Translating Knowledge Into Clinical Practice Goals Review indications for cervical length measurement in the second and third trimester Describe management of the short second trimester cervix based on fetal number and obstetrical history including variations of routine management options ID: 575004
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Slide1
Cervical Length Ultrasound
Translating Knowledge Into Clinical PracticeSlide2
Goals
Review indications for cervical length measurement in the second and third trimester
Describe management of the short second trimester cervix based on fetal number and obstetrical history, including variations of routine management options
Describe evaluation and management of third trimester threatened preterm labor using cervical length and fetal
fibronectin
testing.Slide3
Indications for Cervical Length Measurement
Second Trimester
assess SPTB risk in women with or without prior SPTB
guide preventative care of SPTB in women with short cervix
Third Trimester
assess and guide care of women with threatened preterm laborSlide4
Second Trimester Cervical Length Measurement – Universal Screening?
“although this document does not mandate universal cervical length screening in women without a prior preterm birth, this screening strategy may be considered.”
ACOG Practice Bulletin #130
“CL screening in singleton gestations without prior PTB cannot yet universally be mandated.” …”such a screening strategy can be viewed as reasonable…”
SMFM Publications
ACOG Practice Bulletin #130.
Obstet
Gynecol
2012;120:964
Berghella
et al. Am J
Obstet
Gynecol
2012;10:1016Slide5
Singleton, no prior SPTB, short cervix (
≤20mm) ≤24
weeks
Is there an intervention to reduce prematurity risk?
VAGINAL PROGESTERONE daily from diagnosis to 36 weeks
200 mg
suppository or capsule, or 90 mg gel Slide6
Benefits of Vaginal Progesterone
Romero
R, et al. Am J Obstet Gynecol
2012;206:123
Outcome
RR (95%
CI)
Preterm birth <33w
.56 (.40-.80)
Composite morbidity
.59 (.38-.91)Slide7
Suspected
S
hort
C
ervix on
Transabdominal
Ultrasound34 year old G1P0 at 22-2/7 weeksTVU CL 15mm
Cervical length 15mmSlide8
Suspected Short Cervix on
Transabdominal
Ultrasound
Negative urinalysis
No contractions
VAGINAL PROGESTERONE CANDIDATE!Slide9
Algorithm
Singleton Gestation
No prior spontaneous preterm birth
Cervical length <20mm at
≤24 weeks
Vaginal progesterone daily to 36 weeks
200
mg
suppository or capsule, or 90
mg gel
Evidence does not support cerclage
or
17-hydroxyprogesterone caproate*
ACOG Practice Bulletin #130.
Obstet
Gynecol
2012;120:964
Berghella
et al. Am J
Obstet
Gynecol
2012;10:1016Slide10
Prior Spontaneous Preterm Birth,
N
ormal Transvaginal Cervical Length
Singleton, prior SPTB, unknown or normal (>25mm) cervix
≤24 weeks
Is there an intervention to reduce prematurity risk?
17-hydroxyprogesterone caproate (17P) weekly 16-36 weeks, 250 mg IMSlide11
Benefits of 17P
Meis
P
et al. N
Eng
J Med 2003;348:2379
Delivery
%
RR (95% CI)
NNT
<37w
36.3
0.66 (0.54-0.81)
5-6
<32w
11.4
0.58 (0.37-0.91)
12Slide12
Prior Spontaneous Preterm Birth, Normal Transvaginal Cervical Length
Is there a role for cervical length surveillance?
YES!
meta-analysis, 4 randomized trials
prior SPTB <37w, cervix
≤25mm
Berghella
et
al.
