Preterm birth prevention in twin pregnancies with progesterone, pessary, or cerclage: a systematic review and meta‐analysis

Jarde, Alexander; Lutsiv, Olha; Ck, Park; Barrett, Jon; Beyene, Joseph; Saito, Shigeru; Dodd, Jodie M; Shah, PS; Cook, J.M.; Biringer, AB; Giglia, Lucy; Han, Zhen; Staub, Katharina; Mundle, William; Vera, Claudio; Sabatino, Lisa; Liyanage, S Korale; McDonald, SD

doi:10.1111/1471-0528.14513

Cited by 76 publications

(56 citation statements)

References 42 publications

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“…Interventions of interest were either type of progesterone (natural progesterone per vagina or oral, or intramuscular 17a-hydroxyprogesterone caproate ), cerclage (McDonald or Shirodkar), or pessary. We excluded all other study designs including cluster-randomised trials, non-peer reviewed literature, and studies including, but not stratifying for, multiple pregnancies (twin pregnancies were synthesised in a separate study), 15 published only as abstracts, or treating women with contractions (i.e. tocolytics).…”

Section: Eligibility Criteriamentioning

confidence: 99%

Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta‐analysis

Jarde

Lutsiv

Park

et al. 2017

BJOG

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Background Preterm birth (PTB) is the leading cause of infant death, but it is unclear which intervention is best to prevent it.Objectives To compare progesterone, cerclage and pessary, determine their relative effects and rank them.Search strategy We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL and Web of Science (to April 2016), without restrictions, and screened references of previous reviews.Selection criteria We included randomised trials of progesterone, cerclage or pessary for preventing PTB in women with singleton pregnancies at risk as defined by each study.Data collection and analysis We extracted data by duplicate using a piloted form and performed Bayesian random-effects network meta-analyses and pairwise meta-analyses. We rated evidence quality using GRADE, ranked interventions using SUCRA and calculated numbers needed to treat (NNT).Main results We included 36 trials (9425 women; 25 low risk of bias trials). Progesterone ranked first or second for most outcomes, reducing PTB < 34 weeks [odds ratio (OR) 0.44; 95% credible interval (CrI) 0.22-0.79; NNT 9; low quality], <37 weeks (OR 0.58; 95% CrI 0.41-0.79; NNT 9; moderate quality), and neonatal death (OR 0.50; 95% CrI 0.28-0.85; NNT 35; high quality), compared with control, in women overall at risk. We found similar results in the subgroup with previous PTB, but only a reduction of PTB < 34 weeks in women with a short cervix. Pessary showed inconsistent benefit and cerclage did not reduce PTB < 37 or <34 weeks.Conclusions Progesterone was the best intervention for preventing PTB in singleton pregnancies at risk, reducing PTB < 34 weeks, <37 weeks, neonatal demise and other sequelae.Keywords Cervical cerclage, cervical pessary, network metaanalysis, preterm birth, progesterone, systematic review.Tweetable abstract Progesterone was better than cerclage and pessary to prevent preterm birth, neonatal death and more in network meta-analysis.Please cite this paper as: Jarde A, Lutsiv O, Park CK, Beyene J, Dodd JM, Barrett J, Shah PS, Cook JL, Saito S, Biringer AB, Sabatino L, Giglia L, Han Z, Staub K, Mundle W, Chamberlain J, McDonald SD. Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta-analysis.

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Section: Eligibility Criteriamentioning

confidence: 99%

Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta‐analysis

Jarde

Lutsiv

Park

et al. 2017

BJOG

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“…Romero et al in a recent updated meta‐analysis found a significant reduction of the risk of PTB before 30‐35 weeks of gestation with also lower rates of neonatal mortality and morbidity in this group of selected women . Interestingly Jarde et al in 2017 tried to analyze the data available in the literature on the use of cerclage, pessary and progesterone in twin gestations on the possible reduction of PTB and the neonatal outcome; for those with a short TVCL, rates of PTB were not reduced by any intervention, but among the secondary outcomes they reported that gestational age at delivery was increased by vaginal progesterone and pessary, and vaginal progesterone also reduced neonatal deaths …”

