Activity Restriction Among Women With a Short Cervix

Abstract

OBJECTIVE-To estimate determinants of and outcomes associated with activity restriction among women with a short cervix.METHODS-This was a secondary analysis of a randomized trial of 17-α hydroxyprogesterone caproate for prevention of preterm birth among nulliparous women with singleton gestations and cervices less than 30 mm by midtrimester ultrasonography. Women were asked weekly whether they had been placed on pelvic, work, or nonwork rest. "Any activity restriction" was defined as being placed on any type of rest. Factors associated with any activity restriction were determined and the association between preterm birth and activity restriction was estimated with multivariable logistic regression.RESULTS-Of the 657 women in the trial, 646 (98%) responded to questions regarding activity restriction. Two hundred fifty-two (39.0%) were placed on any activity restriction at a median of 23.9 weeks (interquartile range 22.6-27.9 weeks).Women on activity restriction were older, more Dr. Spong, and Dr. Rouse, Associate Editors of Obstetrics & Gynecology, were not involved in the review or decision to publish this article.Presented at the Society for Maternal-Fetal Medicine meeting, February 11-16, 2013, San Francisco, California. Financial DisclosureThe authors did not report any potential conflicts of interest. likely to have private insurance, less likely to be Hispanic, had a shorter cervical length, and were more likely to have funneling and intra-amniotic debris. Preterm birth at less than 37 weeks of gestation was more common among women placed on activity restriction (37% compared with 17%, P<.001). After controlling for potential confounding factors, preterm birth remained more common among those placed on activity restriction (adjusted odds ratio 2.37, 95% confidence interval 1.60-3.53). Results were similar for preterm birth at less than 34 weeks of gestation. NIH Public AccessCONCLUSION-Activity restriction did not reduce the rate of preterm birth in asymptomatic nulliparous women with a short cervix.Preterm birth remains a leading cause of perinatal morbidity and mortality. 1 In an effort to reduce its frequency, investigators have studied a wide variety of prophylactic and therapeutic strategies such as antibiotics, intravenous fluids, and both short-term and longterm tocolysis. None of these strategies, however, has been proven to reduce the frequency of preterm birth. 2Similarly, activity restriction has been widely studied for preterm birth prophylaxis and treatment. [3][4][5] Activity restriction takes many forms, including pelvic rest, work stoppage, and bed rest. None of these variations is known to be efficacious, and each may be associated with adverse social, economic, and health consequences. 6,7 Two randomized trials have demonstrated that vaginal progesterone, when administered to women found to have a short cervix on transvaginal ultrasonography, reduces the frequency of preterm birth. 8,9 Accordingly, some have advocated for midtrimester cervical length screening for all pregnant wo...

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

“…In a secondary analysis of an RCT of 17‐α hydroxyprogesterone caproate among nulliparous women with singleton gestations and mid‐trimester TVS‐CL < 30 mm, Grobman et al . showed that activity restriction increased the risk of PTB < 37 weeks.…”

Reducing the Risk of Preterm Birth by Ambulatory Risk Factor Management

“…In a systematic review from 2014 (34) and subsequent study, physical rest could not be shown to reduce the preterm birth rate. Two studies of pregnant women at risk of preterm birth even found a 2.1-2.4-fold increase in the preterm birth rate <34 weeks' gestation or <37 weeks' gestation (aOR: 2.37; [1.60; 3.53]) (35,36).…”

Pros and Cons of Maternal Cervical Length Screening to Identify Women at Risk of Spontaneous Preterm Delivery

“…The analysis by Werner et al 19 is based in large part on probabilities reported in the randomized trial by Fonseca et al, 12 but Werner et al 19 performed their cost analysis using only singleton pregnancies without a history of previous preterm birth, and the subgroup with greatest benefit from cervical length screening and treatment with progesterone in the trial by Fonseca et al 12 was the group of women with a history of previous preterm birth. In addition, baseline cost estimates in the analysis by Werner et al 19 were $0 for hospital admission for short cervix and $0 for loss of productivity secondary to bed rest; therefore, it will be important to avoid hospitalization and activity restrictions in women with short cervices to realize the savings described by Werner et al 19 Avoidance of activity restrictions is particularly important as activity restriction has been shown NOT to reduce the rate of preterm birth in asymptomatic women with a short cervix, 20 while there is strong evidence that there are detrimental effects to the mother and her family when the gravid patient is placed on activity restriction. In addition, baseline cost estimates in the analysis by Werner et al 19 were $0 for hospital admission for short cervix and $0 for loss of productivity secondary to bed rest; therefore, it will be important to avoid hospitalization and activity restrictions in women with short cervices to realize the savings described by Werner et al 19 Avoidance of activity restrictions is particularly important as activity restriction has been shown NOT to reduce the rate of preterm birth in asymptomatic women with a short cervix, 20 while there is strong evidence that there are detrimental effects to the mother and her family when the gravid patient is placed on activity restriction.…”