Obstet
Gynecol
2005;106:181
Outcome
Cerclage
No Cerclage
RR (95% CI)
NNT
Delivery <35w
23.4%
39.0%
0.61 (0.40-0.92)
8Slide13
Prior Spontaneous Preterm Birth, Normal Transvaginal Cervical Length
Randomized trial cerclage vs. no cerclage
Prior SPTB <34w, cervix
≤25mm at
16-22w
Outcome
Cerclage RR (95% CI)
<37w
0.75 (0.60-0.93)
<35w
0.78 (0.58-1.04)
0.23 (0.08-0.66)*
<24w
0.44 (0.21-0.92)
Perinatal death
0.54 (0.29-0.99)
*<15mm
Owen
et al. Am J Obstet Gynecol 2009;201;375Slide14
Algorithm
Singleton
Gestation
Prior Spontaneous Preterm Birth
17P starting at 16-36w
+
q2 week
cervical lengths 16-24w
Cervix length remains
≥25mm at 24 weeks
Cervix length <25mm at
≤24 weeks
Continue 17P
Offer
cerclage
if prior birth <34w
+
Continue 17P
ACOG Practice Bulletin #130.
Obstet
Gynecol
2012;120:964
Berghella
et al. Am J
Obstet
Gynecol
2012;10:1016Slide15
Prior Spontaneous Preterm Birth with Prior Successful Cerclage
26-year old G
3
P
1102
at 11
5/7 weeksPregnancy #1short cervixpreterm labor at 26 weeks
d
elivery at 28 weeks
Pregnancy #2
c
erclage at 13 weeksdelivery at 40 weeksSlide16
Prior Spontaneous Preterm Birth with Prior Successful Cerclage
17P 16-36 weeks
Every 2 week cervix lengths 16-24 weeks
, weekly for cervical length 25-29mm
24 week cervix length =
37mmSlide17
Prior Spontaneous Preterm Birth with Prior Successful Cerclage
Spontaneous labor at 39 weeks
Delivered 9
lb
6
oz
infant, Apgars 9/9Slide18
Variation to the Algorithm
Patient receives her first
17-hydroxyprogesterone
caproate
injection
. She refuses to continue with the weekly injections. What next?
Offer her vaginal progesterone (200 mg suppository or capsule, or 90 mg gel) daily through 36 weeksSlide19
Rationale
142 high-risk singletons
24-34 weeks
V
aginal progesterone 100 mg
vs
placebo
Progesterone
Placebo
SPTB <37w
13.8%
28.5%
SPTB <34w
2.8%
18.6%
da Fonseca et al. Am J Obstet Gynecol 2003;188:419Slide20
Rationale
502 subjects with prior 2
nd
trimester spontaneous preterm birth or history of cerclage
Excluded
:
Advanced dilation & effacement, cerclage in placeShort Cx
< 25 mm or funneling at 14-18
weeks
Randomized to 17P vs. vaginal progesterone
Outcome
17-Progesterone
Vaginal P
SPTB <34w
25.7%
16.6%
SPTB 34-37w
9.3%
16.6%
NICU
25.7%
15.4%
Maher
et al.
Acta
Obstet-Gynecol 2013;92:215Slide21
Prior Spontaneous Preterm Birth, No Prior Cerclage or Progesterone
39-year old, G
4
P
0030
Two 2
nd trimester losses (16w, 18w) 17P 16-36 weeksTV cervix lengths every 1-2 weeks from 16-24 weeksSlide22
Prior Spontaneous Preterm Birth, No Prior Cerclage or Progesterone
16
weeks
cervix
= 32mm
18
weeks
cervix
= 27mm
19 weeks
cervix
= 8mmSlide23
Prior Spontaneous Preterm Birth, No Prior Cerclage or Progesterone
Patient continued 17P and cerclage placed
Emergency cesarean at 34 weeks – abruptionSlide24
How well do 17P,
C
erclage, or Both
P
erform in Patients with a Singleton and
P
rior SPTB?
Berghella
et al. Am J Obstet Gynecol 2010;202:351
Delivery
No Rx
n=52
17P
n=100
Cerclage
n=101
17P
+
Cerclage
n=47
<24w
20%
2%
7%
4%
<28w
25%
15%
17%
9%
<32w
34%
21%
25%
17%Slide25
Prior Spontaneous Preterm Birth with History-Indicated Cerclage
30-year old, G
3
P
0111
1
st pregnancy was an 19 week loss consistent with cervical insufficiency2nd pregnancy was a 34 week delivery secondary to spontaneous preterm birth with a history-indicated cerclage placed at 12 weeks
She’s now in her 3
rd
pregnancy and already had her history-indicated cerclage at 12 weeksSlide26
Prior Spontaneous Preterm Birth with History-Indicated Cerclage
She returns for a follow-up cervical length at 16 weeks and to discuss whether or not she needs progesteroneSlide27
Prior Spontaneous Preterm Birth with History-Indicated Cerclage
Management questions:
Should she be initiated on progesterone?
