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In the name of God

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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  1. In the name of God

  2. 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

  3. Preterm birth remains the leading cause of perinatal morbidity & mortality worldwide so Preventive strategies required to minimize burden of prematurity

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

  5. 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

  6. In a Cochrane review : cerclage in comparison with no treatment for preterm birth prevention in singleton pregnancy reported a less marked, but statistically significant

  7. In meta-analysis Benefit of cerclage for women with singleton pregnancy is highlighted in: • Short Cx • Previous preterm birth

  8. 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%)

  9. 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

  10. 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

  11. 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

  12. 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

  13. Cerclage removing • 37 W GA in NL pregnancy • Early removing in : • chorioamnion rupture • labor • hemorrhage

  14. Vaginal progesterone 59 high risk Singleton pregnant women with: • Spontaneous preterm birth • Preterm ROM • Significant cervical surgery referred to the weekly outpatient clinic

  15. Short cervix Cervical length < 3rd centile • 30.5mm at 16 W • 24.5mm at 23W

  16. 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

  17. 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

  18. 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

  19. results

  20. Clinical outcom

  21. Clinical outcom in cervical lenght<25 irrespective of GA

  22. 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

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

  24. 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…

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

  26. 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

  27. Thanks for your attention Thanks for your attention

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