Cervical pessary use and preterm birth: how little we know

Magee Womens Hospital, Pittsburgh, PA 15213, USA.
The Lancet (Impact Factor: 39.21). 04/2012; 379(9828):1769-70. DOI: 10.1016/S0140-6736(12)60116-0
Source: PubMed
  • Gynécologie Obstétrique & Fertilité 04/2013; 41(4):260–261. DOI:10.1016/j.gyobfe.2013.02.014 · 0.58 Impact Factor
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    ABSTRACT: Routine second-trimester transvaginal ultrasonographic (TVU) screening for short cervical length (CL) predicts spontaneous preterm delivery (SPTD), albeit with limited sensitivity (35-40%) and moderate positive likelihood ratio (LR+: 4-6). However, CL describes one of multidimensional changes associated with precocious cervical ripening (PCCR), which also include cervical softening, cervical funneling (CF), and dilation. PCCR, a precursor and a strong predictor for SPTD, was proposed as a potential screening target. We hypothesized that screening for composite measures of PCCR (e.g. CL, CF, cervical consistency, and dilation) using either digital exam (DE) or TVU would improve prediction of SPTD compared to screening for short CL alone. We searched PubMed and EMBASE electronic databases for observational cohort studies to evaluate cervical screening in asymptomatic obstetric populations. Multidimensional composite cervical measures were assessed in 10 datasets (n=22,050 pregnancies) and 12 publications. Appreciable heterogeneity in cervical measurements, data quality, and outcomes across studies prevented quantitative meta-analysis. Only one study reported intra- and inter-observer reliability of cervical measurements. The prevalence of CF ranged from 0.7% to 9.1%. Five studies compared composite measures of PCCR (i.e., CL and CF) to short CL alone, and consistently reported improved screening performance. Among three TVU studies, gains in sensitivity ranged from 5% to 27%, and increases in LR+ ranged from 3 to 16. Our findings suggest composite measures of PCCR might serve as valuable screening targets. High-quality interdisciplinary studies integrating epidemiologic approaches are needed to test this hypothesis and accelerate the translation of advances in cervical pathophysioloy into effective preventive interventions.
    American Journal of Obstetrics and Gynecology 06/2014; 212(2). DOI:10.1016/j.ajog.2014.06.053 · 3.97 Impact Factor
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    ABSTRACT: Preterm birth remains a considerable public health concern and priority. Little headway has been made in the prevention of preterm birth despite considerable research in this area. New ideas and treatments are desperately needed. The pessary has emerged as a possible treatment for the prevention of preterm birth in both singleton and twin gestations. It appears to be low cost with minimal side effects. This review focuses on the available evidence for the use of cervical pessaries for the prevention of preterm birth, especially in a high-risk population with a shortened cervical length. Larger scale randomized-controlled trials are warranted before incorporation of the pessary into standard obstetrical practice.
    Clinical Obstetrics and Gynecology 06/2014; DOI:10.1097/GRF.0000000000000036 · 1.53 Impact Factor