Progesterone or Cerclage in Preterm Prevention in Women with Previous Preterm Birth and Short Cervix?
BACKGROUND AND PURPOSE:
A short cervix in women with previous preterm birth significantly raises the risk of recurrence by 3 fold
Conde-Agudelo et al. (AJOG 2018) compared the efficacy of vaginal progesterone and cerclage in prevention of preterm birth and adverse perinatal outcomes in this group of previous preterm birth and short cervix
Systematic Review and meta-analysis
Participants: Women with singleton gestation, previous spontaneous preterm birth and a second trimester short cervix (<25 mm) on ultrasound
Literary search included RCTs with a primary aim of preventing preterm birth in the above group
Daily dose of vaginal progesterone used in the trials varied from 90 to 200 mg, administered from 18–25 to 34–36 weeks of gestation
Trials used both McDonald and Shirodkar technique
Preterm birth <35 weeks of gestation
Preterm birth <37, <32, and <28 weeks of gestation
Respiratory distress syndrome and other adverse neonatal outcomes
Composite perinatal morbidity and mortality
Pooled relative risk (RRs) with 95% confidence intervals were calculated
Five trials comparing vaginal progesterone vs placebo (265 women) and 5 comparing cerclage vs no cerclage (504 women) were included
Vaginal progesterone, compared with placebo
Significantly reduced the risk of preterm birth <35 and <32 weeks of gestation, composite perinatal morbidity, mortality, neonatal sepsis, composite neonatal morbidity, and admission to the neonatal intensive care unit (RRs from 0.29 to 0.68)
Cerclage, compared with no cerclage
Significantly decreased the risk of preterm birth <35, <37, <32, and <28 weeks of gestation, composite perinatal morbidity/mortality, birthweight <1500 g (RRs from 0.64 to 0.70)
There were no differences in grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, and birthweight <2500 g regardless of progesterone or cerclage
Indirect Comparison Between Cerclage and Progesterone
Adjusted indirect comparison meta-analyses showed no differences between vaginal progesterone and cerclage
Preventing preterm birth <35 weeks of gestation (RR, 0.97; 95% CI, 0.66–1.44; P =.93)
Perinatal death (RR, 0.97; 95% CI, 0.35–2.69; P =.96)
There were no differences in secondary outcomes
Vaginal progesterone and cerclage are equally effective for the prevention of preterm birth in women with singleton pregnancies, previous preterm birth and short cervix
These findings agree with a previous, smaller RCT and Cochrane review comparing vaginal progesterone to cerclage that likewise did not show any difference in this population
There is data suggesting that there may be increased use of tocolysis and preterm PROM when using cerclage
Clinical implications of this study suggest either progesterone or cerclage may be used but further properly powered, large RCTs are required
In the interim, the data provided by this study may serve as the best evidenced based guide to care
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