Analysis of risk factors and predictors of pregnancy loss and strategies for the management of cervical insufficiency in pregnant women at a high risk of preterm birth.

AIM

To identify risk factors and predictors of pregnancy loss and to compare the efficacy of Arabin's pessary with cervical cerclage in women at a high risk of pregnancy loss.

MATERIALS AND METHODS

This was a two-center retrospective case-control study that included 240 women at a high risk of preterm delivery. Group I ( = 161) included women who underwent insertion of the Arabin's pessary between 14 and 24 weeks of pregnancy. Group II ( = 79) included women who had undergone circular cervical cerclage during the current pregnancy. All women included in the study received micronized vaginal progesterone at the dose of 200 mg/day until and including 34 weeks of gestation.

RESULTS

Threatened pregnancy loss defined as spotting or vaginal bleeding in the first trimester was diagnosed in 29.8% (48/161) of patients in Group I versus 37.9% in Group II ( = .448). Postpartum bleeding occurred in 8.1% (13/161) in women in Group I versus 22.8% in Group II ( = 6.500;  = .011). Our study showed that cervical cerclage was most suitable for patients with history of obstetric complications, cervical length <15 mm, and large isthmic uterine fibroids. The use of the Arabin's pessary reduced the rate of preterm births by 1.7-fold. A cluster analysis demonstrated that predictors of preterm birth in women with a high risk of pregnancy loss included: threatened pregnancy loss associated with chorionic/placental abruption, cervical incompetence, uterine fibroid growth to a large size, history of multiple spontaneous pregnancy losses, cervical tears during past labor, and gestational diabetes diagnosed for the first time during the current pregnancy.

CONCLUSIONS

Women with a high risk of pregnancy loss treated with Arabin's pessary or cerclage plus vaginal progesterone had a term delivery rate of 70.4% (169/240). The combined strategy of pregnancy management allowed to markedly reduce the number of preterm births.