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Background Cervical cerclage, cervical pessary, and vaginal progesterone have each been shown to reduce preterm birth (PTB) in high-risk women, but to our knowledge, there has been no randomised comparison of the 3 interventions. The SuPPoRT 'Stitch, Pessary, or Progesterone Randomised Trial' was designed to compare the rate of PTB Methods and findings SuPPoRT was a multicentre, open label 3-arm randomised controlled trial designed to demonstrate equivalence (equivalence margin 20%) conducted from 1 July 2015 to 1 July 2021 in 19 obstetric units in the United Kingdom. Asymptomatic women with singleton pregnancies with transvaginal ultrasound cervical lengths measuring A total of 386 pregnant women between 14.sup.+0 and 23.sup.+6 weeks' gestation with a cervical length 14 weeks gestation); and 45.8% had prior cervical surgery. Data from 381 women were available for outcome analysis. Using binary regression, randomised therapies (cerclage versus pessary versus vaginal progesterone) were found to have similar effects on the primary outcome PTB A small proportion of women did not receive the intervention as per protocol; however, per-protocol and as-treated analyses showed similar results. The main study limitation was that the trial was underpowered for neonatal outcomes and was stopped early due to the COVID-19 pandemic. Conclusions In this study, we found that for women who develop a short cervix, cerclage, pessary, and vaginal progesterone were equally efficacious at preventing PTB, as judged with a 20% equivalence margin. Commencing with any of the therapies would be reasonable clinical management. These results can be used as a counselling tool for clinicians when managing women with a short cervix. Trial registration EU Clinical Trials register. EudraCT Number: 2015-000456-15, clinicaltrialsregister.eu., ISRCTN Registry: ISRCTN13364447, isrctn.com., Author(s): Natasha L. Hezelgrave 1,2, Natalie Suff 1,*, Paul Seed 1, Vicky Robinson 1, Jenny Carter 1, Helena Watson 1,3, Alexandra Ridout 1, Anna L. David 4, Susana Pereira 5, [...]

BACKGROUND: Preterm preeclampsia is a pregnancy complication associated with myocardial dysfunction and premature cardiovascular disease morbidity and mortality. Left atrial (LA) strain is a noninvasive index of left ventricular end diastolic pressure and an early marker of heart failure risk. This study aimed to evaluate LA strain during the postpartum period in participants with and without preterm preeclampsia and to assess whether this varied in the presence of hypertension, cardiac dysfunction or both. METHODS: In this longitudinal cohort study, 321 women from 28 hospitals with preterm preeclampsia (cases) underwent cardiovascular assessment 6 months postpartum. This is a secondary analysis of the PHOEBE study (ISRCTN01879376). An uncomplicated pregnancy control group (n=30) was recruited from a single center for comparison. A full cross-sectional transthoracic echocardiogram was performed, and from these images, the myocardial strain of the left atrium, including reservoir, conduit, and contractile strain, as well as LA stiffness, were calculated. RESULTS: At 6 months postpartum, compared with controls, prior preeclampsia was associated with a significantly attenuated LA reservoir, conduit, and contractile strain, as well as increased LA stiffness (all P<0.001). LA strain was further reduced in preeclamptic women who had and had not developed hypertension, systolic, or diastolic dysfunction at 6 months postpartum (all P<0.05). CONCLUSIONS: LA mechanics were significantly attenuated at 6 months postpartum in participants with preterm preeclampsia, whether or not they remained hypertensive or had evidence of ventricular dysfunction. Further studies are needed to determine whether postnatal LA strain may identify women at greater risk for future cardiovascular disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: PlGF (placental growth factor)-based testing reduces severe maternal adverse outcomes. Repeat PlGF-based testing is not associated with improved perinatal or maternal outcomes. This planned secondary analysis aimed to determine whether there is a subgroup of women who benefit from repeat testing. METHODS: Pregnant individuals with suspected preterm preeclampsia were randomized to repeat revealed PlGF-based testing, compared with usual care where testing was concealed. Perinatal and maternal outcomes were stratified by trial group, by initial PlGF-based test result, and by PlGF-based test type (PlGF or sFlt-1 [soluble fms-like tyrosine kinase-1]/PlGF ratio). RESULTS: A total of 1252 pregnant individuals were included. Abnormal initial PlGF-based test identified a more severe phenotype of preeclampsia, at increased risk of adverse maternal and perinatal outcomes. Repeat