequent in the progesterone group than in the placebo group (60.94% vs. 90.63%). Vaginal progesterone was also associated with a significant reduction in adverse neonatal outcomes like the rate of sepsis (6.25% vs. 18.75%), requirement of ventilator (12.5% vs. 26.56%), admission to NICU (10.94% vs. 26.56%) and birth weight ≤1.5kg (7.81% vs. 21.88%).Conclusions: Vaginal progesterone reduces the risk of preterm birth and adverse perinatal outcomes in pregnant women without any deleterious effects on the foetus or mother.

Use of the pessary in the prevention of preterm delivery / Uso do pessário na prevenção de parto pretermo

Abstract Objective The gestational complication most associated with perinatalmortality 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. Themeta-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.

Resumo Objetivo O parto com idade gestacional < 37 semanas é a complicação gestacional mais associada à mortalidade e morbidade perinatal, sendo necessária a identificação de seus fatores de risco e a tentativa de sua prevenção. Os benefícios do pessário na prematuridade estão sendo investigados. Nosso objetivo foi analisar os estudos publicados sobre uso do pessário na prevenção do parto pretermo e comparar sua eficácia perante outros métodos. Métodos Foramselecionados estudos clínicos randomizados publicados entre 2010 e 2018, extraídos de bases eletrônicas de dados. Estudos de gestações múltiplas foram excluídos. Resultados Dois estudos semostraram a favor do pessário comométodo preventivo, um estudo foi contrário ao método, e outros dois não demonstraram diferença estatisticamente significativa. A meta-análise não mostrou diferença significativa no Conclusão Os dados agrupados disponíveis até o momento parecem mostrar uma falta de eficácia do pessário cervical na prevenção do parto pretermo, embora a heterogeneidade dos estudos tenha dificultado as comparações.

Addition of Cervical Elastography May Increase Preterm Delivery Prediction Performance in Pregnant Women with Short Cervix: a Prospective Study

BACKGROUND: We investigated whether there is a difference in elastographic parameters between pregnancies with and without spontaneous preterm delivery (sPTD) in women with a short cervix (≤ 25 mm), and examined the ability of elastographic parameters to predict sPTD in those women. METHODS: E-CervixTM (WS80A; Samsung Medison, Seoul, Korea) elastography was used to examine the cervical strain. Elastographic parameters were compared between pregnancies with and without sPTD. Diagnostic performance of elastographic parameters to predict sPTD ≤ 37 weeks, both alone and in combination with other parameters, was compared with that of cervical length (CL) using area under receiver operating characteristic curve (AUC) analysis. RESULTS: A total of 130 women were included. Median gestational age (GA) at examination was 24.4 weeks (interquartile range, 21.4–28.9), and the prevalence of sPTD was 20.0% (26/130). Both the elastographic parameters and CL did not show statistical difference between those with and without sPTD. However, when only patients with CL ≥ 1.5 cm (n = 110) were included in the analysis, there was a significant difference between two groups in elasticity contrast index (ECI) within 0.5/1.0/1.5 cm from the cervical canal (P < 0.05) which is one of elastographic parameters generated by E-Cervix. When AUC analysis was performed in women with CL ≥ 1.5 cm, the combination of parameters (CL + pre-pregnancy body mass index + GA at exam + ECI within 0.5/1.0/1.5 cm) showed a significantly higher AUC than CL alone (P < 0.05). CONCLUSION: An addition of cervical elastography may improve the ability to predict sPTD in women with a short CL between 1.5 and 2.5 cm.