Short Cervix and Risk for Preterm Birth: Do Pessaries Work?
This study by Xin-Hang et al. (Scientific Reports, 2017) sought to explore the effectiveness of using cervical pessaries to prevent preterm birth and perinatal morbidity and mortality in asymptomatic women with a singleton pregnancy and a short cervix (length ≤25 mm).
Systematic Review and Meta-Analysis
A total of 1,412 women were analyzed. Cervical pessary placement was not shown to reduce the risk of spontaneous preterm birth <34 weeks’ gestation (RR 0.71; 95%CI, 0.21–2.43, P = 0.59). Cervical pessary placement was not associated with any maternal or neonatal adverse effects. The authors concluded that although analysis of these trials did not indicate that cervical pessaries decrease the risk of spontaneous preterm birth, large randomized controlled trials are needed to confirm the findings due to study limitations. Such limitations include the potential bias due to inability to blind researchers and providers. Furthermore, only 3 studies could be included and therefore the sample size does not allow for proper analysis of cofounding variable (for example BMI and varying cervical lengths). Finally, the use of progestogens in combination with pessaries remains to be determined.
Endometrial Hyperplasia – Current Nomenclature and Treatment
Endometrial intraepithelial neoplasia (EIN) is the precursor of type I endometrioid adenocarcinoma.
There are three categories in the EIN classification:
Benign endometrial hyperplasia (benign), a diffuse condition due to prolonged estrogen effect
Treatment is hormonal therapy
Endometrial intraepithelial neoplasia (premalignant), a focal abnormality progressing to diffuse, precancerous in nature
Treatment can be hormonal therapy or surgery
Endometrial adenocarcinoma, endometrioid type, well differentiated (malignant), a focal abnormalitiy progressing to diffuse
Treatment is surgical.
Criteria for diagnosing endometrial intraepithelial neoplasia include the following:
Architectural change with area of glands greater than stroma
Cytologic abnormality in area of architectural change
Size of abnormal area > 1 mm
Not a polyp, area of repair, secretory endometrium (excludes mimics)
Not carcinoma (excludes cancer)
Endometrial hyperplasia can be a precursor to adenocarcinoma of the endometrium. Distinguishing between hyperplasia and a precancerous lesion is important in optimizing management. The endometrial intraepithelial neoplasia (EIN) classification described here is intended to achieve this, while incorporating pathologic criteria that have become available since the World Health Organization’s 1994 four-class classification was developed.
The EIN system appears to increase reproducibility and reduce subjective, descriptive interpretation of pathology
Hysteroscopy with directed biopsy of any discrete lesions is the best way to confirm a premalignant endometrial lesion and to exclude endometrial carcinoma
Both suction curettage and dilation and curettage have significant sampling limitations
Acceptable surgical treatment is hysterectomy, abdominal, vaginal or minimally invasive, with or without removal of fallopian tubes and ovaries
Supracervical hysterectomy and morcellation are contraindicated
Medical treatment, progestins, can be offered to patients who wish to retain fertility, desire uterine retention, or have multiple medical comorbidities
Medroxyprogesterone acetate and megestrol acetate are most commonly used
The 52 mg levonorgestrel containing IUD provides another option
Regression rates approach 90% with any of the above
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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