YES
!
She qualifies based on her history and has a shortening
cervixIf so, which route?
Either
IM or vaginal progesterone (but not both!) is
acceptable
Should she continue to have cervical lengths?
Individualize serial cervical length monitoring based on patient and clinical circumstances Digital and speculum exams should be consideredSlide28
What About Obesity and Progesterone?
Retrospective Cohort Study of 390 women with prior SPTB on 17P
216 women with BMI >25
174 women with BMI <25
Increased risk for SPTB <32 weeks with BMI >25
No differences in SPTB <35 weeks or <37 weeks
Success rate of 17P at standard dosing may be impacted by BMI.
Co
AL et
al.
Am
J Obstet Gynecol 2015Slide29
What About Obesity and Progesterone?
Secondary analysis of the MFMU 17P (
Meis
) trial
No benefit for 17P prevention of SPTB was noted with BMI >30 or maternal weight>165lbs
Preterm Birth prevention by 17P use may be ineffective in those with BMI >30
Heyborne
KD et
al.
Am
J
Obstet Gynecol 2015Slide30
Do 17P Plasma Levels Matter?
Secondary analysis of 315 patients
Increased risk of SPTB among subjects whose 17P levels were in the lowest quartile
Did not evaluate by BMI
Need additional studies
Caritis et al. Am J Obstet Gynecol 2014;210:128Slide31
Summary
Obesity may decrease success rate of 17P for SPTB prevention
Low plasma levels of 17P may increase risk of SPTB
Further research in these areas are needed
There is NO current recommendation at this time to alter the dose in the obese patient or to evaluate plasma levelsSlide32
Twins,
Normal Cervix Regardless
of
Prior Spontaneous Preterm Birth
“
No evidence of benefit to 17P or vaginal progesterone
”Slide33
Twins,
No Prior Spontaneous Preterm Birth, Short
C
ervix
Vaginal progesterone
may
reduce neonatal composite morbidity, but small numbers RR 0.52 (0.29-0.93) Romero “insufficient evidence to assess effect of progesterone”
SMFM Publications
“available data regarding the efficacy of cerclage placement, progesterone supplementation, or both…do not support their use.”
ACOG Practice BulletinRomero et al. Am J Obstet
Gynecol
2012;206:123
Berghella
et al. Am J
Obstet
Gynecol
2012;10:1016
ACOG Practice Bulletin #130.
Obstet
Gynecol 2012;120:964Slide34
Twins with Short Cervix
17P not efficacious
Avoid
cerclage
meta analysis suggests
increased
adverse outcomes
Berghella
et al.
