الفهرس 
Risk Factors and Prediction of Preterm Labor (PTL)Only 14 pages are availabe for public view
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Abstract
Preterm labor is a common obstetric problem. It is any birth that occurs before 37 completed weeks’ of gestation .The incidence is between 5% and 10% in most developed nations.
Prematurity represents a major cause of perinatal death and long term handicap. Although the incidence of preterm labor has not changed over many years, neonatology has advanced, and the survival of babies has improved. Yet, handicaps continue to occur in babies born at very early gestational ages. The majority of problems facing preterm neonates are mainly due to organ immaturity, particularly the lungs, and it seems clear that the severity is inversely proportional to gestational ages.
Prevention is directed towards identification of women at risk. Recent studies have identified clinical, sonographic, and biochemical markers that help to identify the women at highest risk of PTB. Previous spontaneous PTB, short cervical length in mid trimester and measuring cervico-vaginal fibronectin have been proposed as useful tools for evaluating women at risk of preterm birth.
Because of the multiple roles of progesterone in the establishment and maintenance of pregnancy, it has been a natural choice for the treatment and prevention of preterm labor. Multiple trials have examined the use of progesterone in various preparations for prophylaxis against recurrent preterm birth, which have proved a protective effect of progesterone, with a significantly longer mean duration of pregnancy, higher mean birth weight, and lower perinatal mortality rate. In 2003, the American College of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion entitled ”Use of progesterone to reduce preterm birth”.
Based mainly on an IPD meta-analysis of randomized controlled trials, ACOG 2012 issued that cerclage is associated with a statistically significant reduction in the risk of preterm birth at < 37, < 35, < 32, < 28 and < 24 weeks of gestation, and composite perinatal morbidity and mortality when compared with no cerclage.
Based on state-of-the-art methods for indirect comparisons, either vaginal progesterone or cerclage is equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous preterm birth. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.
Thus far, no prospective studies compared vaginal progesterone and cerclage directly. So in our prospective randomized clinical study we directly compared vaginal progesterone, cervical cerclage and combination of both. 146 pregnant women at high risk of PTL (singleton pregnancy, history of spontaneous PTL, sonographic short cervical length < 25 mm in the mid trimester and twins or triplets pregnancy were assigned to randomization. 49 received vaginal progesterone 200 mg daily at night (Progest, Pharco Egy. 2 capsules each 100 mg. inserted vaginally at night from 20-24wks’ until 34wks’ gestation), 49 were subjected to cerclage only & 48 were randomly assigned to a combination (vaginal progesterone and cerclage).
The outcome information was available for only 42 in progesterone group, 41 in cerclage group and 43 in combination group (Figure 4).
1ry outcome was spontaneous delivery before 37 weeks’ gestation.
2ry outcome was spontaneous delivery before 34 weeks’ gestation as well as neonatal morbidity (birth weight , Apgar score , NICU admission).
Data were statistically analyzed regarding:
A) All women in the three study groups:
We found that combination of vaginal progesterone and cerclage was associated with statistically significant better results than each alone (longer mean gestational age at delivery P=<0.001, higher mean birth weight P=0.047, higher mean Apgar score P=0.003, lower rate of NICU admission P=0.002). B) Women with twin and triplet gestations:
We found that combination of vaginal progesterone and cerclage was associated with statistically significant better results than each alone (longer mean gestational age at delivery P=0.001, higher mean birth weight P=0.043, higher mean Apgar score P=0.013, lower rate of NICU admission P=0.006).
So we concluded that either vaginal progesterone or cerclage is equally effective in prevention of PTL in women with high risk of preterm labor (singleton pregnancy, a sonographic short cervcal length < 25mm in the mid trimester and history of previous spontaneous PTL) and improving the composite perinatal outcomes. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.
Combination of vaginal progesterone and cervical cerclage has a statistically significant better results regarding PTL prevention and improving the composite perinatal morbidity & mortality (significantly higher mean birth weight, higher mean Apgar score and lower rate of NICU admission).
Combination of vaginal progesterone and cervical cerclage found to be significantly effective in reducing the risk of PTL in twins and triplets gestation (longer mean gestational age at delivery) and improving the perinatal outcomes (significantly higher mean birth weight, higher mean Apgar score and lower rate of NICU admission).