Combined method of the cervical insufficiency correction: Dr. Arabin vaginal perforated obstetric pessary and various forms of tableted micronized progesterone

Authors

DOI:

https://doi.org/10.18370/2309-4117.2023.67.90-101

Keywords:

cervical insufficiency, combined technique of correction, Dr. Arabin obstetric perforated pessary, vaginal tablets of micronized progesterone, sublingual tablets of micronized progesterone

Abstract

Objectives: a comparative assessment of the effectiveness of a combined therapeutic and prophylactic method for cervical insufficiency (CI) correcting by using Dr. Arabin vaginal perforated obstetric pessary and various forms of tableted micronized progesterone – vaginal and sublingual.
Material and methods. 215 pregnant women with CI were under observation. The main group included 129 pregnant women with CI, in whom therapeutic and preventive measures included a combination of obstetric perforated pessary by Dr. Arabin and sublingual form of micronized progesterone 100 mg three times a day up to 36 weeks of pregnancy. The compression group included 86 pregnant women with CI treated with Dr. Arabin vaginal perforated obstetric pessary and micronized progesterone vaginal tablets 200 mg twice daily up to 36 weeks’ gestation. All women during the gestational period also received vitamin-mineral complexes for pregnant women, ω3-polyunsaturated fatty acids and magnesium preparations.
Course of pregnancy, obstetric and perinatal consequences were assessed.
Results. The study of combined methods in the CI correction led to similar results in pregnancy outcomes and childbirth: there was no statistically significant difference between the main group and comparison group in the frequency of premature rupture of membranes (χ2 = 6.65% vs. 0.47), labor before 32 weeks (1.55 versus 4.65%, χ2 = 1.83, p = 0.18) labor in 33–36 weeks (4.65 versus 6.98%, χ2 = 0.53, p = 0.47), emergency labor (93.80 versus 88.37%, χ2 = 1.98, p = 0.16), operative delivery by cesarean section (13.95 vs. 2.33% versus 6.98%, χ2 = 2.78, p = 0.10), bleeding in the postpartum period (2.33 vs. 6.98%, χ2 = 2.78, p = 0.10), neonatal morbidity (4.65 versus 10.47%, χ2 = 2.69, p = 0.10), low birth weight – less than 1,500 g (1.55 vs. 5.81%, χ2 = 2.98, р = 0.08), middleweight babies (3,420.24 ± 48.98 vs. 3,360.23 ± 66.38 g, p = 0.47). Comparing the compliance of treatment and preventive measures was established that women in labor in the obstetric pessary + sublingual progesterone group rated them at 9.19 ± 0.11 points, in the obstetric pessary + vaginal progesterone group – at 7.83 ± 0.0.01 points).
Conclusions. Combined methods of CI correction using Dr. Arabin vaginal perforated obstetric pessary in combination with tableted micronized progesterone are effective and safe when using both vaginal and sublingual forms of progesterone. But the method of using a pessary and sublingual progesterone is more optimal, convenient and compliant. Both techniques can be widely used in clinical practice.

