Efficacy of midtrimester short cervix interventions is conditional on intraamniotic inflammation

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• 作者：Daniel G. Kiefer ; MD^a ; Morgan R. Peltier ; PhD^b ; ^c ; Sean M. Keeler ; MD^e ; Orion Rust ; MD^a ; Cande V. Ananth ; PhD^f ; Anthony M. Vintzileos ; MD^c ; Nazeeh Hanna ; MD^b ; ^d ; ^{nazeehhanna@gmail.com" class="auth_mail" title="E-mail the corresponding author}
• 关键词：amniotic fluid ; cerclage ; inflammation ; prematurity ; progesterone ; sonographic short cervix
• 刊名：American Journal of Obstetrics and Gynecology
• 出版年：2016
• 出版时间：February 2016
• 年：2016
• 卷：214
• 期：2
• 页码：276.e1-276.e6
• 全文大小：495 K

文摘

Midtrimester ultrasound is a valuable method for identifying asymptomatic women at risk for spontaneous preterm delivery (PTD). However, response to various treatments (cerclage, progestogen) has been variable in the clinical setting. It remains unclear how other biomarkers may be used to guide intervention strategies.

Objective

We applied an amniotic fluid inflammatory scoring system to determine if the degree of inflammation is associated with intervention efficacy in patients with midtrimester short cervix.

Study Design

Women carrying a singleton fetus between 16-24 weeks’ gestation with a short cervix (≤25 mm) on transvaginal ultrasound underwent amniocentesis and were assigned to McDonald cerclage, no cerclage, or weekly 17-alpha hydroxyprogesterone caproate (17OHP-C). Our previously described inflammatory risk score (comprised of 14 inflammatory markers) was used to classify patients as high (score ≥8) or low (score <8) risk for inflammation. Gestational age at delivery was compared for each intervention and risk score status. Risk of delivering as a function of the remaining gestation was evaluated using modified Cox proportional hazards models with incorporation of methods to account for both left and right truncation bias.

Results

Ninety patients were included: 24 were in the nonintervention control group, 51 received cerclage, and 15 received 17OHP-C. Inflammation status at time of sampling influenced the efficacy of the treatment (P < .001). Compared to the nonintervention control group, in patients with low inflammation (score < 8), both cerclage (adjusted hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.28–6.37) and 17OHP-C (HR, 3.11; 95% CI, 1.04–9.30) were associated with increased hazard of PTD. In contrast, in patients with high inflammation (score ≥8) both cerclage (HR, 0.22; 95% CI, 0.08–0.65) and 17OHP-C (HR, 0.20; 95% CI, 0.05–0.81) were associated with lower hazard of delivering preterm.

Conclusion

Cerclage placement or administration of 17OHP-C therapy for midtrimester short cervix for PTD prevention appears beneficial only in the subset of patients with high inflammation. Knowledge of the amniotic fluid inflammatory status may aid in guiding the appropriate therapy for women presenting with midtrimester short cervix who are at increased risk of PTD.