testing was not significantly associated with clinical benefit in women with abnormal initial results. Of women with a normal initial result, 20% developed preeclampsia, with the majority at least 3 to 4 weeks after initial presentation. Repeat test results were more likely to change from normal to abnormal in symptomatic women (112/415; 27%) compared with asymptomatic women (163/890; 18%). A higher proportion of symptomatic women who changed from normal to abnormal were diagnosed with preeclampsia, compared with asymptomatic women. CONCLUSIONS: Our results do not demonstrate evidence of the clinical benefit of repeating PlGF-based testing if the initial result is abnormal. Judicious use of repeat PlGF-based testing to stratify risk may be considered at least 2 weeks after a normal initial test result, particularly in women who have symptoms or signs of preeclampsia. [ABSTRACT FROM AUTHOR]

Background: Treatment with vaginal progesterone reduces the risk of miscarriage and preterm birth in selected high‐risk women. The hypothesis that vaginal progesterone can reduce the risk of hypertensive disorders of pregnancy (HDP) is unexplored. Objectives: To summarise the evidence on the effectiveness of vaginal progesterone to reduce the risk of HDP. Search strategy: We searched Embase (OVID), MEDLINE (OVID), PubMed, CENTRAL and clinicaltrials.gov from inception until 20 June 2023. Selection criteria: We included placebo‐controlled randomised trials (RCTs) of vaginal progesterone for the prevention or treatment of any pregnancy complications. Data collection and analysis: We extracted absolute event numbers for HDP and pre‐eclampsia in women receiving vaginal progesterone or placebo, and meta‐analysed the data with a random effects model. We appraised the certainty of the evidence using GRADE methodology. Main results: The quantitative synthesis included 11 RCTs, of which three initiated vaginal progesterone in the first trimester, and eight in the second or third trimesters. Vaginal progesterone started in the first trimester of pregnancy lowered the risk of any HDP (risk ratio [RR] 0.71, 95% confidence interval [CI] 0.53–0.93, 2 RCTs, n = 4431 women, I2 = 0%; moderate‐certainty evidence) and pre‐eclampsia (RR 0.61, 95% CI 0.41–0.92, 3 RCTs, n = 5267 women, I2 = 0%; moderate‐certainty evidence) when compared with placebo. Vaginal progesterone started in the second or third trimesters was not associated with a reduction in HDP (RR 1.19, 95% CI 0.67–2.12, 3 RCTs, n = 1602 women, I2 = 9%; low‐certainty evidence) or pre‐eclampsia (RR 0.97, 95% CI 0.71–1.31, 5 RCTs, n = 4274 women, I2 = 0%; low‐certainty evidence). Conclusions: Our systematic review found first‐trimester initiated vaginal micronised progesterone may reduce the risk of HDP and pre‐eclampsia. [ABSTRACT FROM AUTHOR]

Objective To estimate the prevalence and prognosis of proteinuria at enrolment in the 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia cluster randomized trials. Methods We identified pregnant women eligible for inclusion in the trials in their communities in four countries (2013-2017). We included women who delivered by trial end and received an intervention antenatal care visit. The intervention was a community health worker providing supplementary hypertension-oriented care, including proteinuria assessment by visual assessment of urinary dipstick at the first visit and all subsequent visits when hypertension was detected. In a multilevel regression model, we compared baseline prevalence of proteinuria ([greater than or equal to] 1 + or [greater than or equal to] 2+) across countries. We compared the incidence of subsequent complications by baseline proteinuria. Findings Baseline proteinuria was detected in less than 5% of eligible pregnancies in each country (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004; Pakistan: 315/10 885), almost always with normotension (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). There was no consistent relationship between baseline proteinuria (either [greater than or equal to] 1+ or [greater than or equal to] 2+) and progression to hypertension, maternal mortality or morbidity, birth at < 37 weeks, caesarean section delivery or perinatal mortality or morbidity. If proteinuria testing were restricted to women with hypertension, we projected annual cost savings of 153 223 981 United States dollars (US$) in India, US$ 9 055 286 in Mozambique, US$ 53 181 933 in Nigeria and US$ 38 828 746 in Pakistan. Conclusion Our findings question the recommendations to routinely evaluate proteinuria at first assessment in pregnancy. Restricting proteinuria testing to pregnant women with hypertension has the potential to save resources. [phrase omitted] [phrase omitted] Metodos Se identificaron mujeres embarazadas que cumplian los requisitos para participar