Author Biographies

O.M. Nosenko, Odesa National Medical University, Odesa

MD, professor, Department of Obstetrics and Gynecology

F.O. Khancha, Donetsk National Medical University, Kropyvnytskyi

PhD, assistant, Department of Obstetrics and Gynecology

H.V. Rutynska, LLC “Profile hospital AIRMED”, Odesa

PhD, sonologist

References

  1. Belotserkovtseva, L.D., Kovalenko, L.V., Mirzoeva, G.T. “Risk factors for the formation of isthmic-cervical insufficiency leading to premature birth.” Bulletin of SurSU. The medicine 2.20 (2014): 26–30.
  2. Bespalova, O.N., Sargsyan, G.S. “Choice of method for correction of isthmic-cervical insufficiency.” Journal of Obstetrics and Women’s Diseases 66.3 (2017): 157–68. DOI: 10.17816/JOWD663157-168
  3. Bulanov, M.N. Ultrasound diagnosis of diseases of the cervix. Guide for doctors. Moscow: Vidar-M (2017). 304 p.
  4. Egorova, Y.A., Rybalka, A.N. “Unloading obstetric pessary as an addition to the treatment of isthmic-cervical insufficiency.” Crimean Journal of Experimental and Clinical Medicine 2.14 (2014): 17–21.
  5. Zhabchenko, I.A. “Obstetric tactics in isthmic-cervical insufficiency: the solution of the main and related problems.” Protection of motherhood and childhood 1.25 (2015): 58–65.
  6. Zhabchenko, І.А., Oleshko, V.F. “Algorithm of obstetric actions in isthmic-cervical insufficiency.” Women’s health 6.102 (2015): 76–8.
  7. Kaplan, Y.D., Zakharenkova, T.N., Zhuravlev, A.Y. “The role of transvaginal ultrasound as a control method for conservative correction of a short cervix with a cervical pessary.” Reproductive health. Eastern Europe 7.2 (2017): 195–204.
  8. Kaplan, Y.D., Zakharenkova, T.N. “Comparative analysis of methods for diagnosing the state of the cervix during pregnancy.” Problems of health and ecology 1.51 (2017): 6–13.
  9. Lukyanchuk, V.D., Kuznetsova, O.V. “In vitro study of drug solubility in solid dosage form for intravaginal administration.” Medical aspects of a woman’s health 1.97 (2016): 2–5.
  10. Opryshko, V.I., Nosivets, D.S. “Innovations and trends in the clinical pharmacology of vaginal forms of gestagens.” Medical aspects of women’s health 5.102 (2016): 55–61.
  11. Opryshko, V.I., Nosivets, D.S. “Sublingual form of progesterone: the need for innovation or the challenges of modern medicine.” Women’s health 10.106 (2015): 37–42.
  12. Safonova, I.N. “High-risk pregnancy: sonographic monitoring.” Kyiv: Medicine of Ukraine (2019). 246 p. ISBN 978-617-7769-01-8.
  13. Khomyak, N.V., Mamchur, V.Y., Khomyak, E.V. “Clinical and pharmacological features of dosage forms of micronized progesterone used during pregnancy.” Medical aspects of women’s health 2.88 (2015): 28–35.
  14. Tetrusashvili, N.K., Agadzhanova, A.A., Milusheva, A.K. “Cervical incompetence with fetal bladder prolapse: new therapeutic options.” Medical Council XX (2015): 50–3.
  15. Zvigun, M.V. “Failure to bear a pregnancy is one of the consequences of surgical interventions on the cervix in women of reproductive age.” Women’s health 8.94 (2014): 44–6.
  16. Shamina, I.V., Tirskaya, Y.I, Lazareva, O.V., et al. “Prevention of preterm birth in high-risk pregnant women by using Dr. Arabin obstetric pessary.” Siberian Medical Review 1 (2018): 59–65.
  17. Shcherbina, M.O., Muawiya Salem Nasser Almardat. “New ways to optimize the management of women with ischemic-cervical insufficiency.” Collection of scientific papers of the Association of Obstetricians and Gynecologists of Ukraine. Kyiv: Polygraph Plus (2014): 315–7.
  18. Shurpyak, S.A. “Modern forms of natural progesterone with different routes of administration in the treatment of threatened abortions and prevention of preterm birth. Literature review.” Women’s health 10.86 (2013): 2–7.
