Does fetal fibronectin testing prevent preterm birth?

FINDINGS:

In a systemic review and meta-analysis, the authors assessed 6 high quality randomized clinical trials to determine whether the use of fetal fibronectin (FFN) in the clinical setting actually reduces preterm labor. Berghella and Saccone (AJOG, 2016) compared 546 singleton gestations that were randomized to management based on FFN results (intervention group) or not (comparison group). When comparing the intervention to the control group, the researchers found:

No differences in

  • Labor incidence at <37 weeks, <34 weeks <32 weeks and <28 weeks gestation
  • Number of women who delivered within 7 days
  • Mean gestational age at delivery
  • Rate of maternal hospitalization
  • Use of tocolysis or antenatal steroids
  • Mean time in the triage unit
  • Neonatal outcomes, including RDS, admission to the NICU

Statistical difference was identified in

  • Cost of hospitalization charges with a mean additional cost of $153 in the intervention group (95% CI, 24.01 – 281.99)

SYNOPSIS:

FFN is an extracellular matrix glycoprotein produced during pregnancy by amniocytes and cytotrophoblasts. Studies have shown that increased levels of FFN in vaginal and cervical secretions are associated with spontaneous preterm birth (SPTB). Obtaining FFN is easy and safe, using a swab, and FFN has been used to help providers determine whether to keep patients with symptoms of SPTB under surveillance. While clinical validity has been determined – increased FFN levels are associated with SPTB – this meta-analysis sought to determine clinical utility and whether outcomes are altered in a positive way.

KEY POINTS:

  • Based on the findings of this paper, it appears that there is no clinical benefit but there are increased costs to the use of FFN in the management of singleton pregnancies with symptoms suggestive of SPTB
  • An editorial by GA Macones, MD, advocates that based on the findings in this study, the use of FFN testing in treated preterm labor is not justified
  • Studies that included the use of ultrasound measurement of cervical lengths were not included
  • Strengths of study include rigorous adherence to principles of evidence-based medicine, thereby reducing sources of bias
  • Limitations relate to the number of study subjects, and therefore stratification based on more individualized or particular clinical scenarios could not be assessed

Learn More – Primary Sources:

AJOG: Fetal fibronectin testing for prevention of preterm birth in singleton pregnancies with threatened preterm labor: a systematic review and meta-analysis of randomized controlled trials.

AJOG Editorial: Fetal fibronectin testing in threatened preterm labor: time to stop

Guidance Update: Professional Organizations Align on Cervical Cancer Screening

SUMMARY:

ACOG has joined ASCCP and the SGO in endorsing the USPSTF cervical cancer screening recommendations. The ACOG practice document states that

Consistent with prior guidance, screening should begin at age 21 years, and screening recommendations remain unchanged for average-risk individuals aged 21–29 years and those who are older than 65 years

Management of abnormal cervical cancer screening results should follow current ASCCP guidelines

CLINICAL ACTIONS: 

The USPSTF recommends the following (Grade A – “Offer or Provide this Service”) 

  • Begin screening at age 21
    • Screen every 3 years with cytology alone
    • Do not perform HPV testing routinely
  • Age 30 to 65 can be screened
    • Every 5 years ‘cotesting’ with cytology plus HPV
    • Every 3 years with cytology only
    • every 5 years with high-risk human papillomavirus (hrHPV) testing alone

The USPSTF recommends against the following (Grade D – Discourage the use of this service)

  • <21 years
    • Do not offer screening
  • >65 years
    • Do not offer screening in the setting of adequate prior screening and otherwise not at high risk for cervical cancer
  •  Do not offer screening following hysterectomy if
    • Cervix was removed and
    • There is no history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

SYNOPSIS:

Cervical cancer rates in the United States are low due largely to access to effective screening.  Cervical cancer is believed with a high degree of certainty, to be the delayed consequence of infection with high risk or oncogenic human papillomavirus (HPV).  The majority of HPV infections are transient and do not progress to cervical cancer.  However, the consequences of missing precancerous or early cancerous lesions are potentially lethal and should be avoidable with appropriate screening.

KEY POINTS:

  • The goal of cervical cancer screening is to minimize harm and maximize benefit
  • Guidelines focus on increasing the age at which to begin screening, lengthening the screening interval and discontinuing screening women at low risk for future cervical cancer
  • The above action items refer to average risk women
  • Women at increased risk for cervical cancer require a higher level of surveillance and include those who are
    • Immunocompromised (HIV positive, organ transplant recipient, chronic steroid use)
    • Sex workers
    • Women with multiple partners or high risk partners
    • Women with a history of abnormal Pap smear  or precancerous genital conditions
    • Smokers
    • Women with a history of sexually transmitted diseases
  • ACOG has responded to the American Cancer Society (2020) recommendation that hrHPV testing in isolation every 5 years should be prioritized for women 25 to 65 years of age
    • hrHPV alone has demonstrated efficacy and efficiency
    • However, the ACOG Practice Advisory notes significant limitations regarding current healthcare infrastructure, including

Limited access to primary hrHPV testing is of particular concern in rural and under-resourced communities and among communities of color, which have disproportionately high rates of cervical cancer incidence, morbidity, and mortality

Although HPV self-sampling has the potential to greatly improve access to cervical cancer screening, and there is an increasing body of evidence to support its efficacy and utility, it is still investigational in the United States

Learn More – Primary Sources:

ACOG: Updated Cervical Cancer Screening Guidelines

ASCCP Management Guidelines and Algorithms

USPSTF (2018): Cervical Cancer Screening

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

Locate a GYN Oncology Specialist:

Gyn Oncology Locator – SGO