Obstet
Gynecol
2005;106:181
Outcome
RR (95% CI)
Delivery <35w
2.15 (1.15-4.01)
Perinatal
mortality
2.66 (0.83-8.54)Slide35
Twins with Short Cervix
45-year old, G
7
P
1051
five 1
st trimester miscarriagesterm cesareanIVF dichorionic twinsSlide36
Twins with Short Cervix
20
weeks
cervix length = 17 mmSlide37
Twins with Short Cervix
No contractions
Negative urinalysis
Expectant care
Outcome
spontaneous labor at 36 weeksSlide38
Preterm Labor: Importance of Early Diagnosis
Transfer to facility with NICU
Glucocorticoid administration
Group B streptococcal (GBS) prophylaxis
Tocolytic
therapySlide39
Cervix
dilation
≥
3cm
effacement
≥
80%Vaginal bleedingRuptured membranes
Clinical Indicators of Preterm Delivery
(24 hours – 7 days)
*Often occur too late to intervene*Slide40
Evaluation of the Symptomatic Patient
Two Goals:
Identify patient
not likely
to deliver preterm and
avoid
unnecessary interventionIdentify patient likely to deliver preterm, allowing
time for effective interventionsSlide41
Assessment of Symptomatic Patient-Speculum Exam
Obtain vaginal swab for fetal
fibronectin
(FFN)
Evaluate for presence of amniotic fluid
Obtain culture for GBSSlide42
Fetal
Fibronectin
(FFN)
Glycoprotein acts as a “glue” for membrane adherence
Presence
in
cervicovaginal fluid 20-36 weeks associated with increased risk of SPTBAbsence of FFN associated with
reduced risk
of SPTB in next 7-14d
Sanchez-Ramos
L
et
al
Obstet
Gynecol
2009;114:631
Singer E
et
al
Obstet
Gynecol 2007;109:1083
SPTB Detection (%)
PPV (%)
NPV (%)
Singletons
Symptomatic
Asymptomatic
76.1
17-19
25.9
13-24
97.6
97
Twins
71
97Slide43
Assessment of the Symptomatic Patient –
The Cervix
Digital Exam
≥3cm dilated
≥80% effaced
No
Yes
Likely
Preterm
Labor
?Slide44
T
rust
Y
our
V
aginal
U
ltrasound!
(and your FFN, too)
Iams
JD
. Obstet Gynecol
2003;101:402
OPINION never validated
No PTL
FFN (-)
FFN (+)
PTL
>30mm
20-30mm
<20mmSlide45
Case #1
31-year old, G
3
P
2002
, singleton
cc: contractions at 25 6/7 weeksmonitor: no contractionsurinalysis: negativeSlide46
Case #1
Cervical length = 35mm
Diagnosis?
Plan?
Outcome: emergent
c/s
at 34 weeks (abruption)Slide47
Case #2
33-year old, G
4
P
2012
, singleton
cc: contractions at 28 3/7 weeksmonitor: contractions every 1-3”urinalysis: negativeSlide48
Case #2
Cervical length = 20mm
Diagnosis?
Plan?Slide49
Case #2
FFN = negative
Outcome: repeat c/s in labor at 37 weeksSlide50
Case #3
27-year old G
1
P
0
, singleton
cc: contractions at 30 6/7 weeksmonitor: q3” contractionsurinalysis: negativecervix: 1cm/70% effacedSlide51
Case #3
Cervical length = 16mm
Diagnosis?
Plan?Slide52
Case #3
Treatment
steroids
tocolytic
Antibiotic
Outcome
recurrent PTLdelivery at 31 2/7 weeksSlide53
Case #4
31-year old G
1
P
0
,
dichorionic twins 30 weekscc: contractions q3”monitor: q3” contractionsurinalysis: negativecervix: 1-2cm/50% effacedSlide54
Case #4
Cervical length = 27mm
Diagnosis?
Plan?Slide55
Case #4
FFN negative
Every 2 week cervix length (stable) and FFN (-) to 34 weeks
Spontaneous labor at 36 weeksSlide56
Case #5
26-year old G
2
P
0010
,
dichorionic twins 28 weekscc: q4” contractionsmonitor: q4” contractionsurinalysis: negativecervix: 2cm/80% effacedSlide57
Case #5
Cervix length = no measurable cervix, sludge present
Diagnosis?
Plan?Slide58
Case #5
Tocolysis
Steroids
Antibiotics
Progressive labor
Cesarean deliverySlide59
Summary – Singletons
No prior SPTB
cervical length screening optional, but not mandatory
One measurement between 16-24 weeks
treat short cervix with vaginal progesteroneSlide60
Summary – Singletons
Prior SPTB
treat with 17P 16-36 weeks
Vaginal progesterone is a reasonable substitution
serial cervix lengths 16-24 weeks
for short cervix
offer cerclage, continue 17P or vaginal progesteronevaginal progesterone without cerclage or 17PSlide61
Summary – Twins
No current role for 17P or
cerclage
No prior SPTB, short cervix
expectant careSlide62
Summary – Threatened PTL
Cervical length with FFN effectively triages women with threatened PTL and an equivocal digital examSlide63