premature labour - prophylactic vaginal progesterone and prophylactic cervical cerclage

Last edited 05/2023 and last reviewed 05/2023

Preterm birth causes significant neonatal morbidity and mortality, as well as long-term disability.

• therefore strategies for preventing preterm birth are important
• both prophylactic cervical cerclage and prophylactic vaginal progesterone are effective in preventing or delaying preterm birth in women with a short cervix and a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or mid-trimester loss (from 16+0 weeks of pregnancy onwards)
  • the choice as to which treatment is best for each woman will depend on her individual preferences and circumstances, and women should be given information as part of shared decision making

Prophylactic vaginal progesterone and prophylactic cervical cerclage

• a choice of prophylactic vaginal progesterone or prophylactic cervical cerclage should be offered to women who have both:
  
  
  • a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or midtrimester loss (from 16+0 weeks of pregnancy onwards) and
    
    
  • results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that show a cervical length of 25 mm or less

Consider prophylactic vaginal progesterone for women who have either:

• a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or midtrimester loss (from 16+0 weeks of pregnancy onwards) or
  
  
• results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that show a cervical length of 25mm or less

When using vaginal progesterone, start treatment between 16+0 and 24+0 weeks of pregnancy and continue until at least 34 weeks.

Consider prophylactic cervical cerclage for women when results of a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy show a cervical length of 25 mm or less, and who have had either:

• preterm prelabour rupture of membranes (P-PROM) in a previous pregnancy or
  
  
• a history of cervical trauma

If prophylactic cervical cerclage is used, ensure that a plan is in place for removal of the suture.

Progestogen maintenance therapy for prolongation of pregnancy after an episode of preterm labour

• considerations (2):
  • treatment with progestogen, in the form of vaginal progesterone or intramuscular 17-hydroxyprogesterone caproate (17-OHPc), has been shown to be effective in reducing the rate of pre-term birth (PTB) in women with an asymptomatic mid-trimester sonographic short cervix
  • prophylactic treatment with progestogens in women with a history of spontaneous PTB reduces the rate of PTB in a subsequent pregnancy
    
    
• systematic review and meta-analysis concluded (2):
  • progestogen maintenance therapy after pre-term labour might have a modest effect on prolongation of latency time (latency time, defined as time from randomisation to delivery (in days))

Reference:

• NICE (June 2022).Preterm labour and birth
• Breuking SH, De Ruigh AA, Hermans FJR, Schuit E, Combs CA, de Tejada BM, Oudijk MA, Mol BW, Pajkrt E. Progestogen maintenance therapy for prolongation of pregnancy after an episode of preterm labour: A systematic review and meta-analysis. BJOG. 2023 Apr 19. doi: 10.1111/1471-0528.17499.