Cerclage Plus Adjuvant Vaginal Progesterone for Preterm Birth Prevention in Patients with a Short or Dilated Cervix without Prior Preterm Birth

Jessica M. Hart; Annliz Macharia; Anna M. Modest; Katherine M. Johnson; Julianne Lauring; Erica Nicasio; Michele R. Hacker; Melissa H. Spiel

doi:10.1055/s-0044-1786175

American Journal of Perinatology, Table of Contents

Am J Perinatol 2024; 41(12): 1595-1603
DOI: 10.1055/s-0044-1786175

SMFM Fellowship Series Article

Cerclage Plus Adjuvant Vaginal Progesterone for Preterm Birth Prevention in Patients with a Short or Dilated Cervix without Prior Preterm Birth

Authors

Jessica M. Hart

¹Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
Annliz Macharia

¹Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Anna M. Modest

¹Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
Katherine M. Johnson

³Department of Obstetrics and Gynecology, University of Massachusetts Memorial Health, Worcester, Massachusetts

⁴Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
Julianne Lauring

³Department of Obstetrics and Gynecology, University of Massachusetts Memorial Health, Worcester, Massachusetts

⁴Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
Erica Nicasio

⁵Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York
Michele R. Hacker

¹Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts

⁶Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
Melissa H. Spiel

¹Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts

Abstract

Objective The primary objective was to determine if vaginal progesterone following cerclage for cervical length <10 mm or cervical dilation in patients without a history of spontaneous preterm birth (sPTB) decreased the risk of preterm birth at <34 weeks' gestation compared with cerclage alone. Secondary objectives were to determine if vaginal progesterone following cerclage (1) decreased the risk of preterm birth at <24, <28, and <37 weeks' gestation and (2) increased the latency period from cerclage placement to delivery compared with treatment with cerclage alone.

Study Design Multicenter retrospective cohort study from 2015 to 2020 of singleton pregnancies, without prior sPTB, who had cerclage placement <24 weeks' gestation for cervical length <10 mm or cervical dilation. Exposure defined as cerclage plus vaginal progesterone postoperatively (dual therapy) and unexposed as cerclage alone (monotherapy), based on surgeon preference.

Results We included 122 patients, 78 (64%) treated with dual therapy and 44 (36%) treated with monotherapy. In the crude analysis, dual therapy was associated with a lower risk of delivery at <28 weeks' gestation (13%) compared with monotherapy (34%; crude risk ratio: 0.38 [95% confidence interval (CI): 0.19–0.75]). When adjusted for preoperative vaginal progesterone, results were attenuated (adjusted risk ratio: 0.45 [95% CI: 0.20–1.01]). In both the crude and adjusted analyses, the risk of sPTB was not statistically different at <24, <34 or <37 weeks' gestation. Dual therapy was associated with a greater pregnancy latency from cerclage to delivery (16.3 vs. 14.4 weeks; p = 0.04), and greater gestational age at delivery (37.3 vs. 35.8 weeks' gestation; p = 0.02) compared with monotherapy.

Conclusion While not statistically significant, the risk of sPTB was lower at all gestational ages studied in patients treated with dual therapy compared with monotherapy. Dual therapy was associated with longer pregnancy latency and greater gestational age at delivery compared with monotherapy.

Key Points

Dual therapy did not decrease preterm birth risk compared with monotherapy.
Dual therapy prolonged pregnancy compared with monotherapy.
Dual therapy can be considered but further studies are needed.

Keywords

adjuvant vaginal progesterone - cervical insufficiency - pregnancy latency - short cervical length - cervical cerclage - spontaneous preterm birth - preterm delivery - postoperative vaginal progesterone

Full Text

References

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