Section: Discussionmentioning

confidence: 99%

The use of ultrasound‐indicated cerclage or cervical pessary in asymptomatic twin pregnancies with a short cervix at midgestation

Fichera

Prefumo

Mazzoni

et al. 2019

Acta Obstet Gynecol Scand

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Abbreviations: IQR, interquartile range; NICU, neonatal intensive care unit; PTB, preterm birth; TVCL, transvaginal cervical length. AbstractIntroduction: Spontaneous preterm birth in women with a twin pregnancy is one of the main causes of perinatal mortality and morbidity. Our aim was to review the perinatal outcome of asymptomatic twin pregnancies with a sonographic short cervical length during the second trimester treated with an ultrasound-indicated cerclage or cervical pessary. Material and methods:Retrospective study on asymptomatic twin pregnancies with a short cervix (≤ 25 mm) at transvaginal ultrasound examination during the second trimester treated with a cervical cerclage or pessary (2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017). The rate of preterm birth < 28, 32 and 34 weeks of gestation, neonatal mortality, neonatal morbidity and composite adverse neonatal outcome were compared in the groups of women treated with cerclage or pessary.Results: Seventy-four twin pregnancies underwent a cerclage while a cervical pessary was inserted in 34 women with twins at our Department: 36 women with an ultrasound-indicated cerclage and 20 with a pessary were included in the analysis.Median gestational age at delivery was higher in women treated with cerclage compared with those with pessary placement (P = .02) and the rate of preterm birth before 34 weeks of gestation was lower in the cerclage group (P = .03). Admissions to the Neonatal Intensive Care Unit were more frequent in pregnancies with pessary (P = .01), the length of admission was longer (P = .005) and composite adverse neonatal outcome occurred more often (P = .03) compared with the cerclage group.Conclusions: Ultrasound-indicated cerclage appears to reduce the rate of preterm birth before 34 weeks of gestation in asymptomatic twin pregnancies with a short cervix during the second trimester, and also the composite adverse neonatal outcome compared with pessary.

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“…Progesterone’s effectiveness in women with a multiple pregnancy appears much less significant than in singleton pregnancies 37– 40 , although the evidence that it lacks efficacy in this group 41 has recently been challenged 42 ; consensus on this topic remains elusive. The findings of several studies, including a recently published large trial, suggests that vaginal progesterone is more effective than intramuscular 17α-hydroxyprogesterone (17-OHP), although this may depend on various risk factors and aetiology 37, 38, 43– 47 .…”

Section: Recent Advancesmentioning

confidence: 99%

Recent advances in the prevention of preterm birth

Keelan

Newnham

2017

F1000Res

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Preterm birth (PTB) remains a major obstetric healthcare problem and a significant contributor to perinatal morbidity, mortality, and long-term disability. Over the past few decades, the perinatal outcomes of preterm neonates have improved markedly through research and advances in neonatal care, whereas rates of spontaneous PTB have essentially remained static. However, research into causal pathways and new diagnostic and treatment modalities is now bearing fruit and translational initiatives are beginning to impact upon PTB rates. Successful PTB prevention requires a multifaceted approach, combining public health and educational programs, lifestyle modification, access to/optimisation of obstetric healthcare, effective prediction and diagnostic modalities, and the application of effective, targeted interventions. Progress has been made in some of these areas, although there remain areas of controversy and uncertainty. Attention is now being directed to areas where greater gains can be achieved. In this mini-review, we will briefly and selectively review a range of PTB prevention strategies and initiatives where progress has been made and where exciting opportunities await exploitation, evaluation, and implementation.

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Preterm birth prevention in twin pregnancies with progesterone, pessary, or cerclage: a systematic review and meta‐analysis

Abstract: Vaginal progesterone may be beneficial in twin pregnancies, but not 17-OHPC, cerclage, or pessary.

Cited by 76 publications

References 42 publications

Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta‐analysis

Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta‐analysis

The use of ultrasound‐indicated cerclage or cervical pessary in asymptomatic twin pregnancies with a short cervix at midgestation

Recent advances in the prevention of preterm birth

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