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Pessary Cervical and Prevention Preterm Birth Based on Literature Review International Journal of Pregnancy & Child Birth Case Report Open Access Pessary cervical and prevention preterm birth based on literature review Abstract Volume 4 Issue 4 - 2018 Preterm birth is the main individual cause of global perinatal morbidity and mortality, María del Mar Molina Hita, Laura Revelles cervical insufficiency being one of its causes. One of the hypotheses of cervical insufficiency is that it is due to a mechanical problem; hence one of the approaches is Paniza, Susana Ruiz Durán Department of Obstetrics and Gynecology, University Hospital the use of the cervical pessary. We review the most recent literature on the use of the Virgen de las Nieves, Spain cervical pessary in the prevention of premature birth in single and multiple pregnancies, as well as the indications for its use in different clinical practice guidelines. Correspondence: Susana Ruiz Durán, Physician Specialist in Obstetrics and Gynaecology, Department of Obstetrics cervical length, cervical pessary, prematurity, preterm birth, short cervix Keywords: and Gynaecology, University Hospital “Virgen de las Nieves”, Granada. Spain, Avd. Divina Pastora 9, Block 13, 4 B. 18012 Granada, Spain, Tel +34666462333. Email [email protected] Received: June 20, 2018 | Published: July 27, 2018 Introduction problem, hence the approach to address it has been cervical cerclage or with the pessary.6 Preterm birth is the leading individual cause of global perinatal morbidity and mortality and the leading cause of death and disability Cervical pessary: mechanism of action in children up to 5 years old in the developed world.1 Cervical The cervical pessary is a silicone device designed to support the insufficiency is one of its causes. Its definition is not fixed. It could cervix. Its mechanism of action is not clearly established; it could correlate to a structural abnormality of the biochemical components achieve a reduction of the pressure of the uterus on the cervical canal of the cervical tissue that prevents the inhibition of its function as through an alteration of the uterus-cervical angle so that the force sphincter.2 From the clinical point of view the cervical insufficiency is of the weight of the uterine contents moves away from the internal defined as a cervical painless dilation leading to recurrent pregnancy cervical canal and is exerted on the back, towards the sacrum. It loss in the second term and premature delivery, depending on the could also strengthen the immunological barrier between the choro- specific characteristics of the cervix, in particular cervical length.3 amniotic extravascular space and the vaginal flora. It is an easy-to- Under normal conditions the length of the cervix is stable between use, non-invasive, inexpensive tool that does not require anaesthesia weeks 14 and 28 of gestation. For simple pregnancies from weeks and is potentially promising to reduce the risk of premature delivery 22 to 24 the distribution is: 15mm (percentile 2); 25mm (percentile in patients with risk factors.2 So it is a possible alternative to cerclage 10); 30mm (percentile 50). From weeks 28 to 32 a gradual decrease and/or progesterone treatments. It has been used for this purpose since in cervical length is normal. However, taking all this into account, 1950. At the beginning they were designed for genital prolapse and in cervical insufficiency is also defined as a cervical length by transvaginal the 1970s the first ones for use in pregnant women were developed. echography of less than 25mm before week 24 of gestation in a woman There are different types (Smith, Hodge, Risser, Hamann, Portex ), but with a previous spontaneous premature delivery.4 The measurement the most recent studies use the Arabin pessary, with the advantage of a of cervical length in mid pregnancy has been shown to be able to European certification (CEO482, MED / CERT I SO9003 / EN46003). predict accurately preterm delivery. The limitation of screening for It is a flexible silicone ring, available in several sizes. The external the shortened cervix is its low prevalence ranging from 0.9 to 2.3% diameter varies between 65-70 mm, the internal diameter between generally, according to the population and the limit used (under 15, 20 32-35 mm and its height is 17-30 mm. It is perforated to enable the or 25mm). Transvaginal ultrasound is the method of choice to identify flow of vaginal and cervical secretions. It is built in such a way that patients at higher risk of spontaneous preterm birth and it can be the caudal portion of the device surrounds the neck, so it has been offered to women with risk factors for preterm birth (evidence level II- said that it can provide an additional benefit by preventing cervical 2B) according to the clinical practice guide by The Canadian Society dilation, the deterioration of the mucous plug and the exposure