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 Obstet Gynecol 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. Cx pessary versous 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 pessary Spain

11. cerclage
15 clinical center in the USA : 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

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 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 Cerclage Vaginal progesterone Cervical pessary Maternal age
26 ± 5
30 ± 6
31± 7
Racial origine
Afro-caribbean
Caucasian
Other
75(53)
51(36)
16(11)
3(5)
53(89)
1(2)
35(83)
6(14)
Smoker
23(16)
21(36)
11(26)
BMI
30±8
25±6
27±6
Prior birth<34
2(1-3)
1(1-3)
GA in initiation of treatment
19±2
21±3
21±2
Cx length in initiation of treatment
18.4±6.3
21.1±8.1
19.3±5.1
cerclage
142(100)
6(10)
Progesterone
54(38)
59(100)
Cx pessary
42(100)

20. Clinical outcom Cerclage(A) Vaginal progesterone(B)
Cervical pessary (c)
A vs B
A vs c
B vs c
Pregnancy outcom
Birth< 37w
63(44)
27(46)
19(45)
0.97 ( )
0.98 ( )
1.01 ( )
Birth<34w
40(28)
19(32)
5(12)
0.87 ( )
2.37 ( )
2.70 ( )
Birth <28w
20(14)
8(14)
3(7)
1.04 ( )
1.97( )
1.90 ( )
C/s
43(30)
12(20)
10(24)
1.49 ( )
1.23 ( )
0.85 ( )
Neonatal outcom
Perinatal loss
12(8)
5(8)
1(2)
0.99 ( )
3.55 ( )
3.56 ( )
Serious ICH
Serious respiratory
morbidity
6(10)
2(4)
0.83( )
1.77 ( )
2.14 ( )
Necrotizing entrocolitis
2(1)
Retinopathy of prematurity
3(2)

21. Clinical outcom in cervical lenght<25 irrespective of GA
PRIMARY THERAPY FOR SHORT CERVIX
Relative risk(95 CI)
Cerclage (142)
Vaginal progesterone (38)
Cx pessary (42)
A vs B
A vs C
B vs c
Birth <34
40(28)
10(26)
5(12)
1.07 ( )
2.37 ( )
2.21 ( )
Perinatal loss
12(8)
5(13)
1(2)
0.64 ( )
3.55 (0.47_26.51)
5.53 ( )

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