Cervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial

Nicolaides, Kypros H.; Syngelaki, Argyro; Poon, Liona C.; Matallana, Catalina De Paco; Plasencia, W.; Molina, Francisca S.; Picciarelli, Gemma; Tul, Nataša; Çelik, Ebru; Lau, Tze Kin; Conturso, R.

doi:10.1016/j.ajog.2015.08.051

Cited by 143 publications

(152 citation statements)

References 25 publications

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“…A preliminary result confirmed that 2-year neonatal survival in the pessary group was higher than that in the group that was managed expectantly. The second RCT in unselected twin pregnancies by Nicolaides et al could not confirm these results 7 . In their study, the cervical pessary was removed < 34 weeks in 22.3% of pregnancies; however, they did not report the gestational week (or range) at delivery in this group of patients.…”

contrasting

confidence: 44%

“…To our knowledge, three randomized controlled trials (RCTs) on pessary use in twin pregnancy have been published. Two of the studies found that cervical pessary did not reduce the rate of PTB in unselected twin pregnancies 6,7 ; the rate did not differ between women allocated to a pessary or no pessary group. However, in the study by Liem et al 6 , the rate of PTB < 34 weeks was reported as 14% in women with a CL < 38 mm at 22 weeks who received pessary placement, compared to nearly 30% in a matched short-CL control group.…”

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confidence: 99%

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Re: ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Goya

Carreras

Cabero

2016

Ultrasound in Obstet & Gyne

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We wish to express our disagreement with some of the statements relating to preterm birth in the recently published ISUOG Practice Guidelines on the role of ultrasound in twin pregnancy 1 . Firstly, cervical length (CL) measurement is the best predictor of preterm birth (PTB) < 35 weeks' gestation in asymptomatic twin pregnancy, as stated previously 2,3 . However, since the majority of twins are delivered before 37 weeks, CL is not a good predictor for delivery at this gestational age; as in singletons, CL is not a good predictor of PTB at 34-37 weeks. However, for symptomatic women, it is a good predictor for PTB within 48 h to 7 days after assessment 2 .

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contrasting

confidence: 44%

mentioning

confidence: 99%

Re: ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Goya

Carreras

Cabero

2016

Ultrasound in Obstet & Gyne

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“…Pessary use was also associated with less children born with a birth weight <2,500 g (RR 0.72; 95% CI 0.54–0.97). Another recent trial, by Nicolaides et al,82 including 1,180 twin pregnancies without a specific cervical length cutoff, showed no effect of a cervical pessary on PTB rates <34 weeks (RR 1.05; 95% CI 0.79–1.4) and adverse neonatal outcome (RR 1.09; 95% CI 0.85–1.4). The post hoc analysis evaluating 214 women with a short cervix (<25 mm) did not change these results.…”

Section: Prevention Of Ptbmentioning

confidence: 98%

Prevention of preterm delivery: current challenges and future prospects

Zijl

Koullali

Mol

et al. 2016

IJWH

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Preterm birth (PTB), defined as delivery at <37 weeks of gestation, is the most important cause of neonatal morbidity and mortality. Therefore, preventing PTB is one of the main goals in obstetric care. In this review, we provide an overview of the current available literature on screening for risk factors for PTB and a summary of preventive strategies in both low-risk and high-risk women with singleton or multiple gestations. Furthermore, current challenges and future prospects on PTB are discussed. For an optimal prevention of PTB, risk stratification should be based on a combination of (maternal) risk factors, obstetric history, and screening tools. Cervical length measurements can help identify women at risk. Thereafter, preventive strategies such as progesterone, pessaries, and cerclage may help prevent PTB. Effective screening and prevention of PTB vary between the different pregnancy populations. In singleton or multiple pregnancies with a short cervix, without previous PTB, a pessary or progesterone might prevent PTB. In women with a (recurrent) PTB in the past, progesterone and a cerclage may prevent recurrence. The effect of a pessary in these high-risk women is currently being studied. A strong collaboration between doctors, patients’ organizations, pharmaceutical companies, and (international) governments is needed to reduce the morbidity and mortality as a result of spontaneous PTB.

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“…124 Finally, there is recent evidence that cervical pessary may decrease the likelihood of preterm birth in women with twin pregnancies. 36, 125–129 Thus, the improved prediction of PTB using serial measurement of CL may facilitate treatment with progesterone if more evidence becomes available to support the use of progesterone in that context. 22, 26, 66, 124, 130, 131 Still, it should be emphasized that there is currently no level-I evidence that routine monitoring of cervical length in women with twin pregnancies improves pregnancy outcome, 132 and therefore current recommendations do not support such a practice.…”

Section: Commentsmentioning

confidence: 99%

Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations?

Melamed

Pittini

Hiersch

et al. 2016

American Journal of Obstetrics and Gynecology

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Objective To determine whether serial measurements of cervical length can improve the prediction of preterm birth in asymptomatic women with twin gestations compared with a single measurement of cervical length at mid-gestation. Materials and Methods This was a retrospective cohort study of women with twin pregnancies followed in a tertiary medical center between 2012 and 2014. All participants underwent routine measurement of cervical length at mid-gestation and every 2–3 weeks thereafter until 28–32 weeks. For each patient, cervical length was determined at the following time periods: 18+0 to 21+6 weeks (Period 1, routine exam), 22+0 to 24+6 weeks (Period 2), 25+0 to 27+6 weeks (Period 3) and 28+0 to 32+0 weeks (Period 4). Measurements of cervical length at Periods 2–4 were analyzed in the form of either absolute length (in mm) or percent shortening relative to cervical length at Period 1. The performance of a stepwise algorithm that incorporates serial measurements of cervical length for the prediction of preterm birth was compared to that achieved with a single measurement of cervical length at Period 1. Results Overall 441 women with twin pregnancies who were eligible for the study underwent a total of 2,374 cervical length measurements. The association of a short cervix (<10th percentile) with preterm birth at <32 weeks persisted in each of the four periods of gestation [Odds ratio (95%-confidence interval): 7.2 (3.1–16.5), 15.3 (6.4–36.7), 10.3 (4.4–24.3) and 23.1(8.3–64.1), respectively]. Compared with a single measurement of cervical length at mid-gestation (Period 1), a stepwise algorithm integrating serial cervical length measurements from all four successive gestational age periods resulted in a significant increase in the area under the ROC curve (0.917 vs. 0.613, p<0.001). Similarly, when a target false positive rate of 5% was used, the same stepwise algorithm was associated with a higher detection rate (69% vs. 28%, p<0.001), higher positive likelihood ratio (14.54 vs. 5.12) and a lower negative likelihood ratio (0.32 vs. 0.76) for preterm birth at <32 weeks compared with a single measurement of cervical length at Period 1. Conclusions Integration of serial measurements of cervical length using a stepwise algorithm in asymptomatic women with twin gestations can improve the detection of women at risk of preterm birth. Prospective studies are needed to validate these findings, and to investigate whether improved risk assessment performance is sufficient to offset the additional costs associated with serial cervical length measurements.

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Cervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial

Abstract: In women with twin pregnancy, routine treatment with cervical pessary does not reduce the rate of spontaneous early preterm birth.

Cited by 143 publications

References 25 publications

Re: ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Re: ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Prevention of preterm delivery: current challenges and future prospects

Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations?

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