552: Twin pregnancies with short cervix: Vaginal progesterone is agent of choice for preterm delivery prevention

Abstract

To systematically review the literature and quantitatively compare the efficacy and adverse perinatal outcomes of cervical pessary, cervical cerclage, vaginal progesterone, and injectable progesterone (17-OHPC) for the prevention of preterm birth (PTB) <35 weeks in women with twin gestations and a sonographic short cervix. A computerized database search (MEDLINE, PubMed, EMBASE, Cochrane CENTRAL) was conducted to identify randomized controlled trials of patients treated with cervical cerclage, cervical pessary, vaginal progesterone, or 17-OHPC published from January 1966 through July 2018. Data were also obtained from published systematic reviews with individual patient data (IPD) meta-analyses. We used a user-written package in Stata (Stata Corp, College Station, TX) to perform multivariate random-effects meta-analysis and meta-regression on a dataset of point estimates, variances, and covariances. Frequentist method was employed to calculate ranking probabilities. Sixteen studies with 1,019 women allocated to four different treatment arms were included for analysis. Traditional pairwise meta-analysis showed that compared with placebo, vaginal progesterone decreased PTB <35 weeks (RR 0.74, 95% CI 0.56, 0.96). Cervical pessary, 17-OHPC, and cervical cerclage did not significantly reduce PTB risk. Cerclage placement increased risk (RR 2.19 (95% CI 0.72, 6.63). Multi-treatment comparisons found that when compared, vaginal progesterone significantly decreased risk of preterm birth <35 weeks when compared with cerclage (OR 0.14; 95% CI 0.03, 0.68) and 17-OHPC (OR 0.35; 95% CI 0.12, 1.02). Cumulative ranking probability indicated a 66% probability that vaginal progesterone was the best treatment for preventing preterm birth while cervical cerclage had an 85% probability of being the worst treatment. Due to a lack of uniformity in the reporting of other perinatal outcomes and the lack of power for these uncommon events, reliable estimates could not be calculated. When compared with other agents, vaginal progesterone appears to be the most effective in lowering the risk of preterm birth in twin gestations with a sonographic short cervix while placement of a cervical cerclage appears to elevate this risk.View Large Image Figure ViewerDownload Hi-res image Download (PPT)