of the of Gynecology in 2011. Reliability varies, according to the previous membranes. It is associated with a low rate of major complications: obstetric history, being a better predictor of preterm birth in women only a slight discomfort and an increase of vaginal flow without an with a history of previous spontaneous preterm delivery (sensitivity increase in the rate of vaginal infection.7 70%) than in asymptomatic and low risk women (sensitivity 40%).5 The gestational age at which the previous preterm birth occurred Use of the cervical pessary as a unique preventive affects the frequency and rate of shortening in the current pregnancy treatment (level of evidence II-2). The risk of premature labor increases as the Until 2012, only prospective or retrospective observational length of the cervix decreases. Thus, if the cervix measures less than studies with methodological biases had been published, so the 2010 15 mm, the risk of premature delivery approaches 50%. One of the Cochrane review agreed there was no evidence that pessaries reduced hypotheses of cervical insufficiency is that it is due to a mechanical prematurity.8 From 2012 to December 2016, 6 large randomized Submit Manuscript | http://medcraveonline.com Int J Pregn & Chi Birth. 2018;4(4):188‒193. 188 © 2018 Hita et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Pessary cervical and prevention preterm birth based on literature review ©2018 Hita et al. 189 controlled trials (RCTs) have been published. The intervention is twins and 2% triplets) regardless of cervical length, between weeks pessary Arabin versus expectant treatment. 16-22. 808 patients took part in the study. The primary outcome was deficient perinatal outcome and it did not differ significantly A) RCT in single asymptomatic pregnancies with cervix ≤25mm in both groups (13% vs. 14% in the control group). Among the measured by transvaginal echography between week 18-24+6 of secondary results that were analysed, the rate of premature delivery pregnancy: before 37, 32 and 28 weeks, was similar in both groups. An I. Multicenter Spanish study PECEP of 2012 with 385 women with analysis of rheumatism by subgroups was made when the cervix cervix ≤25mm between week 18-22 of gestation in a not selected was shorter than 38mm. In them the deficient perinatal result was group of general population.7 A single pessary size of Arabin (25- lower in the pessary group in a significant way, also the median 65-32mm) was used. The obstetricians who participated carried gestational age at delivery was higher and the pessary significantly out sonographic training in the placement of the pessary. The reduced the risk of preterm birth in pregnancies below 28 and 32 pessary was retired at 37 week. In case of premature rupture of weeks of gestation. They conclude that the use of the pessary is membranes during the study, the pessary remained if there were no not relevant in an asymptomatic general population of multiple signs of chorioamnionitis. The primary outcome was spontaneous pregnancies but the subgroup of patients with cervix shorter than preterm labor before week 34. This rate was significantly lower in 38mm should be featured in future studies. With the same database the pessary group (6% vs 27%), and also in gestations shorter than another multivariant analysis12 was carried out, looking for other 28 and 37 weeks. The need for tocolysis or use of glucocorticoids characteristics, either maternal or having to do with the pregnancy was lower. Neonatal results (3% vs 16%) was also significantly at the beginning, that could improve the identification of women better in the pessary group. The sole adverse effect was an increase more likely to benefit from the placement of the pessary. The result in vaginal discharge. The limitation is that it is an open trial and was that a short cervix, monochorionicity and nulliparity were that the rate of premature delivery in the expectant management predictive factors of a benefit in the insertion of the pessary for group was 27%, much higher than the one published previously. an adverse perinatal outcome. They suggest that their multivariant They conclude that the cervical pessary is an affordable alternative, model to identify women who would benefit most from the pessary safe and effective for the prevention of spontaneous preterm birth is superior to a strategy based solely on cervical length. External in a population of women adequately selected for cervical length validation is necessary in future studies in the area. of the second trimester. II. PECEP-TWINS study by Goya.13 RCT that includes 137 II. RCT published by Hui in 2013 in single pregnancies of asymptomatic twin gestations in 5 hospitals in Spain, regardless asymptomatic women with cervix ≤25mm between week 20- of their obstetric history and with cervix ≤25mm between 18-22 24 with no history of cervical insufficiency or cerclage, in 108 weeks.
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