Cervical cerclage versus cervical pessary with or without vaginal progesterone for preterm birth prevention in twin pregnancies and a short cervix: A two-by-two factorial randomised clinical trial.

IF 15.8 1区 医学 Q1 Medicine
PLoS Medicine Pub Date : 2025-02-21 eCollection Date: 2025-02-01 DOI:10.1371/journal.pmed.1004526
Yen T N He, Ha N H Pham, Tri C Nguyen, Trung Q Bui, Nhu T Vuong, Diem T N Nguyen, Thanh V Le, Wentao Li, Cam H Le, Tuong M Ho, Ben W Mol, Vinh Q Dang, Lan N Vuong
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引用次数: 0

Abstract

Background: Pregnant women with twins and a short cervical length (CL) are at greater risk of preterm birth (PTB). The comparative efficacy of cervical cerclage and cervical pessary with or without additional progesterone to prevent PTB is unknown. We aimed to assess, in women with twin pregnancies and a short CL, the effectiveness of cerclage versus pessary and the additional treatment with 400 mg vaginal progesterone versus no progesterone in preventing PTB.

Methods and findings: This multicenter, two-by-two factorial randomised trial was conducted in 2 hospitals in Ho Chi Minh City, Vietnam. Asymptomatic women with twin pregnancies and a CL ≤28 mm at 16 to 22 gestational weeks were recruited. Between March 2019 and July 2023, we randomised 219 participants (64.4% of the planned sample size) to cerclage plus progesterone (n = 55), Arabin pessary plus progesterone (n = 56), cerclage alone (n = 54) or Arabin pessary alone (n = 54). Primary outcome was any PTB <34 weeks. Following the second interim analysis, the study was terminated due to significantly lower rates of perinatal deaths and deliveries <28 weeks in the cerclage group. The primary outcome occurred in 20 (19.8%) participants receiving cerclage versus 20 (19%) participants receiving pessary (relative risk [RR] 1.04; 95% confidence interval [CI], 0.60 to 1.8). Delivery <28 weeks occurred in 1% versus 8.6% (RR 0.12; 95% CI, 0.01 to 0.52) and perinatal death occurred in 1% versus 5.8% (RR 0.17; 95% CI, 0.05 to 0.62) in the cerclage group and the pessary group, respectively. However, PTB <24 weeks, <32 weeks, and other neonatal outcomes were not significantly different between the 2 groups. For maternal side effects, vaginal discharge was significantly less frequent in the cerclage group. In participants allocated to progesterone, PTB <34 weeks occurred in 19 (18.4%) versus 21 (20.4%) participants who did not have progesterone (RR 0.90; 95% CI, 0.52 to 1.6).

Conclusions: In this prematurely halted study on pregnant women with twins and a CL ≤28 mm, cerclage and cervical pessary were comparably effective on PTB <34 weeks prevention. However, compared to pessary, cerclage was associated with significantly lower rates of PTB <28 weeks and perinatal mortality. ClinicalTrials.gov Registration: NCT03863613 (https://clinicaltrials.gov/study/NCT03863613).

在双胎妊娠和短子宫颈中,宫颈环扎术与阴道孕酮联合或不联合使用宫颈托术预防早产:一项2乘2的随机临床试验。
背景:有双胞胎和短宫颈长度(CL)的孕妇早产(PTB)的风险更大。宫颈环扎术和宫颈托术加或不加黄体酮预防肺结核的比较疗效尚不清楚。我们的目的是评估双胎妊娠和短期妊娠期妇女环扎术与子宫托术的有效性,以及400mg阴道孕酮与无孕酮的额外治疗在预防PTB方面的有效性。方法和结果:这项多中心、二乘二因子随机试验在越南胡志明市的两家医院进行。招募无症状的双胎妊娠,16 ~ 22孕周CL≤28 mm的妇女。在2019年3月至2023年7月期间,我们将219名参与者(占计划样样量的64.4%)随机分配到环扎术加黄体酮组(n = 55)、阿拉伯素子宫托加黄体酮组(n = 56)、单独环扎术组(n = 54)或单独阿拉伯素子宫托组(n = 54)。结论:在这项提前终止的研究中,有双胞胎的孕妇和CL≤28 mm,环扎术和宫颈托环术对PTB相当有效
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来源期刊
PLoS Medicine
PLoS Medicine MEDICINE, GENERAL & INTERNAL-
CiteScore
17.60
自引率
0.60%
发文量
227
审稿时长
4-8 weeks
期刊介绍: PLOS Medicine is a prominent platform for discussing and researching global health challenges. The journal covers a wide range of topics, including biomedical, environmental, social, and political factors affecting health. It prioritizes articles that contribute to clinical practice, health policy, or a better understanding of pathophysiology, ultimately aiming to improve health outcomes across different settings. The journal is unwavering in its commitment to uphold the highest ethical standards in medical publishing. This includes actively managing and disclosing any conflicts of interest related to reporting, reviewing, and publishing. PLOS Medicine promotes transparency in the entire review and publication process. The journal also encourages data sharing and encourages the reuse of published work. Additionally, authors retain copyright for their work, and the publication is made accessible through Open Access with no restrictions on availability and dissemination. PLOS Medicine takes measures to avoid conflicts of interest associated with advertising drugs and medical devices or engaging in the exclusive sale of reprints.
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