Journal Report 41017
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Vaginal progesterone in Twin gestation with short Cx
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Journal Report 41017
- 1. “Vaginal Progesterone decreases PTB & Neonatal Morbidity & Mortality in women w/ TWIN GESTATION & SHORT CERVIX: an updated Meta-Analysis of Individual Patient Data” Roberto Romero, MD, Kypros Nicolaides, et al. Ultrasound Obstet Gynecol 2017; 49: 303-314 Published online in Wiley Onlne Library (wileyonlinelibrary.com). DOI: 10.1002/UOG.17397 Presented by : Maricar G. Chua
- 14. Further research is needed before any conclusive recommendation regarding use of vaginal progesterone in twin gestation at midtrimester with a short cervix due to certain limitations of the study.
- 15. THANK YOU
Editor's Notes
- There has been increasing prevalence of twin births in developed countries over the last decade Twins are at increased risk of maternal, perinatal & infant m/m as well as long term neurodevelopmental disability moreover its significant impact on healthcare cost & qlty of life for both parents and children. The most serious complication of MFG is PTB. When compared to singletons the risk increases 8-9 fold. PTB is the most important factor determining neonatal m/m and long term disability. Births occurring b4 37th week are considered PT. In preparation for birth, cervix thins & shortens prematurely as early as the 4-5th month of pregnancy.
- A short cervix(traditionally described as CL <=2.5cm in the midtrimester) is an important RF for SPTB & is considered the strongest & most consistent predictors of PTB in Asx women w/ singleton
- Current evidence revealed that vaginal progesterone in Asx women w/ singleton who have a sonographically short CL decreased risk of PTB & neonatal m/m. According to a Journal published last 2012 by the same group of researchers “Vaginal Progesterone In Women With An Asymptomatic Sonographic Short Cervix In The Midtrimester Decreases Preterm Delivery And Neonatal Morbidity: A Systematic Review And Meta-Analysis Of Individual Patient Data”
- There have been very few studies re: The efficacy of vaginal progesterone in women w/ twin gestation and a short CL in the mid trimester Thus the objective of the paper was to update on the previous IPD-meta-analysis on the efficacy of vag progesterone in Asx women w/ twin gestation & a sono short CL in midtrimester for preventing PTB & Neonatal m/m.
- 1. Internet DATA SEARCH 2. STUDY SELECTION inclusion/exclusion narrowed the search from 213 6 records
- This meta analysis included 6 studies, encompassing 303 women women w/ twins, all had CL <= 25mm in mid trimester. Of which 144 was assigned to placebo while159 was given vaginal progesterone.
- Effect of vaginal progesterone on: PTB – SIGINICANTLY LOWERED in <33wks, < 35,34,32,30 weeks SPTB – in <33, 34 weeks NNT = 6-12 3. Adverse perinatal outcomes slide 11
- Of these 159 women rcvd vaginal progesterone and 144 rcvd placebo Women who rcvd vaginal progesterone were 31 % less likely to deliver b4 33 weeks vs 43 % who did’nt Vaginal progesterone significantly reduced the PTD rate before 32 wks and 34 wks
- Significantly lowered neonatal death, perinatal death, composite neonatal m/m, RDS, BW<1500g, MV use NNT 6-8 NO Effect seen w/ NEC, IVH, ROP, Fdeath, BW<2500g, NICU Adm, neonatal sepsis
- Effect on long term neurodevelopmental outcome: no significant difference in developmental delay/performance at 4-5 yrs with respect to death, cong malformations, growth, global health status no detrimental effects on long term neurodevelopmental outcome but rather a potential long term benefit related to prenatal exposure acting as a neuroprotectant for brain d/o … an issue that deserves further investigation Effect on adverse maternal events: Discharge & pruritus related to intrahepatic cholestasis no significant difference
- This updated IPD meta-analaysis indicates that : Administration of vaginal progesterone to Asx women w/ twin gestation & sonographically short Cx in the Mid trimester Reduces risk of PTB occurring at <30 to <35 gestational weeks, Neonatal mortality & morbidity w/o any deleterious effects on childhood neurodevelopment This is the 1st intervention to successfully reduce both PTB and NDeath
- STRENGTHS: Use of patient level data vs study level analysis Minimal heterogeniety With low risk of bias Baseline balance in prognostic factors -- ? LIMITATIONS – most pooled effect was provided by 1 study w/ moderate risk bias THUS a MODERATE qlty GRADE = there is some confidence that our results approach TRUE IMPACT of progesterone on PTB & adverse neonatal outcomes -Sample size mainly obtained from just 1 study(74%) -only 2 trials designed to assess the efficacy of vaginal progesterone on women with twin and short CL RECOMMENDATIONS -need further research before conclusive advice can be provided re benefits of using vaginal progesterone in twin gestation + short CL