  19. Abdel-Aleem, H., Shaaban, O.M., Abdel-Aleem, M.A. “Cervical pessary for preventing preterm birth.” Cochrane Database Syst Rev 31.5 (2013): CD007873. DOI: 10.1002/14651858.CD007873.pub3
  20. Alfirevic, Z., Stampalija, T., Medley, N. “Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy.” Cochrane Database Syst Rev 2017.6 (2017): CD008991. DOI: 10.1002/14651858.CD008991.pub3
  21. Allen, K.G., Harris, M.A. “The role of n-3 fatty acids in gestation and parturition.” Exp Biol Med (Maywood) 226.6 (2001): 498–506. DOI: 10.1177/153537020122600602
  22. Arabin, B., Halbesma, J.R., Vork, F., et al. “Is treatment with vaginal pessaries an option in patients with a sonographically detected short cervix?” Journal of Perinatal Medicine 31.2 (2003): 122–33.
  23. Arabin, B., Alfirevic, Z. “Cervical pessaries for prevention of spontaneous preterm birth: past, present and future.” Ultrasound Obstet Gynecol 42 (2013): 390–9.
  24. Arabin, H. “Pessartherapie (therapy with pessaries).” New York (NY): Thieme (1991): 263–76.
  25. Barinov, S.V., Artymuk, N.V., Novikova, O.N., et al. “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.” J Matern Fetal Neonatal Med 34.13 (2021): 2071–9. DOI: 10.1080/14767058.2019.1656195
  26. Berghella, V., Seibel-Seamon, J. “Contemporary use of cervical cerclage.” Clin Obstet Gynecol 50.2 (2007): 468–77. DOI: 10.1097/GRF.0b013e31804bddfd
  27. Boelig, R.C., Berghella, V. “Current options for mechanical prevention of preterm birth.” Semin Perinatol 41.8 (2017): 452–60.
  28. Bortoletto, T.G., Silva, T.V., Borovac-Pinheiro, A., et al. “Cervical length varies considering different populations and gestational outcomes: Results from a systematic review and meta-analysis.” PLoS One 16.2 (2021): e0245746. DOI: 10.1371/journal.pone.0245746
  29. Brown, R., Gagnon, R., Delisle, M.F. “No. 373-Cervical Insufficiency and Cervical Cerclage.” J Obstet Gynaecol Can 41.2 (2019): 233–47. DOI: 10.1016/j.jogc.2018.08.009
  30. Cannie, M., Dobrescu, O., Gucciardo, L., et al. “Arabin cervical pessary in women at high risk of preterm birth: a magnetic resonance imaging observational follow-up study.” Ultrasound Obstet Gynecol 42.4 (2013): 426–33. DOI: 10.1002/uog.12507
  31. Carbonne, B., Dallot, E., Haddad, B., et al. “Effects of progesterone on prostaglandin E(2)-induced changes in glycosaminoglycan synthesis by human cervical fibroblasts in culture.” Mol Hum Reprod 6.7 (2000): 661–4.
  32. Chan, Y.Y., Jayaprakasan, K., Tan, A., et al. “Reproductive outcomes in women with congenital uterine anomalies: a systematic review.” Ultrasound Obstet Gynecol 38.4 (2011): 371–82. DOI: 10.1002/uog.10056
  33. Chawanpaiboon, S., Vogel, J.P., Moller, A.B., et al. “Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis.” Lancet Glob Health 7.1 (2019): e37-e46. DOI: 10.1016/S2214-109X(18)30451-0
  34. Committee on Practice Bulletins-Obstetrics, The American College of Obstetricians and Gynecologists. “Practice bulletin No. 130: prediction and prevention of preterm birth.” Obstet Gynecol 120.4 (2012): 964–73.
  35. Cross, R.G.“Treatment of habitual abortion due to cervical incompetence.” Lancet 274 (1959): 127. DOI: 10.1016/S0140-6736(59)92242-1
  36. Cruz-Melguizo, S., San-Frutos, L., Martínez-Payo, C., et al. “Cervical pessary compared with vaginal progesterone for preventing early preterm birth: a randomized controlled trial.” Obstet Gynecol 132.4 (2018): 907–15. DOI: 10.1097/AOG.0000000000002884
  37. Driggers, R.“Prevention of preterm birth – what works and what doesn’t?” Obstet Gynecol Int J 2.5 (2015): 179–82. DOI: 10.15406/ogij.2015.02.00057
  38. Dugoff, L., Berghella, V., Sehdev, H., et al. “Prevention of preterm birth with pessary in singletons (PoPPS): randomized controlled trial.” Ultrasound Obstet Gynecol 51 (2018): 573–9. DOI: 10.1002/uog.18908