en los ensayos en sus comunidades en cuatro paises (2013-2017). Se incluyeron las mujeres que tuvieron un parto al final del ensayo y recibieron una visita de atencion prenatal de intervencion. Esta intervencion consistio en un profesional sanitario de la comunidad quien presto atencion suplementaria centrada en la hipertension, incluida la evaluacion de la proteinuria a traves del analisis visual de la tira reactiva de orina en la primera visita y en todas las visitas posteriores si se presentaba hipertension. En un modelo de regresion multinivel, se comparo la prevalencia del valor basal de la proteinuria ([greater than or equal to] 1 + o [greater than or equal to] 2+) en todos los paises. Luego, se comparo la incidencia de las complicaciones posteriores en funcion del valor basal de la proteinuria. Resultados El valor basal de la proteinuria se detecto en menos del 5 % de los embarazos que cumplian los requisitos en cada pais (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004, Pakistan: 315/10 885), la mayoria de las veces con una tension arterial normal (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). No se observo una relacion coherente entre el valor basal de la proteinuria (ya sea [greater than or equal to] 1 + o [greater than or equal to] 2+) y la progresion a la hipertension, la mortalidad o morbilidad materna, el nacimiento a las < 37 semanas, el parto por cesarea o la mortalidad o morbilidad perinatal. Si la prueba de proteinuria se limitara a las mujeres con hipertension, se calcularian ahorros anuales de 153 223 981 dolares estadounidenses (USD) en la India, 9 055 286 USD en Mozambique, 53 181 933 USD en Nigeria y 38 828 746 USD en Pakistan. Conclusion Los resultados cuestionan las recomendaciones de evaluar la proteinuria de forma rutinaria en la primera evaluacion durante el embarazo. Limitar la prueba de proteinuria a las mujeres embarazadas con hipertension podria suponer un ahorro de recursos. [phrase omitted] Objectif Estimer la prevalence et le pronostlc de la proteinurie au moment de l'inscription dans l'un des 27 groupes repris dans les essais randomises en grappes sur les interventions communautaires liees a la preeclampsie. Methodes Nous avons selectionne des femmes enceintes remplissant les conditions requises pour les essais menes au sein de leur communaute dans quatre pays (2013-2017). Nous avons inclus des femmes ayant accouche au terme de l'essai et ayant fait l'objet d'une consultation prenatale avec intervention. Lintervention etait menee par un professionnel de sante communautaire prodiguant des soins complementaires en lien avec l'hypertension, dont un controle de la proteinurie par examen visuel d'une bandelette reactive trempee dans les urines lors de la premiere visite, ainsi que lors des visites qui suivent tout diagnostic d'hypertension. Nous avons employe un modele de regression multiniveaux pour analyser la prevalence initiale de la proteinurie ([greater than or equal to] 1+ ou [greater than or equal to] 2+) dans les differents pays. Enfin, nous avons compare l'incidence des complications ulterieures en fonction de la proteinurie initiale. Resultats La proteinurie initiale a ete detectee chez moins de 5% des grossesses etudiees dans chaque pays (Inde: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004, Pakistan: 315/10 885), et allait presque toujours de pair avec une tension arterielle normale (Inde: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). Nous n'avons identifie aucun lien concluant entre la proteinurie initiale (qu'elle soit [greater than or equal to] 1+ ou [greater than or equal to] 2+) et une progression vers de l'hypertension, une mortalite ou morbidite maternelle, une naissance avant 37 semaines, un accouchement par cesarienne, ou encore une mortalite ou morbidite perinatale. Si les tests de depistage de proteinurie etaient reserves aux femmes souffrant d'hypertension, les economies realisees chaque annee representeraient 153 223 981 dollars americains en Inde, 9 055 286 dollars americains au Mozambique, 53 181 933 dollars americains au Nigeria et 38 828 746 dollars americains au Pakistan. Conclusion Nos resultats remettent en question les recommandations selon lesquelles il convient de controler regulierement la proteinurie des le premier bilan de grossesse. Limiter les tests aux femmes enceintes souffrant d'hypertension pourrait potentiellement permettre de menager les ressources. Objetivo Estimar la prevalencia y el pronostico de la proteinuria al momento de la inscripcion en los 27 grupos de intervencion de los ensayos aleatorizados del grupo de intervenciones a nivel comunitario para la preeclampsia., Introduction Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal death and disability worldwide. As such, antenatal care is devoted in large part to the detection of [...]