Platt, Faye
(2021)
Prevention of preterm birth in women with prior cervical excision.
Master of Philosophy thesis, University of Liverpool.
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Abstract
Background: Women with previous cervical surgery are at an increased risk of preterm birth (PTB) and this risk is present in all pregnancies thereafter. PTB remains the leading cause of neonatal morbidity and mortality. Interventions to prevent preterm birth are vaginal cerclage, vaginal progesterone and the Arabin pessary, indicated in women with cervical surgery with a mid-trimester cervical length <25mm between 16-24 weeks of gestation. It is unknown which intervention has the greatest efficacy in preventing PTB in this cohort. Methods: This thesis systematically reviewed the literature surrounding the management of women with a previous LLETZ or knife cone biopsy. We performed searches within Scopus, Pubmed and Cinahl databases to identify any observational studies or randomised controlled trials comparing either progesterone, vaginal cerclage or Arabin pessary to a control or comparator group. Two independent review authors screened papers for inclusion and assessed risk of bias, cases of uncertainty were discussed with a third review author. The GRADE approach was used for quality assessment. A retrospective cohort study was conducted of all women with prior cervical surgery attending the specialist PTB prevention clinic at Liverpool Women’s hospital between 2008-2020. Exclusions were made for women presenting more than once within the study period, missing data, transabdominal cerclage, radical trachelectomy and laser procedures. Data were analysed using univariable and multivariable generalised linear models in R (Version 3). Separate models were performed for women with and without a previous spontaneous preterm birth. Results: We identified 6 studies eligible for inclusion in the systematic review. There was insufficient evidence to draw conclusions for progesterone or pessary. Studies demonstrated no evidence to support the use of cerclage in women with previous cervical surgery. Our cohort study identified 441 patients for analysis, which demonstrated no statistically significant association between vaginal cerclage or Arabin pessary and gestation time. Progesterone was associated with a decrease in gestation time (Est -3.15 (1.059); p-value 0.004) in women with a previous sPTB. Conclusion: The systematic review yielded no studies comparing the efficacy of cerclage, pessary and progesterone to one another. Studies of cerclage found no additional benefit of its use in women with previous cervical surgery. These findings are supported by the findings of the retrospective cohort study. Vaginal cerclage, vaginal progesterone and the Arabin pessary, that are effective in other high-risk cohorts, do not present the same efficacy in women with previous cervical surgery.
| Item Type: | Thesis (Master of Philosophy) |
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| Divisions: | Faculty of Health and Life Sciences Faculty of Health and Life Sciences > Institute of Life Courses and Medical Sciences Faculty of Health and Life Sciences > Institute of Life Courses and Medical Sciences > School of Medicine |
| Depositing User: | Symplectic Admin |
| Date Deposited: | 10 Sep 2021 08:38 |
| Last Modified: | 18 Jan 2023 21:29 |
| DOI: | 10.17638/03136360 |
| Supervisors: |
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| URI: | https://livrepository.liverpool.ac.uk/id/eprint/3136360 |
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