  39. Eleje, G.U., Eke, A.C., Ikechebelu, J.I., et al. “Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies.” Cochrane Database Syst Rev 9.9 (2020): CD012871. DOI: 10.1002/14651858.CD012871.pub2
  40. Fox, N.S., Gupta, S., Lam-Rachlin, J., et al.“Cervical pessary and vaginal progesterone in twin pregnancies with a short cervix.” Obstet Gynecol 127 (2016): 625–30. DOI: 10.1097/AOG.0000000000001300
  41. Gernand, A.D., Schulze, K.J., Stewart, C.P., et al. “Micronutrient deficiencies in pregnancy worldwide: health effects and prevention.” Nat Rev Endocrinol 12.5 (2016): 274–89. DOI: 10.1038/nrendo.2016.37
  42. Gonzales, S.K., Adair, C.D., Torres, C., et al. “Robotic-Assisted Laparoscopic Abdominal Cerclage Placement During Pregnancy.” J Minim Invasive Gynecol 25.5 (2018): 832–5.
  43. Goya, M., Pratcorona, L., Merced, C., et al. “Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial.” Lancet 379.9828 (2012): 1800–6. DOI: 10.1016/S0140-6736(12)60030-0
  44. Hassan, S.S., Romero, R., Vidyadhari, D., et al. “Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial.” Ultrasound Obstet Gynecol 38.1 (2011): 18–31. DOI: 10.1002/uog.9017
  45. House, M., Tadesse-Telila, S., Norwitz, E.R., et al. “Inhibitory effect of progesterone on cervical tissue formation in a three-dimensional culture system with human cervical fibroblasts.” Biol Reprod 90.1 (2014): 18.
  46. Hui, S.Y.A., Chor, C.M., Lau, T.K., et al. “Cerclage pessary for preventing preterm birth in women with a singleton pregnancy and a short cervix at 20 to 24 weeks: a randomized controlled trial.” Am J Perinatol 30.4 (2013): 283–8. DOI: 10.1055/s-0032-1322550
  47. Iams, J.D., Goldenberg, R.L., Meis, P.J., et al. “The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network.” N Engl J Med 334.9 (1999): 567–72.
  48. Karbasian, N., Sheikh, M., Pirjani, R., et al. “Combined treatment with cervical pessary and vaginal progesterone for the prevention of preterm birth: A randomized clinical trial.” J Obstet Gynaecol Res 42.12 (2016): 1673–9. DOI: 10.1111/jog.13138
  49. Keelan, J.A., Newnham, J.P. “Recent advances in the prevention of preterm birth.” F1000Res 1 (2017): 6. DOI: 10.12688/f1000research.11385.1
  50. Koullali, B., van Kempen, L.E.M., van Zijl, M.D., et al. “A multi-centre, non-inferiority, randomised controlled trial to compare a cervical pessary with a cervical cerclage in the prevention of preterm delivery in women with short cervical length and a history of preterm birth – PC study.” BMC Pregnancy Childbirth 17.1 (2017): 215. DOI: 10.1186/s12884-017-1393-6
  51. Landy, H.J., Laughon, S.K., Bailit, J.L., et al. “Characteristics associated with severe perineal and cervical lacerations during vaginal delivery.” Obstet Gynecol 117.3 (2011): 627–35.
  52. Liem, S.M.S., van Pampus, M.G., Mol, B.W.J., et al. “Cervical Pessaries for the Prevention of Preterm Birth: A Systematic Review.” Obstetrics and Gynecology International 2013 (2013): 1–10. DOI: 10.1155/2013/576723
  53. Maxson, W.S., Hargrove, J.T. “Bioavailability of oral micronized progesterone.” Fertil Steril 44.5 (1985): 622–6.
  54. Mahendroo, M. “Cervical remodeling in term and preterm birth: insights from an animal model.” Reproduction 143.4 (2012): 429–38.
  55. Mahendroo, M.S., Porter, A., Russell, D.W., et al. “The parturition defect in steroid 5alpha-reductase type 1 knockout mice is due to impaired cervical ripening.” Mol Endocrinol 13.6 (1999): 981–92.
  56. McDonald, I.A. “Suture of the cervix for inevitable miscarriage. Journal of Obstetrics and Gynaecology of the British Commonwealth.” 64.3 (1957): 346–50.
