Routine ultrasound screening for vasa previa using American Institute of Ultrasound in Medicine criteria will almost universally lead to good outcomes and prevent perinatal mortality.
Because of the potential for intracranial and/or intradural extension associated with some scalp dermoids, however, a comprehensive clinical evaluation incorporating MRI and CT imaging is included in the diagnostic process.
Perhaps cerclage is the ideal treatment for the cervix <1 cm TO THE EDITORS: We wish to commend Romero et al 1 on their important meta-analysis demonstrating a dramatic reduction in the rate of preterm birth in women with short cervices (without a history of prior preterm birth) treated with vaginal progesterone. This is certainly an important advance in the quest to find methods of decreasing the rate of preterm birth, and is certain to have major public health implications. 1 We wish to point out that in this meta-analysis, vaginal progesterone did not appear to have a benefit when the cervix was <1 cm in length.Berghella et al 2 recently performed a meta-analysis that showed that while cerclage did not benefit women with cervices <2.5 cm in length, there appeared to be a significant reduction in preterm birth rates in the subgroup of women with cervical lengths <1 cm. The planned subgroup analyses revealed a significantly lower rate of preterm birth <35 weeks in these patients with cervical lengths <1 cm (39.5% vs 58.0%; relative risk, 0.68; 95% confidence interval, 0.47e0.98).Putting these 2 studies together, it would appear that cerclage might be the optimal therapy for women with cervices <1 cm, while vaginal progesterone would be ideal in women who have a cervical length of 1-2.5 cm.Disclosure: Dr Oyelese is on the speakers' bureau for Hologic and has received honoraria and traveling expenses to speak about preterm birth and fetal fibronectin. No funding was received in relation to this letter. Drs Powel and Benito report no conflicts of interest. REFERENCES 1. Romero R, Conde-Agudelo A, Da Fonseca E, et al. Vaginal progesterone to prevent PTB and adverse outcomes in singleton gestations with a short cervix. Am J Obstet Gynecol 2018;218:161-80. 2. Berghella V, Ciardulli A, Rust OA, et al. Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data. Ultrasound Obstet Gynecol 2017;50:569-77.There is insufficient evidence to claim that cerclage is the treatment of choice for patients with a cervical length <10 mm TO THE EDITORS: We thank Dr Powel et al for their interest in our report as well as in the optimal treatment of patients with a short cervix. They raised some questions about the prevention of preterm birth in women with a singleton gestation and an extremely short cervix, defined as a cervical length <10 mm.First, we would like to reaffirm that our individual patient data (IPD) meta-analysis clearly showed that vaginal progesterone significantly reduced the risk of preterm birth <33 weeks of gestation in women with a singleton gestation and a cervical length 25 mm, regardless of their history of spontaneous preterm birth (relative risk [RR], 0.65; 95% confidence interval [CI], 0.45e0.94 for women with no previous spontaneous preterm birth, and RR, 0.59; 95% CI, 0.40e0.88 for women with previous spontaneous preterm birth). 1 The quality of the evidence in ...
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