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A stepwise approach for the management of short cervix: time to evolve beyond progesterone treatment in the presence of progressive cervical shortening

Published:January 25, 2019DOI:https://doi.org/10.1016/j.ajog.2019.01.221

      Objective

      Progesterone treatment can effectively manage cervical shortening in women with cervical length (CL) of ≤25 mm, but not in those with a CL <10 mm.
      • Romero R.
      • Conde-Agudelo A.
      • Da Fonseca E.
      • et al.
      Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix: a meta-analysis of individual patient data.
      To date, a consensus concerning the management of women who have progressive cervical shortening while on progesterone treatment or of those who have a very short CL has not been reached. Recent studies have suggested that cervical cerclage in this group of women may prolong pregnancy and decrease preterm births.
      • Enakpene C.A.
      • DiGiovanni L.
      • Jones T.N.
      • Marshalla M.
      • Mastrogiannis D.
      • Della Torre M.
      Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening.
      • Makrydimas G.
      • Barmpalia Z.
      • Sotiriadis A.
      Cervical cerclage for women with shortening cervix while on progesterone.

      Study design

      We conducted a prospective study that was based on singleton pregnancies screened for fetal anomalies during the second trimester scan and were diagnosed with CL shortening (≤25mm). Major fetal anomalies, the presence of placenta previa, active vaginal bleeding, cervical cerclage in situ, as well as adolescent pregnancy and signs of active labor were considered as exclusion criteria. The study received institutional review board approval (527/29.9.2014), and eligible women provided informed consent prior to their inclusion to the protocol. All women with ultrasonographic evidence of CL ≤25 mm and a singleton pregnancy received vaginal progesterone (80 mg/dL vaginal gel) at night and were followed up once a week. If CL was reduced ≤15 mm, or, in cases with an initial cervical length ≤15 mm and a gestational age of <26 weeks, a modified McDonald procedure with a 5-mm polyester cerclage tape (Cervix-Set, B. Braun, Aesculap AG, Tuttlingen, Germany) was offered under epidural anesthesia. We chose 15 mm as the cut-off for cerclage based on previously published evidence for cerclage effectiveness.
      • Berghella V.
      • Rafael T.J.
      • Szychowski J.M.
      • Rust O.A.
      • Owen J.
      Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis.
      • Owen J.
      • Hankins G.
      • Iams J.D.
      • et al.
      Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length.
      After the procedure, all women were routinely treated with intravenous cefuroxime 750 mg and metronidazole 500 mg every 8 hours for the first 2 days, while prophylaxis was continued for an additional 8 days with oral roxithromycin 300 mg once a day.

      Results

      Overall, 101 patients were included, of whom 25 were treated with elective cervical cerclage (CL ≤15mm), whereas 76 received vaginal progesterone. Of the latter, 37 women were diagnosed with progressive CL shortening (≤15 mm) and were also managed with cerclage; thus, only 39 women remained in the progesterone-only group. One woman was excluded from analysis because she declined cerclage insertion. Baseline characteristics concerning first-trimester abortions and second-trimester pregnancy losses, history of preterm birth, cervical conization, and presence of preterm contractions were similar in the 3 groups. The perinatal outcome was comparable among the groups; preterm premature rupture of membranes was more frequent in the cerclage group, as well gestational latency period (increased in the progesterone group) (Table). The Kaplan−Meier survival plot depicted comparable outcomes among the 3 groups concerning gestational age at delivery (log rank 1.275, P = .529).
      TableOutcomes
      Progesterone n = 38Cerclage n = 25Progesterone+cerclage n = 37P value
      Gestational age at intervention, wk22 (19–25)23 (19–25)22 (19–24) progesterone

      23 (19–26) cerclage
      <.001
      Post hoc analysis revealed that gestational latency period differed between cerclage following progesterone administration and all other groups. No other differences were noted.
      PPROM0/38 (0%)3/25 (12%)0/37 (0%).014
      Gestational age at delivery, wk38.4 (25.3–41.1)38.3 (28–40.3)38.5 (20–40.4).683
      Delivery <37 wk6/38 (15.8%)7/25 (28%)8/37 (21.6%).498
      Delivery <34 wk4/38 (10.5%)5/25 (20%)5/37 (13.5%).586
      Delivery <32 wk2/38 (5.2%)3/25 (12%)3/37 (8.1%).594
      Delivery <28 wk1/38 (2.6%)0/25 (0%)2/37 (5.4%).622
      Latency period, wk16 (1.6–19.1)14.4 (4.4–20.4)15.3 (0.7–17.3).028
      Post hoc analysis revealed significant differences among progesterone-only and cerclage-only latency periods. No other differences were noted.
      Birthweight, g3100 (820–3960)3200 (970–4500)3120 (510–3935).818
      Apgar score 1'9 (2–9)9 (5–9)9 (0–9).303
      Apgar score 5'10 (2–10)10 (7–10)10 (0–10).478
      NICU4/38 (10.5%)4/25 (16%)5/37 (13.5%).870
      CPAP1/38 (2.6%)3/25 (12%)5/37 (13.5%).266
      Intubation3/38 (7.9%)0/25 (0%)0/37 (0%).114
      Neonatal death1/38 (2.6%)0/25 (0%)2/37 (5.4%).622
      Neonatal hospitalization, days3 (0–60)3 (0–7)3 (0–5).398
      CPAP, continuous positive airway pressure; NICU, neonatal intensive care unit; PPROM, preterm premature rupture of membranes.
      Continuous variables are expressed as median (range) values.
      Daskalakis. A stepwise management of short cervix. Am J Obstet Gynecol 2019.
      a Post hoc analysis revealed that gestational latency period differed between cerclage following progesterone administration and all other groups. No other differences were noted.
      b Post hoc analysis revealed significant differences among progesterone-only and cerclage-only latency periods. No other differences were noted.

      Conclusions

      Our study findings support a stepwise approach in cervical shortening management, with the addition of cervical cerclage in women who do not respond to vaginal progesterone, or in those with a very short cervix during the initial evaluation. This approach was complemented by an extended course of antibiotic and anti-inflammatory prophylaxis, as there is evidence that supports a cross-link between intra-amniotic inflammation/infection and preterm birth.

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