  57. Medley, N., Poljak, B., Mammarella, S., Alfirevic, Z. “Clinical guidelines for prevention and management of preterm birth: a systematic review.” BJOG 125.11 (2018): 1361–9. DOI: 10.1111/1471-0528.15173
  58. Mönckeberg, M., Valdés, R., Kusanovic, J.P., et al. “Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis.” J Perinat Med 47.5 (2019): 500–9.
  59. Nicolaides, K.H., Syngelaki, A., Poon, L.C., et al. “Cervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial.” Am J Obstet Gynecol 214.1 (2016):3. e1-9. DOI: 10.1016/j.ajog.2015.08.051
  60. Nicolaides, K.H., Syngelaki, A., Poon, L.C., et al. “A Randomized Trial of a Cervical Pessary to Prevent Preterm Singleton Birth.” N Engl J Med 374.11 (2016): 1044–52. DOI: 10.1056/NEJMoa1511014
  61. Nold, C., Maubert, M., Anton, L., et al. “Prevention of preterm birth by progestational agents: what are the molecular mechanisms?” Am J Obstet Gynecol 208.3 (2013): 223.e1-7.
  62. Norman, T.R., Morse, C.A., Dennerstein, L. “Comparative bioavailability of orally and vaginally administered progesterone.” Fertil Steril 56.6 (1991): 1034–9. DOI: 10.1016/s0015-0282(16)54713-x
  63. Olsen, S.F., Østerdal, M.L., Salvig, J.D., et al. “Duration of pregnancy in relation to fish oil supplementation and habitual fish intake: a randomised clinical trial with fish oil.” Eur J Clin Nutr 61.8 (2007): 976–85. DOI: 10.1038/sj.ejcn.1602609
  64. Pacagnella, R.C., Mol, B.W., Borovac-Pinheiro, A., et al. “A randomized controlled trial on the use of pessary plus progesterone to prevent preterm birth in women with short cervical length (P5 trial).” BMC Pregnancy Childbirth 19.1 (2019): 442. DOI: 10.1186/s12884-019-2513-2
  65. Pacagnella, R.C., Silva, T.V., Cecatti, J.G., et al. “Pessary Plus Progesterone to Prevent Preterm Birth in Women with Short Cervixes: A Randomized Controlled Trial. Obstet Gynecol.” 139.1 (2022): 41–51. DOI: 10.1097/AOG.0000000000004634
  66. Pérez-López, F.R., Chedraui, P., Pérez-Roncero, G.R., et al. “Health Outcomes and Systematic Analyses (HOUSSAY) Project. Effectiveness of the cervical pessary for the prevention of preterm birth in singleton pregnancies with a short cervix: a meta-analysis of randomized trials.” Arch Gynecol Obstet 299.5 (2019): 1215–31. DOI: 10.1007/s00404-019-05096-x
  67. Rådestad, A., Christensen, N.J., Strömberg, L. “Induced cervical ripening with Mifepristone in first trimester abortion. A double-blind randomized biomechanical study.” Contraception 38.3 (1988): 301–12.
  68. Resnik, R., Lockwood, C., Moore, T., et al. Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th Edition. Elsevier (2018). 1408 р.
  69. Rios, J.D., Shah, P.S., Beltempo, M., et al. “Costs of Neonatal Intensive Care for Canadian Infants with Preterm Birth.” J Pediatr 229 (2021): 161–167.e12. DOI: 10.1016/j.jpeds.2020.09.045
  70. Romero, R., Conde-Agudelo, A., Da Fonseca, E., et al. “Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix: a meta-analysis of individual patient data.” Am J Obstet Gynecol 218.2 (2018): 161–80. DOI: 10.1016/j.ajog.2017.11.576
  71. Romero, R., Nicolaides, K., Conde-Agudelo, A., et al. “Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data.” Am J Obstet Gynecol 206.2 (2012): 124.e121-119. DOI: 10.1016/j.ajog.2011.12.003
  72. Saccone, G., Berghella, V. “Omega-3 long chain polyunsaturated fatty acids to prevent preterm birth: a systematic review and meta-analysis.” Obstet Gynecol 125.3 (2015): 663–72. DOI: 10.1097/AOG.0000000000000668
  73. Saccone, G., Berghella, V. “Omega-3 supplementation to prevent recurrent preterm birth: a systematic review and metaanalysis of randomized controlled trials.” Am J Obstet Gynecol 213.2 (2015): 135–40. DOI: 10.1016/j.ajog.2015.03.013
  74. Saccone, G., Maruotti, G.M., Giudicepietro, A., et al. “Effect of cervical pessary on spontaneous preterm birth in women with singleton pregnancies and short cervical length: a randomized clinical trial.” JAMA 318.23 (2017): 2317–24. DOI: 10.1001/jama.2017.18956
  75. Shirodkar, V.N. “A new method of operative treatment for habitual abortions in the second trimester of pregnancy.” Antiseptic 52 (1955): 299–300.
  76. Society for Maternal and Fetal Medicine. SMFM Preterm Birth Toolkit. Available from: [https://www.smfm.org/publications/231-smfm-preterm-birth-toolkit], last accessed on December 31, 2017.
  77. Stadnick, N.A., Sadler, E., Sandall, J., et al. “Comparative case studies in integrated care implementation from across the globe: a quest for action.” BMC Health Serv Res 19.1 (2019): 899. DOI: 10.1186/s12913-019-4661-5
  78. Stricker, N., Timmesfeld, N., Kyvernitakis, I., et al. “Vaginal progesterone combined with cervical pessary: a chance for pregnancies at risk for preterm birth?” Am J Obstet Gynecol 214 (2016): 739. e1-739.e10. 10.1016/j.ajog.2015.12.007
  79. Suhag, A., Berghella, V. “Cervical cerclage. Clin Obstet Gynecol.” 57.3 (2014): 557–67. DOI: 10.1097/GRF.0000000000000044
  80. Thakur, M., Mahajan, K. “Cervical Incompetence. StatPearls [Internet].” Treasure Island (FL): StatPearls Publishing (2019), Dec 9.
  81. Tyan, P., Mourad, J., Wright, B., et al. “Robot-assisted transabdominal cerclage for the prevention of preterm birth: A multicenter experience.” Eur J Obstet Gynecol Reprod Biol 232 (2019): 70–4.
  82. Vink, J., Myers, K. “Cervical alterations in pregnancy.” Best Pract Res Clin Obstet Gynaecol 52 (2018): 88–102. DOI: 10.1016/j.bpobgyn.2018.03.007
  83. Vousden, N., Hezelgrave, N., Carter, J., et al. “Prior ultrasound-indicated cerclage: how should we manage the next pregnancy?” Eur J Obstet Gynecol Reprod Biol 188 (2015): 129–32. DOI: 10.1016/j.ejogrb.2015.02.007
  84. Wang, H.L., Yang, Z., Shen, Y., et al. “Clinical outcome of therapeutic cervical cerclage in short cervix syndrome.” Zhonghua Fu Chan Ke Za Zhi 53.1 (2018): 43–6.
  85. Wei, M., Jin, X., Li, T.C., et al. “A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy.” Arch Gynecol Obstet 297.3 (2018): 645–52.
  86. Wing, D.A., Fassett, M.J., Mishell, D.R. “Mifepristone for preinduction cervical ripening beyond 41 weeks’ gestation: a randomized controlled trial.” Obstet Gynecol 96.4 (2000): 543–8.
  87. Word, R.A., Li, X.H., Hnat, M., Carrick, K. “Dynamics of cervical remodeling during pregnancy and parturition: mechanisms and current concepts.” Semin Reprod Med 25.1 (2007): 69–79.
  88. Zheng, L., Dong, J., Dai, Y., et al. “Cervical pessaries for the prevention of preterm birth: a systematic review and meta-analysis.” J Matern Fetal Neonatal Med 32.10 (2019): 1654–63. DOI: 10.1080/14767058.2017.1414795
  89. Zimerman, A.L., Neeman, O., Wiener, Y., et al. “First year experience using arabin cervical pessary with intravaginal micronized progesterone for the prevention of preterm birth in patients with mid-trimester short cervix.” Harefuah 153.2 (2014): 79–82.

Downloads

Published

2023-03-31

How to Cite

Nosenko, O. ., Khancha, F., & Rutynska, H. (2023). Combined method of the cervical insufficiency correction: Dr. Arabin vaginal perforated obstetric pessary and various forms of tableted micronized progesterone. REPRODUCTIVE ENDOCRINOLOGY, (67), 90–101. https://doi.org/10.18370/2309-4117.2023.67.90-101

Issue

No. 67 (2023)

Section

Pregnancy and childbirth

License

Copyright (c) 2023 О. М. Носенко, Ф.О. Ханча, Г.В. Рутинська

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Authors who publish with this journal agree to the following terms:

    1. Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.

    1. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.